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Objective: The objective of this study was to examine whether prophylactic use of EndoAnchors (Medtronic, Santa Rosa, Calif) contributes to improved outcomes after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms through 2 years., Methods: The Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR) subjects who received prophylactic EndoAnchors during EVAR were considered for this analysis. Imaging data of retrospective subjects who underwent EVAR at ANCHOR enrolling institutions were obtained to create a control sample. Nineteen baseline anatomic measurements were used to perform propensity score matching, yielding 99 matched pairs. Follow-up imaging of the ANCHOR and control cohorts was then compared to examine outcomes through 2 years, using Kaplan-Meier survival analysis., Results: Freedom from type Ia endoleak was 97.0% ± 2.1% in the ANCHOR cohort and 94.1% ± 2.5% in the control cohort through 2 years (P = .34). The 2-year freedom from neck dilation in the ANCHOR and control cohorts was 90.4% ± 5.6% and 87.3% ± 4.3%, respectively (P = .46); 2-year freedom from sac enlargement was 97.0% ± 2.1% and 94.0% ± 3.0%, respectively (P = .67). No device migration was observed. Aneurysm sac regression was observed in 81.1% ± 9.5% of ANCHOR subjects through 2 years compared with 48.7% ± 5.9% of control subjects (P = .01). Cox regression analysis found an inverse correlation between number of hostile neck criteria met and later sac regression (P = .05). Preoperative neck thrombus circumference and infrarenal diameter were also variables associated with later sac regression, although not to a significant degree (P = .10 and P = .06, respectively). Control subjects with thrombus were significantly less likely to experience later sac regression than those without thrombus (6% and 43%, respectively; P = .001). In ANCHOR subjects, rate of regression was not significantly different in subjects with or without thrombus (33% and 36%, respectively; P = .82). Control subjects with wide aortic necks (>28 mm) were observed to experience sac regression at a lower rate than subjects with smaller diameter necks (10% and 44%, respectively; P = .004). Wide neck and normal neck subjects implanted with EndoAnchors experienced later sac regression at roughly equivalent rates (44% and 33%, respectively; P = .50)., Conclusions: In propensity-matched cohorts of subjects undergoing EVAR, the rate of sac regression in subjects treated with EndoAnchors was significantly higher. EndoAnchors may mitigate the adverse effect of wide infrarenal necks and neck thrombus on sac regression, although further studies are needed to evaluate the long-term effect of EndoAnchors., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective/background: The aim was to describe the re-interventions after endovascular and open repair of rupture, and investigate whether these were associated with aortic morphology., Methods: In total, 502 patients from the IMPROVE randomised trial (ISRCTN48334791) with repair of rupture were followed-up for re-interventions for at least 3 years. Pre-operative aortic morphology was assessed in a core laboratory. Re-interventions were described by time (0-90 days, 3 months-3 years) as arterial or laparotomy related, respectively, and ranked for severity by surgeons and patients separately. Rare re-interventions to 1 year, were summarised across three ruptured abdominal aortic aneurysm trials (IMPROVE, AJAX, and ECAR) and odds ratios (OR) describing differences were pooled via meta-analysis., Results: Re-interventions were most common in the first 90 days. Overall rates were 186 and 226 per 100 person years for the endovascular strategy and open repair groups, respectively (p = .20) but between 3 months and 3 years (mid-term) the rates had slowed to 9.5 and 6.0 re-interventions per 100 person years, respectively (p = .090) and about one third of these were for a life threatening condition. In this latter, mid-term period, 42 of 313 remaining patients (13%) required at least one re-intervention, most commonly for endoleak or other endograft complication after treatment by endovascular aneurysm repair (EVAR) (21 of 38 re-interventions), whereas distal aneurysms were the commonest reason (four of 23) for re-interventions after treatment by open repair. Arterial re-interventions within 3 years were associated with increasing common iliac artery diameter (OR 1.48, 95% confidence interval [CI] 0.13-0.93; p = .004). Amputation, rare but ranked as the worst re-intervention by patients, was less common in the first year after treatment with EVAR (OR 0.2, 95% CI 0.05-0.88) from meta-analysis of three trials., Conclusion: The rate of mid-term re-interventions after rupture is high, more than double that after elective EVAR and open repair, suggesting the need for bespoke surveillance protocols. Amputations are much less common in patients treated by EVAR than in those treated by open repair., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Purpose: To describe a case of extrinsic compression of the Ovation stent-graft following glue embolization for type II endoleak., Case Report: A 75-year-old man with a past history of ischemic heart disease and endovascular aneurysm repair with an Ovation stent-graft was admitted for treatment of type II endoleaks from the right L2 and left L4 lumbar arteries with egress via the inferior mesenteric and right L4 lumbar arteries, respectively. Successful embolization was performed via a translumbar sac puncture with a combination of coils and histoacryl glue. On final angiography severe lumen narrowing of the unsupported portion of the Ovation stent-graft was seen owing to extrinsic compression by the glue. This was successfully salvaged with percutaneous transarterial kissing balloon angioplasty., Conclusion: Aortic lumen narrowing caused by extrinsic compression of an Ovation stent-graft following glue embolization of type II endoleak is an unusual and potentially problematic complication.

Background: Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related death or morbidity., Methods: The committee made specific practice recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. Three systematic reviews were conducted to support this guideline. Two focused on evaluating the best modalities and optimal frequency for surveillance after endovascular aneurysm repair (EVAR). A third focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus included (1) general approach to the patient, (2) treatment of the patient with an AAA, (3) anesthetic considerations and perioperative management, (4) postoperative and long-term management, and (5) cost and economic considerations., Results: Along with providing guidance regarding the management of patients throughout the continuum of care, we have revised a number of prior recommendations and addressed a number of new areas of significance. New guidelines are provided for the surveillance of patients with an AAA, including recommended surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. We recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. Incorporating knowledge gained through the Vascular Quality Initiative and other regional quality collaboratives, we suggest that the Vascular Quality Initiative mortality risk score be used for mutual decision-making with patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented mortality and conversion rate to open surgical repair of 2% or less and that perform at least 10 EVAR cases each year. We also suggest that elective open aneurysm repair be limited to hospitals with a documented mortality of 5% or less and that perform at least 10 open aortic operations of any type each year. To encourage the development of effective systems of care that would lead to improved outcomes for those patients undergoing emergent repair, we suggest a door-to-intervention time of <90 minutes, based on a framework of 30-30-30 minutes, for the management of the patient with a ruptured aneurysm. We recommend treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion. Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised. Increased utilization of color duplex ultrasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion., Conclusions: Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective/background: Proximal type I endoleaks are associated with abdominal aortic aneurysm (AAA) growth and rupture and necessitate repair. The Nellix™ EndoVascular Aneurysm Sealing (EVAS) system is a unique approach to AAA repair, where the appearance and treatment of endoleaks is also different. This study aimed to analyse and categorise proximal endoleaks in an EVAS treated cohort., Methods: All patients, treated from February 2013 to December 2015, in 15 experienced EVAS centres, presenting with proximal endoleak were included. Computed tomography scans were analysed by a core laboratory. A consensus meeting was organised to discuss and qualify each case for selection, technical aspects, and possible causes of the endoleak. Endoleaks were classified using a novel classification system for EVAS., Results: During the study period 1851 patients were treated using EVAS at 15 centres and followed for a median of 494 ± 283 days. Among these, 58 cases (3.1%) developed a proximal endoleak (1.5% early and 1.7% late); of these, 84% of 58 patients were treated outside the original and 96% outside the current, refined, instructions for use. Low stent positioning was the most likely cause in 44.6%, a hostile anatomy in 16.1%, and a combination of both in 33.9%. Treatment, by embolisation or proximal extension, was performed in 47% of cases, with a technical success of 97%., Conclusion: The overall incidence of proximal endoleak after EVAS is 3.1% after a mean follow-up period of 16 months, with 1.5% occurring within 30 days. Their occurrence is related to patient selection and stent positioning. Early detection and classification is crucial to avoid the potential of sac rupture., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Type II endoleak after endovascular aneurysm repair (EVAR) is frequently caused by persistent flow from the inferior mesenteric artery (IMA). The aim of this study was to assess the perioperative and midterm efficacy of laparoscopic ligation of the IMA for treatment of endoleak., Methods: MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane databases and key references were searched with Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for studies reporting on laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR., Results: Eight case studies and one study of a retrospective nature were identified. In total, 20 patients (18 men; mean age, 73.6 ± 2 years; with a mean abdominal aortic aneurysm diameter of 64.3 ± 10 mm) who underwent post-EVAR laparoscopic ligation of the IMA for type II endoleak were analyzed. The mean time from EVAR until intervention ranged from 6 to 18 months. All but one patient were asymptomatic; in 9, the aneurysm sac was enlarged, and in 11, the endoleak was considered persistent without sac enlargement. The mean procedural duration was 99 ± 24 minutes, with technical success rate of 90% (18/20); in two cases, the patients were successfully reoperated on laparoscopically in 24 hours. The mean hospitalization was 3.6 ± 1.2 days, with 0% (0/20) perioperative and 30-day mortality. No patient underwent open conversion or showed signs of intestinal ischemia. During follow-up of 32.6 ± 12 months, 13 of 20 patients had aneurysm sac regression, whereas the rest had a stable sac diameter without evidence of persistent type II endoleak., Conclusions: Laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR is a feasible and safe technique in specialized centers with high technical success rate and good midterm outcomes., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

