PURPOSE: To compare the outcome of endovascular aneurysm repair (EVAR) versus conventional open repair (OR) in patients with a short, angulated or otherwise challenging proximal neck. METHODS: The definition of a challenging proximal neck was based on diameter (>or=28 mm), length (or=60 degrees ), shape (reverse tapered or bulging), and thrombus lining (>50%). Between January 2005 and December 2007, 187 consecutive patients (159 men; mean age 73 years, range 48-92) operated for asymptomatic abdominal aortic aneurysm (AAA) were identified as having challenging proximal neck morphology. Of these, 61 patients were treated with OR at center I (group A), 71 with standard EVAR (group B; 45 center I, 29 center II) and 52 with fenestrated EVAR (group C) at center II. Clinical examination and computed tomography were performed at 1 month and yearly thereafter. RESULTS: There was no statistically significant difference between groups A, B, and C regarding primary technical success rate, 30-day mortality, or late AAA-related mortality. The mean length of follow-up was 19.5 months (range 0-40). Freedom from reintervention at 3 years was 91.8%, 79.7%, and 82.7% for groups A, B, and C, respectively (p = 0.042). The only statistically significant difference between standard and fenestrated EVAR was a higher incidence of late sac expansion [9 (12.2%) versus 1 (1.9%), p = 0.036] in the standard stent-graft group. Reinterventions were more frequent after EVAR (p = NS), but open reinterventions were more common after OR. Reinterventions after EVAR were related to the presence of an angulated (p = 0.039) or short neck (p = 0.024). CONCLUSION: The results of EVAR and OR were similar for AAAs with a challenging proximal neck. Endovascular reinterventions were more frequent after EVAR, particularly in patients with an angulated or short neck. Open reinterventions were more common after OR. More patients and long-term data are needed to confirm these findings.
To assess the rate of complications associated with the fascia closure technique for femoral access sites in which 18-F or 20-F sheaths were introduced during endovascular aneurysm repair (EVAR).
A retrospective analysis was done of 50 consecutive patients (41 men; median age 75 years, range 62-85) who received Excluder stent-grafts in planned percutaneous EVAR procedures from May 2006 until December 2009. The fascia closure technique was routinely used for all femoral access sites in which large bore (18-F and 20-F) introducers were employed. One patient with extremely calcified and narrowed vessels was converted to primary cutdown bilaterally after percutaneous access failed. In the 49 remaining patients, 81 femoral access sites were closed with the fascia closure technique; 17 sites with smaller 12-F introducers were closed using other techniques. Computed tomographic angiography (CTA) was performed within 30 days, at 6 months, and at 1, 2, and 3 years.
Of the 81 femoral access sites closed with the fascia closure technique, only 1 patient had persistent bleeding that required an immediate cutdown and suture repair of the deep femoral artery (99.0% technical success rate). In the immediate postoperative period, 5 patients required additional interventions for bleeding (n?=?2), occlusion (n?=?2), or a pseudoaneurysm [92.6% 30-day technical success]. At 30 days, 11 (13.9%) of 79 access sites had pseudoaneurysms, all of which resolved within a year; none required a secondary intervention. Later surveillance scans did not detect pseudoaneurysms.
The fascia closure technique during EVAR is safe and has few complications. The low frequencies of pseudoaneurysms and other access site complications make the femoral closure technique a durable alternative.
To report the early results of a multicenter registry of endovascular aneurysm repair (EVAR) using the Endurant stent-graft.
Patients having elective treatment of infrarenal abdominal aortic aneurysm (AAA) with the Endurant stent-graft at 3 Canadian centers were enrolled in a prospective registry between September 2008 and January 2010. In the 16-month period, 111 patients (90 men; mean age 75 years, range 53-93) were registered. Thirty-seven (33.3%) patients had challenging anatomy: short proximal aortic necks (n=17), large diameter (>28 mm) aortic necks (n=4), angulated (>60°) necks (n=3), and small (5 mm, secondary intervention, stent-graft migration, and graft thrombosis.
The overall technical success rate was 100%. Nineteen (17.1%) patients experienced perioperative complications. After a mean follow-up of 6 months (range 0.1-16), mortality in the series was 4.5%: 1 perioperative death (multisystem organ failure) and 4 (3.6%) late deaths (3 cardiac, 1 cancer). Clinical and imaging follow-up past the perioperative period were available in 107 (96.4%) and 99 (89.2%) patients, respectively. Among the latter, 9 (9.1%) had a type II endoleak on the first scan; 4 resolved spontaneously. Three (3.0%) patients developed graft limb thrombosis in follow-up; one required an intervention. There was no graft migration, aneurysm expansion, secondary intervention for endoleak, aneurysm rupture, or conversion.
