Search

International audience; ObjectiveWe evaluated whether a combination of intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) and postoperative contrast-enhanced ultrasound (CEUS) after infrarenal endovascular abdominal aortic aneurysm repair (EVAR) could reduce late stent graft–related complications and, consequently, reintervention.MethodsAll consecutive patients who had received infrarenal bifurcated stent grafts in our hybrid room (IGS 730; GE Healthcare, Île-de-France, France) during two discrete periods were included in the present study. From November 2012 to September 2013, two-dimensional completion angiography was performed after each EVAR, followed by computed tomography angiography (CTA) before discharge (group 1). From October 2013 to January 2015, intraoperative ceCBCT was performed, followed by CEUS within the first postoperative days (group 2). Comparative analyses of the outcomes were performed. The primary endpoint was late stent graft–related complications, a composite factor incorporating aneurysm-related death, type I or III endoleaks, kink or occlusion of the iliac limb, and aortic sac enlargement after the first 30 postoperative days. The secondary endpoint was all stent graft–related reinterventions. All-cause and aneurysm-related deaths were also recorded.ResultsOverall, 100 consecutive patients (50 each in groups 1 and 2) were enrolled, with a median follow-up of 60 months (interquartile range, 41-69 months). At 60 months after the index procedure, the freedom from late stent graft–related complications in each group was 61.6% (95% confidence interval [CI], 47.0%-80.6%) for group 1 and 81.7% (95% CI, 70.1%-95.2%) for group 2 (P = .033). The use of intraoperative ceCBCT was independently associated with a reduced rate of late stent graft–related complications on multivariate analysis (hazard ratio, 0.39; 95% CI, 0.16-0.95; P = .038) but did not appear to significantly protect against stent graft–related reinterventions (hazard ratio, 0.53; 95% CI, 0.20-1.39; P = .198) or all-cause death (P = .47).ConclusionsTo the best of our knowledge, the present study is the first to report the influence of routine ceCBCT on late outcomes after EVAR. The use of ceCBCT shows the potential for reducing late stent graft–related complications associated.

Background Endovascular repair of aortic aneurysms involving the visceral segment of the aorta often requires placement of a covered bridging stent in the celiac axis (CA). The median arcuate ligament (MAL) is a fibrous arch that unites the diaphragmatic crura on either side of the aortic hiatus. The ligament may compress and distort the celiac artery and result in difficult cannulation, or stenosis and occlusion of the vessel. This study evaluated the influence of the MAL compression on the technical success and the patency of the celiac artery after branched and fenestrated endovascular aortic repair. Methods We retrospectively analyzed a cohort of consecutive patients treated electively for complex aneurysms with branched and fenestrated endovascular aortic repair between January 2007 and April 2014. All data were collected prospectively. Analysis of preoperative computed tomography angiography on a three-dimensional workstation determined the presence of MAL compression. Patency of the CA bridging stent was assessed during follow-up by computed tomography angiography and duplex ultrasound evaluation. Statistical analysis was performed to compare the outcomes of patients with MAL (MAL+) and without MAL (MAL-) compression. Results Of 315 patients treated for aortic disease involving the visceral segment during the study period, 113 had endografts designed with a branch (n = 57) or fenestration (n = 56) for the CA. In 45 patients (39.8%), asymptomatic compression of the CA by the MAL was depicted (MAL+). Complex endovascular techniques were required in this group to access the CA in 16 (14.2%) patients (vs none in the MAL- group; P = .003), which lead to a failed bridging stent implantation in seven patients (6.2%). Increased operative time and dose area product were observed in the MAL+ group, but this did not reach statistical significance. In the MAL+ group, no thrombosis of the CA bridging stents were observed during follow-up; an external compression of the CA bridging stent was depicted in six patients but without hemodynamic effect on duplex ultrasound imaging. In the MAL- group, one CA bridging stent occlusion occurred owing to an embolus from a cardiac source. Conclusions MAL compression is associated with good celiac trunk bridging stent patency during follow-up, but with a higher rate of technical difficulties and failed bridging stent implantation during the procedure.

OBJECTIVE To evaluate radiation exposure in standard endovascular aneurysm repair (EVAR) using intra-operative guidance with pre-operative computed tomographic angiography (CTA) fusion and strict ALARA guidelines in a modern hybrid room. MATERIAL AND METHODS Between February and November 2016, consecutive patients with AAA undergoing EVAR with a bifurcated device in a hybrid room under fusion imaging guidance were prospectively enrolled in six aortic centres from the United States (n = 1), Europe (n = 4), and Japan (n = 1). Demographic data including body mass index (BMI), indirect dose area product (DAP), cumulative air kerma (CAK), variables influencing dose delivery, and contrast media volume were collected. RESULTS 85 patients (90.4% males) were included. The median age was 75 (IQR 69-81), with a median BMI of 27.4 (IQR 24.7-30.6). Median DAP and CAK were 14.7 (IQR 10.0-27.7) Gy·cm and 107 (IQR 68.0-189.0) mGy, respectively. The median contrast volume was 47 mL (IQR 35-70) (equivalent to 14.1g of iodine [IQR 10.5-21.0]). Median DAP per centre was 28.1 (n = 16, IQR 12.6-47.1), 15.9 (n = 11, IQR 11.9-22.5), 14.2 (n = 12, IQR 10.9-25.7), 20.2 (n = 18, IQR 7.0-39.5), 10.3 (n = 27, IQR 8.2-14.7) and 26.5 (n = 1) Gy·cm. In multivariable analysis, collimation was the only factor that was significantly associated with DAP reduction, (coefficient = -0.014 per percentage of collimation, 95% CI -0.019 to -0.008, p

