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Hence J M Verhagen - One of the best experts on this subject based on the ideXlab platform.
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regarding outcomes of persistent intraoperative type ia endoleak after standard Endovascular Aneurysm Repair
2015Co-Authors: Nelson Oliveira, Frans L. Moll, Frederico Bastos Goncalves, Joost A Van Herwaarden, Hence J M VerhagenAbstract:Objective This study analyzed outcomes for patients with persistent intraoperative type Ia endoleaks after standard Endovascular Aneurysm Repair (EVAR). Methods The study group was identified from a consecutive cohort of 209 patients undergoing EVAR in a tertiary center in the United Kingdom during a 2-year period. Data prospectively collected on departmental computerized databases were retrospectively analyzed. Primary outcome parameters were defined as freedom from type Ia endoleak, EVAR-related reintervention, Aneurysm rupture, and Aneurysm-related mortality. Results A completion angiogram identified 44 patients (21%) as having a type Ia endoleak, and 33 (75%) had a persistent endoleak after intraoperative adjunctive procedures, including repeated balloon moulding, aortic cuff extension, and Palmaz stent (Cordis, Miami Lakes, Fla) deployment. In the 11 patients (25%) whose endoleak was successfully abolished intraoperatively, there was no recurrence of type Ia endoleak or secondary intervention to treat type 1a endoleak during a median follow-up period of 27 months. Of the 33 patients with persistent endoleak, 31 (94%) demonstrated resolution of the endoleak on first surveillance computed tomography angiography. One patient was lost to follow-up. Embolization of the endoleak in another patient was successful using Onyx (Micro Therapeutics, Inc, Irvine, Calif) 8 days after the initial procedure. No type Ia endoleak was identified after this on any surveillance imaging, and the patient was alive 28 months later with a stable Aneurysm size. In the rest of the patients, no recurrence of the endoleak in any subsequent imaging was noticed, and no secondary intervention was required during follow-up. No Aneurysm-related deaths occurred, and 91% of the patients had a stable or shrinking Aneurysm. Conclusions Despite adjunctive intraoperative maneuvers, persistent type Ia endoleaks can be relatively common. Our study indicates that they may be observed in selected patients. Further research is required to investigate the natural course and management of type Ia endoleaks identified intraoperatively.
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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
2013Co-Authors: Frederico Bastos Goncalves, Koen M Van De Luijtgaarden, Sanne E Hoeks, Johanna M Hendriks, Sander Ten Raa, Ellen V Rouwet, Robert Jan Stolker, Hence J M VerhagenAbstract: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 & 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 adverse events. Multivariable Cox regression was used to test postoperative CTA characteristics as independent risk factors, which were subsequently used as selection criteria for low-risk and high-risk groups. Estimates for freedom from adverse events were obtained using Kaplan-Meier survival curves. Results Included were 131 patients. The median follow-up was 4.1 years (interquartile range, 2.1-6.1). During this period, 30 patients (23%) sustained Aneurysm-related adverse events. Seal length P Conclusions Our results suggest that the first postoperative CTA provides important information for risk stratification after Endovascular Aneurysm Repair when the Excluder endoprosthesis is used. In patients with adequate seal and no endoleaks, the risk of Aneurysm-related adverse events was significantly reduced, resulting in a large number of unnecessary image examinations. Adjusting the imaging protocol beyond 30 days and up to 5 years, based on individual patients' risk, may result in a more efficient and rational postoperative surveillance.
