RESUMEN
Thoracic endovascular aortic repair is commonly used in the surgical treatment of patients with aortic coarctation, but complications such as endoleaks can occur. This video tutorial presents a case study involving the exclusion of a stent graft from the bloodstream through total transection of the aortic arch and abdominal aorta, with off-pump aortic grafting and debranching of the left carotid and subclavian arteries.
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Implantación de Prótesis Vascular , Endofuga , Procedimientos Endovasculares , Humanos , Endofuga/etiología , Endofuga/cirugía , Endofuga/diagnóstico , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/efectos adversos , Implantación de Prótesis Vascular/métodos , Implantación de Prótesis Vascular/efectos adversos , Masculino , Aorta Abdominal/cirugía , Stents , Aorta Torácica/cirugía , Prótesis Vascular/efectos adversos , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnósticoRESUMEN
CASE: We present a case of a 66-year-old man with lumbar vertebral body erosions after glue embolization of a Type II endoleak secondary to endovascular repair of an infrarenal aortic aneurysm. Multiple biopsies of the affected vertebrae were culture-negative confirming no evidence of infection. He underwent posterior spinal fusion from L2 to L5 with complete resolution of mechanical low back pain and improved functional outcomes. CONCLUSION: Vertebral body osseous erosion is a rare complication of aortic endoleak intervention that can be successfully treated with spinal fusion.
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Embolización Terapéutica , Endofuga , Humanos , Masculino , Anciano , Endofuga/etiología , Endofuga/diagnóstico por imagen , Endofuga/terapia , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Cuerpo Vertebral/diagnóstico por imagen , Cuerpo Vertebral/cirugía , Procedimientos Endovasculares/efectos adversos , Vértebras Lumbares/cirugía , Fusión Vertebral/efectos adversos , Fusión Vertebral/instrumentaciónRESUMEN
OBJECTIVE: To evaluate the mid-term outcomes of different treatment strategies for the internal iliac artery (IIA) during EVAR. METHODS: This was a retrospective study. All patients undergoing EVAR, who required treatment of at least one side of IIA from January 2013 to July 2022 in a single center, were included. According to the different treatment strategies for IIA, the patients were divided into UP (unilateral preservation), BP (bilateral preservation) and BE (bilateral embolization) groups. The primary outcomes included buttock claudication, bowel ischemia and iliac-related reintervention. Then patients who underwent IIA reconstruction were divided into IPG (iliac parallel stent graft) and IBG (iliac branch stent graft) groups according to the reconstruction technique. The primary outcomes included endoleak, iliac branch occlusion and iliac-related reintervention. RESULTS: A total of 237 patients were included, including 167 in the UP group, 9 in the BP group and 61 in the BE group. The mean follow-up time was 39.0 ± 27.7, 50.0 ± 22.1 and 25.8 ± 18.9 months in UP, BP and BE groups, respectively. Thirty cases (12.7%) of buttock claudication occurred, and it was significantly higher in the BE group than the UP group (26.2% vs. 7.8%, p < 0.001). There were no significant differences in the other follow-up outcomes among three groups. The K-M analysis indicated that the patients in the BE group had a lower survival rate than those in the other two groups (p = 0.024). 24 patients underwent IIA reconstruction, including 8 in the IPG group and 16 in the IBG group. The endoleak in the IBG group was significantly lower than that in the IPG group (0% vs. 25.0%, p = 0.041). The iliac-related reintervention, iliac occlusion and mortality were similar between the two groups. CONCLUSION: Overall it is beneficial for patients to preserve at least one side of IIA during EVAR as much as possible. Compared with IPG, IBG might be more applicable for IIA reconstruction.
