Chiara Mascoli

Commentary on: "could four dimensional contrast-enhanced ultrasounds replace computed tomography angiography during follow-up of fenestrated endografts? Results of a preliminary experience".

OBJECTIVE To evaluate four-dimensional contrast-enhanced ultrasound (4D-CEUS) as an alternative imaging method to computed tomography angiography (CTA) during follow up of fenestrated endovascular aneurysm repair (FEVAR) for juxta- and para-renal abdominal aortic aneurysms (AAA). METHODS Between October 2011 and March 2012, all consecutive patients who underwent FEVAR follow up were included in the study and evaluated with both 4D-CEUS and CTA. The interval between the two examinations was always ≤ 30 days. Endpoints were the comparison of postoperative AAA diameter, AAA volume, presence of endoleaks, revascularized visceral vessel (RVV) visualization, and patency. Comparative analysis was performed using Bland-Altman plots and McNemars Chi-square test. RESULTS Twenty-two patients (96% male, 4% female; mean age 74 ± 7 years; American Society of Anesthesiologists grade III/IV 82%/18%) were enrolled. Seventy-eight RVV (fenestrations: 60; scallops: 17; branches: 1) were analyzed. The mean AAA diameter evaluated by 4D-CEUS and CTA was 45 ± 10 mm (range 30-69 mm) and 48 ± 9 mm (range 32-70 mm), respectively. The mean difference was 3 ± 3 mm. The mean AAA volume evaluated by 4D-CEUS and CTA was 150 ± 7 cc (range 88-300 cc) and 159 ± 68 cc (range 80-310 cc), respectively. The mean difference was 7 ± 4 cc; a Bland-Altman plot revealed agreement in AAA diameter and volume evaluation (p < .01) between 4D-CEUS and CTA. The observed agreement for the detection of endoleaks was 95%. McNemars Chi-square test confirmed that 4D-CEUS and CTA were equivalent (p > .05) at detecting endoleaks. The first segment of six (8%) RVVs (four renal and two superior mesenteric arteries) was not directly visualized by 4D-CEUS owing to obesity, but the contrast enhancement into the distal part of vessel or into the relative parenchyma gave indirect information about their patency. McNemars Chi-square test demonstrated the superiority of CTA (p = .031) in visualizing RVVs. The patency of 77/78 RVVs was confirmed with both techniques. McNemars Chi-square test confirmed that 4D-CEUS and CTA were equivalent in their ability to detect visceral vessel patency. CONCLUSIONS The data suggest that 4D-CEUS is as accurate as CTA in the evaluation of postoperative AAA diameter and volume, endoleak detection, and RVV patency after FEVAR. Four-dimensional CEUS could provide hemodynamic information regarding RVVs, and reduce radiation exposure and renal impairment during follow up. Obesity limits the diagnostic accuracy of 4D-CEUS.

