Tips and techniques for optimal stent graft placement in angulated aneurysm necks

An increasing number of patients with severely angulated abdominal aortic aneurysm (AAA) necks are being treated by endovascular aneurysm repair (EVAR). Optimal preprocedural planning and investigation of the AAA morphology is essential to achieve a successful EVAR in these patients. In this article, we discuss specific problems that can be encountered during preoperative planning in relation to periprocedural stent graft deployment in patients with angulated AAA necks and offer potential solutions for these problems

Open thoracic or thoracoabdominal aortic aneurysm repair after previous abdominal aortic aneurysm surgery

ObjectiveThe purpose of this study was to provide insight into the incidence of thoracic and thoracoabdominal aortic aneurysm repair following previous infrarenal abdominal aortic aneurysm (AAA) surgery and to determine whether thoracic or thoracoabdominal aortic aneurysm repair after prior infrarenal AAA surgery is associated with higher mortality and morbidity rates.MethodsMEDLINE, Cochrane Library CENTRAL, and EMBASE databases were searched for relevant articles. Selected articles were critically appraised and meta-analyses were performed.ResultsA total of 12.4% of patients with thoracic aortic aneurysms and 18.7% of patients with thoracoabdominal aortic aneurysms have had prior AAA surgery. The chance of developing a thoracic aortic aneurysm in patients with AAA is 2.2% and 2.5% for developing a thoracoabdominal aortic aneurysm. The mean time interval between prior AAA surgery and subsequent thoracoabdominal aortic aneurysm surgery or detection is 8.0 years with a wide variation between individuals. Surgery in these patients is technically feasible. The 30-day mortality of patients undergoing open thoracoabdominal aortic aneurysm repair does not significantly differ from patients without prior AAA surgery and the 30-day mortality is 11.8%. No data were available about mortality of patients with prior AAA repair undergoing thoracic aortic aneurysm surgery. Morbidity risks are higher in patients with thoracic or thoracoabdominal aortic aneurysms. Prior AAA repair was a significant risk factor for neurological deficit after thoracic or thoracoabdominal aortic aneurysms surgery with relative risks (RRs) of 11.1 (95% confidence interval [CI] 3.8-32.3, P value < .0001) and 2.90 (95% CI 1.26-6.65, P value = .008), respectively. Prior AAA repair was a significant risk factor for developing renal failure in patients undergoing thoracoabdominal aortic aneurysm repair (RR 3.47, 95% CI 1.74-6.91, P value = .0001). Determinants of the prognosis in these patients include distal aortic perfusion, distal extent of the landing zone of the graft, drainage of cerebrospinal fluid for thoracic aortic aneurysm repair and age, history of cardiac diseases, extent of the aneurysm, rupture, amount of estimated blood loss, aortic clamp time, and visceral ischemic times for thoracoabdominal aortic aneurysm repair.ConclusionsA considerable group of patients with thoracic or thoracoabdominal aortic aneurysms have had prior AAA repair. The risk of postoperative morbidity is increased in these patients. Mortality appears to be similar for patients with thoracoabdominal aortic aneurysms. Patients with prior AAA repair undergoing thoracic or thoracoabdominal aortic aneurysm repair should be provided maximum care to protect their spinal cord and renal function

Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm

IntroductionRuptured descending thoracic aortic aneurysm (rDTAA) is associated with high mortality rates. Data supporting endovascular thoracic aortic aneurysm repair (TEVAR) to reduce mortality compared with open repair are limited to small series. We investigated published reports for contemporary outcomes of open and endovascular repair of rDTAA.MethodsWe systematically reviewed all studies describing the outcomes of rDTAA treated with open repair or TEVAR since 1995 using MEDLINE, Cochrane Library CENTRAL, and Excerpta Medica Database (EMBASE) databases. Case reports or studies published before 1995 were excluded. All articles were critically appraised for relevance, validity, and availability of data regarding treatment outcomes. All data were systematically pooled, and meta-analyses were performed to investigate 30-day mortality, myocardial infarction, stroke, and paraplegia rates after both types of repair.ResultsOriginal data of 224 patients (70% male) with rDTAA were identified: 143 (64%) were treated with TEVAR and 81 (36%) with open repair. Mean age was 70 ± 5.6 years. The 30-day mortality was 19% for patients treated with TEVAR for rDTAA compared 33% for patients treated with open repair, which was significant (odds ratio [OR], 2.15, P = .016). The 30-day occurrence rates of myocardial infarction (11.1% vs 3.5%; OR, 3.70, P < .05), stroke (10.2% vs 4.1%; OR, 2.67; P = .117), and paraplegia (5.5% vs 3.1%; OR, 1.83; P = .405) were increased after open repair vs TEVAR, but this failed to reach statistical significance for stroke and paraplegia. Five additional patients in the TEVAR group died of aneurysm-related causes after 30 days, during a median follow-up of 17 ± 10 months. Follow-up data after open repair were insufficient. The estimated aneurysm-related survival at 3 years after TEVAR was 70.6%.ConclusionEndovascular repair of rDTAA is associated with a significantly lower 30-day mortality rate compared with open surgical repair. TEVAR was associated with a considerable number of aneurysm-related deaths during follow-up