: Paravalvular leak (PVL) is an uncommon but serious complication associated with the implantation of prosthetic valves. Following aortic valve replacement, up to 5% of patients affected by PVL develop clinical symptoms of heart failure, hemolysis or both. Percutaneous treatment of PVL has emerged instead of conventional surgery, as a well tolerated and less invasive procedure but remains a challenge. We present the case of a young woman with mechanical aortic and mitral prostheses, who presented surgical aortic PVL caused by a serious frailty of native annulus, became symptomatic after 5 months and was successfully percutaneously treated with an Amplatzer Duct Occluder device.

Aims: Postdeployment mutual orientation between the disk and the lobe in patients undergoing left atrial appendage closure with Amplatzer cardiac plug/Amulet device might impact on the risk of residual leak during follow-up. Thus, we evaluated in an exploratory, pilot study whether the degree of intradevice misalignment, measured by cardiac computed tomography (CT), discriminates the occurrence of peridevice leak in those patients., Methods: All patients (N = 15) undergoing percutaneous left atrial appendage closure with those specific devices between April 2013 and January 2015 were prospectively included. All patients received follow-up evaluation by cardiac CT at 6 months after the intervention to calculate the angle of misalignment within the device and to detect presence of residual peridevice leak., Results: The angle of misalignment between the disk and the lobe of the device significantly discriminated between patients with and without peridevice leak (area under the curve 0.96, 95% confidence interval 0.88-1.0; P = 0.003), with an angle more than 20° being associated with nine-fold higher risk of residual leak. This angle of intradevice misalignment calculated by cardiac CT was significantly correlated with that measured by two-dimensional transesophageal echocardiography or X-rays in the cath lab after the device deployment (r = 0.943 and r = 0.938, respectively)., Conclusion: A marked intradevice misalignment after Amplatzer cardiac plug/Amulet device implantation significantly predicts the occurrence of postprocedural leak in patients with atrial fibrillation; if confirmed by larger studies, these findings may impact on practice patterns.

Objectives: Type 1a endoleak is one of the most severe complications after thoracic endovascular aortic repair (TEVAR), because it carries the risk of aortic rupture. The association between bird-beak configuration and Type 1a endoleak remains unclear. The purpose of this study was to analyse the predictors of Type 1a endoleak following Zone 1 and Zone 2 TEVAR, with a particular focus on the effect of bird-beak configuration., Methods: From April 2008 to July 2015, 105 patients (mean age 68.6 years) who underwent Zone 1 and 2 landing TEVAR were enrolled, with a mean follow-up period of 4.3 years. The patients were categorized into 2 groups, according to the presence (Group B, n = 32) or the absence (Group N, n = 73) of bird-beak configuration on the first postoperative multidetector computed tomography., Results: The Kaplan-Meier event-free rate curve showed that Type 1a endoleak and bird-beak progression occurred less frequently in Group N than in Group B. Five-year freedom from Type 1a endoleak rates were 79.7% and 100% for Groups B and N, respectively (P = 0.007). Multivariable logistic regression analysis showed that dissecting aortic aneurysm (odds ratio 3.72, 95% confidence interval 1.30-11.0; P = 0.014) and shorter radius of inner curvature (odds ratio 1.09, 95% confidence interval 0.85-0.99; P = 0.025) were significant risk factors for bird-beak configuration. Multivariable Cox proportional hazard regression showed that Z-type stent graft (hazard ratio 2.69, 95% confidence interval 1.11-6.51; P = 0.030) was a significant risk factor for bird-beak progression., Conclusions: Appropriate stent grafts need to be chosen carefully to prevent Type 1a endoleak and bird-beak configuration after landing Zone 1 and 2 TEVAR. Patients with bird-beak configuration on early postoperative multidetector computed tomography require closer follow-up to screen for Type 1a endoleak., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Post-endovascular aortic aneurysm repair (EVAR) endoleaks and the need for reintervention are challenging. Additional endovascular treatment is advised for type Ia endoleaks detected on post-EVAR completion angiogram. This study analyzed management and late outcomes of these endoleaks., Study Design: This was a retrospective review of prospectively collected data from EVAR patients during a 10-year period. All post-EVAR type Ia endoleaks on completion angiogram were identified (group A) and their early (30-day) and late outcomes were compared with outcomes of patients without endoleaks (group B). Kaplan-Meier analysis was used for survival analysis, sac expansion, late type Ia endoleak, and reintervention., Results: Seventy-one of 565 (12.6%) patients had immediate post-EVAR type Ia endoleak. Early intervention (proximal aortic cuffs and/or stenting) was used in 56 of 71 (79%) in group A vs 31 of 494 (6%) in group B (p < 0.0001). Late type Ia endoleak was noted in 9 patients (13%) in group A at a mean follow-up of 28 months vs 10 patients (2%) in group B at a mean follow-up of 32 months (p < 0.0001). Late sac expansion and reintervention rates were 9% and 10% for group A vs 5% and 3% for group B (p = 0.2698 and p = 0.0198), respectively. Freedom rates from late type Ia endoleaks at 1, 3, and 5 years for group A were 88%, 85%, and 80% vs 98%, 98%, and 96% for group B (p < 0.001); and for late intervention, were 94%, 92%, and 77% for group A, and 99%, 97%, and 95% for group B (p = 0.007), respectively. Survival rates were similar., Conclusions: Immediate post-EVAR type Ia endoleaks are associated with higher rates of early interventions, late endoleaks and reintervention, which will necessitate strict post-EVAR surveillance., (Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: The aim of our study is to verify the role of metalloproteinases in endovascular repair (EVAR) and OPEN surgery treatment for abdominal aortic aneurysm (AAA). Postoperatively, these enzymes could represent an important biomarker to adapt diagnostic tests and further investigations during follow-up., Material and Method: From 2004 to 2008, 55 patients were considered with AAA. Of these, 33 patients (mean age: 70.1 years), (mean AAA diameter: 5.4cm) were treated with OPEN surgery (group A) and 22 (mean age: 74.1 years) (mean AAA diameter: 5.1cm) were treated with EVAR. In 17 of them, there were no signs of endoleak (group B1), while in 5 patients, a presence of endoleak (group B2) was detected. Plasma samples were collected in order to determine MMP-9 activity. Enzyme immunoassay was performed preoperatively at 1, 3, 6 and 12 months. Patients treated conventionally were clinically examined after 1 and 12 months by ultrasound. Patients undergoing EVAR treatment were clinically examined by CT scan after 1, 3, 6 and 12 months. The analysis was done by assessing the interaction over time of the MMP-9 value in B1 and B2 groups., Results: The average values observed for MMP-9 were preoperatively and at 1, 3, 6 and 12 months, respectively: in group A 150.8ng/mL (SD=30.5), 252.5ng/mL (SD=25.2), 315.4ng/mL (SD=22.7), 295.3ng/mL (SD=26.8), 210.7ng/mL (SD=30.2); in group B1 105ng/mL (SD=10.8), 125.6ng/mL (SD=18), 85.8ng/mL (SD=19.9), 95ng/mL (SD=20.2), 80.4ng/mL (SD=15.6); in group B2 149ng/mL (29.2), 375.4ng/mL (SD=40.2), 215ng/mL (SD=35.9), 180ng/mL (SD=20.2), 175ng/mL (SD=33.4). The MMP-9 level was higher in group B2 compared to group B1 (P=0.01), suggesting a correlation with the presence of the endoleak., Conclusions: This preliminary study shows that MMP-9 may be a biomarker of the presence of endoleak. Other further investigations and larger series are needed to show that metalloproteases could play a role in the follow-up of EVAR treated patients., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