Fenestrated and Branched Endograft after Previous Aortic Repair

BACKGROUND Para-anastomotic aneurysms (P-AAA) and proximal aortic aneurysmal degeneration after previous aortic open repair (OR) or endovascular repair (EVAR) are challenging clinical scenarios. OR is technically demanding, and standard EVAR could be impossible due to the absence of proximal landing zone. The aim of the study is to report midterm results of fenestrated and branched endografts (FB-EVAR) to treat proximal aortic lesions after previous aortic repair. METHODS Since 2010, patients that underwent FB-EVAR after previous aortic repair were prospectively enrolled. Clinical or morphologic or intraoperative or postoperative data were collected and retrospectively analyzed. Primary end points were technical success and clinical success. Secondary end points were procedure-related events (endoleaks, target visceral vessels occlusion, mortality), midterm survival and freedom from FB-EVAR-related reinterventions. RESULTS Twenty patients (Male: 98%, age: 75 ± 6 years, American Society of Anesthesiologists [ASA] ≥ III: 100%) were enrolled. Fifteen patients (75%) underwent previous aortic OR and 5 (25%) standard EVAR. The mean time since the previous treatment was 12 ± 10 years. Present aortic lesions included thoracoabdominal aneurysms 12 (60%) and juxtarenal and pararenal aneurysms 8 (40%). The mean aortic aneurysm diameter was 67 ± 15 mm. All patients were at high risk for OR and had anatomies precluding standard EVAR. Seventy-two visceral vessels (renal arteries: 34, superior mesenteric artery: 20, celiac trunk: 18) were targeted: 49 fenestrations, 19 branches, and 4 scallops. An FB-EVAR tube and trimodular endograft was planned in 17 and 3 cases, respectively. Technical success was 95%; operative target vessel perfusion was 98.5%. Thirty-day mortality was 0%. Clinical success was 80% because there was a transient renal function worsening in 4 patients (>30% of baseline). One distal type I endoleak was detected and treated at 1-month. The mean follow-up was 15 ± 11 months. There were not proximal type I endoleaks, target visceral vessel occlusions, or aneurismal-related mortality. Survival at 1 year was 85 ± 5%. One late FEVAR-related reintervention occurred. CONCLUSIONS According to the reported data, FB-EVAR for treating P-AAA or proximal aneurysmal degeneration after previous aortic OR/EVAR in high-risk patients is a safe and/or effective solution.

Off-the-shelf multibranched endograft for urgent endovascular repair of thoracoabdominal aortic aneurysms

Objective: The aim of this paper was to report early and midterm results of endovascular repair of urgent thoracoabdominal aortic aneurysms (TAAAs) by the off‐the‐shelf multibranched Zenith t‐Branch endograft (Cook Medical, Bloomington, Ind). Methods: Between January 2014 and April 2016, all patients with urgent TAAAs (asymptomatic with diameter >8 cm, symptomatic, or ruptured TAAAs) and aortoiliac anatomic feasibility underwent endovascular repair by t‐Branch and were prospectively enrolled. Clinical, morphologic, intraoperative, and postoperative data were recorded. Follow‐up was performed by duplex ultrasound, contrast‐enhanced duplex ultrasound, and computed tomography angiography. Early end points were technical success (absence of type I or type III endoleak, loss of target visceral vessels [TVVs], conversion to open repair, or 24‐hour mortality), spinal cord ischemia, and 30‐day mortality. Follow‐up end points were survival, TVV patency, type I or type III endoleaks, and freedom from reintervention. Results: Seventeen patients (male, 71%; age, 73 ± 6 years; American Society of Anesthesiologists class 3/4, 60%/40%) affected by type II (47%), III (29%), and IV (24%) TAAAs were enrolled. The indications for t‐Branch were as follows: contained TAAA rupture, four (24%); symptomatic TAAA (pain or peripheral embolism), four (24%); and TAAA diameter ≥8 cm, nine (52%). The mean TAAA diameter was 80 ± 19 mm, with 63 TVVs. Fifteen patients (87%) needed adjunctive intraoperative procedures: 14 proximal thoracic endografts (thoracic endovascular aortic repair), 1 left carotid‐subclavian bypass, 2 endovascular hypogastric branches, and 2 surgical iliac conduits. In four cases (24%), a significant malorientation (≥60 degrees) of the main body occurred during t‐Branch deployment. Technical success was achieved in 14 cases (82%), with technical failures consisting of the loss of three renal arteries (TVV patency, 95%). Spinal cord ischemia occurred in one case (6%) with temporary paraparesis. The 30‐day mortality was 6% (one patient with ruptured type II TAAA died on postoperative day 7 of respiratory failure). Renal function worsening occurred in four patients (25%), with one case requiring permanent hemodialysis. The mean follow‐up was 11 ± 9 months. Survival at 1 month, 6 months, and 12 months was 94%, 82%, 82%, respectively. No TAAA‐related mortality and TVV occlusion occurred in the follow‐up. One type III endoleak was detected at 3 months and successfully treated. Freedom from reintervention at 1 month, 6 months, and 12 months was 88%, 82%, and 82%, respectively. Conclusions: The off‐the‐shelf multibranched endograft is a safe and effective therapeutic option for urgent total endovascular TAAA repair for which a custom‐made endograft is not obtainable in due time. However, the complex anatomy of these aneurysms needs a number of adjunctive and complex intraoperative procedures to achieve a durable repair.