A ruptured aneurysm after stent graft puncture during computed tomography-guided thrombin injection

Type II endoleaks occur in 5% to 10% of patients who are treated by endovascular aneurysm repair. A persistent type II endoleak combined with documented aneurysm expansion is generally considered an indication for intervention. Thrombin injection directly into the aneurysm sac is described as a safe and efficient treatment option. We present a patient with a ruptured aneurysm caused by a puncture of the stent graft during computed tomography-guided thrombin injection. This case highlights a possible harmful complication of thrombin injection and emphasizes the need for caution while performing such a procedure

Carotid endarterectomy with patch angioplasty versus primary closure in patients with symptomatic and significant stenosis:a systematic review with meta-analyses and trial sequential analysis of randomized clinical trials

Background: Patch angioplasty in conventional carotid endarterectomy is suggested to reduce the risk of restenosis and recurrent ipsilateral stroke compared with primary closure. A systematic review of randomized clinical trials is needed to compare outcomes (benefits and harms) of both techniques. Methods: Searches (CENTRAL, PubMed/MEDLINE, EMBASE, and other databases) were last updated 3rd of January 2021. We included randomized clinical trials comparing carotid endarterectomy with patch angioplasty versus primary closure of the arterial wall in patients with a symptomatic and significant (> 50%) carotid stenosis. Primary outcomes are defined as all-cause mortality and serious adverse events. Results: We included 12 randomized clinical trials including 2187 participants who underwent 2335 operations for carotid stenosis comparing carotid endarterectomy with patch closure (1280 operations) versus carotid endarterectomy with primary closure (1055 operations). Meta-analysis comparing carotid endarterectomy with patch angioplasty versus carotid endarterectomy with primary closure may potentially decrease the number of patients with all-cause mortality (RR 0.53; 95% CI 0.26 to 1.08; p = 0.08, best-case scenario for patch), serious adverse events (RR 0.73; 95% CI 0.56 to 0.96; p = 0.02, best-case scenario for patch), and the number of restenosis (RR 0.41; 95% CI 0.23 to 0.71; p < 0.01). Trial sequential analysis demonstrated that the required information sizes were far from being reached for these patient-important outcomes. All the patient-relevant outcomes were at low certainty of evidence according to The Grading of Recommendations Assessment, Development, and Evaluation. Conclusions: This systematic review showed no conclusive evidence of a difference between carotid endarterectomy with patch angioplasty versus primary closure of the arterial wall on all-cause mortality, < 30 days mortality, < 30 days stroke, or any other serious adverse events. These conclusions are based on data from 15 to 35 years ago, obtained in trials with very low certainty according to GRADE, and should be interpreted cautiously. Therefore, we suggest conducting new randomized clinical trials patch angioplasty versus primary closure in carotid endarterectomy in symptomatic patients with an internal carotid artery stenosis of 50% or more. Such trials ought to be designed according to the Standard Protocol Items: Recommendations for Interventional Trials statement (Chan et al., Ann Intern Med 1:200–7, 2013) and reported according to the Consolidated Standards of Reporting Trials statement (Schulz et al., 7, 2010). Until conclusive evidence is obtained, the standard of care according to guidelines should not be abandoned. Systematic review registration: PROSPERO CRD42014013416. Review protocol publication 2019 DOI: https://doi.org/10.1136/bmjopen-2018-026419

Carotid endarterectomy with primary closure versus patch angioplasty in patients with symptomatic and significant stenosis:protocol for a systematic review with meta-analyses and trial sequential analysis of randomised clinical trials

Introduction Use of patch angioplasty in carotid endarterectomy (CEA) is suggested to reduce the risk of restenosis and recurrent ipsilateral stroke. The objective is to conduct a systematic review with meta-analysis and trial sequential analysis as well as Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessments comparing the benefits and harms of CEA with primary closure of the arterial wall versus CEA with patch angioplasty in patients with a symptomatic and significant carotid stenosis.Methods and analysis The review shall be conducted according to this published protocol following the recommendations of the ` Cochrane' and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Randomised clinical trials comparing CEA with primary closure of the arterial wall versus CEA with patch angioplasty (regardless of used patch materials) in human adults with a symptomatic and significant carotid stenosis will be included. Primary outcomes are all-cause mortality at maximal follow-up, health-related quality of life and serious adverse events. Secondary outcomes are symptomatic or asymptomatic arterial occlusion or restenosis, and non-serious adverse events. We will primarily base our conclusions on meta-analyses of trials with overall low risk of bias. However, if pooled point estimates of all trials are similar to pooled point estimates of trials with overall low risk of bias and there is lack of a statistical significant interaction between estimates from trials with overall high risk of bias and trials with overall low risk of bias we will consider the precision achieved in all trials as the result of our meta-analyses.Ethics and dissemination The proposed systematic review will collect and analyse secondary data from published studies therefor ethical approval is not required. The results of the systematic review will be disseminated by publication in a peer-review journal and submitted for presentation at relevant conferences.</p