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decision making in follow up after Endovascular Aneurysm Repair based on diameter and volume measurements a blinded comparison
2003Co-Authors: Monique Prinssen, Hence J M Verhagen, Eric L G Verhoeven, J D BlankensteijnAbstract:Abstract Objective: to assess whether volume, in addition to diameter, measurements facilitate decision-making after Endovascular Aneurysm Repair (EVAR). Material/Methods: patients ( n = 82) with an immediately post-EVAR, and at least one follow-up (3-60 months), computed tomographic angiogram (CTA) were studied. The actual and all preceding proportional sac size changes were recorded. The resulting 347 diameter and 347 volume data were placed in random order and reviewed by three blinded observers who then recommended one of three treatment policies: "good/wait", "uncertain/intensify follow-up" or "not good/further diagnostics (Dx) or intervention (Rx)". The observers were instructed to consider changes of 10% relevant. One observer reviewed the graphs twice. Results: the interobserver agreements (kappa) for the diameter were 0.92, 0.81 and 0.76 and for volumes 0.91, 0.88 and 0.86. The intra-observer agreement was 0.93 for both diameter and volume. Volume data resulted in significantly more "good/wait" decisions out to 36 months. Diameter data resulted in more "not good/Dx or Rx"-decisions out to 36 months (all p Conclusion: post-EVAR Aneurysm sac volume data appears to provide earlier reassurance, reduce unnecessary interventions and to be more sensitive to secondary problems than diameter data alone. Eur J Vasc Endovasc Surg 26 , 184-187 (2003)
Richard G Mcwilliams - One of the best experts on this subject based on the ideXlab platform.
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Endovascular Aneurysm Sealing Is Associated With Reduced Radiation Exposure and Procedure Time Compared With Standard Endovascular Aneurysm Repair
2016Co-Authors: George A Antoniou, Robert K Fisher, Richard G Mcwilliams, Yashika Senior, Luigi Iazzolino, Andrew England, Francesco TorellaAbstract:Purpose: To compare indirect measures of radiation exposure and operating time between Endovascular Aneurysm sealing (EVAS) and Endovascular Aneurysm Repair (EVAR) for the treatment of abdominal aortic Aneurysm (AAA). Methods: The study compared 32 consecutive patients (mean age 78 years; 21 men) with AAA who underwent standard EVAS with 32 consecutive patients (mean age 78 years; 25 men) treated with EVAR between November 2013 and May 2015. Electronic medical records and image archiving databases were interrogated to retrieve relevant information and scans. Screening time and dose area product (DAP) were the primary outcome measures. Data are presented as median and interquartile range (IQR). Correlations were tested with the Spearman rank coefficient (ρ). Results: The screening time was shorter in EVAS than in EVAR [16 (IQR 14, 20) vs 32 (IQR 26, 38) minutes; p
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fractured superior mesenteric artery stents after fenestrated Endovascular Aneurysm Repair
2013Co-Authors: Rana Canavati, J A Brennan, S R Vallabhaneni, Robert K Fisher, Richard G McwilliamsAbstract:Stent fracture after fenestrated Endovascular Aneurysm Repair is a recognized complication. In this report, we record the occurrence of superior mesenteric artery stent fractures in our series and describe the management of embolized stent fragments during secondary intervention.
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aortic side branch embolization before Endovascular Aneurysm Repair incidence of type ii endoleak
2001Co-Authors: Derek A Gould, J A Brennan, Richard G Mcwilliams, Richard D Edwards, Janis Martin, Donagh White, Elizabeth Joekes, Peter Rowlands, G L Gillingsmith, Peter L HarrisAbstract:PURPOSE: To assess the feasibility of embolization of aortic side branches and its impact on the incidence of type II endoleak after Endovascular Aneurysm Repair. MATERIALS AND METHODS: Endovascular Aneurysm Repair was performed in 74 patients. Aortic side branch vessels were evaluated on the preoperative angiogram and computed tomography (CT) and, where embolization of lumbar and inferior mesenteric vessels was considered technically possible, this was attempted prior to Endovascular Repair. Follow-up CT was used to assess the presence of type II endoleak. RESULTS: Seventy-two patients were followed up for longer than 1 month. Embolization was attempted in 25 cases, successfully in 10, with partial success in 11, and failure in four. Twenty patients with successful or partly successful preoperative embolization were discharged and followed-up. Four (20%) had demonstrable type II endoleak during follow-up, with two of these persisting at latest follow-up. Of 43 patients without previous embolization, there were 10 (23.3%) type II endoleaks during the follow-up period, four of these persisting. In cases with type II endoleak, mean sac diameter change was -0.5 mm in the cases with previous embolization and +3.1 mm without. The mean period to onset of type II endoleak was 6.9 months without, and 15.3 months with, previous embolization. CONCLUSION: Although the cohort size is below a level that would confer significance, the trend of these findings is such as to suggest a lack of influence of aortic side branch embolization on the incidence of type II endoleak during the follow-up period.