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Procedimientos Endovasculares , Arteria Ilíaca , Humanos , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/efectos adversos , Masculino , Femenino , Anciano , Arteria Ilíaca/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Stents , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma Ilíaco/cirugía , Endofuga/cirugía , Endofuga/etiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Embolización Terapéutica/métodos , Reparación Endovascular de AneurismasAsunto(s)
Aprendizaje Profundo , Endofuga , Procedimientos Endovasculares , Tomografía Computarizada por Rayos X , Humanos , Endofuga/diagnóstico por imagen , Endofuga/etiología , Procedimientos Endovasculares/métodos , Tomografía Computarizada por Rayos X/métodos , Implantación de Prótesis Vascular/métodos , Reparación Endovascular de AneurismasRESUMEN
BACKGROUND: Our aim was to analyse abdominal aneurysm sac thrombus density and volume on computed tomography (CT) after endovascular aneurysm repair (EVAR). METHODS: Patients who underwent EVAR between January 2005 and December 2010 and had at least four follow-up CT exams available over the first five years of follow-up were included in this retrospective single-centre study. Thrombus density and aneurysm sac volume were calculated on unenhanced CT scans. Linear mixed models were used for data analysis. RESULTS: Out of 82 patients, 44 (54%) had an endoleak on post-EVAR contrast-enhanced CT. Thrombus density significantly increased over time in both the endoleak and non-endoleak groups, with a slope of 0.159 UH/month (95% confidence interval [CI] 0.115-0.202), p < 0.0001) and 0.052 UH/month (95% CI 0.002-0.102, p = 0.041). In patients without endoleak, a significant decrease in aneurysm sac volume was identified over time (slope -0.891 cc/month, 95% CI -1.200 to -0.581); p < 0.001) compared to patients with endoleak (slope 0.284 cc/month, 95% CI -0.031 to 0.523, p = 0.082). The association between thrombus density and aneurysm sac volume was positive in the endoleak group (slope 1.543 UH/cc, 95% CI 0.948-2.138, p < 0.001) and negative in the non-endoleak group (slope -1.450 UH/cc, 95% CI -2.326 to -0.574, p = 0.001). CONCLUSION: We observed a progressive increase in thrombus density of the aneurysm sac after EVAR in patients with and without endoleak, more pronounced in patients with endoleak. The association between aneurysm volume and thrombus density was positive in patients with and negative in those without endoleak. RELEVANCE STATEMENT: A progressive increase in thrombus density and volume of abdominal aortic aneurysm sac on unenhanced CT might suggest underlying endoleak lately after EVAR. KEY POINTS: Thrombus density of the aneurysm sac after EVAR increased over time. Progressive increase in thrombus density was significantly associated to the underlying endoleak. The association between aneurysm volume and thrombus density was positive in patients with and negative in those without endoleak.
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Aneurisma de la Aorta Abdominal , Endofuga , Procedimientos Endovasculares , Trombosis , Tomografía Computarizada por Rayos X , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Endofuga/diagnóstico por imagen , Endofuga/etiología , Femenino , Masculino , Estudios Retrospectivos , Anciano , Procedimientos Endovasculares/métodos , Trombosis/diagnóstico por imagen , Trombosis/etiología , Tomografía Computarizada por Rayos X/métodos , Anciano de 80 o más AñosRESUMEN
OBJECTIVES: To develop and validate a deep learning model for detecting post-endovascular aortic repair (EVAR) endoleak from non-contrast CT. METHODS: This retrospective study involved 245 patients who underwent EVAR between September 2016 and December 2022. All patients underwent both non-enhanced and enhanced follow-up CT. The presence of endoleak was evaluated based on computed tomography angiography (CTA) and radiology reports. First, the aneurysm sac was segmented, and radiomic features were extracted on non-contrast CT. Statistical analysis was conducted to investigate differences in shape and density characteristics between aneurysm sacs with and without endoleak. Subsequently, a deep learning model was trained to generate predicted segmentation of the endoleak. A binary decision was made based on whether the model produced a segmentation to detect the presence of endoleak. The absence of a predicted segmentation indicated no endoleak, while the presence of a predicted segmentation indicated endoleak. Finally, the performance of the model was evaluated by comparing the predicted segmentation with the reference segmentation obtained from CTA. Model performance was assessed using metrics such as dice similarity coefficient, sensitivity, specificity, and the area under the curve (AUC). RESULTS: This study finally included 85 patients with endoleak and 82 patients without endoleak. Compared to patients without endoleak, patients with endoleak had higher CT values and greater dispersion. The AUC in validation group was 0.951, dice similarity coefficient was 0.814, sensitivity was 0.877, and specificity was 0.884. CONCLUSION: This deep learning model based on non-contrast CT can detect endoleak after EVAR with high sensitivity.
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Aneurisma de la Aorta Abdominal , Angiografía por Tomografía Computarizada , Aprendizaje Profundo , Endofuga , Procedimientos Endovasculares , Humanos , Endofuga/diagnóstico por imagen , Endofuga/etiología , Estudios Retrospectivos , Masculino , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/efectos adversos , Femenino , Anciano , Angiografía por Tomografía Computarizada/métodos , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Implantación de Prótesis Vascular/métodos , Implantación de Prótesis Vascular/efectos adversos , Valor Predictivo de las Pruebas , Reparación Endovascular de AneurismasRESUMEN
AIM: This study aimed to investigate the utility of low-energy virtual monochromatic imaging (VMI) combined with deep-learning image reconstruction (DLIR) in improving the delineation of endoleaks (ELs) after endovascular aortic repair (EVAR) in contrast-enhanced dual-energy CT (DECT). METHODS: A total of 61 consecutive patients (mean age, 77 years; 46 men) after EVAR who underwent contrast-enhanced DECT were enrolled. Virtual monochromatic 40- and 70-keV images were reconstructed using DLIR (TrueFidelity-H) and conventional hybrid iterative reconstruction (IR). Contrast-to-noise ratio (CNR) of the EL on the venous-phase CT was calculated. Four different reconstructed image series (hybrid IR and DLIR at two energy levels, 40- and 70-keV) were displayed side-by-side and visually assessed for EL conspicuity on a 5-point comparative scale from 0 (best) to -4 (significantly inferior). Two experienced radiologists independently conducted a qualitative evaluation of the CT images. RESULTS: A total of 30 out of 61 patients presented with an EL. On both 40- and 70-keV images, the CNR of the EL was significantly higher in DLIR than in hybrid IR (40-keV, 14.5 ± 7.3 vs 8.6 ± 4.2, P<0.001; 70-keV, 8.7 ± 4.5 vs 5.5 ± 2.6, P<0.001). The comparative scale of EL conspicuity in the 40-keV DLIR images (Observer1, -0.2 ± 0.4; Observer2, 0.0 ± 0.0) was significantly higher than 40-keV hybrid IR (Observer1, -0.5 ± 0.5; Observer2, -1.0 ± 0.0; P<0.05), 70-keV DLIR (Observer1, -1.8 ± 0.4; Observer2, -2.0 ± 0.0; P<0.001) and 70-keV hybrid IR images (Observer1, -1.8 ± 0.4; Observer2, -2.4 ± 0.5; P<0.001), respectively. CONCLUSIONS: Using 40-keV VMI in combination with DLIR improves EL delineation after EVAR compared with the 70-keV VMI with hybrid IR or DLIR.