Early results from this prospective multicenter registry indicate that the Endurant stent-graft is a safe option for elective EVAR in selected AAA patients. Longer follow-up is required to determine the durability of these outcomes.
Aortic prosthetic graft infection (AGI) is a major challenge in vascular surgery. Eradicating the infection requires prosthetic material removal, debridement, and lower limb revascularization. For the past 15 years, we have used femoral veins for aorto-iliac reconstruction and tensor fascia lata to strengthen the upper anastomosis.
The purpose of this single institution retrospective study is to present results regarding in situ replacement of infected aortic grafts with autologous femoral veins (FVs).
From October 2000 to March 2013, patients treated for AGI with graft removal and autologous FV reconstruction at Helsinki University Hospital were included. Primary outcome measures were 30 day mortality, long-term treatment related mortality, and re-infection rate. Secondary outcome measures were long-term all cause mortality and event free survival (graft rupture, re-intervention, major amputation).
During a 13 year period 55 patients (42 male, 13 female) were operated on using a venous neo-aorto-iliac system for AGI. The mean follow up was 32 months (1-157 months). The 30 day mortality rate was 9% (5) and overall treatment related mortality 18% (10). All cause mortality during follow up was 22 (40%) and overall Kaplan-Meier survival was 90.7% at 30 days, 81.5% at 1 year, and 59.3% at 5 years. Graft rupture occurred in three (5%) cases, two of which were caused by graft re-infection (4%). Four patients required major amputation, one of them on arrival and three (5%) during the post-operative period. Nine (16%) patients needed interventions for the vein graft, and two graft limbs occluded during follow up.
In situ reconstruction for aortic graft infection with autologous FV presents acceptable rates of morbidity and mortality, and remains the treatment of choice for AGI at Helsinki University Hospital.
This study reports the early and midterm to long-term experience of chimney grafts (CGs) in urgent endovascular repair of complex lesions in the thoracic aorta.
Twenty-nine high-risk patients (20 men) who were unfit for open repair were treated using CG technique for ruptured (n = 14) or symptomatic (n = 15) aortic lesions engaging the aortic arch itself (n = 9), the descending aorta (n = 10), or the thoracoabdominal aorta (n = 10). Twenty-two patients (76%) were treated urgently (=24 hours) and seven were semiurgent (=3 days). Of 41 chimneys used, 24 were placed in supra-aortic branches and 17 in visceral branches. Median follow-up (interquartile range) for the entire cohort was 2 years (0.6-3.8 years), 2.5 years (1-4 years) for 30-day survivors, and 3.5 years (1.9-6.4 years) for those who were still alive.
Four patients (14%) died =30 days of cerebral infarction (n = 1), visceral ischemia secondary to the initial rupture (n = 1), multiple organ failure (n = 1), or heart failure (n = 1). There were 11 late deaths (38%); however, only two deaths were related to the CG technique. The primary and secondary technical success rates were 86% (25 of 29) and 97% (28 of 29), respectively. The secondary patency rate of CGs was 98%. Seventeen (68%) of the aortic lesions shrank significantly. Three patients (10%) had primary type I endoleak and another three (10%) had secondary type I endoleak. The endoleaks were managed with Onyx (ev3 Endovascular, Inc, Plymouth, Minn) or coil embolization (n = 2), restenting (n = 1), and conversion to open repair (n = 2). One secondary endoleak is still under observation after >20 months. All primary endoleaks and one secondary endoleak originated from CGs in the brachiocephalic trunk (4 of 6 [67%]).
The midterm to long-term results of the CG technique for urgent and complex lesions of the thoracic aorta in high-risk patients are promising, with low early mortality and long durability of the CGs. More patients with longer follow-up are still needed.
To report an initial experience and midterm results of a novel hybrid technique (EndoVAC) combining stent-grafts, surgical revision, and vacuum-assisted wound closure (VAC).
All 10 patients (5 men; mean age 62 years) treated with the EndoVAC technique for infected vascular reconstructions (5 carotid, 4 femoral) or access sites (1 femoral and 1 brachial artery) between November 2007 and June 2010 were retrospectively reviewed. Follow-up included laboratory investigations, duplex ultrasonography, and imaging.
