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1.
J Pak Med Assoc ; 71(9): 2224-2229, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34580519

RESUMO

Endoleaks are the most common complications following endovascular aneurysm repair. Depending upon their origin, there are five types of endoleaks, types I-V, which can also be classified as direct and indirect endoleaks. Direct endoleaks (type I and III) have higher risk of aneurysm rupture due to rapid sac expansion, and require immediate correction. Indirect endoleaks ( type II, IV and V) have a relatively benign course compared to direct endoleaks. Most of them resolve with time and very few need interventions upon sac enlargement. Type V endotension is a special situation where there is sac enlargement despite no demonstrable endoleak. Proper planning and appropriate selection of stent-graft can prevent most of these endoleaks. With improvement in stent-graft technology, the incidence of endoleaks has been reduced. The current narrative review was planned to describe the pathophysiology, risk factors and treatment options for each type of endoleak.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/terapia , Humanos , Estudos Retrospectivos , Stents , Resultado do Tratamento
2.
Angiol Sosud Khir ; 27(3): 28-32, 2021.
Artigo em Russo | MEDLINE | ID: mdl-34528586

RESUMO

Endovascular abdominal aortic aneurysm repair is an operation of choice in rendering hi-tech care for patients with aneurysms of the infrarenal aortic portion. The most frequently performed reoperations account for cases related to removing endoleaks. The article deals with assessing the presence of various types of endoleaks depending on the time elapsed after abdominal aortic aneurysm repair by means of duplex scanning and multislice computed tomography. Duplex scanning proved highly informative in detecting various types of endoleaks, being comparable with the findings of multislice computed tomography (p=0.917). The presence or absence of aneurysmal cavity coloration in the mode of Doppler colour mapping makes it possible to dynamically follow up the process of thrombogenesis. For timely diagnosis of complications after endoprosthetic repair of abdominal aortic aneurysms, the use of ultrasound duplex scanning is considered to be an informative and safe technique, possessing potential possibility of detecting endoleaks and, in our opinion, may be included into the protocol of follow-up of patients in the early postoperative period.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Seguimentos , Humanos , Ultrassonografia
3.
Eur J Vasc Endovasc Surg ; 62(3): 409-421, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34301460

RESUMO

OBJECTIVE: To investigate whether patients with severe infrarenal aortic neck angulation have worse outcomes than those without severe angulation after endovascular aneurysm repair (EVAR). DATA SOURCES: The HDAS (Healthcare Database Advanced Search) interface developed by NICE (National Institute for Health and Care Excellence) was used to search electronic bibliographic databases. REVIEW METHODS: Studies comparing outcomes of standard EVAR in patients with and without severe neck angulation were considered. Pooled outcome estimates were calculated using the odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI), using the Mantel-Haenszel or inverse variance method, as appropriate. Random effects models of meta-analysis were applied. The GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) methodology was used to assess the certainty of evidence. RESULTS: Ten studies reporting a total of 7 371 patients (1 576 with severe neck angulation and 5 795 without) were included. The studies reported medium term follow up. No statistically significant difference was found for the primary outcomes (overall mortality: HR 1.27, 95% CI 0.88 - 1.85, low certainty; aneurysm related mortality: HR 1.07, 95% CI 0.80 - 1.44, moderate certainty; aneurysm rupture: HR 1.41, 95% CI 0.66 - 2.99, low certainty). The hazard of type Ia endoleak (HR 1.86, 95% CI 1.32 - 2.61) and re-intervention was higher in patient with severe angulation (HR 1.24, 95% CI 1.01 - 1.54), but there was no significant difference in the odds of adjunctive procedures (OR 1.23, 95% CI 0.48 - 3.11), or the hazard of sac expansion (HR 0.83, 95% CI 0.44 - 1.55) or stent migration (HR 1.22, 95% CI 0.78 - 1.92). Meta-analysis of studies that conducted multiple Cox regression analysis showed no significant difference for any of the primary outcomes. CONCLUSION: Severe neck angulation may not be a poor prognostic indicator for overall/aneurysm related mortality and rupture in the medium term after EVAR but may increase the risk of late type 1 endoleaks and re-intervention; therefore, patients require close surveillance.


