Exploring the boundaries of endovascular aneurysm repair:studying an all-comers population

An abdominal aortic aneurysm can be treated endovascularly since the early 1990s. In the endovascular technique, a stent is placed through the groin, which is less invasive than the open technique. An important limitation is that ruptured and complex aneurysms are less suitable and more long-term complications are seen. With the help of registration studies, this thesis investigated how stents function at the extremes of the manufacturers' instructions for use. The thesis shows that in the case of ruptured aneurysms, the technical results are good. Additionally, it is shown that in complex aneurysms the short-term number of complications is not unacceptable, despite the challenging anatomy. The long-term results will have to be determined in the future. The above results can contribute to determining the optimal treatment strategy of ruptured and complex aneurysms

Upside-Down Gore Excluder as an Endoprosthesis for Aortoiliac Aneurysm Exclusion:A Retrospective Multicenter Study

Objective: The upside-down configuration of a Gore Excluder contralateral leg endoprosthesis has been used to overcome diameter differences in the endovascular treatment of aortoiliac aneurysms. Our goal was not to describe the technique but to study the applicability and safety. Material and methods: Patients were retrospectively enrolled. The indication and details of the procedure were at the discretion of the treating physicians. A case report form was completed including baseline characteristics, indication for treatment, procedural data, and outcomes during follow-up. Results: A total of 31 subjects were enrolled with a range of indications, including 3 patients treated in the emergency setting (9.7%). In 64.5% (n=20), it was a primary intervention for a common iliac aneurysm (n=10), internal iliac aneurysm (n=4), or abdominal aortic aneurysm (n=6). In 11 subjects (35.5%), treatment was performed after previous aortoiliac interventions, including anastomotic iliac artery aneurysm (n=5), type III endoleak (n=3), and endograft thrombus (n=3). Median follow-up was 13 months (range=1-142 months). During follow-up, 2 patients required an upside-down contralateral leg–related secondary intervention, one for an occlusion and another for a type Ia endoleak. There was no type Ib or III endoleak, and no migration, kinking/stenosis, or conversion to open repair was observed. The aneurysm-related mortality was 3.3% (n=1). Conclusion: An upside-down contralateral leg is a valuable technique that can be used to achieve adequate aneurysm exclusion or resolve complications. It is associated with a limited number of complications. Clinical impact: This article studies the use of an upside-down iliac endograft. We describe a wide range of indications in which this previously published technique has been applied. In elective and acute settings and as primary and revision intervention an upside-down iliac endograft was performed successfully. Furthermore, follow-up data is presented showing the effectiveness of the technique. Knowledge of this procedure is a valuable addition to the skillset of every interventionalist.</p

Endovascular treatment of ruptured abdominal aortic aneurysms with hostile aortic neck anatomy

\u3cp\u3eObjective: To compare the mid-term results of endovascular aortic aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (RAAAs) in patients with favourable aortic neck anatomy (FNA) and hostile aortic neck anatomy (HNA). Methods: Patients treated for a RAAA in a high volume endovascular centre in the Netherlands between February 2009 and January 2014 were identified retrospectively and divided into two groups based on aortic neck anatomy, FNA and HNA. HNA was defined as RAAA with a proximal neck of &lt;10 mm, or a proximal neck of 10-15 mm with a suprarenal angulation (α) &gt;45° and/or an infrarenal angulation (β) &gt;60°, or a proximal neck of &gt;15 mm combined with α &gt;60° and/or β &gt;75°. Patient demographics, procedure details, 30 day and 1 year outcomes were recorded. Results: Of 39 included patients, 17 (44%) had HNA. Technical success was 100% for FNA and 88% for HNA (p =.184). There were no type IA endoleaks on completion angiography in either group; however, more adjunctive procedures were necessary for intra-operative type IA endoleaks in the HNA group (24% vs. 0%, p =.029). Thirty day mortality rates were comparable, FNA 14% vs. HNA 12% (p = 1.000). There were no statistically significant differences at 1 year follow up in type I endoleaks, secondary endovascular procedures, or all cause mortality. Conclusion: Emergency EVAR provides excellent results for treatment of RAAA patients with both FNA and HNA. EVAR in RAAAs with HNA is technically feasible and safe in experienced endovascular centres. Article history:\u3c/p\u3