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Aprendizaje Profundo , Endofuga , Tomografía Computarizada por Rayos X , Humanos , Masculino , Anciano , Femenino , Endofuga/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Procedimientos Endovasculares/métodos , Medios de Contraste , Interpretación de Imagen Radiográfica Asistida por Computador/métodos , Imagen Radiográfica por Emisión de Doble Fotón/métodos , Anciano de 80 o más Años , Estudios Retrospectivos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagenRESUMEN
BACKGROUND: The unibody bifurcated aortic endograft (AFX/AFX2) has emerged as a treatment option for abdominal aortic aneurysms (AAAs). This systematic review and meta-analysis aimed to evaluate the safety of the unibody endograft. METHODS: A literature search was conducted in Cochrane Library, Scopus, Web of Science, and PubMed. Studies assessing the unibody endograft for AAA repair between 2014 and 2023 were included. The defined primary outcomes were the incidences of type I, II, and III endoleaks. The secondary outcomes were access site problems, aneurysm-related mortality, aneurysm rupture, all-cause mortality, aneurysm sac growth, limb occlusion, stent graft migration, and technical success rate. RESULTS: Fourteen studies including 12 observational studies and 2 randomized controlled trials were included in the systematic review. The meta-analysis included 10 studies with 12,690 patients that reported the measured outcomes, and excluded 4 studies that did not. Type II endoleaks had the highest incidence of 12% (95% confidence interval [CI]: 4-20%), followed by type III endoleaks with an incidence of 3% (95% CI: 1-5%). The incidence of type I endoleaks was 1% (95% CI: 0-2%). A subgroup analysis by follow-up duration showed that type II endoleak incidence was higher after 1 to 2 years of follow-up than 3 to 4 years of follow-up. The incidence of aneurysmal mortality was 2% (95% CI: 0-7%), limb occlusion was 1% (95% CI: 0-1%), stent graft migration was 1% (95% CI: 0-2%), aneurysmal rupture was 6% (95% CI: 2-11%), access site problems were 7% (95% CI: 2-13%), aneurysm sac growth was 2% (95% CI: 0-4%), all-cause mortality was 21% (95% CI: 4-38%), and technical success rate was 100% (95% CI: 98-100%). CONCLUSIONS: The unibody endograft is a safe and minimally invasive approach for AAA repair. However, potential complications necessitate close patient follow-up after the intervention.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Prótesis Vascular , Endofuga , Procedimientos Endovasculares , Diseño de Prótesis , Stents , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Implantación de Prótesis Vascular/instrumentación , Resultado del Tratamiento , Endofuga/etiología , Factores de Riesgo , Medición de Riesgo , Masculino , Anciano , Femenino , Factores de Tiempo , Persona de Mediana Edad , Anciano de 80 o más Años , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND: The Global Iliac Branch Study (NCT05607277) is an international, multicenter, retrospective cohort study of anatomic predictors of adverse iliac events (AIEs) in aortoiliac aneurysms treated with iliac branch devices (IBDs). METHODS: Patients with pre-IBD and post-IBD computed tomography imaging were included. We measured arterial diameters, stenosis, calcification, bifurcation angles, and tortuosity indices using a standardized, validated protocol. A composite of ipsilateral AIE was defined, a priori, as occlusion, type I or III endoleak, device constriction, or clinical event requiring reintervention. Paired t-test compared tortuosity indices and splay angles pretreatment and post-treatment for all IBDs and by device material (stainless steel and nitinol). Two-sample t-test compared anatomical changes from pretreatment to post-treatment by device material. Logistic regression assessed associations between AIE and anatomic measurements. Analysis was performed by IBD. RESULTS: We analyzed 297 patients (286 males, 11 females) with 331 IBDs (227 stainless steel, 104 nitinol). Median clinical follow-up was 3.8 years. Iliac anatomy was significantly straightened with all IBD treatment, though stainless steel IBDs had a greater reduction in total iliac artery tortuosity index and aortic splay angle compared to nitinol IBDs (absolute reduction -0.20 [-0.22 to -0.18] vs. -0.09 [-0.12 to -0.06], P < 0.0001 and -19.6° [-22.4° to -16.9°] vs. -11.2° [-15.3° to -7.0°], P = 0.001, respectively). There were 54 AIEs in 44 IBDs in 42 patients (AIE in 13.3% of IBD systems), requiring 35 reinterventions (median time to event 41 days; median time to reintervention 153 days). There were 18 endoleaks, 29 occlusions, and 5 device constrictions. There were no strong associations between anatomic measurements and AIE overall, though internal iliac diameter was inversely associated with AIE in nitinol devices (nAIE, nitinol = 8). CONCLUSIONS: Purpose-built IBDs effectively treat aortoiliac disease, including that with tortuous anatomy, with a high patency rate (91.5%) and low reintervention rate (9.1%) at 4 years. Anatomic predictors of AIE are limited.