Matthew J Eagleton - One of the best experts on this subject based on the ideXlab platform.
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renal artery coverage during Endovascular Aneurysm Repair for ruptured abdominal aortic Aneurysm
2019Co-Authors: Adam Tanious, Matthew J Eagleton, Jason T Lee, Laura T Boitano, Linda J Wang, Murray L Shames, Darrin W Clouse, Mark F ConradAbstract:Introduction Coverage of one or both renal arteries may be required to facilitate Endovascular Aneurysm Repair (EVAR) in patients who are not candidates for open surgery in ruptured abdominal aortic Aneurysms (rAAAs). We sought to understand the consequences of renal coverage during these emergent procedures. Methods Using the VQI data set from 2013 to 2018, we selected patients who had undergone EVAR for rAAA. Patients were distinguished by whether they had none, unilateral, or bilateral renal artery coverage. Patients were excluded if they were previously on dialysis or had an intervention to preserve renal perfusion. Primary endpoints included inhospital mortality, composite permanent dialysis/30-day death, and 1-year survival. Results Overall, there were 2,278 patients presenting with ruptured Aneurysms. Most patients had no renal artery coverage (n = 2,230; 98%), followed by single renal artery coverage (n = 30; 1.2%), and finally bilateral renal artery coverage (n = 18, 0.8%). On multivariate regression, bilateral renal coverage was associated with increased odds of inhospital mortality (odds ratio [OR] = 5.7, ±4; P = 0.030), permanent dialysis/30-day death (OR = 9.5, ±7; P = 0.016), and permanent dialysis (OR = 47.5, ±47; P Single renal artery coverage significantly increased the odds of permanent dialysis/30-day death (OR = 2.8, ±1.6; P = 0.044) driven mainly by its effect on the outcome of permanent dialysis (OR = 12.3, ±6; P Unadjusted Kaplan-Meier one-year survival estimates were significantly lower with bilateral renal coverage (hazard ratio [HR] = 3.4, P = 0.0002). Bilateral coverage remained a significant predictor on adjusted analysis (HR = 3.5, P = 0.002); however, single renal coverage did not significantly affect survival in unadjusted or adjusted models. Conclusions Bilateral renal coverage in rAAA significantly increases inhospital mortality and lowers long-term survival. While single renal artery coverage increases the risk of permanent dialysis/30-day death driven mainly by its effect on permanent dialysis, it does not significantly affect inhospital mortality or one-year survival and may be a viable option for select patients with rAAAs.
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fenestrated and branched Endovascular Aneurysm Repair outcomes for type ii and iii thoracoabdominal aortic Aneurysms
2016Co-Authors: Matthew J Eagleton, Matthew Follansbee, Katherine E Wolski, Tara M Mastracci, Yuki KuramochiAbstract:Objective Thoracoabdominal aortic Aneurysm (TAAA) Repair remains a challenging clinical pathology. Endovascular technology, in particular the evolution of fenestrated and branched (F/B) endografts used in Endovascular Aneurysm Repair (EVAR) has provided a less invasive method of treating these complex Aneurysms. This study evaluated the technical and clinical outcomes of F/B-EVAR for extensive type II and III TAAA. Methods Data from 354 high-risk patients enrolled in a physician-sponsored investigational device exemption trial (2004-2013) undergoing F/B-EVAR for type II and III TAAA were evaluated. Technical success, perioperative clinical outcomes, and midterm outcomes (36 months) for branch patency, reintervention, Aneurysm-related death, and all-cause mortality were analyzed. Data are presented as mean ± standard deviation and were assessed using Kaplan-Meier, univariate, and multivariate analysis. Results F/B-EVARs incorporating 1305 fenestration/branches were implanted with 96% of target vessels successfully stented. Completion aortography showed 2.8% patients had a type I or III endoleak. Procedure duration (6.0 ± 1.7 vs 5.5 ± 1.6 hours; P P P P P P Conclusions F/B-EVAR is a robust treatment option for patients at increased risk for conventional Repair of extensive TAAAs. Technical success and branch patency are excellent, but some patients will require reintervention for branch-related endoleak. Aneurysm extent portends a higher risk of perioperative and long-term morbidity and mortality. Additional efforts are needed to improve outcomes and understand the utility of this treatment option in the general TAAA population.