The authors share herein their experience with hybrid surgical treatment of 21 patients presenting with lesions of the aortic arch and descending thoracic aorta. Aortic pathology included dissection of the thoracoabdominal aorta (n=15), a sacciform aneurysm of the aortic arch (n=5), and a spindle-shaped aneurysm of the distal portions of the aortic arch (n=1). The first stage consisted of the following operations: transposition of the left subclavian artery into the left common carotid artery (n=9; 42.8%), partial debranching (n=11; 52.5%), and total debranching (n=1; 4.7%). The second stage consisted in implantation of a stent graft: to the thoracic aorta in 18 (85.8%) cases, and to the thoracic and abdominal portions of the aorta in 3 (14.2%) cases. The most significant complications of the immediate postoperative period included acute cerebral circulation impairment (n=1) and local dissection of the ascending aorta (n=1). Type I endoleaks were observed in 4 (19%) patients, type II endoleaks in 1 (4.7%), and type III endoleaks in 1 (4.7%). The mean duration of the follow up after discharge from hospital amounted to 11.6±7.9 months. In 4 patients after 6 months the findings of the control MSCT angiography showed no significant changes of the endoleaks. 1-year patency of the shunted branches of the aortic arch amounted to 95.2%. The cumulative survival rate amounted to 95.2%.

The article deals with a case report regarding successful surgical management of a patient presenting with an anatomically complicated aneurysm of the aortic infrarenal portion and iliac arteries. The first stage consisted in performing implantation of the Ovation Prime stent graft into the abdominal aorta. One month later, the second stage carried out for residual type IB endoleak consisted in implantation of the iliac components of the stent graft into the external iliac arteries on the right and the left. The postoperative period turned out uneventful. The findings of the check ultrasonographic examination showed no evidence of endoleak, with the stent graft's patency preserved. The patient was discharged in a satisfactory condition. The check multispiral computed tomography performed 30 days after the operation also demonstrated complete isolation of the aneurysm of the aorta and iliac arteries from blood flow, with the graft's being patent. The presented herein clinical case report is of sporadic occurrence and is of practical importance for extending the indications for aortic endoprosthetic repair.

The article deals with a case report regarding successful surgical management of late type IB endoleak caused by dislocation of the leg of the stent graft, occurring three years after endoprosthetic repair of an aneurysm of the aortic infrarenal portion with the COOK stent graft, aneurysmectomy with prosthetic repair of the right common femoral artery using the linear vascular graft Intergard 8Ч20. The patient underwent surgical treatment: endoprosthetic repair of the iliac branch ZSLE-24-90-90 ZT of the Zenith Spiral AAA stent graft. The findings of the check-up angiography and ultrasonographic examination revealed no evidence of endoleak, with the stent graft's patency preserved. The early postoperative period was marked with moderate manifestations of asthenic syndrome. The patient was discharged in a satisfactory condition. Cases concerning removal of similar complication in the remote period following endoprosthetic repair of the aorta are mentioned sporadically in the available literature.

Introduction: Computed tomography angiography (CTA) has been widely used in the diagnostic evaluation of many aortic diseases, but no standardized techniques actually exist for aortic CTA. The aim of this study was to describe the usefulness of triphasic CTA in aortic assessment in both non-traumatic emergency and surveillance conditions., Methods: We performed non ECG-gated CTA examinations with a 64-slice CT scanner using a triphasic protocol consisting of an unenhanced acquisition, and two (early and delayed) contrastographic phases with a delay of 25-30 s and 100-120 s respectively after the injection of contrast medium. Were retrospectively selected adult patients with imaging findings of acute aortic dissection (AAD) or endoleak (EL) from November 2012 to November 2014., Results: AAD was detected in 36 (67%) patients: 23 type A-AADs, and 13 type B-AADs. The presence of EL was observed in 18 (33%) patients: 1 type Ia, 5 types IIa, 2 types IIb, 1 type IIIa and 9 types IIIb., Discussion: Triphasic CTA is useful to provide correct and prompt diagnosis of AAD in emergency, allowing the evaluation of type and atypical forms of AAD, and the identification of possible branch-vessel involvement and complications. During surveillance, triphasic CTA assures accurate and complete assessment of all known and unknown ELs and it is essential for first follow-up examination., Conclusion: Triphasic CTA represents a reliable imaging tool for aortic assessment in both non-traumatic emergency and surveillance after endovascular aneurysm repair. Modified protocol could be employed in selected patients and tailored in their known disease., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

As more challenging aortic arch anatomy is being treated using aortic stent-grafts, there is an increased risk for proximal Type I endoleaks at the proximal seal zone or subsequent graft migration. We report a case of an endoanchor-assisted thoracic endovascular aneurysm repair of a patient with an aberrant right subclavian artery (ARSA) and aortic arch aneurysm who developed a proximal Type I endoleak in the aortic arch which was subsequently treated with endoanchors., (© 2016 Wiley Periodicals, Inc.)

