Primary Absence of Type II Endoleak is A Positive Prognostic Factor against the Risk of Late Conversion of EVAR for AAA

Introduction: The aim of this study is to analyze 12 late conversion to open surgery after Endovascular Repair of Abdominal Aortic Aneurysms (EVAR) while comparing the follow up of these cases to that of the definitely successful procedures (absence of surgical conversion, type I or III endoleaks, or presence of type II endoleaks without any aneurysmal sac enlargement) . Methods: From a series of over 300 EVAR procedures performed at our department we have selected 215 cases with a follow up ≥ 6 month and primary technical success (successful deployment of the devices and discharge of patients without neither type I nor III endoleaks). Based on the final data recorded at the end of the follow up (mean+ IQR: 38.16 months + 41), these cases were divided into three groups: group 1, with 12 cases (5.6%) which needed surgical conversion in a later stage (5 to 55 months from EVAR); group 2, with 39 cases (18.1%) with type II endoleaks without aneurysmal sac enlargement; group 3, with 164 cases (76.5%) without endoleaks. The groups were compared in relation to the following parameters: a) personal data and common atherogenic risk factor, b) diameter of the aneurysm, c) kind of the proximal fixation of the endograft (suprarenal or infrarenal), d) presence of endoleaks at the first postoperative check. We have compared the data from the three groups and we have analyzed them with chi-square test (Χ2). Results: Personal data and common atherogenic risk factor have proved no significant difference among the three groups. The incidence of the other three parameters of group 1 was compared with the incidence of these in groups 2 and 3: the mean pre-operative diameter of the aneurysm results 51 mm in group 1, 54 mm in group 2 and 55 mm in group 3 (not significant); suprarenal fixation of the prosthesis accounts for 50% in group 1, 51% in group 2 and 60% in group 3 (not significant); presence of type II endoleak at the first post-operative check was 41.6% in group 1, 56.4% in group 2 (not significant) and 9.7% in group 3 (p<0.001, compared to groups 1 and 2). Conclusion: In the EVAR procedures with primary technical success, the absence of type II endoleak at the first post-operative check represents a favorable prognostic factor against the risk of late conversion to open repair. Personal data, common atherogenic risk factor, diameter of the aneurysm and fixing type of the prosthesis don’t seem to influence the onset of this complication

Sequential multiple visceral arteries dissections without aortic involvement

Isolated dissection of visceral arteries without associated aortic pathology is very rare. Risk factors, etiology, and natural history of this pathology continue to be unclear, and the guidelines for clinical management remain to be defined. We present a case not described previously, with sequential dissections of the celiac trunk, superior mesenteric artery, and renal arteries without aortic involvement. The patient presented with severe back thoracic and abdominal pain and without evidence of peritonitis. An abdominal angio-CT scan showed dissection of the superior mesenteric artery (SMA), with partial thrombosis of the false lumen and subsequent stenosis of around 60%. Conservative treatment with anticoagulants seemed to be appropriate in the beginning, because the patient became asymptomatic spontaneously within a few hours and angio-CT showed dissection but no ischemic lesions. On day 10 after onset, however, he again indicated severe back thoracic and abdominal pain. Emergent CT was performed. The prior SMA dissection appeared to be worse due to increased size of the false lumen, followed by SMA stenosis (about 75‒80%). In addition, dissection of the celiac artery and both renal arteries could be seen. The patient underwent angiography and stenting of the main trunk of the SMA, with good clinical and radiologic outcome. Double oral antiplatelet therapy was then introduced. An angio-MRI scan 6 months later showed stability of the multiple dissections

Spinal cord ischemia after simultaneous and sequential treatment of multilevel aortic disease.

