Bianca Dona

Examination of factors in type I endoleak development after thoracic endovascular repair

OBJECTIVE The objective of this study was to assess the effects of operative indication, anatomy, and stent graft on type I endoleak occurrence after thoracic endovascular aortic repair. METHODS A retrospective review was conducted of patients admitted for thoracic endovascular aortic repair between 2007 and 2013. All computed tomography angiography imaging was analyzed for the presence of endoleak and measurement of diameters and lengths. Variables studied included underlying disease, emergency, achieved aortic neck length, difference between proximal and distal neck diameters, landing zone 2, and stent graft characteristics (diameter, number, type of device, oversizing degree, and covered aorta length). RESULTS The study population involved 84 patients (mean age, 56 years; range, 17-94 years) who were treated for thoracic aortic aneurysm (TAA) (n = 29; 34.5%), traumatic aortic rupture (n = 27; 32%), type B aortic dissection (n = 19; 22.5%), intramural hematoma (n = 2; 2%), penetrating aortic ulcer (n = 5; 6%), and aortoesophageal fistula (n = 2; 2%). Of these, 60 patients (71.5%) were treated emergently and 24 (28.5%) electively. Primary type I endoleak was noted in eight patients (9.5%), of which two resolved spontaneously. After a mean follow-up of 32 months (range, 3-76 months), secondary type I endoleak was detected in four patients (4.5%). All of them occurred after emergent TAA treatment. Comparison between emergent and elective groups revealed no significant differences in neck length (19.5 mm vs 26.5 mm; P = .197), oversizing degree (11.1% vs 10.9%; P = .811), or endoleak rates (13.3% vs 8.3%; P = .518). Hemorrhagic shock was not predictive of endoleak (P = .483). Cox regression analysis of the different anatomic and stent graft-related factors revealed short proximal landing zone as the unique independent predictor of type I endoleak (hazard ratio, 0.89; 95% confidence interval, 0.81-0.99; P = .032). CONCLUSIONS Endoleak risk seems not to be increased by an emergency setting. However, the relatively high rate of late endoleak observed after emergent TAA repair advocates for close follow-up, contrary to traumatic aortic rupture. Furthermore, regardless of the pathologic process, a longer proximal landing zone is likely to guarantee early and late success.

A comparison of the standard bolia technique versus subintimal recanalization plus Viabahn stent graft in the management of femoro-popliteal occlusions

OBJECTIVE To assess the potential benefit of the addition of a covered stent to a subintimal recanalized artery in patients with femoro-popliteal occlusions. METHODS From September 2003 to October 2005, we retrospectively analyzed all patients admitted for severe claudication or critical limb ischemia related to long femoro-popliteal occlusions and treated with subintimal recanalization. Patients were divided into two groups depending on whether they received a stent or not. All patients in the group treated with stent received a stent graft, and the entire length of the recanalized artery was covered in each case. Demographic data, indications, procedure, and outcomes were examined using survival analysis statistical techniques. RESULTS Fifty-three patients (54 limbs) were treated consecutively for severe claudication (n=19) or critical limb ischemia (n=34). Thirty-four (64%) had a stent placed, while 19 (35.8%) did not. The mean length of the lesions treated was 20.11 cm (range, 5-35 cm). Statistically, there was no significant difference in lesion length, Rutherford stage of peripheral-artery disease, Transatlantic Inter-Society Consensus classification, and distal run-off between the two groups. The technical success rate was 94.5%, and two out of the three failures were treated with surgical bypass in one case and major amputation in the other. The third patient received only medical treatment. Combined procedures were required in the treatment of 68.2% of limbs in the no-stent group and 55.8% in the stent group. Mean follow up was 16.9 months (range, 1-35 months). At 1 year, primary, primary-assisted, and secondary patency for the stent vs no-stent groups was, respectively, 61.8% vs 78.9% (P=.49), 70.6% vs 78.9% (P=.78), and 88.2% vs 78.9% (P=.22). The 1-year limb salvage rate for the stent vs no-stent group was 94.1% vs 100% (P=.7). CONCLUSION Combining subintimal angioplasty with a stent graft in femoro-popliteal lesions does not improve patency. The limb salvage rate remains high after addition of a stent graft. Rigorous monitoring is recommended to diagnose and treat restenosis early in order to improve patency.