Background: Early morbidity and mortality are generally lower after endovascular aortic repair (EVAR), than after open repair but re-interventions and late complications are more common. The aim of the present study was to make a detailed description of re-interventions after EVAR-including incidence, indications, procedures, and outcome-with special reference to non-access-related re-interventions., Methods: This is a retrospective single-center cohort study of re-interventions after standard EVAR with special reference to non-access-related re-interventions. Consecutive patients (n = 405) treated with standard EVAR for non-ruptured (n = 337) or ruptured (n = 68) infrarenal aneurysms between 2005 and 2013 were analysed. Median follow-up was 29 months (range 0-108)., Results: Eighty-nine patients (22 %) underwent 113 re-interventions during follow-up. Twenty-seven patients (7 %) had 28 access related re-intervention, 65 patients (16 %) had 85 non-access related reinterventions. Non-access related re-interventions were more common in ruptured aneurysms than in unruptured aneurysms (22 vs. 15 %, p = 0.002). The most frequent indications were endoleak type I (n = 19), type II (n = 21), or type III (n = 5); stent graft migration (n = 9); and thrombosis (n = 14). The most frequent procedures were embolization of endoleak type II (n = 21), additional iliac stent graft (n = 19), proximal extension (n = 12), thrombolysis (n = 8), iliac limb bare-metal stenting (n = 6), and stent graft relining (n = 7). Endovascular technique was used in 83 % of re-interventions. Thirty-day mortality after non-access-related re-interventions was 15 % when initiated from symptoms (rupture or infection) and 0 % when initiated from follow-up findings (p = 0.014). Cumulative survival five years after EVAR was 72 % in patients with a re-intervention and 59 % in patients without (p = 0.21)., Conclusions: Non-access-related re-intervention rates are still considerable after EVAR and more frequent after ruptured aneurysms. Endoleak embolization is the most frequent procedure, followed by additional iliac stent grafts. Outcomes after re-interventions are generally good, except when initiated by rupture or infection.

Background: Persistent type II endoleaks (T2Ls) with sac enlargement after endovascular abdominal aortic aneurysm repair are still of concern in view of the potential for rupture. Current treatments (embolization and stent graft [SG] explantation) are associated with lack of efficacy or high perioperative morbidity and mortality. This study evaluated an alternative technique that combines sacotomy, ligation of patent back-bleeding vessels, and SG preservation for T2L or unspecified endoleak repair., Methods: This multicenter study in France included 28 patients (27 men; median age, 78 years). Twenty-one patients (75%) had a bifurcated SG (including 3 fenestrated SGs) and seven (25%) had an aortouni-iliac SG (2 for ruptured aneurysm). Unsuccessful embolization had been performed in 10 patients (36%). Four patients (14%) presented sac enlargement with no endoleak visible on computed tomography. The origin of the endoleak remained unspecified in three patients 3 (11%). The median diameter of the aneurysmal sac was 78 mm (vs 55 mm at the time of endovascular abdominal aortic aneurysm repair) after a median follow-up of 24 months., Results: A transperitoneal approach was used in 21 patients (75%) and a retroperitoneal approach was used in seven (25%). A guidewire was placed in the supraceliac aorta in 14 patients, and an occlusion balloon was temporarily inflated in six. Aortic cross-clamping was performed in five patients. T2Ls were identified in 26 patients, and associated with a distal type I endoleak in 1 patient, a type III endoleak in 3, and a type IV endoleak in 1. Two patients presented with endotension. All the endoleaks were treated successfully, with a mean operating time of 120 minutes and a mean blood loss of 450 mL. One SG was explanted 12 days after the procedure because of early infection. One patient died during SG explantation for an aortoduodenal fistula 26 months after the endoaneurysmorrhaphy. During a median follow-up of 24 months, the control computed tomography scan showed shrinkage of the aneurysmal sac with stable diameters in all patients. No missed T2Ls, no recurrence of T2L, and no SG migration or disjunction was observed., Conclusions: Obliterating endoaneurysmorrhaphy with SG preservation can be considered as an alternative to SG removal in cases of persistent T2L responsible for aneurysmal sac enlargement after embolization failure. By avoiding extensive dissection for surgical aortic cross-clamping, minimizing hemodynamic changes, and reducing blood loss and operating time, this procedure can be performed even in patients initially considered unfit for surgery., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Type II endoleaks are common after endovascular aneurysm repair (EVAR), but their clinical significance remains undefined and their management controversial. We determined risk factors for type II endoleaks and associations with adverse outcomes., Methods: We identified all EVAR patients in the Vascular Study Group of New England abdominal aortic aneurysm database. Patients were subdivided into two groups: (1) those with no endoleak or transient type II endoleak and (2) persistent type II endoleak or new type II endoleak (no endoleak at completion of case). Patients with other endoleak types and follow-up shorter than 6 months were excluded. Multivariable analysis was used to evaluate predictors of persistent or new type II endoleaks. Kaplan-Meier and Cox regression analysis were used to evaluate predictors of reintervention and survival., Results: Two thousand three hundred sixty-seven EVAR patients had information on endoleaks: 1977 (84%) were in group 1, of which 79% had no endoleaks at all, and 21% had transient endoleaks that resolved at follow-up. The other 390 (16%) were in group 2, of which 31% had a persistent leak, and 69% had a new leak at follow-up that was not seen at the time of surgery. Group 2 was older (mean age, 75 vs 73 years; P < .001) and less likely to have chronic obstructive pulmonary disease (COPD; 24% vs 34%; P < .001) or elevated creatinine levels (2.6% vs 5.3%; P = .027). Coil embolization of one or both hypogastric arteries was associated with a higher rate of persistent type II endoleaks (12 vs 8%; P = .024), as was distal graft extension (12% vs 8%; P = .008). In multivariable analysis, COPD (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.5-0.9; P = .017) was protective against persistent type II endoleak, while hypogastric artery coil embolization (OR, 1.5; 95% CI, 1.0-2.2; P = .044), distal graft extension (OR, 1.6; 95% CI, 1.1-2.3; P = .025), and age ≥ 80 (OR, 2.7; 95% CI, 1.4-5.3; P = .004) were predictive. Graft type was also associated with endoleak development. Persistent type II endoleaks were predictive of postdischarge reintervention (OR, 15.3; 95% CI, 9.7-24.3; P < .001); however, they were not predictive of long-term survival (OR, 1.1; 95% CI, 0.9-1.6; P = .477)., Conclusions: Persistent type II endoleak is associated with hypogastric artery coil embolization, distal graft extension, older age, the absence of COPD, and graft type, but not with aneurysm size. Persistent type II endoleaks are associated with an increased risk of reinterventions, but not rupture or survival. This reinforces the need for continued surveillance of patients with persistent type II endoleaks and the importance of follow-up to detect new type II endoleaks over time., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Type II endoleaks are the most common endovascular complications of endovascular abdominal aortic aneurysm repair (EVAR); however, there has been a divided opinion regarding their significance in EVAR. Some advocate a conservative approach unless there is clear evidence of sac expansion, while others maintain early intervention is best to prevent adverse late outcomes such as rupture. There is a lack of level-one evidence in this challenging group of patients, and due to a low event rate of complications, large numbers of patients would be required in well-designed trials to fully understand the natural history of type II endoleak. This review will discuss the imaging, management, and outcome of patients with isolated type II endoleaks following infra-renal EVAR.