Assuntos
Aneurisma da Aorta Abdominal/patologia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Aorta Abdominal/patologia , Ruptura Aórtica/epidemiologia , Ruptura Aórtica/etiologia , Implante de Prótese Vascular/métodos , Endoleak/epidemiologia , Endoleak/etiologia , Humanos , Modelos Estatísticos , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Reoperação/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento
5.
Eur J Vasc Endovasc Surg ; 62(2): 193-201, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34140226

RESUMO

OBJECTIVE: Use of colour duplex ultrasound (CDUS) and computed tomography angiography (CTA) for infrarenal endovascular aortic aneurysm repair (EVAR) surveillance differs in internationally published guidelines. This study aimed firstly to compare CDUS detection of significant sac abnormalities with CTA. Secondly, a sensitivity analysis was conducted to compare financial estimates of the, predominantly CDUS based, local and Society of Vascular Surgery (SVS) protocols, the risk stratified European Society of Vascular Surgery (ESVS) protocol, and the CTA based National Institute of Health and Care Excellence (NICE) protocol. METHODS: Agreement between CDUS and CTA was assessed for detection of significant sac abnormalities. Surveillance protocols were extrapolated from published guidelines and applied to infrarenal EVAR patients active on local surveillance at a large, single centre. Surveillance intensity was dependent on presence of endoleak and subsequent risk of treatment failure in accordance with surveillance recommendations. Estimates for each surveillance protocol were inclusive of a range of published incidences of endoleak, contrast associated acute kidney injury (AKI), and excess hospital bed days, and estimated for a hypothetical five year surveillance period. RESULTS: The kappa coefficient between CDUS and CTA for detecting sac abnormalities was 0.68. Maximum five year surveillance cost estimates for the 289 active EVAR patients were £272 359 for SVS, £230 708 for ESVS, £643 802 for NICE, and £266 777 for local protocols, or £1 270, £1 076, £3 003, and £1 244 per patient. Differences in endoleak incidence accounted for a 1.1 to 1.4 fold increase in costs. AKI incidence accounted for a 3.3 to 6.2 fold increase in costs. CONCLUSION: A combined CTA and CDUS EVAR surveillance protocol, with CTA reserved for early seal assessment and confirmatory purposes, provides an economical approach without compromising detection of sac abnormalities. AKI, as opposed to direct imaging costs, accounted for the largest differences in surveillance cost estimates.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Angiografia por Tomografia Computadorizada/economia , Endoleak/diagnóstico por imagem , Vigilância da População/métodos , Ultrassonografia Doppler em Cores/economia , Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/economia , Idoso , Idoso de 80 Anos ou mais , Meios de Contraste/efeitos adversos , Endoleak/economia , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Feminino , Seguimentos , Fidelidade a Diretrizes/economia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Guias de Prática Clínica como Assunto , Reoperação , Estudos Retrospectivos
6.
Eur J Vasc Endovasc Surg ; 62(2): 177-185, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34144884

RESUMO

OBJECTIVE: The Gore Excluder Iliac Branch Endoprosthesis (IBE) was developed to preserve perfusion in the hypogastric artery after endovascular repair of aorto-iliac aneurysms. This study reports the 12 month technical and clinical outcomes of treatment with this device. METHODS: This study was a physician initiated international multicentre, prospective cohort study. The primary endpoint was primary patency of the hypogastric branch at 12 months. Secondary endpoints included technical and clinical outcomes. Patients with an indication for elective treatment with the Gore Excluder IBE were enrolled between March 2015 and August 2018. Baseline and procedural characteristics, imaging data, physical examinations and questionnaire data (Walking Impairment Questionnaire [WIQ], EuroQol-5-Dimensions [EQ5D], International Index of Erectile Function 5 [IIEF-5]) were collected through 12 month follow up. RESULTS: One hundred patients were enrolled of which 97% were male, with a median age of 70.0 years (interquartile range [IQR] 64.5 - 75.5 years). An abdominal aortic aneurysm (AAA) above threshold for treatment was found in 42.7% and in the remaining patients the iliac artery diameter was the indication for treatment. The maximum common iliac artery (CIA) diameter on the Gore Excluder IBE treated side was 35.5 mm (IQR 30.8 - 42.0) mm. Twenty-two patients received a bilateral and seven patients had an isolated IBE. Median procedural time was 151 minutes (IQR 117 - 193 minutes) with a median hospital stay of four days (IQR 3 - 5 days). Primary patency of the IBE at 12 month follow up was 91.3%. Primary patency for patients treated inside and outside the instructions for use were 91.8% and 85.7%, respectively (p = .059). Freedom from secondary interventions was 98% and 97% at 30 days and 12 months, respectively. CIA and AAA diameters decreased significantly through 12 months. IIEF-5 and EQ5D scores remained stable through follow up. Patency of the contralateral internal iliac artery led to better IIEF-5 outcomes. WIQ scores decreased at 30 days and returned to baseline values through 12 months. CONCLUSION: Use of the Gore Excluder IBE for the treatment of aorto-iliac aneurysms shows a satisfactory primary patency through 12 months, with significant decrease of diameters, a low re-intervention rate, and favourable clinical outcomes.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Prótese Vascular , Aneurisma Ilíaco/cirurgia , Grau de Desobstrução Vascular , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Disfunção Erétil/etiologia , Feminino , Humanos , Aneurisma Ilíaco/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Prospectivos , Falha de Prótese/efeitos adversos , Sistema de Registros , Reoperação , Caminhada
7.
Eur J Vasc Endovasc Surg ; 62(1): 26-35, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34090782

