Type II endoleak after endovascular aneurysm repair

Background The aim was to assess the risk of rupture, and determine the benefits of intervention for the treatment of type II endoleak after endovascular abdominal aortic aneurysm repair (EVAR). Methods This systematic review was done according to PRISMA guidelines. Outcome data included incidence, spontaneous resolution, sac expansion, interventions, clinical success, and complications including conversion to open repair, and rupture. Results Thirty-two non-randomized retrospective studies were included, totalling 21 744 patients who underwent EVAR. There were 1515 type II endoleaks and 393 interventions. Type II endoleak was seen in 10·2 per cent of patients after EVAR; 35·4 per cent resolved spontaneously. Fourteen patients (0·9 per cent) with isolated type II endoleak had ruptured abdominal aortic aneurysm; six of these did not have known aneurysm sac expansion. Of 393 interventions for type II endoleak, 28·5 per cent were unsuccessful. Translumbar embolization had a higher clinical success rate than transarterial embolization (81 versus 62·5 per cent respectively; P = 0·024) and fewer recurrent endoleaks were reported (19 versus 35·8 per cent; P = 0·036). Transarterial embolization also had a higher rate of complications (9·2 per cent versus none; P = 0·043). Conclusion Aortic aneurysm rupture after EVAR secondary to an isolated type II endoleak is rare (less than 1 per cent), but over a third occur in the absence of sac expansion. Translumbar embolization had a higher success rate with a lower risk of complications

Endoleak after endovascular aneurysm repair: Current status

Since the introduction in 1991 of endovascular aortic aneurysm repair (EVAR), through its evolution from a straight graft system to modular component systems with supported prostheses, endoleak has been its Achilles heel. Defined as continued perfusion of the aneurysm sac in spite of endograft deployment and associated with sac expansion, re-intervention and the risk of rupture, here in this review we discuss the different types of endoleak and current evidence regarding its management

National vascular registry report on surgical outcomes and implications for vascular centres

Background The National Vascular Registry Report on Surgical Outcomes (NVSRO) coincided with the update of the National Health Service Standard Contract for Specialized Vascular Services in Adults (NHSSCSVS). The latter promises patients minimum standards for vascular centres. The present study aimed to determine whether current data support the standards proposed in the NHSSCSVS. Methods Numbers of abdominal aortic aneurysm (AAA) repairs and carotid endarterectomies (CEAs) performed by hospital Trust and surgeon, and their outcomes were obtained from the NVRSO. These were assessed against NHSSCSVS recommendations that included: more than 60 AAA repairs per year per Trust, over 50 CEAs per year per Trust and at least six vascular surgeons per Trust. Results Based on NVRSO data, 107 hospital Trusts (92·2 per cent) would fail to meet the minimum standards required to achieve vascular centre status. Outcomes were poorer in these hospitals (overall mortality rate after AAA: 2·7 versus 1·3 per cent; P = 0·007). There were strong associations between number of AAA repairs or CEAs per Trust and better outcomes (AAA repair, P < 0·001; CEA, P = 0·004). These remained significant when analysed by individual surgeon (AAA repair, P < 0·001; CEA, P < 0·001). Trusts undertaking 60 or fewer elective AAA repairs per year had significantly higher elective AAA mortality rates (2·7 versus 1·7 per cent; P = 0·010). Trusts performing a minimum of 50 CEAs per year had significantly lower perioperative mortality/morbidity rates (1·9 versus 3·0 per cent; P = 0·032). Trusts with seven or more surgeons demonstrated lower AAA-related mortality rates (1·7 versus 2·7 per cent; P = 0·018). Conclusion Data from the NVRSO suggest that the majority of hospital Trusts presently fail to meet the standards for vascular centre status. NVRSO data support a standard of more than 60 elective AAA repairs and 50 CEAs per Trust per year. A minimum of seven vascular surgeons per unit was associated with better outcomes. These data support the ongoing remodelling of vascular services in the UK

A review of current reporting of abdominal aortic aneurysm mortality and prevalence in the literature