Purpose: To define the diagnostic precision of non-specialized readers in the detection of type 2 endoleaks (T2EL) in arterial versus venous phase acquisitions, and to evaluate an approach for radiation dose reduction., Methods: The pre-discharge and final follow-up multi-slice CT angiographies of 167 patients were retrospectively analyzed. Image data were separated into an arterial and a venous phase reading set. Two radiology residents assessed the reading sets for the presence of a T2EL, feeding vessels, and aneurysm sac size. Findings were compared with a standard of reference established by two experts in interventional radiology. The effective dose was calculated., Results: Overall, experts detected 131 T2ELs, and 331 feeding vessels in 334 examinations. Persistent T2ELs causing aneurysm sac growth > 5 mm were detected in 20 patients. Radiation in arterial and venous phases contributed to a mean of 58.6% and 39.0% of the total effective dose. Findings of reader 1 and 2 showed comparable sensitivities in arterial sets of 80.9 versus 85.5 (p = 0.09), and in venous sets of 73.3 versus 79.4 (p = 0.15), respectively. Reader 1 and 2 achieved a significant higher detection rate of feeding vessels with arterial compared to venous set (p = 0.04, p < 0.01). Both readers correctly identified T2ELs with growing aneurysm sac in all cases, independent of the acquisition phase., Conclusion: Arterial acquisitions enable non-specialized readers an accurate detection of T2ELs, and a significant better identification of feeding vessels. Based on our results, it seems reasonable to eliminate venous phase acquisitions.

Objective: Hostile infrarenal neck characteristics are associated with complications such as type Ia endoleak after endovascular aneurysm repair. Aortic neck angulation has been identified as one such characteristic, but its association with complications has not been uniform between studies. Neck angulation assumes triangular oversimplification of the aortic trajectory, which may explain conflicting findings. By contrast, aortic curvature is a measurement that includes the bending rate and tortuosity and may provide better predictive value for neck complications., Methods: Data were retrieved from the Heli-FX (Aptus Endosystems, Inc, Sunnyvale, Calif) Aortic Securement System Global Registry (ANCHOR). One cohort included patients who presented with intraoperative endoleak type Ia at the completion angiogram as the indication for EndoAnchors (Aptus Endosystems), and a second cohort comprised those without intraoperative or late type Ia endoleak (controls). The aortic trajectory was divided into six segments with potentially different influence on the stent graft performance: suprarenal, juxtarenal, and infrarenal aortic neck (-30 to -10 mm, -10 to 10 mm, and 10-30 mm from the lowest renal artery, respectively), the entire aortic neck, aneurysm sac, and terminal aorta (20 mm above the bifurcation to the bifurcation). Maximum and average curvature were automatically calculated over the six segments by proprietary custom software. Aortic curvature was compared with other standard neck characteristics, including neck length, neck diameter, maximum aneurysm sac diameter, neck thrombus and calcium thickness and circumference, suprarenal angulation, infrarenal angulation, and the neck tortuosity index. Independent risk factors for intraoperative type Ia endoleak were identified using backwards stepwise logistic regression. For the variables in the final regression model, suitable cutoff values in relation to the prediction of acute type Ia endoleak were defined with the area under the receiver operating characteristic curve., Results: The analysis included 64 patients with intraoperative type Ia endoleak and 79 controls. Logistic regression identified only aortic neck calcification and aortic curvature, expressed over the juxtarenal aortic neck, the aneurysm sac, and the terminal aorta, as independent predictors of intraoperative type Ia endoleak., Conclusions: Together with aortic neck calcification, aortic curvature appears to be the best predictor of intraoperative type Ia endoleak, as expressed within the juxtarenal aortic neck, the aneurysm sac, and the terminal aorta. Aortic neck angulation was not a predictor for acute failure. Aortic curvature may provide a better anatomic characteristic to define patients at risk for early complications after endovascular aneurysm repair., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate the aneurysm-related complications and device issues in patients who underwent partial endograft explantation during late conversion of endovascular aneurysm repair (EVAR) to open repair., Methods: A retrospective analysis was performed on patients who had partially explanted endografts during late conversion between 1999 and 2012. Medical records were reviewed for patient demographics, subsequent operations, and aneurysm-related complications. Postoperative abdominal X-ray films and computed tomography scans were analyzed for endograft migration, component separation, device fracture, and arterial growth or aneurysm issues., Results: Between 1999 and 2012, 22 patients had late conversion after EVAR with portions of the device left in situ. Five of the partially removed devices were Zenith, 6 Talent, 5 Ancure, 3 AneuRx, 2 Excluder endografts, and 1 Cook Aorto uni-iliac (AUI) graft. There were 4 in hospital mortalities. There were no graft migrations, component separations, device fractures, new aneurysmal degeneration, or ruptures with a median follow-up of 26.5 months., Conclusions: Partial endograft removal during late conversion is not associated with complications from the remaining device pieces during follow-up. We recommend further study of this patient population., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The aim of this study is to give an overview of current knowledge regarding abdominal aortic aneurysm (AAA) growth after endovascular aortic aneurysm repair (EVAR) that could potentially lead to aortic rupture. A search on Pubmed was performed. A total of 705 articles were found after initial search, of which 49 were included in the final selection. Reports on the incidence of aneurysm enlargement after EVAR vary between 0.2% and 41%. Continuous growth could lead to rupture of the aneurysm sac. There are several supposed risk factors for growth after EVAR. Endoleaks remain a hot topic as these could lead to persistent pressurization of the aneurysm sac causing growth. Various types of endoleak exist, of which each kind requires an individual treatment approach, other risk factors for aneurysm growth include endotension and the use of EVAR outside instructions for use (IFU). Reinterventions after EVAR are common; however, it is unclear how frequently these are required because of aneurysm enlargement. Aneurysm enlargement after EVAR remains a subject of debate, as this could lead to aortic rupture. This emphasizes the need for life-long radiologic surveillance during follow-up. Aortic growth after EVAR is often a result of endoleak; however, in some cases, no endoleak is detectable. Endoleak in combination with aortic growth >5 mm generally requires reintervention. A cause of concern is the liberal use of endovascular devices outside the IFU that may result in increased risk of AAA growth after EVAR., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To describe the use of vascular plugs to close a complex type Ib endoleak following the sandwich procedure used in conjunction with endovascular thoracoabdominal aortic aneurysm (TAAA) repair., Case Report: A 59-year-old man with a 6.5-mm TAAA was treated with initial deployment proximally of 2 Zenith TX2 stent-grafts. In preparation for the sandwich technique to preserve flow to the celiac trunk, a 10×100-mm Viabahn covered stent was delivered from a brachial access into the celiac trunk unprotected by the sheath of the introducer. The trigger wire system became snagged on the struts of the distal aortic stent-graft; when the wire was pulled, the proximal end of the Viabahn migrated outside the aortic stent-graft, which migrated upward. The main body extension intended for the aortic component of the sandwich technique was deployed close to the distal end of the aneurysm sac, but a large type Ib endoleak formed in the gutter between the Viabahn, aortic extension, and sac wall. The leak perfused the celiac trunk, and the procedure was terminated. Increasing sac size on 3-month imaging prompted closure of the leak with 2 type II Amplatzer vascular plugs aiming to occlude the endoleak outflow into the Viabahn and the endoleak outflow at the site of the gutter. Imaging follow-up at 6 months demonstrated successful exclusion of the TAAA with no residual endoleak and excellent perfusion of the celiac trunk., Conclusion: Transarterial treatment of complex endoleaks is feasible when preceded by meticulous imaging and detailed preprocedural planning., (© The Author(s) 2015.)