RESUMO

OBJECTIVE: Aortic neck dilatation (AND) occurs after endovascular aneurysm repair (EVAR) with self expanding stent grafts (SESs). Whether it continues, ultimately exceeding the endograft diameter leading to abdominal aortic aneurysm (AAA) rupture, remains uncertain. Dynamics, risk factors, and clinical relevance of AND were investigated after EVAR with standard SESs. METHODS: All intact EVAR patients treated from 2000 to 2015 at a tertiary institution were included. Demographic, anatomical, and device related characteristics were investigated as risk factors for AND. Outer to outer diameters were measured at a single standardised aortic level on reconstructed computed tomography (CT) images. RESULTS: A total of 460 patients were included (median follow up 5.2 years, interquartile range [IQR] 3.0, 7.7 years; CT imaging follow up 3.3 years, IQR 1.3, 5.4). Baseline neck diameter was 24 mm (IQR 22, 26) and increased 11.1% (IQR 1.5%, 21.9%) at last CT imaging. Endograft oversizing was 20.0% (IQR 13.6, 28.0). AND was greater during the first year (5.2% [IQR 0, 11.7]) decreasing subsequently (two to four years to 1.4%/year [IQR 0.0, 4.5%], p ≤ .001) and was associated with suprarenal fixation endografts (t value = 7.9, p < .001) and oversizing (t value = 4.4, p < .001). AND exceeding the endograft was 3.5% (95% CI 2.2% - 4.8%) and 14.4% (95% CI 11.0% - 17.8%) at five and eight years, respectively. Excessive AND was associated with baseline neck diameter (OR 1.2/mm, 95% CI 1.05 - 1.41) while the Excluder endograft had a protective effect (OR 0.15, 95% CI 0.04 - 0.58). Excessive AND was associated with type 1A endoleak (HR 3.3, 95% CI 1.1 - 9.7) and endograft migration > 5 mm (HR 3.1, 95% CI 1.4 - 6.9). CONCLUSION: AND after EVAR with SES is associated with endograft oversizing and radial force but decelerates after the first post-operative year. Baseline aortic neck diameter and suprarenal stent bearing endografts were associated with an increased risk of AND beyond nominal stent graft diameter. However, it remains unclear whether patient selection, differences in endograft radial force or the suprarenal stent are accountable for this difference.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Ruptura Aórtica/epidemiologia , Dilatação Patológica/epidemiologia , Endoleak/epidemiologia , Procedimentos Endovasculares/efeitos adversos , Migração de Corpo Estranho/epidemiologia , Idoso , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/complicações , Ruptura Aórtica/etiologia , Aortografia , Angiografia por Tomografia Computadorizada , Dilatação Patológica/diagnóstico , Dilatação Patológica/etiologia , Endoleak/diagnóstico , Endoleak/etiologia , Procedimentos Endovasculares/instrumentação , Feminino , Migração de Corpo Estranho/etiologia , Humanos , Masculino , Pescoço , Estudos Retrospectivos , Fatores de Risco , Stents/efeitos adversos , Resultado do Tratamento
8.
J Vasc Surg ; 74(3): 1024-1032, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33940072

