Is emergency endovascular aneurysm repair associated with higher secondary intervention risk at mid-term follow-up?

ObjectiveThe study assessed mid-term outcome of emergency endovascular repair for acute infrarenal abdominal aortic aneurysms, with special attention to secondary interventions.MethodsBetween May 1998 and August 2005, 56 patients underwent emergent endovascular repair for a ruptured abdominal aortic aneurysm (n = 34) or an acute nonruptured abdominal aortic aneurysm (n = 22). During the same period, 322 consecutive patients underwent elective endovascular aneurysm repair and were used as control group. Five types of stent grafts were used: Vanguard, Talent, Excluder, Zenith, and Quantum. Follow-up included abdominal radiograph, duplex ultrasound scanning, and computed tomographic angiography. Outcome measures included all-cause and aneurysm-related mortality, complications, and secondary interventions.ResultsMortality at 30 days was 18%, 5%, and 1% in the ruptured, acute nonruptured, and elective aneurysm groups, respectively. Overall mean follow-up was 38 ± 26 months. In the ruptured aneurysm group, survival was 67.8% ± 8.6% at 1 year and 62.1% ± 9.5% at 2 and 3 years. Seven secondary interventions (4 early and 3 late) were required in five patients (15%), with a cumulative risk of 9.2% ± 5.1% at 1 year and 16.2% ± 8.2% at 2 and 3 years. In the acute nonruptured aneurysm group, survival was 90.9% ± 6.1% at 1 year, 84.8% ± 8.2% at 2 years, and 76.4% ± 10.9% at 3 years. Four secondary interventions (1 early and 3 late) were required in four patients (18%), with a cumulative risk of 9.6% ± 6.5% at 1 and 2 years and 20.9% ± 12.0% at 3 years. In the elective aneurysm (control) group, survival was 95.2% ± 1.2% at 1 year, 89.9% ± 1.8% at 2 years, and 86.2% ± 2.1% at 3 years. A total of 51 secondary interventions (4 early, 47 late) were required in 38 patients (12%), with a cumulative risk of 4.2% ± 1.1% at 1 year, 7.6% ± 1.6% at 2 years, and 12.9% ± 2.2% at 3 years.ConclusionsTo our surprise, emergency endovascular aneurysm repair did not present with higher secondary intervention rate at mid-term follow-up

Custom Made Candy Plug for Distal False Lumen Occlusion in Aortic Dissection: International Experience

Objective: To evaluate early and midterm outcomes of the Candy Plug (CP) technique for distal false lumen (FL) occlusion in thoracic endovascular aortic repair for aortic dissection (AD) in a more real world cohort of patients from an international multicentre registry. Methods: A multicentre retrospective study was conducted of all consecutive patients from the contributing centres with subacute and chronic AD treated with the CP technique from October 2013 to April 2020 at 18 centres. Results: A custom made CP was used in 155 patients (92 males, mean age 62 ± 11 years). Fourteen (9%) presented with ruptured false lumen aneurysms. Technical success was achieved in all patients (100%). Clinical success was achieved in 138 patients (89%). The median hospital stay was 7 days (1 – 77). The 30 day mortality rate was 3% (n = 5). Stroke occurred in four patients (3%). Spinal cord ischaemia occurred in three patients (2%). The 30 day computed tomography angiogram (CTA) confirmed successful CP placement at the intended level in all patients. Early complete FL occlusion was achieved in 120 patients (77%). Early (30 day) CP related re-intervention was required in four patients (3%). The early (30 day) stent graft related re-intervention rate was 8% (n = 12). Follow up CTA was available in 142 patients (92%), with a median follow up of 23 months (6 – 87). Aneurysmal regression was achieved in 68 of 142 patients (47%); the aneurysm diameter remained stable in 69 of 142 patients (49%) and increased in five of 142 patients (4%). A higher rate of early FL occlusion was detected in the largest volume centre patients (50 [88%] vs. 70 [71%] from other centres; p = .019). No other differences in outcome were identified regarding volume of cases or learning curve. Conclusion: This international CP technique experience confirmed its feasibility and low mortality and morbidity rates. Aortic remodelling and false lumen thrombosis rates were high and support the concept of distal FL occlusion in AD using the CP technique

