Carotid Artery Stenting and Endarterectomy: a clinical evaluation

Stroke is a major cause of mortality and morbidity in the western world. Atherosclerotic disease of the carotid arteries is in approximately 25% of the cases responsible for the cerebral infarction.1 Since NASCET and ECST, carotid endarterectomy (CEA) is considered the standard treatment for severe atherosclerotic carotid obstructive disease in symptomatic patients.2, 3 Similar landmark studies were performed for asymptomatic carotid artery disease.4, 5 On the basis of these trials the American Heart Association has recommended CEA for symptomatic patients with stenosis of 50% to 99% if the perioperative risk of stroke or death is <6%.6 In asymptomatic patients CEA is recommended for a stenosis of 60% to 99% if the perioperative of stroke or death is < 3%. In an effort to minimise interventions, in the last decade carotid artery stenting (CAS) has been suggested as an alternative to surgical endarterectomy for patients with symptomatic and asymptomatic extra cranial obstructive disease. Initially, percutaneous transluminal balloon angioplasty (PTA) was used. Later stent placement was introduced and has been used with or without initial PTA. Current data on CAS and CEA suggest that CAS is quickly gaining ground on CEA as a first-line treatment The advantages of CAS include avoidance of general anaesthesia, an incision in the neck and the risk of cranial and cutaneous nerve damage from the dissection. Surgically inaccessible lesion can be treated with CAS and both procedure- and admission times are usually shorter than for surgery, therefore reducing some cost. On the other hand, devices used for CAS are more expensive. At this moment many interventionists embrace carotid stenting, in particular for patients with obvious contraindications for surgical endarterectomy like high cardiopulmonary risk, high cervical lesion or “hostile neck”. CAS is relatively new compared to CEA and it should be acknowledged that CAS is an evolving technique and dedicated materials became only available recently

Unexplained rupture after endovascular aneurysm repair

textabstractWe present a case of a 70-year-old man who was admitted with rupture of an abdominal aneurysm 4 years after endovascular aneurysm repair. He was compliant with yearly follow-up computed tomography angiography. One month earlier, his computed tomography angiogram showed perfect exclusion of the aneurysm and no endoleak. We explanted the stent graft and confirmed effective sealing, and the graft was intact. We found no signs of infection during 2 years of follow-up. This rupture is nonpredictable and unexplained and illustrates that unremarkable imaging does not guarantee prevention of rupture. This case shows that the ultimate failure of endovascular aneurysm repair cannot be prevented despite surveillance protocols

Systematic review and meta-analysis of sex differences in outcome after intervention for abdominal aortic aneurysm

Background: The aim of this study was to assess possible differences in mortality between men and women with an abdominal aortic aneurysm (AAA) treated either by elective repair or following aneurysm rupture. Metlioclss A systematic literature search was performed using the MEDLINE, Cochrane and Embase databases. Data were analysed by means of bivariate random-effects meta-analysis. Data were pooled and odds ratios (ORs) calculated for women compared with men. Resulte: Sixty-one studies (516118 patients) met the predetermined inclusion criteria. Twenty-six reported on elective open AAA repair, 21 on elective endovascular repair, 25 on open repair for ruptured AAA and one study on endovascular repair for ruptured AAA Mortality rates for women compared with men were 7-6 versus 5-1 per cent (OR 1-28, 95 per cent confidence interval (c.i.) 1.09 to 1.49) for elective open repair, 2-9 versus 1.5 per cent (OR 2.41, 95 per cent c.i. 1.14 to 5.15) for elective endovascular repair, and 61.8 versus 42.2 percent (OR 1.16, 95 perent c.i. 0.97 to 1.37) in the group that had open repair for rupture. The group that had endovascular repair for ruptured AAA was too small for meaningful analysis. Concluslon: Women with an AAA had a higher mortality rate following elective open and endovascular repair. Copyrigh

Device-specific outcomes after endovascular abdominal aortic aneurysm repair

Over the last decade, endovascular aneurysm repair (EVAR) has been used extensively for the elective treatment of infra-renal abdominal aneurysms. However, it remains unclear how specific devices perform and how they compare to others. We provide an overview of currently used endografts, and discuss the current evidence regarding device-specific outcomes. Published literature confirms differences in results according to endograft selection. These differences were more pronounced with older generations of devices, in comparison to newer models. Contemporary results are generally good and one should remember that no randomized data exist regarding individual device performance. Moreover, by the time there is enough follow-up to draw conclusions, the data is relatively obsolete due to constant improvements in endograft technology and design. Results from EVAR have been steadily improving and individualized device selection has shown to be valuable. It appears that patients with favorable anatomy do well with most modern endografts. Those with challenging anatomies may benefit more from a particular design, delivery and deployment feature requiring greater knowledge and experience for adequate device selection

Treatment of post-implantation aneurysm growth by laparoscopic sac fenestration: Long-term results

Objectives: Sac growth after endovascular aneurysm repair (EVAR) is an important finding, which may influence prognosis. In case of a type II endoleak or endotension, clipping of side branches and subsequent sac fenestration has been presented as a therapeutic alternative. The long-term clinical efficacy of this procedure is unknown. Methods: The study included eight patients who underwent laparoscopic aortic collateral clipping and sac fenestration for enlarging aneurysms following EVAR. Secondary interventions and clinical outcome were retrieved from hospital records. Sac behaviour was evaluated measuring volumes on periodical computed tomography angiography (CTA) imaging using dedicated software. Results: Follow-up had a median length of 6.6 (range 0.6-8.6) years. During this time, only three pati