RESUMO

OBJECTIVE: The long-term success of endovascular aneurysm repair (EVAR) is limited by complications, most importantly endoleaks. In case of (persistent) type I endoleak (T1EL), secondary intervention is indicated to prevent secondary aneurysm rupture. Different treatment options are suggested for T1ELs, such as endo anchors, (fenestrated) cuffs, embolization, or open conversion. Currently, the treatment of T1EL with liquid embolic agents is available; however, results are not yet addressed. This review presents the safety and efficacy of embolization with liquid embolic agents for treatment of T1ELs after EVAR. METHODS: A systematic literature search was performed for all studies reporting the use of liquid embolic agents as monotherapy for treatment of T1ELs after EVAR. Patient numbers, technical success (successful delivery of liquid embolics in the T1EL) and clinical success (absence of aneurysm related death, endoleak recurrence or additional interventions during follow-up) were examined. RESULTS: Of 1604 articles, 10 studies met the selection criteria, including 194 patients treated with liquid embolics; 73.2% of the patients were male with a median age of 71 years. The overall technical success was 97.9%. Clinical success was 87.6%. Because the median follow-up was only 13.0 months (range, 1-89 months), data on long-term success are almost absent. Four cases (2.1%) of secondary aneurysm rupture after embolization owing to endoleak recurrence were reported. All ruptures occurred in aneurysms exceeding initial treatment diameter of 70 mm. CONCLUSIONS: Initial technical success after liquid embolization for T1EL is high, although long-term clinical success rates are lacking. Within this review, the risk of secondary rupture is comparable with untreated T1EL at 2% with a median follow-up of 13 months, regardless of the initial success of embolization. In general, no decrease in secondary aneurysm rupture after embolization of T1EL after EVAR is demonstrated, although the results of late embolization are debated.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Embolização Terapêutica , Endoleak/terapia , Procedimentos Endovasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/mortalidade , Dimetil Sulfóxido/administração & dosagem , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/mortalidade , Embucrilato/administração & dosagem , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/mortalidade , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Polivinil/administração & dosagem , Medição de Risco , Fatores de Risco , Trombina/administração & dosagem , Fatores de Tempo , Resultado do Tratamento
9.
Acta Biomed ; 92(2): e2021046, 2021 05 12.
Artigo em Inglês | MEDLINE | ID: mdl-33988179

RESUMO

Objectives Type Ia endoleak (EL) after endovascular abdominal aortic repair (EVAR) may be misdiagnosed at completion angiography. Intraoperative contrast-enhanced ultrasound (CEUS) may play a role in early detection and immediate treatment of type Ia EL. Methods From January 2017 to April 2018, patients treated with EVAR underwent intraoperative CEUS. After endograft deployment and ballooning, digital subtraction angiography (DSA) and intraoperative CEUS were performed in a blinded fashion. All cases of type Ia EL at DSA or CEUS were considered. Results Type Ia EL detected at intraoperative CEUS and undetected at DSA was defined in 2 patients. The former was solved with intraoperative re-ballooning; in the latter case, a Palmaz stent deployment was required. The resolution of type Ia EL was detected at intraoperative CEUS control and post-operative computed tomography angiography (CTA). In another patient, the DSA detected a type Ia EL, but intraoperative CEUS reveal a type II EL from lumbar arteries. Post-operative CTA confirm the type II EL. Conclusions The reported cases prove the clinical utility of the intraoperative CEUS, permitting the early identification of 2 type Ia EL. In addition, the intraoperative CEUS is useful in case of dubious type Ia EL at DSA, avoiding unnecessary intraoperative adjunctive procedure or post-operative CTA.


Assuntos
Aneurisma da Aorta Abdominal , Procedimentos Endovasculares , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Meios de Contraste , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Humanos , Resultado do Tratamento
10.
Eur J Vasc Endovasc Surg ; 62(2): 204-213, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33994306