Selective transarterial catheterisation and translumbar sac puncture are well established techniques for the management of significant type 2 endoleaks. We report an additional technique for endovascular access to the endoleak sac through the space between the iliac endograft and artery wall.

Purpose: To report 2 cases of type IIIb endoleak with the Endurant stent-graft and postulate the cause for the events., Case Report: A type IIIb endoleak was diagnosed at open conversion for a ruptured aneurysm 4 years after implantation of an Endurant stent-graft. In the other case, the endoleak was diagnosed at angiography 4 years after the Endurant stent-graft was implanted; the stent-graft was relined. In both cases the fabric hole was in the body of the stent-graft at the level of the top of the contralateral limb., Conclusion: The cause of the type IIIb endoleaks in these cases was fabric erosion likely due to interaction between the bare metal at the top of the contralateral limb and the fabric of the stent-graft body., (© The Author(s) 2015.)

Purpose: To describe 2 patients with a distally migrated endograft causing a type Ia endoleak and treatment with a proximal cuff and chimney grafts that required EndoAnchors to finally seal the leak., Case Report: Two men, ages 86 and 72 years, presented with stent-graft migration and type Ia endoleak at 5 and 15 years after endovascular repair, respectively. Both were treated with a proximal cuff in combination with a chimney graft to the left renal artery. In both cases, the type Ia endoleak persisted, likely due to gutter formation. Both patients were treated in the same setting with EndoAnchors that instantly resolved the endoleak. At 1-year follow-up, there was no recurrent endoleak or migration, with patent chimney grafts and renal arteries and stable renal function., Conclusion: EndoAnchors may effectively resolve a persistent type Ia endoleak arising from gutter formation after placement of a proximal cuff and chimney grafts., (© The Author(s) 2015.)

Endovascular aneurysm sealing (EVAS) using the Nellix system is a new and different method of abdominal aortic aneurysm repair. Normal postoperative imaging has unique appearances that change with time; complications also have different and specific appearances. This consensus document on the imaging findings after Nellix EVAS is based on the collective experience of the sites involved in the Nellix EVAS Global Forward Registry and the US Investigational Device Exemption Trial. The normal findings on computed tomography (CT), duplex ultrasound, magnetic resonance imaging, and plain radiography are described. With time, endobag appearances change on CT due to contrast migration to the margins of the hydrogel polymer within the endobag. Air within the endobag also has unique appearances that change over time. Among the complications after Nellix EVAS, type I endoleak usually presents as a curvilinear area of flow between the endobag and aortic wall, while type II endoleak is typically small and usually occurs where an aortic branch artery lies adjacent to an irregular aortic blood lumen that is not completely filled by the endobag. Procedural aortic injury is an uncommon but important complication that occurs as a result of overfilling of the endobags during Nellix EVAS. The optimum imaging surveillance algorithm after Nellix EVAS has yet to be defined but is largely CT-based, especially in the first year postprocedure. However, duplex ultrasound also appears to be a sensitive modality in identifying normal appearances and complications., (© The Author(s) 2015.)

Purpose: To report the use of the off-the-shelf Zenith t-Branch Thoracoabdominal Endovascular Graft for the treatment of a symptomatic acute type Ia endoleak subsequent to previous infrarenal bifurcated endovascular aneurysm repair., Case Report: A 72-year-old man presented 4 years after implantation of an Anaconda stent-graft with sac expansion and type II endoleak, which was treated over the next 18 months with repeated coil and glue embolization of the leak and sac. Six months after the last attempt, imaging disclosed a new type Ia endoleak. Sac enlargement became symptomatic, and emergent treatment was performed using the off-the-shelf Zenith b-Branch device. The 4 visceral arteries were bridged with Fluency stent-grafts. The Anaconda stent-graft precluded the use of a standard Zenith universal distal body bifurcated device below the t-Branch graft, so a reversed tapered 16×20×82-mm iliac limb was placed to bridge the t-Branch to the larger Anaconda limb; the smaller 12-mm contralateral Anaconda limb was occluded. The procedure was concluded with a femorofemoral bypass. At 10 months after the procedure, the patient is well; the sac diameter has decreased, and there is no endoleak on imaging., Conclusion: The multibranched Zenith t-branch device may be useful in treating proximal endoleaks in bifurcated stent-grafts., (© The Author(s) 2015.)

Purpose: To describe the successful endovascular treatment of 2 patients with type IIIb endoleak using the Nellix EndoVascular Aneurysm Sealing (EVAS) System., Case Report: Two men aged 75 and 83 years presented with type IIIb endoleak several years (8 and 3, respectively) after initial endovascular aneurysm repair. Dual Nellix endoprosthesis were deployed in the stent-grafts, and the endobags were filled with polymer to seal the defect and eliminate the endoleak. The perioperative periods were uneventful. At up to 6-month follow-up, no endoleaks were detected, aneurysm diameters were unchanged, and the endografts were patent. One patient died 7 months after revision due to a metastatic malignancy., Conclusion: The Nellix EVAS System may prove useful for the treatment of type IIIb endoleak., (© The Author(s) 2015.)

Treatment of type IB endoleak after thoracic endovascular aortic repair (TEVAR) for post-dissection aortic aneurysm usually includes attempts of endovascular interventions using coils or plugs to occlude the false lumen or placement of a distal fenestrated endograft. Open conversion usually requires deep hypothermia and circulatory arrest with the associated increased mortality and complications. We present a case of a young patient with a 90 mm descending thoracic aneurysm caused by a chronic type B aortic dissection. A type II endoleak after TEVAR was successfully treated with left subclavian artery transposition. The patient had a rapidly increasing aortic aneurysm with a persistent type IB endoleak in spite of placement of an Amplatzer plug into the false lumen of the dissection. He developed progressive acute compression of the main stem bronchi by the aneurysm sac and his dyspnea worsened by an acute pulmonary embolism treated with anticoagulation. Adequate oxygenation could only be achieved with mechanical ventilation using a double-lumen endobronchial tube. A left thoracotomy was performed and the type IB endoleak was treated with bending of the distal aorta around the stent graft with a Dacron graft sleeve. Aortic clamping and circulatory support devices were avoided. The sac of the aneurysm was opened, a giant hematoma was evacuated, and aneurysmorrhaphy was performed to cover the stent graft. There was no residual endoleak and the bronchi were decompressed. The patient recovered after prolonged hospitalization and he was discharged home in good condition 24 days after admission. He returned to his normal activities and is asymptomatic 5 months later. Computed tomographic angiography showed decreased aneurysm sac, no evidence of endoleak, no residual pulmonary embolus, and no bronchial compression., (Copyright © 2016 Elsevier Inc. All rights reserved.)

A delayed secondary open conversion (SOC) after endovascular aneurysm repair may be necessary due to a failing graft. Many surgical techniques can be performed, and one such approach is partial explantation of the graft with resuturing of a new graft to the retained components of the endograft. No guidelines exist with regards to the follow-up of retained endovascular components after a delayed SOC. The theoretical risk of endoleaks remains with retained components, and this case demonstrates the development of a type Ib endoleak after SOC leading to free flow of blood into a partially resected aneurysm sac and causing a symptomatic aneurysm rupture., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To report the causes of second rupture in patients treated with a stent graft for ruptured abdominal aortic aneurysm (rAAA)., Case Report: A 69-year-old man was admitted for abdominal pain and hypovolemic shock 22 months after endovascular exclusion of an rAAA with an aortomonoiliac stent graft and a crossover bypass despite normal duplex ultrasound and sac shrinkage at 1 year. During emergent laparotomy, a type IA endoleak was discovered and the aortomonoiliac stent graft was explanted. A Dacron bypass was interposed between the infrarenal aorta and the iliac extension stent graft., Conclusions: Considering the literature, this report has 3 implications for the endovascular treatment of rAAA. First, 30% oversizing is preferable to 15% when treating an rAAA assessed by computed tomography angiography (CTA) performed during permissive hypotension. Second, the surveillance program should rely on CTA and not on a duplex examination to detect any endoleaks or migration. Finally, partial stent graft explantation is a valid option for decreasing aortic clamping time., (Copyright © 2016 Elsevier Inc. All rights reserved.)