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Aleaciones , Implantación de Prótesis Vascular , Prótesis Vascular , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares , Aneurisma Ilíaco , Valor Predictivo de las Pruebas , Diseño de Prótesis , Stents , Humanos , Femenino , Masculino , Aneurisma Ilíaco/diagnóstico por imagen , Aneurisma Ilíaco/cirugía , Aneurisma Ilíaco/fisiopatología , Estudios Retrospectivos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Anciano , Resultado del Tratamiento , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/efectos adversos , Factores de Tiempo , Factores de Riesgo , Anciano de 80 o más Años , Persona de Mediana Edad , Aortografía , Acero Inoxidable , Endofuga/etiología , Endofuga/diagnóstico por imagen , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/cirugía , Aneurisma de la Aorta/fisiopatología , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Arteria Ilíaca/cirugía , Estados UnidosRESUMEN
We present a rare case of short-segment jejunal infarction following inferior mesenteric artery embolisation for type 2 endoleak in a patient who previously underwent endovascular repair of abdominal aortic aneurysm. Potential causes for the event might include thromboembolism or traumatic thrombosis of a jejunal branch of the superior mesenteric artery (SMA) caused by a buddy guide wire used to maintain the position of the long vascular sheath in the SMA hiatus. The condition was recognised on CT and treated with resection of the infarcted segment of the small bowel followed by primary anastomosis.
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Embolización Terapéutica , Endofuga , Yeyuno , Arteria Mesentérica Inferior , Humanos , Arteria Mesentérica Inferior/diagnóstico por imagen , Embolización Terapéutica/métodos , Endofuga/etiología , Endofuga/diagnóstico por imagen , Endofuga/terapia , Yeyuno/irrigación sanguínea , Yeyuno/cirugía , Masculino , Aneurisma de la Aorta Abdominal/cirugía , Isquemia/etiología , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/efectos adversos , Tomografía Computarizada por Rayos X , AncianoRESUMEN
BACKGROUND: The occurrence of type II endoleaks after endovascular repair of aortic aneurysm has gradually gained increasing attention. We present a case of a patient with an expanding aneurysm after thoracic endovascular aortic repair (TEVAR) for a type II endoleak, in which successful direct ligations of the intercostal artery were performed using a sac incision without cardiopulmonary bypass (CPB) or graft replacement. CASE PRESENTATION: A 62-year-old male patient, previously treated with TEVAR for a descending thoracic aortic aneurysm, presented with ongoing chest discomfort. Based on the diagnosis of a growing aneurysm and type II endoleak, the patient was prepared for CPB and aortic cross-clamping, as a precautions against the possibility of a type I endoleak. A longitudinal opening of the thoracic aortic aneurysm sac was performed following left thoracotomy. Visual confirmation identified the T5 level intercostal artery as the source of the endoleak, and after confirming the absence of a type I endoleak, multiple ligations were applied to the intercostal artery. Follow-up computed tomography confirmed the absence of endoleaks or sac growth. CONCLUSION: In a case involving TEVAR for a thoracic aortic aneurysm, open suture ligations were used to treat type II endoleaks without having to resort to CPB, resulting in successful outcomes.