Vascular surgeons are an innovative group, and during the last decade, we have seen unparalleled advances in the endovascular treatment of extensive aortic pathologies. Collaborative efforts between surgeons and industry have introduced fenestrated and branched devices that are becoming more widely used, with wider regulatory approval, availability, and less need for customization. Prior to this, parallel stent approaches had been developed to fill the void where this technology was not available or for urgent cases. A separate and distinct body of evidence and expertise subsequently developed for both strategies. This debate explores where these approaches now sit in the armamentarium of vascular surgeons.

OBJECTIVE/BACKGROUND Spinal cord ischemia (SCI) is a devastating complication following endovascular thoracoabdominal aortic aneurysm (TAAA) repair. In an attempt to reduce its incidence two peri-procedural changes were implemented by the authors in January 2010: (i) all large sheaths are withdrawn from the iliac arteries immediately after deploying the central device and before cannulation and branch extension to the visceral vessels; (ii) the peri-operative protocol has been modified in an attempt to optimize oxygen delivery to the sensitive cells of the cord (aggressive blood and platelet transfusion, median arterial pressure monitoring >85 mmHg, and systematic cerebrospinal fluid drainage). METHODS Between October 2004 and December 2013, 204 endovascular TAAA repairs were performed using custom made devices manufactured with branches and fenestrations to maintain visceral vessel perfusion. Data from all of these procedures were prospectively collected in an electronic database. Early post-operative results in patients treated before (group 1, n = 43) and after (group 2, n = 161 patients) implementation of the modified implantation and peri-operative protocols were compared. RESULTS Patients in groups 1 and 2 had similar comorbidities (median age at repair 70.9 years [range 65.2-77.0 years]), aneurysm characteristics (median diameter 58.5 mm [range 53-65 mm]), and length of procedure (median 190 minutes [range 150-240 minutes]). The 30 day mortality rate was 11.6% in group 1 versus 5.6% in group 2 (p = .09). The SCI rate was 14.0% versus 1.2% (p

Objective The purpose of this study was to compare renal outcomes (glomerular filtration rate [GFR] and renal volume) after endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysm (AAA). Methods All AAA repairs performed between November 2009 and July 2011 were included in this retrospective study. Patients requiring suprarenal clamping and renal bypass or reimplantation and patients requiring fenestrated endografting were excluded from the OR and EVAR groups, respectively. All EVARs were performed with transrenal proximal fixation. Renal volume (calculated with a three-dimensional workstation) and GFR (estimated with the Modification of Diet in Renal Disease formula) were evaluated before the procedure, at 12 months after the procedure, and yearly thereafter. Results The study included 90 patients (41 ORs and 49 EVARs). Both groups were comparable except for age at intervention, body mass index, smoking, peripheral arterial disease, arrhythmia, and vitamin K antagonist treatment. Median follow-up was 2.8 years for OR (2.5-2.9 years) and 3.2 years for EVAR (3.0-3.4 years). In both groups, we found a significant decrease when comparing postoperative estimated GFR with 1-year (14.4% decrease [3.8%-23.8%]; P = .002) and 3-year (12.8% decrease [3.8%-20.9%]; P = .0007) levels. In both groups, total renal volumes significantly diminished. Median preoperative total renal volume (372 cm 3 [311-349]) significantly decreased (6.7% [2.8%-10.5%]; P = .008) between 1 year and 2 years of follow-up. Conclusions Renal function impairment is similar after open and endovascular AAA repair. It is associated with a decrease in total renal volume, which seems to be an early and constant marker of postoperative renal impairment.

ObjectivesTo evaluate the influence of planning endovascular aneurysm repair (EVAR) with a three-dimensional (3D) workstation on early and midterm outcomes.MethodsAll patients undergoing infrarenal EVAR performed between 2006 and 2009 at our institution were included in the current study. Prior to 2008 (group 1), endograft sizing was performed by interrogation of computed tomography angiography axial images. After 2008 (group 2), endograft sizing was routinely performed using a 3D workstation (Aquarius, Terarecon), allowing for multiplanar reconstruction and centerline analysis. Pre-, peri-, postoperative, and follow-up data were prospectively entered in an electronic database. All postoperative complications and subsequent secondary interventions depicted during the 2-year period following EVAR were compared. Secondary intervention and mortality rates were defined at 2 years and compared. Freedom from secondary intervention and overall survival rates were calculated using the Kaplan–Meier method during follow-up and compared by log-rank test.ResultsA total of 295 patients (149 patients in group 1 and 146 patients in group 2) were included. All patients had completed a minimum of 2 years of follow-up. During this 2-year period following EVAR, the type 1 endoleak rate was 8.7% in group 1 and 1.4% in group 2 (p = .004) respectively. Secondary intervention rates related to type 1 endoleak was 5.4% in group 1 and 0 in group 2 (p