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late graft explants in Endovascular Aneurysm Repair
2014Co-Authors: Eric J Turney, Sean P Steenberge, Sean P Lyden, Sunita D Srivastava, Timur P Sarac, Rebecca Kelso, Matthew J Eagleton, Daniel G. ClairAbstract:Objective With more than a decade of use of Endovascular Aneurysm Repair (EVAR), we expect to see a rise in the number of failing endografts. We review a single-center experience with EVAR explants to identify patterns of presentation and understand operative outcomes that may alter clinical management. Methods A retrospective analysis of EVARs requiring late explants, >1 month after implant, was performed. Patient demographics, type of graft, duration of implant, reason for removal, operative technique, length of stay, complications, and in-hospital and late mortality were reviewed. Results During 1999 to 2012, 100 patients (91% men) required EVAR explant, of which 61 were placed at another institution. The average age was 75 years (range, 50-93 years). The median length of time since implantation was 41 months (range, 1-144 months). Explanted grafts included 25 AneuRx (Medtronic, Minneapolis, Minn), 25 Excluder (W. L. Gore & Associates, Flagstaff, Ariz), 17 Zenith (Cook Medical, Bloomington, Ind), 15 Talent (Medtronic), 10 Ancure (Guidant, Indianapolis, Ind), 4 Powerlink (Endologix, Irvine, Calif), 1 Endurant (Medtronic), 1 Quantum LP (Cordis, Miami Lakes, Fla), 1 Aorta Uni Iliac Rupture Graft (Cook Medical, Bloomington, Ind), and 1 homemade tube graft. Overall 30-day mortality was 17%, with an elective case mortality of 9.9%, nonelective case mortality of 37%, and 56% mortality for ruptures. Endoleak was the most common indication for explant, with one or more endoleaks present in 82% (type I, 40%; II, 30%; III, 22%; endotension, 6%; multiple, 16%). Other reasons for explant included infection (13%), acute thrombosis (4%), and claudication (1%). In the first 12 months, 23 patients required explants, with type I endoleak (48%) and infection (35%) the most frequent indication. Conversely, 22 patients required explants after 5 years, with type I (36%) and type III (32%) endoleak responsible for most indications. Conclusions The rate of EVAR late explants has increased during the past decade at our institution. Survival is higher when the explant is done electively compared with emergent Repair. Difficulty in obtaining a seal at the initial EVAR often leads to failure ≤1 year, whereas progression of Aneurysmal disease is the primary reason for failure >5 years.
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long term outcomes of palmaz stent placement for intraoperative type ia endoleak during Endovascular Aneurysm Repair
2011Co-Authors: Zachary M Arthurs, Sean P Lyden, Matthew J Eagleton, Ravi R Rajani, Daniel G. ClairAbstract:Background Perioperative proximal endoleaks during Endovascular Aneurysm Repair potentiate graft migration, Aneurysm sac expansion, and stent-graft failure. Adjunctive placement of a Palmaz stent at the proximal landing zone can improve proximal seal and eliminate perigraft flow; however, the long-term sequelae associated with this maneuver are unknown. We sought to evaluate the effect of Palmaz stent placement for type Ia endoleaks on delayed endoleak formation, graft migration, and Aneurysm expansion. Methods A retrospective cohort review of a prospectively maintained database was performed. Between 2000 and 2005, all consecutive patients who had undergone infrarenal Endovascular Aneurysm Repair were evaluated for a type I endoleak that was treated with Palmaz stent placement. Fenestrated, juxtarenal, and investigational devices were excluded from the analysis. Postoperative and follow-up axial imaging were analyzed for the following three primary endpoints: type I endoleak formation, stent-graft migration, and Aneurysm sac expansion. In addition, a paired analysis was performed comparing suprarenal aortic diameters, infrarenal aortic neck diameters, aortic neck lengths, and proximal seal zones. Results In all, 36 consecutive patients were identified with intraoperative type I endoleaks that were treated with Palmaz stenting. Five patients with ruptured abdominal aortic Aneurysms died before discharge; the remaining 31 patients comprised the cohort for analysis. During a median follow-up period of 53 months (interquartile range: 14-91 months), no type I endoleak developed after Palmaz stent placement. Despite patients experiencing shortening of aortic neck length (26%) and loss of the proximal seal zone (35%), no stent-graft migration was seen in this population. Continued aortic degeneration accounted for proximal seal zone loss. At a distance 15 mm below the lowest renal artery, the mean aortic diameter increased by 3.2 mm (95% confidence interval: 0.4-6, p 10%. Mean aortic sac regression was 5.8 mm (95% confidence interval: 0.5-11.0, p Conclusions Proximal neck reinforcement with a Palmaz stent serves as an effective Endovascular adjunct to treat intraoperative type I endoleaks, and has a very high technical success rate. Most importantly, it has a clinical effect on delayed type I endoleak formation and stent-graft migration.