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Aneurisma de la Aorta Torácica , Endofuga , Procedimientos Endovasculares , Humanos , Masculino , Endofuga/cirugía , Endofuga/etiología , Persona de Mediana Edad , Aneurisma de la Aorta Torácica/cirugía , Procedimientos Endovasculares/métodos , Implantación de Prótesis Vascular/métodos , Implantación de Prótesis Vascular/efectos adversos , Tomografía Computarizada por Rayos X , Aorta Torácica/cirugía , Ligadura , Reparación Endovascular de AneurismasRESUMEN
INTRODUCTION: Type II endoleaks (T2ELs) following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) can lead to aneurysm growth, compromising the stent graft seal and risking rupture. Preventing these endoleaks during EVAR involves filling the AAA sac around the stent graft to exclude the aneurysm and block any arteries causing the endoleak. This study investigates the feasibility and safety of using AneuFix, a biocompatible injectable polymer developed by TripleMed (Geleen, the Netherlands), for aneurysmal sac filling during EVAR in high-risk T2EL patients. METHODS AND ANALYSIS: A feasibility, single-arm, single-centre clinical trial will initially include five patients with infrarenal AAA, eligible for EVAR, and at high risk for T2EL based on the number of patent lumbar arteries and the cross-sectional area of the aortic lumen at the level of the inferior mesenteric artery. Postevaluation by the Data Safety and Monitoring Board, the study cohort will extend to 25 patients. During EVAR and after stent graft deployment, the aneurysm sac is filled with AneuFix polymer using a filling sheath positioned parallel to the contralateral limb with the tip inside the aneurysm sac. Primary outcome is technical success (successful AAA sac filling). The secondary outcomes include clinical success at 6 and 12 months (occurrence of T2ELs and AAA growth assessed with CT angiography), intraoperative and perioperative complications, all endoleaks, adverse events, re-interventions, aneurysm rupture and patient survival. ETHICS AND DISSEMINATION: This trial was approved by the Dutch Authorities (Central Committee on Research Involving Human Subjects, IGJ), Amsterdam University Medical Centre Ethical Commission, and adheres to the Declaration of Helsinki and European Medical Device Regulation. Results will be shared at (inter)national conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04307992.
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Aneurisma de la Aorta Abdominal , Endofuga , Procedimientos Endovasculares , Estudios de Factibilidad , Polímeros , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares/métodos , Endofuga/prevención & control , Implantación de Prótesis Vascular/métodos , Stents , Prótesis Vascular , Masculino , Femenino , Países Bajos , Reparación Endovascular de AneurismasRESUMEN
Thoracic endovascular aortic repair (TEVAR) is a minimally invasive procedure involving the placement of an endograft inside the dissection or an aneurysm to direct blood flow and prevent rupture. A significant challenge in endovascular surgery is the geometrical mismatch between the endograft and the artery, which can lead to endoleak formation, a condition where blood leaks between the endograft and the vessel wall. This study uses computational modeling to investigate the effects of artery curvature and endograft oversizing, the selection of an endograft with a larger diameter than the artery, on endoleak creation. Finite element analysis is employed to simulate the deployment of endografts in arteries with varying curvature and diameter. Numerical simulations are conducted to assess the seal zone and to quantify the potential endoleak volume as a function of curvature and oversizing. A theoretical framework is developed to explain the mechanisms of endoleak formation along with proof-of-concept experiments. Two main mechanisms of endoleak creation are identified: local buckling due to diameter mismatch and global buckling due to centerline curvature mismatch. Local buckling, characterized by excess graft material buckling and wrinkle formation, increases with higher levels of oversizing, leading to a larger potential endoleak volume. Global buckling, where the endograft bends or deforms to conform to the centerline curvature of the artery, is observed to require a certain degree of oversizing to bridge the curvature mismatch. This study highlights the importance of considering both curvature and diameter mismatch in the design and clinical use of endografts. Understanding the mechanisms of endoleak formation can provide valuable insights for optimizing endograft design and surgical planning, leading to improved clinical outcomes in endovascular aortic procedures.
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Procedimientos Endovasculares , Modelos Cardiovasculares , Humanos , Procedimientos Endovasculares/métodos , Endofuga , Prótesis Vascular , Simulación por Computador , Análisis de Elementos Finitos , Implantación de Prótesis Vascular , Aorta Torácica/cirugía , Reparación Endovascular de AneurismasRESUMEN