RESUMO

OBJECTIVE: The aim was to describe initial outcomes of physician modified stent grafts using antegrade laser fenestrations and image fusion guidance (LEVAR) and company manufactured custom made (CM) stent grafts for the treatment of complex abdominal aortic aneurysms (CAAAs), thoraco-abdominal aortic aneurysms (TAAAs) and type I endoleaks (T1ELs). METHODS: This was a retrospective single centre study. All LEVAR and Zenith (Cook) CM stent graft procedures between 1 January 2012 and 31 December 2018 were reviewed. Endpoints included intra-operative adverse events (IOAEs), in hospital mortality, re-interventions, target vessel patency, and 12 month outcomes (overall survival, freedom from re-intervention, target vessel patency). Outcomes at 12 months were estimated using the Kaplan-Meier method. RESULTS: A hundred patients were identified and included in the study. All patients were deemed unfit for open repair. The cohort included 22 LEVAR and 78 CM stent grafts. LEVAR cases included painful aneurysms (n = 5), > 65 mm aneurysms (n = 10), anatomical constrains and/or presence of previous renal stents (n = 7) or cases declined by the manufacturer planning centre (n = 2). IOAEs were recorded in 41% of cases (n = 9) in the LEVAR group vs. 10% (n = 8, p = .002) in the CM group. The in hospital mortality rate in the LEVAR group was 9% (n = 2) vs. 4% (n = 3, p = .30) in the CM group. The median follow up duration was 22 months (7 - 38) in the LEVAR group and 28 months (11 - 78) in the CM group. The estimate of overall survival at one year was 91% in both groups. The freedom from re-intervention rate at one year was 58% in the LEVAR group vs. 87% in the CM group. The target vessel patency rates at one year were 95% in both groups. CONCLUSION: In high risk patients deemed unfit for open repair, LEVAR may provide satisfactory 12 month overall survival and target vessel patency rates, though reported IOAE, mortality, and re-interventions rates were high thus requiring close and extensive follow up.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Endoleak/cirurgia , Procedimentos Endovasculares/instrumentação , Idoso , Idoso de 80 Anos ou mais , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Tomografia Computadorizada de Feixe Cônico , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Feminino , Fluoroscopia , Mortalidade Hospitalar , Humanos , Complicações Intraoperatórias/etiologia , Terapia a Laser , Masculino , Pessoa de Meia-Idade , Imagem Multimodal , Complicações Pós-Operatórias/etiologia , Reoperação , Estudos Retrospectivos , Stents/efeitos adversos , Cirurgia Assistida por Computador , Taxa de Sobrevida , Grau de Desobstrução Vascular
11.
Medicine (Baltimore) ; 100(18): e25732, 2021 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-33950956

RESUMO

INTRODUCTION: Although the clinical significance of type II endoleaks remain controversial, management strategies continue to expand. The laparoscopic approach is a minimally invasive method for persistent type II endoleak repair after endovascular aneurysm repair. PATIENT CONCERNS: A 70 - year - old male patient with a history of endovascular aneurysm repair with left internal iliac artery embolization presented with persistent type II endoleak from the lumbar arteries 2 years ago. The aneurysm sac size had increased more than 10 mm during follow up period. DIAGNOSIS: Persistent type II endoleak after endovascular aneurysm repair. INTERVENTIONS: Transarterial embolization was attempted and failed. A minimally invasive laparoscopic lumbar artery ligation was then utilized. OUTCOMES: The patient was discharged without any complications after surgery. Follow-up computed tomography angiography has shown the complete disappearance of the type II endoleaks. CONCLUSIONS: Laparoscopic lumbar artery ligation may be a safe and effective alternative treatment for type II endoleaks, especially in high resource settings.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Laparoscopia , Idoso , Angiografia por Tomografia Computadorizada , Endoleak/diagnóstico , Endoleak/etiologia , Humanos , Ligadura/métodos , Masculino , Resultado do Tratamento
12.
PLoS One ; 16(4): e0249549, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33852618

RESUMO

PURPOSE: The use of the pressure gradient measurements to assess the renal artery flow hemodynamics after chimney endovascular aortic repair (chEVAR). METHODS: The study was a prospective analysis of 37 chEVAR procedures performend in 24 patients with perirenal aortic aneurysm. In all patients the measurement of: distal renal artery pressure (Pd), aortic pressure (Pa), Pd/Pa ratio (Pd/Pa) and mean gradient (MG) between the aorta and the distal renal artery were performed. Measurements were taken with 0.014 inch pressure wire catheter before and after the chEVAR procedure. MG greater than 9 mmHg and Pd/Pa ratio below 0.90 were considered as the measures of a significant decrease in distal pressure that limited flow in renal arteries. The 6 month follow-up computed tomographic angiography (CTA) was performed in all patients to diagnose potential endoleak presence and to verify the patency of the chimney stent-grafts. RESULTS: All procedures were successful, and no periprocedural complications were observed in any of the patients. The mean gradient values before and after the chimney implantation did not change significantly (6,2±2,0 mmHg and 6,8±2,2 mmHg, respectively). Similarly, no significant change in Pd/Pa values was noted with the value of 0.9 observed both before and after the procedure. All chimney stents were patent on the control CTA. Type Ia endoleak was found in 4 (10.8%) patients. CONCLUSIONS: The application of the described technique seems to be a safe method which allows a direct measurement of renal artery flow hemodynamics before and after chimney implantation during the chEVAR technique. The use of covered balloon expandable stents, ensures the proper blood flow in the renal arteries during the chEVAR technique.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Endoleak/diagnóstico por imagem , Artéria Renal/diagnóstico por imagem , Idoso , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Endoleak/etiologia , Feminino , Humanos , Masculino , Estudos Prospectivos , Resultado do Tratamento
13.
J Vasc Surg ; 74(2): 639-645, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33813025