New insights in (acute) endovascular abdominal aneurysm repair:when fenestrated devices fall short

The suitability for endovascular aneurysm repair (EVAR) is determined primarily by abdominal aortic aneurysm (AAA) anatomy. For patients unsuitable for standard EVAR, due to proximal neck anatomy, fenestrated aortic stent-grafting (FEVAR) is a viable alternative to open repair surgery. Initially FEVAR stent-grafts were custom-made to fit the unique anatomical characteristics of each treated individual. This customization leads to production delays therefore excluding acute aneurysms from endovascular treatment. For patients in need for more urgent treatment, several alternatives have currently been developed. The aim of this review is to provide an overview on current developments and results in acute endovascular abdominal aortic aneurysm repair

EVAR for aortoiliac aneurysms, including iliac branched grafts

For aortoiliac aneurysms involving the common iliac arteries several treatment options have been developed. In the early stages of the endovascular era the internal iliac artery was usually overstented with or without embolization. Thereafter relocation or bypass techniques were used in an attempt to preserve the internal iliac artery. Then endovascular techniques were used that involved the need for a femoro-femoral cross-over bypass. The development of iliac branched devices made it possible to preserve the internal iliac artery by endovascular means only. A first version of the iliac bifurcated graft needed to be pulled into the internal iliac artery but this technique proved too difficult. Newer versions including straight side-branches or helical side-branches for the internal iliac artery require a cross-over catheterization and introduction of a stent-graft to bridge the gap between the internal iliac artery and the iliac branch. Anatomical criteria including sufficient length of the common iliac artery and a normal calibre internal iliac artery should be taken into account, but also the health status of the patient, before one decides to use an iliac branched device for a patient with an aortoiliac aneurysm. Additional costs and technical challenges need to be balanced with the potential benefits for active patients who would be at risk for buttock claudication

New insights in (acute) endovascular abdominal aneurysm repair:when fenestrated devices fall short

The suitability for endovascular aneurysm repair (EVAR) is determined primarily by abdominal aortic aneurysm (AAA) anatomy. For patients unsuitable for standard EVAR, due to proximal neck anatomy, fenestrated aortic stent-grafting (FEVAR) is a viable alternative to open repair surgery. Initially FEVAR stent-grafts were custom-made to fit the unique anatomical characteristics of each treated individual. This customization leads to production delays therefore excluding acute aneurysms from endovascular treatment. For patients in need for more urgent treatment, several alternatives have currently been developed. The aim of this review is to provide an overview on current developments and results in acute endovascular abdominal aortic aneurysm repair.</p

Present and Future of Branched Stent Grafts in Thoraco-abdominal Aortic Aneurysm Repair:A Single-centre Experience

AbstractBackgroundRecent developments with fenestrated and branched stent grafts have opened the way to treat complex aortic aneurysms involving the visceral arteries. Early reports on endovascular treatment of thoraco-abdominal aneurysms have demonstrated the feasibility of the technique. Given the sparse literature, its safety has not been established yet.MethodsA literature review was conducted, and the results of our own series of 30 patients treated with a custom-made Zenith device with fixed branches are presented. Most of the patients were refused open surgery mainly for the extent of the disease combined with co-morbidity, which included in most patients a combination of several risk factors. The mean aneurysm size was 70mm and the extent of the aneurysm was type I in eight cases, type II in five, type III in 12 and type IV in five patients.ResultsTechnical success in our series was achieved in 93% (28/30). Two out of 97 (2%) targeted vessels were lost. In one patient, a renal artery ruptured during insertion of the bridging stent graft. In a second patient, a coeliac artery could not be catheterised and was lost. The 30-day mortality was 6.7% and corroborated with 5.5% in the largest series reported so far. The 6 months and 1-year survival were 89.3% and 76.0%, respectively.ConclusionThe results of fully endovascular repair of selected thoraco-abdominal aneurysms are promising. A learning curve should be expected. Anatomical limitations such as extremely tortuous vessels and access problems should be taken into account, as well as the quality of the targeted side branches. Although longer-term results need to be awaited, it is likely that endovascular repair of thoraco-abdominal aneurysms will become a preferential treatment option for many patients in the future