OBJECTIVES: Aneurysm sac changes after fenestrated-branched endovascular aneurysm repair (FBEVAR) for postdissection thoracoabdominal aortic aneurysms (PD-TAAs) are poorly understood. Partial thrombosis of the false lumen and endoleaks may impair sac regression. To characterize sac changes after FBEVAR for PD-TAAs, this study examined midterm results and predictors for sac enlargement. METHODS: FBEVARs performed for PD-TAAs in 10 physician-sponsored investigational device exemption studies from 2008 to 2023 were analyzed. The maximum aortic aneurysm diameter was compared between the 30-day computed tomography angiogram and follow-up imaging studies. Aneurysm sac enlargement was defined as an increase in diameter of ≥5 mm. Kaplan-Meier curves and Cox regression were used to evaluate sac enlargement and midterm FBEVAR outcomes. RESULTS: Among 3296 FBEVARs, 290 patients (72.4% male; median age, 68.4 years) were treated for PD-TAAs. Most aneurysms treated were extent II (72%) and III (12%). Mean aneurysm diameter was 66.5 ± 11.2 mm. Mortality at 30 days was 1.4%. At a mean follow-up of 2.9 ± 1.9 years, at least one follow-up imaging study revealed sac enlargement in 43 patients (15%), sac regression in 115 patients (40%), and neither enlargement nor regression in 137 (47%); 5 (2%) demonstrated both expansion and regression during follow-up. Freedom from aneurysm sac enlargement was 93%, 82%, and 80% at 1, 3, and 5 years, respectively. Overall, endoleaks were detected in 27 patients (63%) with sac enlargement and 143 patients (58%) without enlargement (P = .54). Sac enlargement was significantly more frequent among older patients (mean age at the index procedure, 70.2 ± 8.9 years vs 66.5 ± 11 years; P = .04) and those with type II endoleaks at 1 year (74% vs 52%; P = .031). Cox regression revealed age >70 years at baseline (hazard ratio [HR], 2.146; 95% confidence interval [CI], 1.167-3.944; P = .010) and presence of type II endoleak at 1 year (HR, 2.25; 95% CI, 1.07-4.79; P = .032) were independent predictors of sac enlargement. Patient survival was 92%, 81%, and 68% at 1, 3, and 5 years, respectively. Cumulative target vessel instability was 7%, and aneurysm-related mortality was 2% at 5 years. At least 42% of patients required secondary interventions. Sac enlargement did not affect patient survival. CONCLUSIONS: Aneurysm sac enlargement occurs in 15% of patients after FBEVAR for PD-TAAs. Elderly patients (>70 years at baseline) and those with type II endoleaks at 1 year may need closer monitoring and secondary interventions to prevent sac enlargement. Despite sac enlargement in some patients, aneurysm-related mortality at 5 years remains low and overall survival was not associated with sac enlargement.
Asunto(s)
Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Prótesis Vascular , Procedimientos Endovasculares , Humanos , Anciano , Femenino , Masculino , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Implantación de Prótesis Vascular/instrumentación , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Factores de Tiempo , Factores de Riesgo , Resultado del Tratamiento , Estudios Retrospectivos , Persona de Mediana Edad , Endofuga/etiología , Endofuga/diagnóstico por imagen , Disección Aórtica/cirugía , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Diseño de Prótesis , Anciano de 80 o más Años , Medición de Riesgo , StentsRESUMEN
BACKGROUND: Assess subsequent cardiovascular events and all-cause mortality in patients with intact abdominal aortic aneurysm (AAA) treated by endovascular aneurysm repair (EVAR) according to the existence of isolated endoleak type 2 (EL2) at 1 year after EVAR implantation. METHODS: This retrospective, single-center study included patients treated with EVAR between 2010 and 2017 in the vascular surgery department of the University Hospital of Lyon with an infrarenal AAA > 50 mm. The baseline clinical characteristics collected just before EVAR were retrieved from electronic patient records of our institution. AAA characteristics, procedure, and the 1-year postoperative computed tomography angiography (CTA) were reported. Study end points, major adverse cardiovascular events (MACE), major adverse lower-extremity events (MALE), and all-cause mortality were recorded during follow-up. Patients were divided into 2 groups according to the presence of isolated EL2 (EL2 +) or absence (EL2 -) of any endoleak on CTA at 1 year. MACE, MALE, and all-cause mortality were compared between both groups. RESULTS: During the study period, 589 patients were treated by endovascular surgery and 207 were included. According to the CTA results at 1 year, 60 patients (29%) were included in the EL2 + group and 147 patients (71%) in the EL2 - group. A total of 109 patients (53%) experienced a MACE or MALE; significantly fewer patients in the EL2 + than in the EL2 - group did so (P = 0.009). There were 47 patients (23%) who experienced at least 1 MALE, and the frequency was significantly lower in the EL2 + group (P = 0.017). CONCLUSIONS: Patients with AAA treated by EVAR who did not develop EL2 at 1 year were at higher risk of MALE during follow-up. This might be explained by more frequent symptomatic lower extremity peripheral arterial disease at baseline in this group. These patients therefore require a closer follow-up and strict control of cardiovascular risk factors to prevent cardiovascular morbi-mortality.