Influence of Statin Therapy on Type 2 Endoleak Evolution

BACKGROUND Endovascular repair (EVAR) for abdominal aortic aneurysm (AAA) is widely adopted; however, the procedure may be jeopardized by type 2 endoleak (T2E). Most T2Es regress over time, but their evolution is unpredictable. There is some evidence about the pleiotropic statin effect on AAA and thrombus stabilization, but there are no data on the influence of statins on T2E. The studys aim is therefore to evaluate a possible effect of statins on T2E evolution. METHODS A retrospective analysis of patients discharged from 2008 to 2013 with T2E after EVAR was performed. Patients were followed up with duplex ultrasound and computed tomography angiography and divided on statin and no statin users. The primary end point was to evaluate the T2E persistence at 6 months and during follow-up. The secondary end points were to compare the shrinkage (median and rate), the sac increasing rate, and reintervention at 6 months and during follow-up. RESULTS In the period examined, 756 EVARs were performed and 85 (11%) had T2E at discharge. Thirty-two (37%) patients with T2E were on statins. The median follow-up was 19 (interquartile range [IQR] 7) months. Statin and no statin patients had similar clinical and anatomical characteristics, endoprosthesis type, and medical therapy. At 6 months, patients on statins had lower T2E persistence ([26] 81% vs. [49] 93%, P = 0.16), reaching the significance at 36 months (11 ± 9% vs. 64 ± 7%, P = 0.001). By Cox analysis, statins are independently associated with T2E regression (hazard ratio 0.40, 95% confidence interval 0.020-0.81, P = 0.01), other characteristics are: >2 lumbar arteries or inferior mesenteric artery patency or oral anticoagulant therapy did not reduce T2E. At 6 months, statin patients had higher shrinkage rate and diameter reduction compared with no statin patients (18% vs. 3%, P = 0.03 and 11 mm (IQR 4) vs. 6 mm (IQR 4), P = 0.05, respectively). Freedom from growth diameter and reintervention rate were not significantly different (85 ± 9% vs. 81 ± 14%, P = 0.10 and 75 ± 17% vs. 37 ± 16%, P = 0.13, respectively). CONCLUSION Statin therapy seems to influence T2E regression and aortic sac stabilization after EVAR in the early medium follow-up; however, prospective studies need to confirm the present results.

Impact of kidney ischemic lesions on renal function after fenestrated endovascular repair

OBJECTIVE Fenestrated endovascular aortic repair (fEVAR) is being used increasingly in the treatment of complex aortic aneurysms; however, this procedure can be associated with visceral and renal complications. Because the causes of possible renal function (RF) impairment have not been fully examined yet, we conducted a study to investigate whether there are risk factors associate with renal ischemic lesions (RILs) and if they influence RF in patients treated for complex aortic aneurysm with fEVAR. METHODS We evaluated the clinical, anatomic, and technical characteristics of consecutive patients treated with fEVAR from 2008 to 2014. RIL were identified by postoperative computed tomography angiography and the volume of renal parenchyma involved quantified. A decrease in RF (>30% glomerular filtration rate reduction) was evaluated at discharge, and at the 6- and 12-month follow-ups. RESULTS Among 53 patients, we analyzed 38 (72%) juxta/pararenal and 15 (28%) thoracoabdominal aortic aneurysms (33 [64%] with ≥3 fenestrations) and 102 renal arteries. Fifteen patients (30%) showed RIL, which was caused by accessory renal artery (ARA) coverage in 6 cases (38%), distal embolism in 6 (38%), renal artery thrombosis in 2 (18%), and iatrogenic embolization for intraoperative bleeding during fEVAR in 1 (6%). The volume of renal parenchyma involved was less than 25% in 10 (67%) and 25% to 50% in 5 (33%) cases. In no cases was more than 50% renal volume affected. On multivariate analysis, RIL predictors were the presence of ARA (odds ratio [OR], 8.00; 95% confidence interval [CI], 1.16-54.89; P = .03) and extensive thrombosis of the pararenal aorta (OR, 39.93; 95% CI, 3.36-474.23; P = .003). At discharge, chronic renal failure (CRF; OR, 4.80; 95% CI, 1.27-18.09; P = .01), diabetes (OR, 8.44; 95% CI, 1.33-53.51; P = .01), and extensive thrombosis of the pararenal aorta (OR, 5.50; 95% CI, 1.32-29.92; P = .01) were significantly associated with worsening RF. RIL, independent from volume, did not influence the postoperative RF. At 6 months and 1-year, preoperative CRF and perioperative declines in RF were identified as the only risk factors for worsening RF. CONCLUSIONS RIL is a common fEVAR complication and is primarily owing to ARA coverage and aortic thrombus embolization. However, RIL does not influence RF, which is predicted by preoperative CRF, diabetes, and extensive aortic thrombus.

