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Introduction: Stentgraft limb occlusion (SLO) is a potential complication of endovascular aneurysm repair (EVAR). The purposes of this single centre study are to report the incidence of SLO after EVAR and to detect possible risk factors. Methods: All patients who underwent EVAR between June 2001 and February 2020 were included in this retrospective study. Demographic data, cardiovascular risk factors, aneurysm characteristics, arterial anatomy, repair strategy, systemic and stentgraft-related complications, and in-hospital and late mortality were collected. Routine follow-up included duplex examination and/or CT angiography at 3 months, 12 months and annually thereafter. Logistic regression analysis was performed to detect predictors for SLO. Results: A total of 221 patients (425 stentgraft limbs) were included; of whom 11 patients (5.0%) occluded. Median time to occlusion was 3.3 months and most of the patients presented ischemic signs. Two risk factors for SLO could be identified: symptomatic aneurysm (P.015, odds ratio 4.62, 95% confidence interval 1.35-15.86) and length of the infrarenal abdominal aortic aneurysm (AAA) (P.021, odds ratio 1.31, 95% confidence interval 1.04 - 1.64). Conclusion: The incidence of SLO after EVAR is low, and most occlusions occur within the first year. Predictors for SLO are the symptomatic aneurysm and the length of the infrarenal AAA. Further research is necessary to pool all predictors and to assess the clinical impact of different follow-up strategies for high-vs low-risk patients. [ABSTRACT FROM AUTHOR]

Endoleaks remain one of the most common indications for reintervention after endovascular aortic repair. Occasionally, aneurysm sac expansion will occur in the absence of a visible endoleak or due to endotension. We describe a case of continued sac expansion without an identifiable endoleak after endovascular aortic repair. Technical challenges during the case included a short distance from the renal arteries to the flow divider and a significant metal artifact. These challenges were addressed by shortening the gate of a Gore Excluder (W.L. Gore & Associates, Flagstaff, Ariz) to the desired length. The contralateral gate was preloaded to allow for use of the snare-ride technique for gate cannulation and overcome the metal artifact that was hindering visualization.

Spinal cord infarction (SCI) is a rare but serious complication of endovascular aortic repair (EVAR) for abdominal aortic aneurysms (AAA). It is difficult to predict, prevent, and treat and can cause significant impairment. We describe the case of a patient who experienced paraplegia and thermal pain dysfunction of the lower extremities shortly after EVAR for an infrarenal AAA. Immediately after confirming SCI, we initiated cerebrospinal fluid drainage, administered steroids, naloxone, and free radical scavengers, and maintained high blood pressure. However, the patient's symptoms did not improve sufficiently. Since the possibility of a SCI exists, prompt treatment should be initiated., (@ 2024 The Editorial Committee of Annals of Vascular Diseases.)

Objectives: This study aims to examine the American Society of Anesthesiologists (ASA) classification of Physical Status as a preoperative risk prediction method for early mortality and morbidity in patients undergoing elective endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm (AAA). Patients and methods: A total of 134 consecutive patients (124 males, 10 females; mean age 69.6±6.9 years; range, 52 to 85 years) with an infrarenal AAA who underwent EVAR between January 2012 and January 2018 were retrospectively analyzed. The patients were divided into two groups as Group 1 (low risk; ASA I-II; n=63) and Group 2 (high risk; ASA III-IV; n=71). Early and postoperative one-year mortality and morbidity were evaluated. Results: The overall early mortality rate was 1.4%. None of the patients were converted to open surgery and overall technical success was 100%. Unibody grafts were performed in 33% patients in Group 1 and 59.2% patients in Group 2 (p=0.003). The length of intensive care unit and hospital stay was longer in Group 2, although it did not reach statistical significance. A total of 64% of local/locoregional anesthesia was performed in Group 2 high-risk patients. Conclusion: Regardless of the ASA risk group, EVAR can be performed successfully. The ASA classification may be useful for decision of treatment modality. Patients unfit for open surgery can be managed safely by EVAR [Turk J Vasc Surg 2019; 28(2.000): 101-6]

Purpose: Preliminary results of the INSIGHT study showed that the low-profile INCRAFT Abdominal Aortic Aneurysm (AAA) Stent-Graft System was safe and effective in the endovascular aneurysm repair (EVAR). This study aimed to assess the durability and the midterm effectiveness of EVAR using the INCRAFT System in the framework of a multicenter, prospective, open-label, post-approval study., Materials and Methods: Between 2015 and 2016, 150 subjects from 23 European centers treated with the INCRAFT System for an infrarenal AAA were included. Clinical and radiologic data were prospectively collected and analyzed using protocol-specified, monitored follow-up clinic visits at 1, 6, and 12 months post-implantation and annually after that. The clinical success at 3 years was determined. Freedom from overall and aneurysm-related mortality, type I endoleak, secondary interventions, and aneurysm sac enlargement through 3 years were evaluated. Kaplan-Meier estimates were used for late outcomes. An independent clinical events committee reviewed all events. The CT (computed tomography) scans through 1 year were reviewed by an independent core laboratory., Results: The primary clinical success rate at 3 years was 84.0% (126/150). There were no aneurysm-related deaths, endograft migration, or aneurysm-related ruptures through 3 years. Stent fracture was detected in 2 subjects (1.3%) without clinical sequelae. Over 3 years, freedom from overall mortality was 89.4%, freedom from secondary interventions was 80%, and freedom from aneurysm sac enlargement was 96.5%. The 3-year freedom from type IA and IB endoleaks was 93.3% and 98.6%, respectively., Conclusions.: In a multicenter real-world study setting, the use of a low-profile INCRAFT device for AAA is associated with sustained clinical success and low rates of reinterventions through 3 years., Clinical Impact: Low-profile endografts have broadened the spectrum of patients with anatomic suitability for endovascular repair of abdominal aortic aneurysms (AAA). However, questions remain regarding the durability of the repair. The INSIGHT study evaluated the use of the INCRAFT System in routine real-world clinical practice, including patients with complex anatomies. The treatment was safe and effective. The results showed sustained clinical success over 3 years, with no aneurysm-related deaths or ruptures, and a high rate of intervention-free survival at 3 years. Despite the low-profile design of the endograft, the midterm results demonstrate the durability of AAA repair using the INCRAFT System.ClinicalTrials.gov Identifier: NCT02477111., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: G.T. is a consultant for Cordis and has received educational grants from Medtronic, Cook, Gore, Boston Scientific, and Biotronik, and is CEO and cofounder of Vascupedia and the Foundation for Cardiovascular Research and Education. L.B. has been a consultant for Cordis. R.K. received honoraria from W.L. Gore and C.R. Bard. J.J.W. is a consultant for Cordis and cofounder of the Haga Vascular Research Foundation. H.v.O. is a Cordis and Boston Scientific consultant and cofounder of the Haga Vascular Research Foundation. K.S. has consulted for Phillips, Shockwave, and Terumo; received honoraria from Medtronic, Boston Scientific, and Biotronic; and is a cofounder of Vascupedia and the Foundation for Cardiovascular Research and Education.

Background:Renal insufficiency is a potential complication after infrarenal abdominal aortic aneurysm repair and is a significant risk factor for postoperative mortality and morbidity.The aim of this study was to analyze the effect of this risk factor, before and during operation.Methods:In this prospective study,between 2003 and 2006, 45 patients underwent repair of an infrarenal abdominal aortic aneurysm.Elective surgical repair was performed in 34 patients and 11 patients underwent immediate surgical repair of ruptured aneurysms. There were 41 males and 4 females. The mean age was 68 years. The patients were divided into four groups depending on their preoperative serum creatinine (Scr), group I, serum creatinine less than 1.4 mg/dl, group II 1.4 < Scr< 2 mg/dl, group III 2 < Scr2.5 mg/dl. In each group postoperative changes in renal function were analyzed. Results: Several factors significantly influenced postoperative serum creatinine concentration and BUN level. These factors were: previous renal disease (diabetic nephropathy and renal artery stenosis), ruptured aneurysm and profound shock, blood transfusion greater than 4 units, duration of clamping time (greater than 2 hrs and 10 min), and age over 65 years. The postoperative rise in serum creatinine level was noted in 33 patients (73.3%) and BUN increased in 27 cases (60%), but only 2 patients out of these 33 patients required hemodialysis. Renal function recovery occurred after several days of surgery (3 to 5 days).Conclusion:The cause of renal dysfunction after elective or emergency repair of an infrarenal abdominal aortic aneurysm is multifactorial and the most important predictor is preoperative renal insufficiency,so special precautions are appropriate in such patients for prevention of this complication. Decreasing the aortic clamp time,operative time and blood loss, and administration of optimal volume loading seems to be essential.

Objective Endovascular aortic sealing (EVAS) with the Nellix endosystem (Endologix, Irvine, CA, USA) is a new concept to treat infrarenal abdominal aortic aneurysms (AAAs). By sealing the aneurysm, potential endoleaks may be avoided. Early results of EVAS are good, but no data have been published regarding peri-procedural changes in aortoiliac anatomy. In this study, 27 consecutive patients who underwent elective EVAS repair of an AAA were reviewed. Method Specific AAA (diameter, length from renal arteries to aortic bifurcation, supra- and infrarenal neck angulation, AAA volume, thrombus volume, and flow lumen volume), and iliac artery characteristics (length, angulation, location of most severe angulation with reference to the origin of the common iliac artery) were determined from pre- and post-procedural reconstructed computed tomography angiograms. Results No type I or II endoleaks were seen at 30 day follow up. Total AAA volume, suprarenal and infrarenal angulation, as well as aortic neck diameter did not change significantly post-EVAS. AAA flow lumen increased significantly (mean difference −4.4 mL, 95% CI 2.0 to −8.6 mL) and AAA thrombus volume decreased (mean difference 3.2 mL, 95% CI 2.0 to −1.1 mL). AAA length (125.7 mm vs. 123.1 mm), left common iliac artery length (57.6 mm vs. 55.3 mm), and right and left maximum iliac artery angulation (right 37.4° vs. 32.2°; left: 43.9° vs. 38.4°) were reduced significantly and the location of maximum angulation was further from the iliac artery origin post-EVAS, suggesting slight straightening of the aortoiliac anatomy. Conclusion Most aortoiliac anatomic characteristics remained unchanged post-EVAS. Filling of the endobags to a pressure of 180 mmHg may lead to lost thrombus volume in some patients, probably because liquid is squeezed into lumbar or the inferior mesenteric artery. The absolute differences in pre- and post-EVAS aortoiliac lengths were small, so pre-operative sizing is accurate for determining stent length. [ABSTRACT FROM AUTHOR]

The repair of abdominal aortic aneurysm (AAA) in the presence of significant coronary artery disease (CAD) carries a high-risk of adverse peri-operative cardiac event. The options to reduce cardiac risk include perioperative β-blockade, preoperative optimization by myocardial revascularization and simultaneous (combined) coronary artery bypass grafting and aneurysm repair. We describe intra-operative controlled phlebotomy to optimize myocardial stress during repair of infrarenal AAA in a patient with significant stable CAD.

Aim: The aim of this study was to investigate the short-term results of endovascular repair of abdominal aortic aneurysms with the Endologix IntuiTrak Powerlink XL® (Endologix) stent graft and to share our clinical experiences in our center. Materials and methods: Endovascular stent graft treatment was applied in 16 cases with infrarenal abdominal aortic aneurysm (13 men and 3 women; mean age: 70.2 years) in 2009 and 2010. Before treatment, all of the patients were examined with 128-slice computed tomography (CT) angiography for the assessment of abdominal aortic aneurysms. The Endologix stent graft (bifurcated system) was used for all of the patients. Results: The aneurysms of the 16 patients were located at the infrarenal level. They were treated with aortobiiliac stent grafts. The technical success rate was 100%. No mortality, major complications, or need of urgent conversion to open surgery occurred in any of the patients. Only 1 patient died due to acute coronary syndrome in the early follow-up period and 1 patient was lost in the follow-up period. There were no aneurysm ruptures, graft migrations, or graft fractures in any of the patients. Conclusion: Endovascular treatment of infrarenal aortic aneurysms with the Endologix stent graft has a high degree of technical success and is a useful alternative to surgery. [ABSTRACT FROM AUTHOR]