M M Thompson - One of the best experts on this subject based on the ideXlab platform.
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current evidence is insufficient to define an optimal threshold for intervention in isolated type ii endoleak after Endovascular Aneurysm Repair
2012Co-Authors: Alan Karthikesalingam, Ian M Loftus, M M Thompson, Sri G Thrumurthy, Dan Jackson, E Choke, Robert D Sayers, Peter J HoltAbstract:PurposeTo report a systematic review and meta-regression of the association between the threshold for intervention in patients with isolated type II endoleak after Endovascular Aneurysm Repair (EVA...
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percutaneous access for Endovascular Aneurysm Repair a systematic review
2010Co-Authors: A H Malkawi, Robert J Hinchliffe, P J Holt, I M Loftus, M M ThompsonAbstract:Abstract Introduction Recent developments in aortic stent-graft technology have led to an increase in the use of wholly percutaneous Endovascular Aneurysm Repair (P-EVAR). The literature was systematically reviewed to analyse the results of P-EVAR. Methods A systematic review of P-EVAR was performed using Ovid-MEDLINE in-process and other nonindexed citations and Ovid-MEDLINE and EMBASE (January 1991–July 2009). Primary outcomes reviewed were success rate and loco-regional complications. Secondary outcomes included; operative time, hospital stay, time to ambulation, blood loss and cost. Prospective randomised and controlled nonrandomised studies were included as were case series (retrospective and prospective). Case reports, letters, review articles and non-English language articles were excluded. Results Twenty-two papers were identified. These included randomised trials (n = 1); prospective nonrandomised (n = 10) and retrospective studies (n = 11). P-EVAR was attempted in 1087 patients (1751 groins). Overall success rate of percutaneous arterial closure was 92% (90.1–93.9, 95% CI). Access related complication rate was 4.4% (3.5–5.3, 95% CI). Seven studies provided data on access related complications in open access cohorts (O-EVAR). In these studies, P-EVAR was associated with fewer access related complications (RR 0.47, 95% CI 0.28–0.78, p = 0.004). P-EVAR was associated with reduced operative time. Conclusion P-EVAR appears safe and effective in selected patients. Local access related complications were low. Further work is required to identify the most suitable candidates for P-EVAR.