OBJECTIVES: The aim of the present study is to report a risk analysis for spinal cord injury in a recent cohort of patients with simultaneous and sequential treatment of multilevel aortic disease. METHODS: We performed a multicenter study with a retrospective data analysis. Simultaneous treatment refers to descending thoracic and infrarenal aortic lesions treated during the same operation, and sequential treatment refers to separate operations. All descending replacements were managed with endovascular repair. RESULTS: Of 4320 patients, multilevel aortic disease was detected in 77 (1.8%). Simultaneous repair was performed in 32 patients (41.5%), and a sequential repair was performed in 45 patients (58.4%). Postoperative spinal cord injury developed in 6 patients (7.8%). At multivariable analysis, the distance of the distal aortic neck from the celiac trunk was the only independent predictor of postoperative spinal cord injury (odds ratio, 0.75; 95% confidence interval, 0.56-0.99; P=.046); open surgical repair of the abdominal aortic disease was associated with a higher risk of spinal cord injury but did not reach statistical significance (odds ratio, 0.16; 95% confidence interval, 0.02-1.06; P=.057). Actuarial survival estimates at 1, 2, and 5 years after the procedure were 80%±5%, 68%±6%, and 63%±7%, respectively. Spinal cord injury did not impair survival (P=.885). CONCLUSIONS: In our experience, the risk of spinal cord injury is still substantial at 8% in patients with multilevel aortic disease. The distance of the distal landing zone from the celiac trunk is a significant predictor of spinal cord ischemia

Spinal cord ischemia after simultaneous and sequential treatment of multilevel aortic disease

OBJECTIVES: The aim of the present study is to report a risk analysis for spinal cord injury in a recent cohort of patients with simultaneous and sequential treatment of multilevel aortic disease. METHODS: We performed a multicenter study with a retrospective data analysis. Simultaneous treatment refers to descending thoracic and infrarenal aortic lesions treated during the same operation, and sequential treatment refers to separate operations. All descending replacements were managed with endovascular repair. RESULTS: Of 4320 patients, multilevel aortic disease was detected in 77 (1.8%). Simultaneous repair was performed in 32 patients (41.5%), and a sequential repair was performed in 45 patients (58.4%). Postoperative spinal cord injury developed in 6 patients (7.8%). At multivariable analysis, the distance of the distal aortic neck from the celiac trunk was the only independent predictor of postoperative spinal cord injury (odds ratio, 0.75; 95% confidence interval, 0.56-0.99; P = .046); open surgical repair of the abdominal aortic disease was associated with a higher risk of spinal cord injury but did not reach statistical significance (odds ratio, 0.16; 95% confidence interval, 0.02-1.06; P = .057). Actuarial survival estimates at 1, 2, and 5 years after the procedure were 80% \ub1 5%, 68% \ub1 6%, and 63% \ub1 7%, respectively. Spinal cord injury did not impair survival (P = .885). CONCLUSIONS: In our experience, the risk of spinal cord injury is still substantial at 8% in patients with multilevel aortic disease. The distance of the distal landing zone from the celiac trunk is a significant predictor of spinal cord ischemia

Predictors and outcomes of acute kidney injury after thoracic aortic endograft repair

Background: This study analyzed the incidence and the predictive factors of postoperative acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) and evaluated the effect of AKI on postoperative survival. Methods: Between November 2000 and April 2011, all consecutive patients undergoing TEVAR of the descending thoracic or thoracoabdominal aorta were enrolled at four teaching hospitals. Estimated glomerular filtration rate (eGFR) was evaluated during the entire hospitalization. AKI was defined by the RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) consensus criteria. Results: The study included 171 patients (80% men) who were a mean age of 69 \ub1 14 years (range, 18-87 years). AKI occurred in 24 patients (14%). Independent predictors of postoperative AKI were preoperative depressed eGFR, thoracoabdominal extent, and postoperative transfusion. Patients with AKI experienced major postoperative complications (P =.001), longer hospitalization (P =.008), and higher hospital mortality (29% vs 4%; P <.001). Kaplan-Meier analysis showed a survival of 82%, 51%, and 51% at 1, 3, and 5 years for patients who developed AKI, which was significantly worse than the 99%, 89%, and 80% for patients who did not experience AKI (P =.001). Conclusions: Preoperative poor renal function, blood transfusions, and the thoracoabdominal extent of the aortic disease were the most important predictors for AKI