VAC therapy was applied for a median 15 days (range 9-54). Three complications occurred: a watershed infarction (dysphasia), a transient hypoglossal nerve palsy, and a late stent-graft thrombosis. Two patients died during treatment but with local infection under control. Over a median follow-up of 11 months (range 1-33), no recurrent infection was noted after healing of the skin in any of the 8 survivors.
The EndoVAC technique seems to be a promising option for treatment of infected vascular reconstructions in selected cases.
Acute thromboembolic occlusion of the superior mesenteric artery (SMA) is associated with high mortality. Recent advances in diagnostics and surgical techniques may affect outcome.
Through the Swedish Vascular Registry (Swedvasc), 121 open and 42 endovascular revascularizations of the SMA at 28 hospitals during 1999 to 2006 were identified. Patient medical records were retrieved, and survival was analyzed with multivariate Cox-regression analysis.
The number of revascularizations of the SMA increased over time with 41 operations in 2006, compared to 10 in 1999. Endovascular approach increased sixfold by 2006 as compared to 1999. The endovascular group had thrombotic occlusion (P
Success with the neoaortoiliac system (NAIS) bypass has previously been reported. Drawbacks to this procedure include prolonged operative times and significant morbidity. The aim of this study was to evaluate whether a 2-team approach in addition to a consistent anastomosis technique reduces the operative time of the NAIS procedure.
A single-center retrospective review was performed for operations using femoral vein in arterial reconstruction from 2003 to 2012.
A total of 40 patients, 25 men and 15 women, were included for analysis. Median operative time for all operations was 300 minutes (interquartile range). Thirty-day mortality was 7.5% (n = 3). Assisted primary patency at 1 year was 100%.
A 2-surgical team approach can reduce the operative time by up to 50%. This improves the attractiveness of this procedure, particularly when recalling that the treatment is definitive by virtue of its eradication of the source of infection.
The aim of this study was to estimate the incidence of the post-implantation syndrome/systemic inflammatory response syndrome (SIRS) after endovascular aortic repair.
All patients, undergoing elective primary endovascular repair of an asymptomatic infrarenal abdominal aortic aneurysm during 2007, were retrospectively evaluated for SIRS within the first 5 postoperative days. The only exclusion-criteria were missing data. SIRS was assessed using the criteria defined by the American College of Chest Physicians and Society of Critical Care Medicine Consensus Conference Committee.
Sixty-six patients were included, 40 (60%) met the SIRS criteria within the first 5 postoperative days (95% of the 40 patients met the criteria within 3 days). We found no significant differences between the SIRS and the non-SIRS group in baseline characteristics or other data including volume of the contrast media used, type of groin access, adjunctive procedures and duration of surgery. In total, 11 (28%) patients in the SIRS group and 4 (15%) patients in the non-SIRS group underwent re-interventions. Median follow-up period was 26 (range 20-32) months. Thirty-day mortality did not differ in the groups (3% in the SIRS group vs. none in the non-SIRS group).
The high incidence of SIRS after EVAR is unexpected considering the minimally invasive procedure. Further studies on the cause of this response and measures to attenuate the response seem appropriate.
Only limited data on the long-term results after endovascular aneurysm repair exist to date.
Data on 282 patients with an abdominal aortic aneurysm treated with a Zenith endoprosthesis between March 2000 and March 2010 were retrospectively analyzed from a prospective database. Operative, total, and aneurysm-related mortality was assessed, as were graft-related complications and reinterventions.
All procedures were performed successfully without primary conversions. Median follow-up was 40 months (range: 1-119 months). Thirty-day mortality was 1.4%, and aneurysm-related mortality was 0.7%. Cumulative survival was 62% at 5 years and 52% at 8 years. Graft-related complications occurred in 107 (38%) patients. The most common finding was a type II endoleak (n = 73) that sealed mainly spontaneously (n = 46, 63%). Most endoleaks, and complications in general (87%), appeared during the first 3 years of follow-up, and no events occurred after 6 years. Altogether, 59 additional procedures, mainly embolizations (n = 35), in 38 patients (24%) were required owing to graft-related complications. Of all the reinterventions, 82% were performed during the first 4 years, and no new complications were treated after 6 years.
Complications and reinterventions related to endovascular aneurysm repair become practically nonexistent after 5 to 6 years. This finding suggests that a lifelong follow-up may not always be needed after treatment with a Zenith endoprosthesis.