Asunto(s)
Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Endofuga , Procedimientos Endovasculares , Humanos , Masculino , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Estudios Retrospectivos , Endofuga/etiología , Endofuga/mortalidad , Endofuga/diagnóstico por imagen , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Anciano , Factores de Riesgo , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Anciano de 80 o más Años , Medición de Riesgo , Angiografía por Tomografía Computarizada , Enfermedades Cardiovasculares/mortalidad , Causas de MuerteRESUMEN
BACKGROUND: Late open conversion (LOC) following endovascular aneurysm repair (EVAR) is a rare complication with a high morbidity and mortality and is often proposed as the last line of treatment after failure of endovascular reintervention of any type. This study aimed to highlights the limitations of EVAR follow-up imaging in characterizing endoleaks, which may contribute to the failure of endovascular reinterventions and lead to LOC. METHODS: This retrospective cohort study recruited all EVAR implanted in Amiens University Hospital (France) between January 2008 and December 2022. Elective LOC was defined as surgical conversion >1 month after EVAR. The primary endpoint was the rate of wrong categorization of endoleaks by follow-up exams before LOC. Secondary endpoints were the morbidity and the mortality associated with LOC. RESULTS: Seven hundred eight EVARs were performed in our institution, 30 required elective LOC. Twenty-five of them were treated for sac enlargement due to an endoleak (83.3%) (all types). Wrong categorization of the endoleak was noted in 13 patients (52.2%). Twelve of these recategorizations involved the preoperative diagnosis of a type II endoleaks (92.3%). The change in categorization in 7 out of 12 cases (58%) was in favor of a type I endoleak, other recategorization included 1 type III (8%) and 4 type IV (33%). One patient died during the 30-day postoperative period and 7 patients (28%) presented a major complication; the median length of stay was 13 days (interquartile range 9-21). CONCLUSIONS: Routine follow-up examinations such as angioscanner and contrast Doppler ultrasound appear to be limited in their ability to categorize the type of persistent endoleak, which may increase the number of patients requiring LOC. New precision diagnostic imaging techniques, such as dynamic examinations, need to be developed to limit the need for LOC.
Asunto(s)
Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Conversión a Cirugía Abierta , Endofuga , Procedimientos Endovasculares , Valor Predictivo de las Pruebas , Humanos , Estudios Retrospectivos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Endofuga/etiología , Endofuga/diagnóstico por imagen , Endofuga/cirugía , Masculino , Femenino , Anciano , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Implantación de Prótesis Vascular/instrumentación , Factores de Tiempo , Anciano de 80 o más Años , Francia , Factores de Riesgo , Resultado del Tratamiento , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Conversión a Cirugía Abierta/efectos adversosRESUMEN
OBJECTIVES: Endovascular aneurysm repair, though minimally invasive and has the benefit of relatively low perioperative complication rates, it is associated with significant long term reintervention rates related to endoleaks. Several variables have been studied to predict the outcomes of endovascular aneurysm repair, 1 of which is the calcium burden of the vasculature. This prompted us to study the association between calcium burden measured by the standardized Agatston scoring system and the outcomes of Endovascular aneurysm repair. METHODS: This is a retrospective study of patients who underwent Endovascular aneurysm repair from 2008 to 2020 at our institution and who had a non-contrast computerized tomography scan preoperatively, accounting for 87 patients. The calcium burden of the vasculature was measured by the Agatston scoring system allowing for better reproducibility, and the outcome variables included mortality and endoleaks. RESULTS: Patients with higher median total calcium scores (≥12966.9) had significantly lesser survival (79.8% vs 52.3% (P = .002) at five years compared to patients with lower median total calcium score (<12966.9). Also, patients with type 2 endoleaks had higher calcium scores in above the aneurysm level ((1591.2 vs 688.2), P = .05)) compared to patients with no type 2 endoleaks. CONCLUSION: Calcium score assigned using a standardized Agatston scoring system can be used as a predictor of mortality risk assisting in deciding the treatment of choice for patients.
Asunto(s)
Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Endofuga , Procedimientos Endovasculares , Valor Predictivo de las Pruebas , Calcificación Vascular , Humanos , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Estudios Retrospectivos , Masculino , Femenino , Anciano , Factores de Riesgo , Resultado del Tratamiento , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Endofuga/etiología , Endofuga/diagnóstico por imagen , Medición de Riesgo , Factores de Tiempo , Anciano de 80 o más Años , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/mortalidad , Calcificación Vascular/terapia , Angiografía por Tomografía Computarizada , Aortografía , Persona de Mediana EdadRESUMEN
OBJECTIVE: A type 2 endoleak (T2EL) is the most frequently occurring endoleak type after endovascular aneurysm repair (EVAR). Residual T2ELs may cause aneurysm rupture; however, the management of a T2EL remains controversial. This study evaluated sac branch preemptive embolization using N-butyl-2-cyanoacrylate, aiming to prevent T2ELs and sac shrinkage. METHODS: Twelve consecutive patients underwent elective preemptive embolization during EVAR at our hospital between August 2018 to March 2019. Their demographic information, operative details, and sac diameters were examined at 6 months after EVAR. RESULTS: No procedural complications were observed. There were no in-hospital deaths among the 12 patients. Sac shrinkage was observed in this cohort (53.8-52.1 mm, p = 0.01). A total of 33 lumbar arteries were occluded with this procedure, and 2 patients had residual T2ELs at 6 months. CONCLUSIONS: A T2EL in preemptive sac branch embolization during EVAR has advantages in terms of safety and reduction. Although no clear evidence is available for the management of T2ELs, this study proposes a new standard to prevent it and improve the long-term outcomes after EVAR. However, embolization remains imperfect and further research is necessary.