Clinical outcome and morphologic determinants of mural thrombus in abdominal aortic endografts

Objective Endograft mural thrombus has been associated with stent graft or limb thrombosis after endovascular aneurysm repair (EVAR). This study aimed to identify clinical and morphologic determinants of endograft mural thrombus accumulation and its influence on thromboembolic events after EVAR. Methods A prospectively maintained database of patients treated by EVAR at a tertiary institution from 2000 to 2012 was analyzed. Patients treated for degenerative infrarenal abdominal aortic aneurysms and with available imaging for thrombus analysis were considered. All measurements were performed on three-dimensional center-lumen line computed tomography angiography (CTA) reconstructions. Patients with thrombus accumulation within the endograft's main body with a thickness >2 mm and an extension >25% of the main body's circumference were included in the study group and compared with a control group that included all remaining patients. Clinical and morphologic variables were assessed for association with significant thrombus accumulation within the endograft's main body by multivariate regression analysis. Estimates for freedom from thromboembolic events were obtained by Kaplan-Meier plots. Results Sixty-eight patients (16.4%) presented with endograft mural thrombus. Median follow-up time was 3.54 years (interquartile range, 1.99-5.47 years). In-graft mural thrombus was identified on 30-day CTA in 22 patients (32.4% of the study group), on 6-month CTA in 8 patients (11.8%), and on 1-year CTA in 17 patients (25%). Intraprosthetic thrombus progressively accumulated during the study period in 40 patients of the study group (55.8%). Overall, 17 patients (4.1%) presented with endograft or limb occlusions, 3 (4.4%) in the thrombus group and 14 (4.1%) in the control group (P =.89). Thirty-one patients (7.5%) received an aortouni-iliac (AUI) endograft. Two endograft occlusions were identified among AUI devices (6.5%; overall, 0.5%). None of these patients showed thrombotic deposits in the main body, nor were any outflow abnormalities identified on the immediately preceding CTA. Estimated freedom from thromboembolic events at 5 years was 95% in both groups (P =.97). Endograft thrombus accumulation was associated with >25% proximal aneurysm neck thrombus coverage at baseline (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3), neck length ≤15 mm (OR, 2.4; 95% CI, 1.3-4.2), proximal neck diameter ≥30 mm (OR, 2.4; 95% CI, 1.3-4.6), AUI (OR, 2.2; 95% CI, 1.8-5.5), or polyester-covered stent grafts (OR, 4.0; 95% CI, 2.2-7.3) and with main component "barrel-like" configuration (OR, 6.9; 95% CI, 1.7-28.3). Conclusions Mural thrombus formation within the main body of the endograft is related to different endograft configurations, main body geometry, and device fabric but appears to have no association with the occurrence of thromboembolic events over time

Adequate seal and no endoleak on the first postoperative computed tomography angiography as criteria for no additional imaging up to 5 years after endovascular aneurysm repair

Objective: Intensive image surveillance after endovascular aneurysm repair is generally recommended due to continued risk of complications. However, patients at lower risk may not benefit from this strategy. We evaluated the predictive value of the first postoperative computed tomography angiography (CTA) characteristics for aneurysm-related adverse events as a means of patient selection for risk-adapted surveillance. Methods: All patients treated with the Low-Permeability Excluder Endoprosthesis (W. L. Gore and Assoc, Flagstaff, Ariz) at a tertiary institution from 2004 to 2011 were included. First postoperative CTAs were analyzed for the presence of endoleaks, endograft kinking, distance from the lowermost renal artery to the start of the endograft, and for proximal and distal sealing length using center lumen line reconstructions. The primary end point was freedom from aneurysm-related

Differences in mortality, risk factors, and complications after open and endovascular repair of ruptured abdominal aortic aneurysms

Objective/background Endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) has faced resistance owing to the marginal evidence of benefit over open surgical repair (OSR). This study aims to determine the impact of treatment modality on early mortality after rAAA, and to assess differences in postoperative complications and long-term survival. Methods Patients treated between January 2000 and June 2013 were identified. The primary endpoint was early mortality. Secondary endpoints were postoperative complications and long-term survival. Independent risk factors for early mortality were calculated using multivariate logistic regression. Survival estimates were obtained by means of Kaplan-Meier curves. Results Two hundred and twenty-one patients were treated (age 72 ± 8 years, 90% male), 83 (38%) by EVAR and 138 (62%) by OSR. There were no differences between groups at the time of admission. Early mortality was significantly lower for EVAR compared with OSR (odds ratio [OR]: 0.45, 95% confidence interval [CI]: 0.21-0.97). Similarly, EVAR was associated with a threefold risk reduction in major complications (OR: 0.33, 95%CI: 0.15-0.71). Hemoglobin level <11 mg/dL was predictive of early death for patients in both groups. Age greater than 75 years and the presence of shock were significant risk factors for early death after OSR, but not after EVAR. The early survival benefit of EVAR over OSR persisted for up to 3 years. Conclusion This study shows an early mortality benefit after EVAR, which persists over the mid-term. It also suggests different prognostic significance for preoperative variables according to the type of repair. Age and the presence of shock were risk factors for early death after OSR, while hemoglobin level on admission was a risk factor for both groups. This information may contribute to repair-specific risk prediction and improved patient selection