Impact of iliac artery anatomy on the outcome of fenestrated and branched endovascular aortic repair

Objective: Fenestrated and branched endovascular aneurysm repair (FB‐EVAR) is a valid option to treat juxtarenal and pararenal abdominal aortic aneurysms and thoracoabdominal aortic aneurysms. Because successful deployment depends on complex maneuvers, hostile iliac artery anatomy (HIA) can prejudice the FB‐EVAR outcome. The aim of the study was to evaluate the impact of HIA on FB‐EVAR outcome. Methods: Between 2010 and 2015, all patients undergoing FB‐EVAR were prospectively categorized according to iliac anatomy (friendly iliac artery anatomy [FIA] or HIA). HIA was defined as the presence of one of the following: severe (>90‐degree) iliac angle, extensive (>50%) iliac circumferential calcification, hemodynamic iliac stenosis or obstruction, external iliac artery diameter <7 mm, or previous aortoiliac/femoral graft. Early end points were technical success (absence of type I or type III endoleak, target visceral vessel [TVV] loss, conversion to open repair), intraoperative adjunctive maneuvers (IAMs; iliac percutaneous transluminal angioplasty/stenting, surgical iliac conduit, intra‐aortic graft rotations, several attempts of TVV cannulation), intraoperative technical problems (iliac rupture, significant endograft twisting, difficult TVV cannulations, TVV injuries, TVV loss), and 30‐day mortality. Follow‐up end points were survival, TVV patency, and freedom from reintervention. Results: Ninety‐four patients (male, 87%; age, 73 ± 6 years) with 59 (63%) juxtarenal and pararenal abdominal aortic aneurysms and 35 (37%) thoracoabdominal aortic aneurysms underwent FB‐EVAR, for a total of 324 TVVs; 60 (64%) patients had HIA and 34 (36%) had FIA. Patients with HIA and FIA had similar preoperative clinical characteristics, except for coronary artery disease, peripheral artery occlusive disease, and American Society of Anesthesiologists class 4 (47% vs 24% [P = .03], 12% vs 0% [P = .04], and 28% vs 9% [P = .03], respectively). Technical success was 96% (HIA, 97%; FIA, 95%; P = .6). In HIA, adjunctive iliac procedures were performed in 32 cases (surgical conduit, 14 [15%]; percutaneous transluminal angioplasty/stenting, 27 [29%]). Endograft twisting and difficult TVV cannulation occurred in 13 (14%) and 33 (35%) cases, respectively (HIA 18% vs FIA 15% [P = .09]; HIA 28% vs FIA 21% [P = .03]). TVV cannulation failed in nine cases and injury occurred in five (TVV patency rate, 97.8%; HIA 94.7% vs FIA 98.3%; P = .3). One (1%) iliac rupture occurred in HIA, needing surgical repair. Overall, 44 (47%; HIA 55% vs FIA 25%; P = .03) IAMs were necessary. Perioperative mortality was 4% (HIA 3% vs FIA 5%; P = .9). At multivariate analysis, predictors of IAMs were external iliac diameter <7 mm (odds ratio [OR], 12.5; 95% confidence interval [CI], 2.2–71.4; P = .004) and extensive iliac calcifications (OR, 8.3; 95% CI, 1.4–50.0; P = .02). The mean follow‐up was 24 ± 17 months, with an overall survival of 87% and 71% at 1 year and 3 years, respectively, significantly lower in HIA compared with FIA (at 3 years, HIA 60% vs FIA 92%; P = .02). On multivariate analysis, HIA was a significant predictor of late mortality (OR, 3.6; 95% CI, 1.1–13.2; P = .04). Freedom from reintervention (87%) and 3‐year TVV patency (92%) were similar in the two groups. Conclusions: HIA does not significantly affect the early outcome of FB‐EVAR. However, in patients with HIA, procedures are technically more demanding and late mortality is increased. Iliac characteristics should be taken into account to correctly stratify the surgical risk in FB‐EVAR.

