Are Endoleaks Type Ia Predictable?

Objectives Aortic proximal (type Ia) endoleak (EL) is one of the possible complications of endovascular aneurysm repair (EVAR) and usually needs a further reintervention. The aim of our study was to assess any preoperative factor which could predict the development of EL Ia and whether it is treatable through an endovascular approach. Methods Data of patients consecutively treated between January 2012 and December 2015 with EVAR for nonruptured abdominal aortic aneurysm (AAA) were retrospectively collected. For each patient, demographic and anatomical factors (sex, age, proximal aortic neck diameter, angulation and length, AAA diameter) and structural characteristics of different endograft (presence of barbs, free flow, and radial force) were analyzed and related to the development of EL Ia using JMP 5.1.2 software. Results We analyzed 190 patients (32 females [16.8%]; mean age, 75.7 years). The mean follow-up time was 19 months. Patients\u2019 mean AAA diameter was 55.9 mm (range, 30-130 mm). A late EL Ia developed in 13 patients (7%), with a mean time of development of 30%, radial force, and the presence of suprarenal free flow and barbs were not significantly associated to the development of EL Ia. Female sex, age >77 years and a neck length <21 mm were statistically significant (P = .01, P = .02, and P = .02, respectively). Conclusions Among factors analyzed, female sex, age >77 years, and a proximal neck <21 mm were significantly associated with the occurrence of late EL Ia

Second asymptomatic carotid surgery trial (ACST-2) : a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86-1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91-1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable