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Objective: The aim of this study was to evaluate outcomes of intraoperative aneurysm sac embolization during endovascular aneurysm repair (EVAR) in patients considered at risk for type II endoleak (EII), using a sac volume-dependent dose of fibrin glue and coils., Methods: Between January 2012 and December 2014, 126 patients underwent EVAR. Based on preoperative computed tomography evaluation of anatomic criteria, 107 patients (85%) were defined as at risk for EII and assigned to randomization for standard EVAR (group A; n = 55, 44%) or EVAR with intraoperative sac embolization (group B; n = 52, 42%); the remaining 19 patients (15%) were defined as at low risk for EII and excluded from the randomization (group C). Computed tomography scans were evaluated with OsiriX Pro 4.0 software to obtain aneurysm sac volume. Freedom from EII, freedom from EII-related reintervention, and aneurysm sac volume shrinkage at 6, 12, and 24 months were compared by Kaplan-Meier estimates. Patients in group C underwent the same follow-up protocol as groups A and B., Results: Patient characteristics, Society for Vascular Surgery comorbidity scores (0.99 ± 0.50 vs 0.95 ± 0.55; P = .70), and operative time (149 ± 50 minutes vs 157 ± 39 minutes; P = .63) were similar for groups A and B. Freedom from EII was significantly lower for group A compared with group B at 3 months (58% vs 80%; P = .002), 6 months (68% vs 85%; P = .04), and 12 months (70% vs 87%; P = .04) but not statistically significant at 24 months (85% vs 87%; P = .57). Freedom from EII-related reintervention at 24 months was significantly lower for group A compared with group B (82% vs 96%; P = .04). Patients in group B showed a significantly overall mean difference in aneurysm sac volume shrinkage compared with group A at 6 months (-11 ± 17 cm(3) vs -2 ± 14 cm(3); P < .01), 12 months (-18 ± 26 cm(3) vs -3 ± 32 cm(3); P = .02), and 24 months (-27 ± 25 cm(3) vs -5 ± 26 cm(3); P < .01). Patients in group C had the lowest EII rate compared with groups A and B (6 months, 5%; 12 months, 6%; 24 months, 0%) and no EII-related reintervention., Conclusions: This randomized study confirms that sac embolization during EVAR, using a sac volume-dependent dose of fibrin glue and coils, is a valid method to significantly reduce EII and its complications during early and midterm follow-up in patients considered at risk. Although further confirmatory studies are needed, the faster aneurysm sac volume shrinkage over time in patients who underwent embolization compared with standard EVAR may be a positive aspect influencing the lower EII rate also during long-term follow-up., (Copyright © 2016 Society for Vascular Surgery. All rights reserved.)

Background: Endovascular repair is associated with better 30-day outcomes than open surgical repair for patients with infrarenal aortic aneurysms. In patients with complex aortic aneurysms (CAAs) requiring suprarenal or supravisceral aortic cross-clamping during open repair, few data exist directly comparing the real-world outcomes of open repair versus endovascular repair with fenestrated-branched stent grafts (FEVAR)., Methods: Outcomes for patients who underwent elective CAA repair using open repair and FEVAR between 2005 and 2010 were analyzed using the American College of Surgeons National Surgical Quality Improvement Program database. CAA was defined as aneurysm of the aorta involving the visceral and/or renal arteries., Results: This study compared 1091 patients who underwent open repair (group A: male, 71.5%; age, 71 ± 9 years) with 264 patients treated with FEVAR (group B: male, 82.2%; age, 74 ± 9 years). The 2 groups did not significantly differ with respect to American Society of Anesthesiologists (ASA) classification (ASA III/IV: A, 93%; B, 95%, P = 0.6), severe chronic obstructive pulmonary disease (A: 21%; B: 22%; P = 0.7), prior cardiac surgery (A: 24%; B: 20%; P = 0.19), or preoperative renal function (glomerular filtration rate: A: 69 ± 2; B: 70 ± 27; P = 0.535). Group A had significantly higher risk of any complication (A: 42%; B: 19%; P < 0.001), nonsurgical complications (A: 30%; B: 8%; P < 0.001), pulmonary complications (A: 21%; B: 2%; P < 0.001), renal complications (A: 10%; B: 1.5%; P = 0.001), and any cardiovascular complication (A: 8%; B: 2%; P < 0.001). The composite end point of surgical site infections/graft failure/bleeding transfusions were also higher in group A (A: 22%; B: 15%; P = 0.014). Thirty-day mortality was significantly lower for FEVAR (A: 5.4%; B: 0.8%; P = 0.001), as was total length of hospital stay (A: 11 ± 10 days; B: 4 ± 5 days; P < 0.001)., Conclusions: This nationwide real-world database suggests that in similar patient populations, repair of CAAs with FEVAR is associated with reduced 30-day morbidity and mortality compared with open repair. Although long-term comparative studies are needed, FEVAR may represent a preferred treatment alternative to open repair for patients with CAAs., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Until fairly recently, experience with advanced endovascular technologies, including fenestrated endovascular repair (FEVAR), has been limited to a relatively small number of practitioners worldwide. Excellent outcomes have been achieved by these accomplished surgeons who, at least initially, have primarily used custom-made devices constructed by a single endograft manufacturer. Access to this technology has been limited by the skills necessary for such procedures and by the customization process with industry partners. However, several issues are changing rapidly with FEVAR. Increasing numbers of surgeons now have the necessary endovascular skills, and off-the-shelf endografts from several manufacturers have become, or are becoming, available. Also, the regulatory landscape is changing with device approval in the United States. Surgeons and patients alike are anticipating the widespread adoption of this advanced technology that will surely benefit increasing numbers of patients. Or will it? Will widespread adoption in a larger number of smaller-volume hospitals, by less experienced surgeons, result in poor patient outcomes, or will excellent results continue with more patients benefitting from these technologic advances? These are important questions to ask before such adoption and are the subject of this debate., (Copyright © 2013. Published by Mosby, Inc.)

Background: In the endovascular era, elderly patients are offered repair of their aortoiliac aneurysms (AAA) more frequently than in the past. Our objective is to compare age groups and draw inferences for AAA repair outcomes., Study Design: We identified 20,095 patients who underwent AAA repair between 2005 and 2010 using the American College of Surgeons NSQIP national database. Preoperative characteristics and outcomes were compared among age groups (group A: 0 to 64 years; B: 65 to 79 years; C: 80 to 89 years; and D: 90 years and older)., Results: The age distribution of the cohort was A: 17.1%, B: 57.2%, C: 24%, and D: 1.7%. Nonagenarians presented significantly more often as emergencies in comparison with groups A to C (A: 13.8%, B: 10.8%, C: 12.9%, D: 22.1%; p < 0.001). Endovascular aneurysm repair was performed more frequently in older patients (A: 55.2%, B: 63.7%, C: 74.6%, D: 77.9%; p < 0.001). Risk of any complication was significantly different among groups, becoming more prevalent with advanced age (A: 22.8%, B: 23.4%, C: 24.7%, D: 27.8%; p = 0.041). Nonsurgical complications (A: 14.7%, B: 16.4%, C: 18%, D: 19.8%; p < 0.001) and cardiovascular complications (A: 3.9%, B: 4.5%, C: 5.5%, D: 5.2%; p = 0.003) were also higher with advanced age. Overall mortality was 3.1%, 4.9%,7.2%, and 13.2% for groups A to D, respectively (p < 0.001). Mortality after elective AAA repair was significantly higher for open surgery compared with endovascular aneurysm repair in all age groups (open surgery vs endovascular aneurysm repair, A:1.9% vs 0.5%; p = 0.001; B: 3.9% vs 1.2%; p < 0.001; C: 7.4% vs 2%; p < 0.001; D: 18.8% vs 3.8%; p = 0.004). After adjusting for confounders in the entire cohort, advanced age persisted as an independent factor for postoperative mortality with a higher risk of death of 1.8 (95% CI, 1.3-2.5), 2.7 (95% CI, 1.9-3.8), and 3.3 (95% CI, 1.8-6.1) times for groups B, C, and D, respectively (group A reference)., Conclusions: Advanced age is independently associated with higher risk of death after AAA repair and indication for surgery should be adjusted for different age groups accordingly. Endovascular aneurysm repair should be preferred for octogenarians and nonagenarians with indication to undergo repair of their AAA., (Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We describe the feasibility and early results of a novel approach to preserve pelvic perfusion during endovascular aortic aneurysm repair (EVAR) in patients with aortoiliac aneurysms extending to the iliac bifurcation., Methods: Three high-risk patients, aged 70+/-7 years, with large aortoiliac aneurysms (mean 6.7+/-0.5 cm) and inadequate distal common iliac artery landing zones were treated with a surgeon-modified hypogastric branch stent graft between June 2007 and July 2008. The modified device was created using a 73 mm iliac stent graft limb with a presewn 6-8 mm polyester side graft. The modified device was resheathed into a 20F sheath, and the side graft was preloaded with a wire and catheter. The resheathed device was introduced to the level of the aortic bifurcation via a 24F peel-away sheath, and using the preloaded catheter, a long wire was snared, establishing through-and-through femoral access. A 12F contralateral femoral sheath was advanced up and over the aortic bifurcation into the presewn side graft. The repair was bridged to the ipsilateral hypogastric artery using a matting self-expandable stent graft and extended distally to the external iliac artery, followed by standard EVAR. All patients were followed clinically and with computed tomography angiography prior to hospital discharge and every 3 months thereafter., Results: Mean procedural time was 172+/-23 min, including 45+/-22 min for device modification. Total fluoroscopy time, contrast load, and radiation dose were 78+/-17 min, 180+/-23 mL, and 3,890+/-1,034 mGy, respectively. The procedure was technically successful in all cases. There were no aneurysm ruptures, deaths, conversions, or complications; and the mean length of hospitalization was 3.5+/-1 days. At a mean follow-up of 9+/-3 months, all branched hypogastric arteries remained patent without endoleak, migration, or loss of device integrity., Conclusion: Surgeon-modified hypogastric branch stent grafts to maintain perfusion to one or both hypogastric arteries is feasible and provides an alternative to hypogastric artery exclusion. Long-term follow-up is needed to evaluate stent-graft patency and failure rates., (Copyright 2010. Published by Elsevier Inc.)

The purpose of this study was to review the management and clinical outcome of patients with aortic dissection and symptomatic or asymptomatic aortic branch compromise. We identified 104 patients (30.7%) with aortic branch compromise from a group of 339 patients who underwent surgical management of aortic dissection from January 1971 to May 2003. Patients were divided into 2 groups: symptomatic and asymptomatic aortic branch compromise, based on the presence or absence of cerebral, extremity, spinal, renal, and visceral ischemia. Clinical data and outcome were reviewed and compared in both groups. There were 74 male (77%) and 30 female patients with a mean age of 58.5 (range, 23-81) years. Aortic dissection was classified as Stanford type A in 58.7%, acute in 58.7%, and was associated with asymptomatic aortic branch compromise in 44 patients (42.3%) and symptomatic aortic branch compromise in 60 patients (57.7%). Asymptomatic and symptomatic aortic branch compromise, respectively, were distributed in the extremity (30 and 33), carotid (5 and 4), renal (21 and 28), visceral (13 and 8), and spinal (0 and 5) arteries. In the asymptomatic aortic branch compromise group, all patients had aortic graft replacement, and 9 had branch reconstructions. In the symptomatic aortic branch compromise group, treatment was aortic graft replacement (48), open fenestration (6), and endovascular treatment (6). Operative mortality rate was 9.1% (4 of 44) in the asymptomatic and 38.3% (23 of 60) in the symptomatic aortic branch compromise during the 30-year study period (P = .001), decreasing from 35.1% (20 of 57) prior to 1990 to 14.9% (7 of 47) since 1990 (P = .04). In the symptomatic group, operative mortality decreased from 56.7% (17 of 30) to 20% (6 of 30) in the same interval (P = .003). Patients treated in both treatment eras were similar except for less aortic graft replacements and more aortic fenestrations and direct branch reconstructions since 1990. Multivariate analysis revealed symptomatic aortic branch compromise group, treatment prior to 1990, Marfan syndrome, age greater than 70 years, and postoperative complications to be independently associated with increased operative mortality. Asymptomatic aortic branch compromise was not associated with increased operative mortality, but organ malperfusion was an independent risk factor for operative death. The operative mortality significantly decreased since 1990, mostly because of changes in our surgical approach, with less aortic graft replacements and more complication-directed procedures.

The aim of the study was to investigate the effect of recent chemotherapy (Chx) on outcome of aorto-iliac aneurysm (AAA) repair. The 2005–2010 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify vascular patients undergoing AAA repair within 30 days after Chx. Seventy-one patients underwent AAA repair within 30 days of receiving Chx, group A (71 ± 8.4 years, 77.5% males) and 20,024 patients underwent AAA repair without prior Chx, group B (73 ± 9 years, 79.2% males). The two groups did not significantly differ with respect to open or endovascular repair (open repair A: 32%, B: 35%, P = 0.66). However, patients in group A presented more often as emergent cases (A: 27%, B: 12%, P = 0.001). Multivariable regression analysis for emergent cases after adjustment for relevant confounders also demonstrated that patients with recent Chx present more often as emergency (P = 0.001, odds ratio [OR]: 2.4). Thirty-day non-surgical complications were more common in group A (A: 25%, B: 16.5%, P = 0.046) while surgical complications were equivalent (A: 15.5%, B: 12.3%, P = 0.414). Risk of death was significantly higher in group A in univariate analysis (A: 13%, B: 5%, P = 0.005, OR: 2.6). Patients who receive Chx within 30 days prior to AAA repair present more frequently as emergencies leading to higher mortality. The reason for this cannot be sufficiently explained by the current database but patient selection for elective repair or the effect of Chx on the natural course of AAA may play a role. [ABSTRACT FROM PUBLISHER]