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Endovascular Aneurysm Repair with preservation of the internal iliac artery using the iliac branch graft device
2010Co-Authors: Alan Karthikesalingam, Peter J Holt, I M Loftus, Jonathan R Boyle, R J Hinchliffe, M M ThompsonAbstract:Abstract Objectives Aortoiliac Aneurysms comprise up to 43% of the specialist Endovascular caseload. In such cases Endovascular Aneurysm Repair (EVAR) requires distal extension of the aortoiliac endograft beyond the ostium of the internal iliac artery (IIA) and into the external iliac artery, conventionally necessitating the embolisation of one or both IIA. This has been associated with a wide range of complications, and the use of an Iliac Branch-graft Device (IBD) offers an appealing Endovascular solution. Design Medline, trial registries, conference proceedings and article reference lists were searched to identify case series reporting IBD use. Data were extracted for review. Results Nine series have reported the use of IBD in a total of 196 patients. Technical success was 85–100%. Median operating times were 101–290 min and median contrast dose was 58–208 g, with no Aneurysm-related mortality. Claudication developed in 12/24 patients after IBD occlusion. One type I endoleak and two type III endoleaks occurred and were managed Endovascularly. Re-occlusion occurred in 24/196 patients. Conclusion IBD was performed with high technical success rates and encouraging mid-term patency. Formalised risk stratification and morphological data are required to identify the group of patients who will benefit most. Cost-effectiveness appraisals are needed for this technique.
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visceral and renal artery complications of suprarenal fixation during Endovascular Aneurysm Repair
2007Co-Authors: Edward Choke, Graham Munneke, Robert Morgan, Annamaria Belli, Joseph Dawson, Ian M Loftus, Robert Mcfarland, Thomas Loosemore, M M ThompsonAbstract:Background The effect of suprarenal fixation of Endovascular grafts on renal and visceral artery function remains undefined. This study aimed to determine renal and visceral artery complications following suprarenal fixation during Endovascular Aneurysm Repair (EVR).
Mark F Conrad - One of the best experts on this subject based on the ideXlab platform.
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renal artery coverage during Endovascular Aneurysm Repair for ruptured abdominal aortic Aneurysm
2019Co-Authors: Adam Tanious, Matthew J Eagleton, Jason T Lee, Laura T Boitano, Linda J Wang, Murray L Shames, Darrin W Clouse, Mark F ConradAbstract:Introduction Coverage of one or both renal arteries may be required to facilitate Endovascular Aneurysm Repair (EVAR) in patients who are not candidates for open surgery in ruptured abdominal aortic Aneurysms (rAAAs). We sought to understand the consequences of renal coverage during these emergent procedures. Methods Using the VQI data set from 2013 to 2018, we selected patients who had undergone EVAR for rAAA. Patients were distinguished by whether they had none, unilateral, or bilateral renal artery coverage. Patients were excluded if they were previously on dialysis or had an intervention to preserve renal perfusion. Primary endpoints included inhospital mortality, composite permanent dialysis/30-day death, and 1-year survival. Results Overall, there were 2,278 patients presenting with ruptured Aneurysms. Most patients had no renal artery coverage (n = 2,230; 98%), followed by single renal artery coverage (n = 30; 1.2%), and finally bilateral renal artery coverage (n = 18, 0.8%). On multivariate regression, bilateral renal coverage was associated with increased odds of inhospital mortality (odds ratio [OR] = 5.7, ±4; P = 0.030), permanent dialysis/30-day death (OR = 9.5, ±7; P = 0.016), and permanent dialysis (OR = 47.5, ±47; P Single renal artery coverage significantly increased the odds of permanent dialysis/30-day death (OR = 2.8, ±1.6; P = 0.044) driven mainly by its effect on the outcome of permanent dialysis (OR = 12.3, ±6; P Unadjusted Kaplan-Meier one-year survival estimates were significantly lower with bilateral renal coverage (hazard ratio [HR] = 3.4, P = 0.0002). Bilateral coverage remained a significant predictor on adjusted analysis (HR = 3.5, P = 0.002); however, single renal coverage did not significantly affect survival in unadjusted or adjusted models. Conclusions Bilateral renal coverage in rAAA significantly increases inhospital mortality and lowers long-term survival. While single renal artery coverage increases the risk of permanent dialysis/30-day death driven mainly by its effect on permanent dialysis, it does not significantly affect inhospital mortality or one-year survival and may be a viable option for select patients with rAAAs.