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

\u3cp\u3eObjective 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 &lt;.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.\u3c/p\u3

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

Midterm results after abandoning routine preemptive coil embolization of the internal iliac artery during endovascular aneurysm repair

\u3cp\u3ePurpose: To analyze the results of endovascular repair of common iliac artery (CIA) aneurysms without preemptive coil embolization of the internal iliac artery (IIA). Materials and Methods: Between January 2010 and July 2016, 79 patients (mean age 74.3±8.4 years; 76 men) underwent endovascular repair extending into the external iliac artery owing to a CIA aneurysm. The procedure was performed for a ruptured aneurysm in 22 (28%) patients. Eighty-one IIAs were intentionally covered. The median CIA diameter was 37 mm (range 20–90). The primary outcomes were the occurrence of type II endoleaks and the incidence of buttock claudication. Results: Five (6%) patients died within 30 days (4 with ruptured aneurysms and 1 elective case). Two type II endoleaks originating from a covered IIA were recorded; one required an endovascular intervention because of aneurysm growth. The other patient died of a rupture based on an additional type III endoleak. Mean follow-up was 37.6±26.3 months. Nineteen (26%) patients required a secondary intervention. Buttock claudication was reported in 21 (28%) of 74 patients and persisted after 1 year in 7. No severe ischemic complications as a result of IIA coverage were recorded, and no revascularization was required during follow-up. Conclusion: Treatment of CIA aneurysms by overstenting the IIA without preemptive coil embolization is safe and has a low risk of type II endoleak and aneurysm growth. Persisting buttock claudication is rare.\u3c/p\u3

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

A 15-Year Single-Center Experience of Endovascular Repair for Elective and Ruptured Abdominal Aortic Aneurysms

\u3cp\u3ePurpose: To evaluate the differences in technical outcomes and secondary interventions between elective endovascular aneurysm repair (el-EVAR) procedures and those for ruptured aneurysms (r-EVAR). Methods: Of the 906 patients treated with primary EVAR from September 1998 until July 2012, 43 cases were excluded owing to the use of first-generation stent-grafts. Among the remaining 863 patients, 773 (89.6%) patients (mean age 72 years; 697 men) with asymptomatic or symptomatic abdominal aortic aneurysms (AAAs) were assigned to the el-EVAR group; 90 (10.4%) patients (mean age 73 years; 73 men) were assigned to the r-EVAR group based on blood outside the aortic wall on preoperative imaging. The primary study outcome was technical success; secondary endpoints, including freedom from secondary interventions and late survival, were examined with Kaplan-Meier analyses. Results: At baseline, r-EVAR patients had larger aneurysms on average (p&lt;0.001) compared to el-EVAR patients. Technical success was comparable (p=0.052), but there were more type Ia endoleaks at completion angiography in the r-EVAR group (p=0.038). As anticipated, more patients died in the first month in the r-EVAR group (18.9% vs 2.2% el-EVAR, p&lt;0.001). At 5 years, there was an overall survival of 65.1% for the el-EVAR patients vs 48.1% in the r-EVAR group (p&lt;0.001). The freedom from AAA-related mortality was 95.7% for el- EVAR and 71.0% for r-EVAR (p&lt;0.001). Five-year freedom from type I/III endoleaks was significantly lower in the r-EVAR group (78.7% vs 90.0%, p=0.003). Five-year freedom from secondary intervention estimates were not significantly different (el-EVAR 84.2% vs r-EVAR 78.2%, p=0.064). Conclusion: Within our cohort of primary EVAR patients, r-EVAR cases showed comparable stent-graft-related technical outcome. Although there was a higher incidence of type Ia endoleaks on completion angiography in the r-EVAR group, the overall secondary intervention rate was comparable to el-EVAR.\u3c/p\u3