Current practices and challenges in ruptured abdominal aortic aneurysm repair

A ruptured abdominal aortic aneurysm is one of the most fatal medical conditions. Although the introduction of endovascular aneurysm repair has improved outcomes in non-ruptured abdominal aortic aneurysm, the merits appear less distinct in emergency repair. Results of randomized controlled trials and cohort studies are conflicting. An increasing number of patients are being treated through endovascular repair. Centers that adopted an EVAR-first approach show improved results. The use of endovascular technology brings new challenges that need to be addressed. Besides endovascular treatment, there is a need for refining preoperative care, patient selection and postoperative management to improve overall survival.</p

Comparison of midterm results for the Talent and Endurant stent graft

Objective Stent graft evolution is often addressed as a cause for improved outcomes of endovascular aneurysm repair for patients with an abdominal aortic aneurysm. In this study, we directly compared the midterm result of Endurant stent graft with its predecessor, the Talent stent graft (both Medtronic, Santa Rosa, Calif). Methods Patient treated from January 2005 to December 2010 in a single tertiary center in The Netherlands with a Talent or Endurant stent graft were eligible for inclusion. Ruptured abdominal aortic aneurysms or patients with previous aortic surgery were excluded. The primary end point was the Kaplan-Meier estimated freedom from secondary interventions. Secondary end points were perioperative outcomes and indications for secondary interventions. Results In total, 221 patients were included (131 Endurant and 90 Talent). At baseline, the median aortic bifurcation was narrower for the Endurant (30 mm vs 39 mm; P <.001). Median follow-up was 64.1 ± 37.9 months and 59.2 ± 25.3 months for Talent and Endurant, respectively. The estimated freedom from secondary interventions at 30 days, 1 year, 5 years, and 7 years was 94.3%, 89.4%, 72.2%, and 64.1% for Talent and 96.8%, 89.3%, 75.2%, and 69.2% for Endurant (P =.528). The indication for secondary interventions does differ; more patients required an intervention for a proximal neck-related complication (type Ia endoleak or migration) in the Talent group (18.2% vs 4.8%; P =.001), whereas more interventions for iliac limb stenosis were seen in the Endurant group (0.0% vs 4.8%; P =.044). In a binomial regression analysis, suprarenal angulation, infrarenal neck length, and type of stent graft were independent predictors of neck-related complications. Conclusions Evolution from the Talent stent graft into the Endurant has resulted in significant reduction of infrarenal neck-related complications; on the other hand, iliac interventions increased. The overall midterm secondary intervention rate was comparable

Editor's Choice - Endurant Stent Graft in Patients with Challenging Neck Anatomy "One Step Outside Instructions for Use": Early and Mid-term Results from the EAGLE Registry

OBJECTIVE: The aim of the Endurant for Challenging Anatomy: Global Experience (EAGLE) registry is to prospectively evaluate the technical and clinical success rate of a stent graft used in patients with challenging neck anatomy outside IFU, but within objective anatomical limits. DESIGN: Prospective, international, multicentre, observational study. METHODS: From 1 February 2012 to 1 September 2017, patients with an abdominal aortic aneurysm with a challenging infrarenal neck that were deemed suitable for EVAR were prospectively included at 23 European centres. Patients were distributed by anatomy into three groups: short neck (SN): infrarenal neck 5-10 mm in combination with suprarenal angulation (α) ≤45° and infrarenal angulation (β) ≤60°; Medium neck (MN): infrarenal neck 10-15 mm with α ≤60° and β 60°-75° or α 45°-60° and β ≤75°; and long angulated neck (LN): infrarenal neck ≥15 mm with α ≤75° and β 75°-90° or α 60°-75° and β ≤90°. All computed tomography scans were reviewed by an independent core laboratory. Primary outcomes were technical and clinical success. Secondary endpoints were perioperative major adverse events, all-cause mortality, aneurysm-related mortality, endoleaks, migration, and secondary intervention. RESULTS: One-hundred-and-fifty patients, 81.3% male, were included, SN=55, MN=16, and LN=79. Median follow-up was 36 ±12.6 months. In the overall cohort, technical success was 93.3%. Estimated freedom from aneurysm-related mortality was 97.3% at 3-years. Freedom from secondary interventions was 84.7% at 3-years. Estimated clinical success was 96.0%, 90.8%, and 83.2% at 30-days, 1-year, and 3-years, respectively. Estimated freedom from all-cause mortality, late type IA endoleak, and migration at 3-years was 75.1%, 93.7%, and 99.3%, respectively. CONCLUSION: The early and mid-term results of the EAGLE registry show that endovascular repair with the Endurant stent graft in selected patients with challenging infrarenal neck anatomy, yields results in line with large 'real-world' registries. Long-term results should be awaited for more definitive conclusions