RESUMO

As the use of endovascular approaches to treat aneurysm repair continues to increase, more and more patients have been identified with endoleaks. Five types of endoleaks have been defined. Endotension, or type V endoleak, remains controversial owing to its variable definition across studies and the range of proposed treatments. Thus, we performed a review of the reported studies to summarize the diagnosis and treatment of this rare complication after endovascular aneurysm repair to determine what we do and do not know about this rare form of endoleak. The presence of an endoleak places patients at an increased risk of aneurysm sac enlargement and potential rupture. Although additional research is essential and yet difficult to perform, we sought to provide a guide for the management of this perplexing endoleak known as endotension.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/efeitos adversos , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Endoleak/diagnóstico por imagem , Endoleak/fisiopatologia , Endoleak/terapia , Humanos , Medição de Risco , Fatores de Risco , Resultado do Tratamento
14.
Eur J Vasc Endovasc Surg ; 61(5): 788-797, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33846073

RESUMO

OBJECTIVE: This study aimed to determine the effect of intervention timing, from symptom onset to thoracic endovascular aortic repair (TEVAR), on early and late outcomes in high risk patients with uncomplicated type B aortic dissection (uTBAD). METHODS: The study retrospectively evaluated 267 uTBAD patients with high risk radiographic features who underwent pre-emptive TEVAR during the acute and subacute periods. Demographics, comorbidities, pre-operative imaging features, peri-procedural details, and follow up outcomes were analysed. RESULTS: Among the 267 pre-emptive TEVARs for high risk uTBAD, 130 were performed in the acute phase (1-14 days); and 137 in the subacute phase (15-90 days), from initial presentation. The mean age was 55.9 ± 11.0 years and 222 (83.1%) were men. The 30 day mortality rate in the acute group was five times higher than that in the subacute group (3.8% vs. 0.7%), although without statistically significant difference (p = .11). No statistically significant difference in 30 day outcomes (aortic rupture, retrograde type A dissection [RTAD], immediate type Ia endoleak, stroke, spinal cord ischaemia, and re-intervention) was noted (p > .05 for each). Of note, aortic rupture, RTAD, and disabling stroke were observed only in the acute group. Multivariable logistic analyses showed that intervention timing was not associated with 30 day outcomes. The median clinical follow up was 48.2 ± 25.9 months (range 1 - 106 months). There were no significant differences in all cause mortality, dissection related death, late intervention, or aortic related late events among timing cohorts (p > .05 for each). Furthermore, aortic remodelling, by analysing the flow status of the false lumen and evaluation of aortic diameters, either at the thoracic aorta level or the abdominal aorta level, was similar between the two groups. Multivariable Cox analyses showed that intervention timing was not associated with late outcomes. CONCLUSION: The present study indicates that TEVAR for high risk uTBAD in the acute phase was associated with a trend toward higher rates of early complications, while the long term outcomes were comparable with those of the subacute phase.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Endoleak/epidemiologia , Procedimentos Endovasculares/efeitos adversos , Isquemia do Cordão Espinal/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Aneurisma Dissecante/diagnóstico , Aneurisma Dissecante/mortalidade , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/mortalidade , Endoleak/etiologia , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Isquemia do Cordão Espinal/etiologia , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento , Remodelação Vascular
15.
Vasc Endovascular Surg ; 55(6): 645-650, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33813979

RESUMO

INTRODUCTION: A retrograde approach of the celiac trunk (CT) and superior mesenteric artery (SMA) to catheterize the visceral vessels during a fenestrated endovascular aortic reparation (FEVAR) is a feasible option when standard access techniques have failed. REPORT: In this report we describe a patient with a previous endoluminal repair of an infrarenal aortic aneurysm, complicated by a persistent type 1a endoleak despite treatment with endoanchor fixation. A decision was made to proceed with a proximal 4 vessel FEVAR to treat the type 1a endoleak. Due to angulation of the mesenteric vessels, and a rotation of the fenestrated stent graft during deployment, the CT and SMA were unable to be catheterized. A decision was made to perform a median laparotomy for retrograde access of the aforementioned vessels, allowing successful catheterization and stenting. The patient was discharged 30 days following the procedure, without any major post-operative complications. Follow up at 6 weeks with a contrasted enhanced computerized tomography scan showed a stable repair with no residual type 1a endoleak. DISCUSSION: Catheterization of the target vessels during a FEVAR can be difficult, especially in patients with challenging anatomy. Prolonged surgical time in an attempt to catheterize the vessels can result in increased morbidity for the patient, and ultimately may result in the procedure being abandoned or conversion to an open repair of the aneurysm. Retrograde access of the target vessels as a bailout measure during fenestrated stent graft repair due to failure of an antegrade approach has rarely been reported in the literature. Only a few cases are described in the available literature, however, none of them describe retrograde approach of both the CT and SMA as described in this case. A median laparotomy for retrograde access is a feasible alternative in these situations, and should be considered if the patient is suitable.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Cateterismo Periférico , Endoleak/cirurgia , Procedimentos Endovasculares , Artéria Mesentérica Superior , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Artéria Mesentérica Superior/diagnóstico por imagem , Punções , Reoperação , Resultado do Tratamento
16.
J Endovasc Ther ; 28(4): 519-523, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33899573

RESUMO

PURPOSE: Open surgical repair of type Ia endoleak after endovascular aortic aneurysm repair/sealing (EVAR/EVAS) is associated with significant perioperative mortality and morbidity. Current endovascular redo techniques face limitations, especially when the infrarenal landing zone is inadequate and the previous endograft is rigid and features a short or no main body. We present a novel concept for the treatment of type Ia endoleak using a custom-made branched device. TECHNIQUE: The 5-branch-device (Cook Medical, Bloomington, IN, USA) consists of a nitinol skeleton with branches, covered with a low-profile polyester fabric loaded in an 18F sheath. The device features a minimum of 2 proximal sealing stents and includes branches for renovisceral vessels as well as an additional 8 mm branch for the contralateral iliac limb. Implantation and sealing in the renovisceral vessels is carried out in standard fashion, using transfemoral and transaxillary access. Distal sealing is achieved by tapering the branched component into the ipsilateral iliac limb and using a bridging balloon-expandable or self-expandable stent-graft through the additional branch to the preexisting contralateral iliac limb. CONCLUSION: Treatment of type Ia endoleak with a new custom-made device enables sufficient proximal seal while minimizing suprarenal aortic coverage and facilitates adequate component overlap. The low profile branched design accommodates implantation through the preexisting endograft and catheterization of target vessels.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aortografia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Humanos , Desenho de Prótese , Stents , Resultado do Tratamento
18.
J Vasc Surg ; 74(1): 309-315.e2, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33722632

RESUMO

OBJECTIVE: The aim of this study was to perform a meta-analysis of relevant published literature to investigate the impact of wide proximal aortic neck diameter on outcomes of endovascular aneurysm repair (EVAR) for the repair of abdominal aortic aneurysm (AAA). METHODS: A systematic literature review was performed to examine the rate of clinical safety and effectiveness end points associated with wide proximal aortic neck diameter after EVAR for the treatment of AAA. A literature search was performed on August 9, 2019, using PubMed as the primary database and Cochrane as the secondary database. In all, there were 11 full articles included in the quantitative and qualitative analyses. RESULTS: There was a total of 7448 patients who were treated for AAA with EVAR. Of these, 26.9% of patients were defined as having wide necks by the individual publications. The definition of wide neck varied in the literature and ranged from 25 mm or greater to 30 mm or greater. The percentage of male patients was 89.1% in the included articles. The mean or median age range was 72.7 to 76.5 years, which was similar for the wide and normal neck groups. Follow-up ranged from 2 to 5 years. Type I and Ia endoleaks occurred at a higher rate in the wide neck group compared with the normal neck group (11.3% vs 3.1%; P < .001). There was no difference in the rate of type Ib endoleaks between the wide and normal neck groups. The weighted averages of composite major adverse events and aneurysm-related mortality were all greater in the wide neck group (33.5% and 15.3%, respectively) compared with the normal neck group (21.2% and 3.9%, respectively) (P = .004). CONCLUSIONS: The rates of type Ia endoleaks, reinterventions, and migrations were all significantly higher in the wide neck patient group compared with patients with normal aortic neck size through follow-up. The results of this literature review showed that, although EVAR for the treatment of AAA in patients with a wide aortic neck is feasible, there is a higher risk for complications, interventions, and mortality. In particular, type Ia endoleak is a risk, which could be mitigated by using proximal seal strategies.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Abdominal/fisiopatologia , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Feminino , Oclusão de Enxerto Vascular/etiologia , Humanos , Masculino , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
19.
J Vasc Surg ; 73(4): 1148-1155.e2, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33766243