Horseshoe kidney may cause technical and access problems during open aortic aneurysm repair. The aim of this study is to report two cases from our institution and to review the world's literature on successful endovascular infrarenal aneurysm repair in patients with horseshoe kidneys. A retrospective review of a prospectively entered departmental computerized database was performed for the two patients from our institution. Articles were searched electronically from PubMed and Medline, using the terms 'horseshoe kidney' and 'aneurysm'. Endovascular cases were reviewed from the world's literature. In addition to the two patients from our institution, there were 19 patients with infrarenal aneurysms and horseshoe kidneys in published literature who underwent successful endovascular aneurysm repair. The occlusion of lower-pole or accessory renal arteries does not seem to cause significant endoleak or renal impairment in the long run. In conclusion, our experience and current literature seem to suggest that endovascular repair of infrarenal aortic aneurysms for patients with horseshoe kidneys is safe. Renal impairment will depend on the area of kidney perfused by the accessory renal arteries. The endovascular treatment option is less invasive than open repair, and circumvents the problem of difficult exposure, especially in those patients with significant co-morbidity. [ABSTRACT FROM AUTHOR]

Aims: Renal dysfunction affects the prognosis of patients after aortic surgery. However, the factors associated with the post operative deterioration of renal function has not been clarified precisely. Method: We prospectively examined renal function in 80 patients (age: 73 ± 7 years, 66 males) who required the elective repair of infrarenal abdominal aortic aneurysm (AAA). Serum creatinine (Scr) was measured. 24-h-creatinine clearance (Ccr) and urinary albumin excretion (UAE) were determined. Renal volume and mean renal length were calculated using the data obtained by ultrasonography. 48 patients showed normal UAE (< 30 mg/day), and 24 had microalbuminuria (30 – 300 mg/day) and 8 had overt proteinuria (> 300 mg/day). Scr were 0.9 ± 0.4, 1.0 ± 0.3 and 2.1 ± 1.3 mg/dl, respectively. Results: On Day 5 after surgery, 12 patients (15%) showed deterioration of renal function as defined either by an increase in Scr (⩾ 0.5 mg/dl) or by a decrease in Ccr (⩾ 20%). The acute deterioration of renal function was related to mean renal volume, mean renal length, duration of operation and the use of antibiotics. At Month 12 after surgery, Scr increased in the overt proteinuria group. The deterioration of renal function at Month 12 was found in 8 patients (10%) with microalbuminuria or overt proteinuria, and related to preoperative Ccr, UAE, mean renal volume, mean renal length, smoking status and blood pressure. Conclusion: We conclude that the deterioration of renal function occurred in considerable number of patients with AAA after elective operation on acute and chronic phase, although the development of end-stage renal failure is rare. Factors related to the acute and late deterioration appears to be different. UAE and renal size should be measured, even if Scr is in normal range at preoperative observation. [ABSTRACT FROM AUTHOR]

Although appreciated for its long-term benefits, open repair of abdominal aortic aneurysms (AAA) is associated with a significant perioperative burden. Enhanced recovery and fast track protocols have improved surgical outcomes in many specialties, but remain scarcely applied in the vascular field. Based on the applied perioperative protocol in a single-center experience, three consecutive study groups were identified among 394 consecutive patients undergoing elective AAA open repair in the last 12 years. Group A included 66 patients who underwent traditional surgery, group B comprised 225 patients treated according to a partially adopted perioperative protocol, and group C consisted of 103 patients, operated in line with a complete perioperative protocol. The aim of this study was to evaluate the impact of the perioperative protocol on recovery time by measuring complication rates, analgesic and antiemetic control, and return of bowel function and ambulation, as well as the length of hospitalization. The study groups had similar baseline characteristics. A significant improvement was noted in the complication rates (P =.019) and hospitalization time (P <.001) following a complete implementation of the perioperative protocol, where the median hospitalization time was 3 days. No mortality and no readmissions within 30 postoperative days were recorded in this group. There was an improvement in pain levels, as well as postoperative nausea and vomiting control (P <.001). Perioperative protocol implementation in AAA open repair is feasible; the clinical outcomes may be improved when strictly adhering to the protocol. All the applied perioperative management interventions seem to have a synergic effect on shortening the recovery time. [ABSTRACT FROM AUTHOR]

Horseshoe kidney is a common urology anomaly, while its association with infrarenal abdominal aortic aneurysm represents a very rare condition. Surgical approach remains controversial however, we believe that the left retroperitoneal approach should be preferred in order to avoid isthmus resection with any subsequent renal infarction, urinary tract damage and to facilitate renal arteries reimplantation, when required. We present a case of voluminous infrarenal abdominal aortic aneurysm associated with horseshoe kidney, successfully treated through a left retroperitoneal approach on the retro-renal space.