Background It is common for authors to introduce a paper by demonstrating the importance of the clinical condition being addressed, usually by quoting data such as mortality and prevalence rates. Abdominal aortic aneurysm (AAA) epidemiology is changing, and therefore such figures for AAA are subject to error. The aim of this study was to analyse the accuracy of AAA prevalence and mortality citations in the contemporaneous literature. Methods Two separate literature searches were performed using PubMed to identify studies reporting either aneurysm prevalence or mortality. The first 40 articles or those published over the last 2 years were included in each search to provide a snapshot of current trends. For a prevalence citation to be appropriate, a paper had to cite an original article publishing its own prevalence of AAA or a national report. In addition, the cited prevalence should match that published within the referenced article. These reported statistics were compared with the most recent data on aneurysm-related mortality. Results The prevalence of AAA was reported to be as low as 1% and as high as 12.7% (mean 5.7%, median 5%). Only 47.5% of studies had referenced original articles, national reports or NICE, and only 32.4% of cited prevalences matched those from the referenced article. In total 5/40 studies were completely accurate. 80% of studies cited aneurysm mortality in the USA, with the majority stating 15,000 deaths per year (range 9,000 to 30,000). Current USA crude AAA mortality is 6,289 (2010). Conclusion References for AAA mortality and prevalence reported in the current literature are often inaccurate. This study highlights the importance of accurately reporting mortality and prevalence data and using up-to-date citations

Editor's choice - Type II endoleak: Conservative management is a safe strategy

Objective Type II endoleak is the most common complication after endovascular abdominal aortic aneurysm repair (EVAR); however, its natural history is unclear. The aim of this study was to examine the incidence and outcomes of type II endoleak, at a single institution after EVAR. Methods A total of 904 consecutive patients who underwent EVAR between September 1995 and July 2013 at a single centre were entered onto a prospective database. All patients were followed up by duplex ultrasound (DUSS). Patients who developed type II endoleak were compared for preoperative demographics, mortality, and sac expansion. Results A total of 175(19%) patients developed type II endoleak over a median follow-up of 3.6 years (1.5–5.9 years); 54% of type II endoleaks spontaneously resolved within 6 months (0.25–1.2 years). No difference was found in preoperative demographics or choice of endograft between the two groups. Survival was significantly higher in the group with type II endoleak (94.1% vs. 85.6%; p = .01) and this effect was most pronounced in those with late type II endoleaks (97.7% vs. 85.6% p = .004). No difference was seen in aneurysm-related mortality or rate of type I endoleak between the two groups. Freedom from sac expansion (>5 mm from preoperative diameter) was significantly lower in the group of patients with type II endoleak (82.5% vs. 93.2%, p = .0001); however, at a threshold of >10 mm from preoperative diameter no difference was seen. Conclusions Patients with isolated type II endoleak demonstrate equivalent aneurysm-related mortality and an improved survival

Short-Term Outcomes of Management of Endovascular Aneurysm Repair in Patients with Dilated Iliacs

Objectives: This study aims to evaluate outcomes following endovascular aneurysm repair (EVAR) in patients with dilated but not aneurysmal common iliac arteries. Methods: Data prospectively collected from 342 elective EVARs were analyzed retrospectively. Dilated common iliac anatomy was defined as 21 to 24 mm. Patients with iliac aneurysms or external iliac artery (EIA) extension were excluded. Patients were followed up using clinical review, plain radiographs, duplex imaging, and selective computed tomography scanning. Results: Median age was 75 years with a mean follow-up of 3.6 years. In all, 33 patients had dilated common iliac arteries (DCIAs) and 309 had non-dilated common iliac arteries (NDCIA). There was no difference in aneurysm diameter or neck characteristics (length, diameter, angulation, thrombus, and flare) between the subgroups. There was no significant difference in technical success, 30-day mortality, late mortality, aneurysm-related mortality, 30-day reinterventions, stent graft migration, limb occlusion, sac expansion, graft rupture, type 1 endoleaks, type 3 endoleaks, and total reinterventions (all Ps > .05). There was a significant decrease in type II endoleaks in patients with DCIA compared to NDCIA (NDCIA 12.9% and DCIA 0.0%; P = .02). Conclusion: Patients presenting with abdominal aortic aneurysms with DCIA can be successfully treated with EVAR with no increase in complications without extension into the EIA