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.)

Objective/background: Persistent type II endoleak (EL II) with sac enlargement after endovascular repair of abdominal aortic aneurysm requires treatment to prevent rupture. Embolization is not always effective. Conversion to open repair with stent graft (SG) explantation is a high risk option. The aim of this study was to evaluate the feasibility and immediate results of an alternative technique combining obliterative endoaneurysmorrhaphy (OEA) with SG preservation., Methods: The open surgical technique combined sacotomy, ligation of all patent back-bleeding vessels and SG preservation. The aneurysmal shell was tightly closed over the SG to protect it from the intestines. An intra-aortic occlusion balloon was used when clamping was required., Results: Twelve patients were treated with the OEA technique at Amiens University Hospital. All 12 procedures were successful. Four patients had previously undergone unsuccessful transarterial or translumbar embolization. Aortic clamping was performed in four cases. No SG migration or graft dislocation was observed. Follow up computed tomography scan at a median of 12 months showed shrinkage of the aneurysm sac with stable diameters and no recurrence of EL II in all cases., Conclusion: The OEA technique is an alternative option for the treatment of progressive EL II, which can be particularly useful after failure of embolization., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

We present a case of an endovascular aneurysm repair for a Q-fever-infected acute abdominal aortic aneurysm with aortocaval fistula. Type 2 endoleak persisted after successful endovascular repair., (© The Author(s) 2014.)

Type II endoleak after endovascular aortic aneurysm repair still remains the Achilles' heel of the treatment, the source of which regularly is difficult to identify and treat. We present a patient with a persistent type II endoleak associated with a continuous aneurysm sac expansion after endovascular aortic aneurysm repair for which many diagnostic modalities were used during his follow-up such as duplex scan, computed tomography angiography and magnetic resonance angiography. Attempts were undertaken to treat the source of endoleak including coil micro-embolisation of lumbar arteries and subsequent open ligation of the inferior mesenteric artery, but they failed to eliminate the endoleak. Finally, a middle sacral artery was identified as the source of the endoleak. At that time, the patient was subjected to surgery for sigmoid carcinoma, and simultaneously, a ligation of the sacral artery was undertaken which eventually eliminated the endoleak completely. This case highlights that type II endoleak may be evoked by various sources and there can be a great difficulty to identify these feeding vessels; thus, careful planning for its management is mandatory., (© The Author(s) 2014.)