RESUMO

BACKGROUND: Fenestrated/branched endovascular aneurysm repair (F/BEVAR) volume has increased rapidly, with favorable outcomes at centers of excellence. We evaluated changes over time in F/BEVAR complexity and associated outcomes at a single-center complex aortic disease program. METHODS: Prospectively collected data of all F/BEVAR (definition: requiring ≥1 fenestration/branch), procedures performed in an institutional review board-approved registry and/or physician-sponsored investigational device exemption trial (IDE# G130210), were reviewed (11/2010-2/2019). Patients were stratified by surgery date into thirds: early experience, mid experience, and recent experience. Patient and operative characteristics, aneurysm morphology, device types, perioperative and midterm outcomes (survival, freedom from type I or III endoleak, target artery patency, freedom from reintervention), were compared across groups. RESULTS: For 252 consecutive F/BEVARs (early experience, n = 84, mid experience, n = 84, recent experience, n = 84), 194 (77%) company-manufactured custom-made devices, 11 (4.4%) company-manufactured off-the-shelf devices, and 47 (19%) physician-modified devices, were used to treat 5 (2.0%) common iliac, 97 (39%) juxtarenal, 31 (12%) pararenal, 116 (46%) thoracoabdominal, and 2 (0.8%) arch aneurysms. All patients had follow-up for 30-day events. The mean follow-up time for the entire cohort was 589 days (interquartile range, 149-813 days). On 1-year Kaplan-Meier analysis, survival was 88%, freedom from type I or III endoleak was 91%, and target vessel patency was 92%. When stratified by time period, significant differences included aneurysm extent (thoracoabdominal, 33% early experience, 40% mid experience, and 64% recent experience; P < .001) and target vessels per case (four-vessel case, 31% early experience, 39% mid experience, and 67% recent experience; P < .0001). There was no difference, but a trend toward improvement, in composite 30-day events (early experience, 39%; mid experience, 23%; recent experience, 27%; P = .05). On Kaplan-Meier analysis, there was no difference in survival (P = .19) or target artery patency (P = .6). There were differences in freedom from reintervention (P < .01) and from type I or III endoleak (P = .02), with more reinterventions in the early experience, and more endoleaks in the recent period. CONCLUSIONS: Despite increasing repair complexity, there has been no significant change in perioperative complications, overall survival, or target artery patency, with favorable outcomes overall. Type I or III endoleaks remain a significant limitation, with increased incidence as the number of branch arteries incorporated into the repairs has increased.


Assuntos
Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Endovasculares/métodos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Endoleak/etiologia , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Artéria Ilíaca/cirurgia , Complicações Intraoperatórias , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Prospectivos , Sistema de Registros , Artéria Renal/cirurgia , Taxa de Sobrevida , Resultado do Tratamento , Grau de Desobstrução Vascular
20.
J Vasc Interv Radiol ; 32(6): 807-812, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33771713

RESUMO

A type-2 endoleak after an endovascular aneurysm repair is the most prevalent type of endoleak, but as the clinical consequence of its diagnosis is uncertain, at present, management decisions are solely based on aneurysm sac growth. The aim of this study was to investigate the potential of various computed tomography perfusion parameters for their ability to distinguish high-risk type-2 endoleaks from low-risk type-2 endoleaks after an endovascular aneurysm repair.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aortografia , Implante de Prótese Vascular/efeitos adversos , Angiografia por Tomografia Computadorizada , Endoleak/diagnóstico por imagem , Procedimentos Endovasculares/efeitos adversos , Imagem de Perfusão , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/fisiopatologia , Endoleak/etiologia , Endoleak/fisiopatologia , Estudos de Viabilidade , Hemodinâmica , Humanos , Masculino , Valor Preditivo dos Testes , Fluxo Sanguíneo Regional , Resultado do Tratamento
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