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improved results using onyx glue for the treatment of persistent type 2 endoleak after Endovascular Aneurysm Repair
2011Co-Authors: Christopher J Abularrage, Mark F Conrad, Richard P Cambria, Virendra I Patel, Eric B Schneider, Christopher J KwolekAbstract:Objective Persistent type 2 (PT2) endoleaks (present ≥6 months) after Endovascular Aneurysm Repair are associated with adverse outcomes, and selective secondary intervention is indicated in those patients with an expanding Aneurysm sac. This study evaluated the outcomes of secondary intervention for PT2. Methods From 1999 to 2007, 136 patients who underwent Endovascular Aneurysm Repair developed PT2 and comprised the study cohort. Primary end points included PT2 resolution (secondary interventional success) and survival, and were evaluated using multiple logistic regression and Kaplan-Meier analyses, respectively. Results Fifty-one patients underwent a total of 68 secondary interventions for PT2 with expanding Aneurysm sacs with a median postsecondary interventional follow-up of 13.7 months. Secondary interventions included 20 inferior mesenteric artery coil embolizations, 17 Onyx glue embolizations, 11 Aneurysm sac coil embolizations, 10 non-Onyx glue embolizations, 7 lumbar artery coil embolizations, 2 open lumbar ligations, and 1 graft explant. The overall secondary interventional success rate was 43% (29 of 68). Onyx glue embolization was associated with a greater success rate when used as the initial secondary intervention (odds ratio, 59.61; 95% confidence interval, 4.78-742.73; P Conclusions Secondary intervention for PT2 is associated with success in less than half of all cases. Onyx glue embolization was associated with greater long-term success when used as the initial secondary intervention.
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preoperative variables predict persistent type 2 endoleak after Endovascular Aneurysm Repair
2010Co-Authors: Christopher J Abularrage, Robert S Crawford, Mark F Conrad, Hang Lee, Christopher J Kwolek, David C Brewster, Richard P Cambria, Glenn M LamuragliaAbstract:Objective Persistent type 2 endoleaks (PT2, present ≥6 months) after Endovascular Aneurysm Repair (EVAR) are associated with adverse outcomes. This study evaluated the preoperative risk factors and natural history of PT2 in order to define a population at high risk. Methods From January 1999 to December 2007, 595 of 832 EVAR patients had long-term computed tomography follow-up and comprised the study cohort. Preoperative anatomic and clinical variables were correlated with PT2 using Cox regression. Composite hazard ratios (HRs) were constructed with clusters of high-risk preoperative variables. Primary end points, including spontaneous resolution, sac enlargement >5 mm, and freedom from reintervention, were evaluated using Kaplan-Meier analysis. Results There were 136 PT2 patients (23%) with a median follow-up of 34.8 months (range, 6.4-121.2 months). Positive predictive factors included patent inferior mesenteric artery (IMA; HR, 4.00; 95% confidence interval [CI], 1.62-9.90; P = .003), increasing number of patent lumbar arteries (HR, 1.24; 95% CI, 1.10-1.41; P = .0006), increasing age (HR, 1.04; 95% CI, 1.01-1.06; P = .005), and increasing luminal diameter on CT-contrast opacified lumen (HR, 1.03; 95% CI, 1.02-1.05; P = .0001). During follow-up, spontaneous PT2 resolution occurred in 34 patients (25%), sac diameter remained stable in 63 (46%), and rupture occurred in 2 (1.5%). Kaplan-Meier analysis estimated that 35.2% ± 5.6% (95% CI, 23.8%-46.2%) of PT2 resolve spontaneously at 5 years after the index procedure. Freedom from sac enlargement >5 mm was 54.6% ± 7.2% (95% CI, 40.6%-69.4%) at 5 years. Fifty-nine reinterventions were performed in 39 patients with PT2. Freedom from reintervention was 67.3% ± 5.0% (95% CI, 57.0%-77.0%) at 5 years. The combination of a patent IMA and one risk factor of more than six patent lumbar arteries, maximum luminal diameter >30 mm, or age >70 years increased the odds of PT2 approximately ninefold. The combination of a patent IMA and any two risk factors increased the odds of PT2 approximately 18-fold. Conclusions Several readily identifiable preoperative variables are associated with PT2 whose natural history was benign in but 35% of patients. On the basis of the composite high-risk HRs, there is accordingly a cohort of patients in whom perioperative interventions to preclude PT2 should be considered.