Asunto(s)
Aneurisma de la Aorta Abdominal , Embolización Terapéutica , Enbucrilato , Endofuga , Procedimientos Endovasculares , Humanos , Embolización Terapéutica/métodos , Enbucrilato/administración & dosificación , Procedimientos Endovasculares/métodos , Masculino , Femenino , Anciano , Endofuga/prevención & control , Endofuga/etiología , Anciano de 80 o más Años , Resultado del Tratamiento , Aneurisma de la Aorta Abdominal/cirugía , Reparación Endovascular de AneurismasRESUMEN
OBJECTIVE: Type II endoleak (T2EL) is the most common type of endoleak after endovascular aneurysm repair (EVAR) and a common indication for reintervention due to late sac enlargement. Although pre-emptive embolization of the inferior mesenteric artery (IMA) has been proposed to prevent this, no studies have prospectively demonstrated its efficacy. This study aimed to prove the validity of IMA embolization during EVAR in selective cases by analyzing the mid-term outcomes of a randomized clinical trial (RCT). METHODS: This single-center, parallel-group, non-blinded RCT included participants at high risk of T2EL, characterized by a patent IMA in conjunction with one or more following risk factors: a patent IMA ≥3 mm in diameter, lumbar arteries ≥2 mm in diameter, or an aortoiliac-type aneurysm. The participants were randomly assigned to two groups in a 1:1 ratio: one undergoing EVAR with IMA embolization and the other without. The primary endpoint was T2EL occurrence. The secondary endpoints included aneurysm sac changes and reintervention. In addition to RCT participants, outcomes of patients with low risk of T2EL were also analyzed. RESULTS: The embolization and non-embolization groups each contained 53 patients. Five-year follow-up after the last patient enrollment revealed that T2ELs occurred in 28.3% and 54.7% of patients in the IMA embolization and non-embolization groups, respectively (P = .006). Both freedom from T2EL-related sac enlargement ≥5 mm and cumulative incidence of sac shrinkage ≥5 mm were significantly higher in the IMA embolization group than in the non-embolization group (95.5% vs 73.6% at 5 years; P = .021; 54.2% vs 33.6% at 5 years; P = .039, respectively). The freedom from T2EL-related sac enlargement ≥10 mm, an alternative indicator for T2EL-related reintervention, showed similar results (100% vs 90.4% at 5 years; P = .019). Outcomes in the low-risk group were preferable than those in the non-embolization group and comparable to those in the IMA embolization group. CONCLUSIONS: A lower threshold for pre-emptive IMA embolization when implementing EVAR would be more appropriate if limited to patients at high risk of T2ELs.
Asunto(s)
Aneurisma de la Aorta Abdominal , Embolización Terapéutica , Endofuga , Reparación Endovascular de Aneurismas , Arteria Mesentérica Inferior , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Embolización Terapéutica/efectos adversos , Endofuga/etiología , Endofuga/prevención & control , Endofuga/terapia , Reparación Endovascular de Aneurismas/efectos adversos , Estudios de Seguimiento , Arteria Mesentérica Inferior/diagnóstico por imagen , Estudios Prospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Endovascular aortic repair (EVAR) has become the standard of care for patients with infrarenal aortic aneurysms over the last 2 decades. Endograft technology and treatment of complications like endoleaks, graft migration, or graft occlusion developed over time. However, sometimes open surgical conversion maybe required. Our aim was to analyze the indications, the technical aspects and outcomes in patients who underwent open conversion after EVAR with different types and generations of endografts. METHODS: This retrospective single-center study reviewed all patients who underwent EVAR from 2004 to 2020. Open surgical conversions >1 month post EVAR were identified. Conversions for graft infection were excluded. Indications for conversion and operative technique were analyzed. Primary endpoint of the study was 30-day mortality. Secondary endpoints were re-interventions and follow-up mortality. RESULTS: During 2004 and 2020, 443 consecutive EVARs were performed, and 28 patients required open surgical conversion, with an additional 3 referred from other hospitals (N = 31). The median age was 75 (range 58-93); 94% were male. Conversion was performed after a median time of 55 months (range 16-209). Twenty patients underwent elective and 11 emergency conversion. Indications for open conversion were graft migration, respectively, disease progression with endoleak type Ia and/or Ib in 52% (16/31) and sac expansion due to endoleak type II in 26% (8/31). Of the 31 patients, 17 (55%) had at least one previous endovascular re-intervention. All patients met the device-specific instructions for use for each implanted endograft. In-hospital intervention rate was 16% (5/31). Thirty-day mortality rate was 3% (1/31) with one patient died due to multiorgan failure after rupture with complete endograft replacement. Five patients (16%) died during follow-up. Mid-term follow-up was 47.5 months (range 24-203) with estimated cumulative survival rates of 97%, 89%, and 84%, at 1, 3, and 5 years, respectively. CONCLUSIONS: Late open conversion remains a valuable treatment option and can be performed safely in elective and emergency setting with a low early mortality. Lifelong surveillance and prompt intervention when necessary are essential in ensuring optimal outcomes after EVAR and preventing the need for emergent conversions.