The frozen elephant procedure, as a hybrid method to treat aortic pathologies involving the aortic arch and the proximal descending aorta, has become an accepted treatment option. We report two late fractures of the nitinol stents of the endograft of an early frozen elephant trunk prosthesis. One patient suffered from a tear of the woven polyester fabric, causing a Type III endoleak and rapid progression of the existing descending aortic aneurysm. The patient received replacement of the descending aorta. The second patient showed a fracture of a nitinol stent without further complications during follow-up., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: The advent of branched and fenestrated aortic endografts has facilitated the treatment of increasingly complex aortic pathology. The management of complications and endoleaks involving the branches and fenestrations of these grafts represents an increasingly significant clinical and technical challenge., Methods: A 79-year-old woman developed a rare type IIIb endoleak from a tear in the graft fabric immediately posterior to the celiac axis branch 3 years after the placement of an off-the-shelf branched endograft for a type II thoracoabdominal aortic aneurysm. The patient presented urgently with abdominal pain and a maximal aneurysm diameter of 15.3 cm., Results: The operative plan was to create a chimney graft completely within the original branched endograft to cover the defect and maintain celiac branch flow. The celiac trunk was accessed from a left axillary approach and access for the main endograft body was achieved via the left femoral artery. Two balloon-expandable covered stents were deployed from the celiac branch extending into the main endograft as a chimney and molded to 2 aortic extension cuffs to cover the fabric defect. The resultant configuration was a modified-sandwich graft within the original stent graft and resulted in successful exclusion of the endoleak. Postoperative imaging at 1, 6, and 12 months has demonstrated continued patency of the celiac trunk, no further endoleak, and a 16-mm reduction in aneurysm size., Conclusions: The chimney technique was successfully applied as an endovascular option to salvage a multibranched endograft with a significant and anatomically unfavorable defect. Careful follow-up and additional clinical study are required to clarify the role of off-the-shelf solutions in complex endoleak management., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: A recent investigation has documented an increased risk of aneurysm-related complications after endovascular aneurysm repair (EVAR) of familial abdominal aortic aneurysms (fAAAs). We hypothesized that fAAA patients are not at increased risk for complications following open AAA repair or EVAR when compared with sporadic abdominal aortic aneurysm (spAAA) patients. To this end, we performed a single institution retrospective review., Methods: Epidemiologic data were collected through the electronic medical record. Family history data were obtained from a questionnaire administered at the initial vascular surgery consultation. Major adverse events were defined as myocardial infarction, respiratory failure, renal failure, bowel ischemia, limb ischemia, multisystem organ failure, intracranial hemorrhage, paraplegia, hemorrhage, or death. Endoleaks were classified in accordance with the standardized reporting practices of the Society for Vascular Surgery. AAA-related complications were defined as the need for a secondary intervention due to endoleak, limb ischemia, or postimplantation rupture., Results: A total of 392 patients with complete clinical data underwent elective AAA repair from 2004 to 2014. Of these 392 patients, 89 (23%) were classified as fAAA patients and 303 (77%) were classified as spAAA patients. With the exception of increased rates of chronic obstructive pulmonary disease (P = .0009) and pack-years smoked (P = .03) in spAAA patients, demographics did not differ. Sixty-two percent (n = 55) of fAAA patients and 68% (n = 205) of spAAA patients underwent EVAR (P = .30). fAAA patients did not incur any significant difference in major adverse events following open AAA repair (fAAA, 9% vs spAAA, 11%; P = .75). Additionally, fAAA patients did not incur any significant difference in major adverse events following EVAR (fAAA, 4% vs spAAA, 5%; P = .70). Patients with fAAA did have a significantly increased rate of endoleak (fAAA, 24% vs spAAA, 12%; P = .03) and secondary intervention following EVAR (fAAA, 21% vs spAAA, 12%; P = .04)., Conclusions: The current study shows that patients with fAAA do not have increased perioperative morbidity following open or endovascular AAA repair. However, patients with fAAA do have an increased risk of endoleak and secondary intervention following EVAR. These findings suggest that EVAR and open AAA repair are both safe and effective for fAAA patients. The increased rate of endoleak and secondary intervention in patients with fAAA suggests that this subpopulation may benefit from closer post-EVAR surveillance or open surgical repair in good risk patients., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to identify the predictive factors for the development of type II endoleaks (EL-II) after endovascular aneurysm repair (EVAR)., Methods: We assessed the preoperative and postoperative computed tomography data of 308 patients who underwent EVAR between 2000 and 2012 and in 84 of whom primary or secondary EL-II occurred. The data analyzed were: demographics, number and diameter of lumbar arteries (LAs), inferior mesenteric artery (IMA), median sacral artery (MSA), accessory renal arteries (ARas), maximum diameter of infrarenal abdominal aortic aneurysm, diameter and length of proximal aortic neck. Statistical analysis was performed using Stata software (version 12). Categorical parameters were compared between groups using chi-squared or Fisher's exact tests as appropriate. Continuous variables were analyzed using Student's t-test or Mann-Whitney test as appropriate (normality studied by the Shapiro-Wilk and homoscedasticity verified using the Fisher-Snedecor test)., Results: Of the 308 patients included (mean age, 73.8 ± 8.74 years), 284 (92%) were men, 61 (20%) were smokers, 113 (37%) had chronic obstructive pulmonary disease, 215 (70%) were taking antiplatelet. Respectively, 13, 51, 60, 103, 28, 40, 2, and 7 patients had 1, 2, 3, 4, 5, 6, 7, and 8 patent LAs. Before surgery, 221 IMAs and 136 MSA were patent. The sources of EL-II were: LA (n = 51), IMA (n = 22), MSA (n = 1), IMA and LA (n = 8), IMA and ARa (n = 1), and unknown (n = 1). Logistic regression models adjusting for clinically relevant covariables (age, American Society of Anesthesiologists, smoking status, dyslipidemia, and diuretics) were proposed to study morphologic EL-II predictive factors, first in the entire population, and then in the more specific population for whom IMA was patent. Risk factors of occurrence EL-II were: permeability of the IMA (70 patients [83%] vs. 155 [69%], P = 0.01), IMA diameter (3.49 mm vs. 2.71 mm, P < 0.001), number of LAs patent higher than or equal to 4 (P < 0.001), the mean LA diameter greater than 2.4 mm (P < 0.001), and MSA diameter (2.28 mm vs. 1.94 mm; P < 0.01)., Conclusions: Our results show the major role of the number and diameter of the patent aortic branches in the development of EL-II. As they can result in complications increasing the morbidity and mortality after EVAR, it is relevant to identify the risk factors of their occurrence., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Abdominal aneurysmal sac enlargement after endovascular aortic repair (EVAR) is a critical issue. However, the predictors have not yet been fully determined. Although unrecognized, intraluminal thrombus volume (ITV) is an important index. Therefore, we retrospectively evaluated the correlation among preoperative ITV, residual type II endoleak, and sac enlargement after EVAR, based on the long-term follow-up., Methods: Between 2006 and 2011, 151 consecutive patients underwent EVAR at a single cardiovascular institute. Emergency surgery was performed on 7 patients (4.7%). Of 148 patients excluding 3 patients with residual type I endoleak, sac enlargement (≥5 mm progression) after EVAR was observed in 24 patients (16.2%) and 8 patients required reintervention. The mean follow-up period was 2.4 ± 1.4 years. The outer volume and enhanced luminal volume were calculated from enhanced 1-mm slice computed tomography, and the difference was defined as ITV., Results: Age (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.04-1.20, P = 0.0007), outer volume (HR 1.04, 95% CI 1.01-1.07, P = 0.0118), percentage of ITV (HR 0.90, 95% CI 0.84-0.96, P = .0027), and type II endoleak (HR 10.15, 95% CI 3.55-31.10, P < 0.0001) were isolated as predictors of sac enlargement by multivariate analysis. Also, patent inferior mesenteric artery (odds ratio [OR] 4.45, 95% CI 1.38-20.07, P = 0.0105) and percentage of ITV < 30.1% (OR 3.52, 95% CI 1.32-10.30, P = 0.0112) were detected as independent risk factors for residual type II endoleaks. Additionally, in patients without endoleak, patient age (≥83 years) was an independent risk factor for sac enlargement after EVAR (P = 0.0056)., Conclusion: Age and ITV percentage had significantly great impact on sac enlargement and type II endoleak after EVAR., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To report a systematic literature review of late rupture of abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) and the results of a pooled analysis of causes, treatment, and outcomes., Methods: Electronic information sources and bibliographic reference lists were interrogated using a combination of free text and controlled vocabulary searches; 11 articles were ultimately identified that fulfilled the inclusion criteria. The articles reported a total of 190 patients who were included in the qualitative and quantitative synthesis. Mortality within 30 days or during the admission with aneurysm rupture was a primary endpoint; major perioperative morbidity was a secondary endpoint. A meta-analysis was performed for 30-day/in-hospital mortality using the random effects model., Results: A total of 152 ruptures occurred after 16,974 EVAR procedures reported by 8 of the case series, giving an incidence of 0.9% [95% confidence interval (CI) 0.77 to 1.05]. The mean time to rupture was 37 months. Twenty-nine percent (95% CI 20 to 39) of the patients had at least one previous secondary endovascular intervention following the initial EVAR, and 37% (95% CI 30 to 45) were not compliant with surveillance. Type I and III endoleaks were the predominant causes of rupture. Open surgical treatment was undertaken in 61% (95% CI 53 to 68) of the patients who underwent treatment. The pooled estimate for perioperative mortality was 32% (95% CI 24 to 41). A significantly lower mortality was found with endovascular treatment than open surgical management (p=0.027)., Conclusion: Graft-related endoleaks appear to be the predominant causes of late aneurysm rupture. Quality of and compliance with post-EVAR surveillance are important factors in late rupture; a large proportion of late ruptures are amenable to endovascular treatment., (© The Author(s) 2015.)

Objective: There is considerable controversy about the significance and appropriate treatment of type II endoleaks (T2Ls) after endovascular aneurysm repair (EVAR). We report our long-term experience with T2L management in a large multicenter registry., Methods: Between 2000 and 2010, 1736 patients underwent EVAR, and we recorded the incidence of T2L. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size, major adverse events, and reintervention., Results: During the follow-up (median of 32.2 months; interquartile range, 14.2-52.8 months), T2L was identified in 474 patients (27.3%). There were no late abdominal aortic aneurysm ruptures attributable to a T2L. Overall mortality (P = .47) and ARM (P = .26) did not differ between patients with and without T2L. Sac growth (median, 5 mm; interquartile range, 2-10 mm) was seen in 213 (44.9%) of the patients with T2L. Of these patients with a T2L and sac growth, 36 (16.9%) had an additional type of endoleak. Of all patients with T2L, 111 (23.4%) received reinterventions, including 39 patients who underwent multiple procedures; 74% of the reinterventions were performed in patients with sac growth. Reinterventions included lumbar embolization in 66 patients (59.5%), placement of additional stents in 48 (43.2%), open surgical revision in 14 (12.6%), and direct sac injection in 22 (19.8%). The reintervention was successful in 35 patients (31.5%). After patients with other types of endoleak were excluded, no difference in overall all-cause mortality (P = .57) or ARM (P = .09) was observed between patients with T2L-associated sac growth who underwent reintervention and those in whom T2L was left untreated., Conclusions: In our multicenter EVAR registry, overall all-cause mortality and ARM were unaffected by the presence of a T2L. Moreover, patients who were simply observed for T2L-associated sac growth had aneurysm-related outcomes similar to those in patients who underwent reintervention. Our future work will investigate the most cost-effective ways to select patients for intervention besides sac growth alone., Competing Interests: Author conflict of interest: none., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)