Portal/Superior Mesenteric Vein Reconstruction during Pancreatic Resection Using a Cryopreserved Arterial Homograft.

Background: Portal-superior mesenteric vein (PV/SMV) resection during pancreatic resection has been widely applied in clinical practice. Methods: From a prospective data base of pancreatic resections, patients undergoing PV/SMV resection and reconstruction with a cryopreserved arterial homograft were extracted with the aim of evaluating the safety, feasibility and reproducibility of the procedure. Data regarding patient demographics, preoperative staging, surgery, histopathology and postoperative outcomes were analyzed. Results: Five patients were extracted in the last year. Indications for this technique were type IV-V degree of vein involvement and a 3.5 cm median length of vein infiltration. Median operative and clamping times were satisfactory (385 and 27 min, respectively), postoperative outcomes were good and there was no graft infection, thrombosis or stenosis occurred postoperatively and during the follow-up period. Conclusion: The use of a cryopreserved arterial homograft for PV/SMV reconstruction after pancreatic resection seems to be a feasible, safe and easily reproducible surgical technique in high-volume specialized centers and can be added to the pool of surgical solutions in selected patients.

The Assessment of Carbon Dioxide Automated Angiography in Type II Endoleaks Detection: Comparison with Contrast-Enhanced Ultrasound

Introduction Iodinated contrast media completion angiography (ICM-A) may underestimate the presence of type II endoleak (ELII) after endovascular aortic repair (EVAR), particularly if they are at low flow. Contrast-enhanced ultrasound (CEUS) has been proposed as the gold standard in ELII detection during EVAR follow-up. Intraprocedural carbon dioxide (CO2) angiography has been shown to be useful in this setting; however no comparative studies including these three techniques are currently available. Our aim was to investigate the accuracy of a new automated CO2 angiographic (CO2-A) system in the detection of ELII, by comparing it with ICM-A and CEUS. Methods A series of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) were enrolled and submitted to ICM-A and CO2-A during the procedure. The iodinated contrast media were delivered through an automatic injector connected to a pigtail catheter in the suprarenal aorta. CO2 was delivered through a recently available automatic injector connected to a 10 F sheath positioned in the external iliac artery. All patients were blindly evaluated by CEUS within postoperative day 1. The ICM-A and CO2-A ability to detect ELII was compared with that of CEUS through Cohens concordance Index (K). Results Twenty-one patients were enrolled in the study. One (5%), seven (33%), and four (19%) ELII were detected by ICM-A, CO2-A, and CEUS, respectively. The only ELII detected by ICM-A was also detected by CO2-A and CEUS. Three cases of ELII detected by CO2-A were not detected by CEUS. All ELII detected by CEUS were visualized by CO2-A. CEUS and ICM-A showed a poor agreement (Cohens K: 0.35) while CEUS and CO2-A showed a substantial agreement (Cohens K: 0.65) for ELII detection. Conclusion CO2-A is safe and effective method for ELII detection in EVAR, with a significantly higher agreement with CEUS if compared with ICM-A. This trial is registered with 155/2015/U/Oss.

Aortic Aneurysm in Elderly Patients

The appropriateness of endovascular abdominal aortic repair (EVAR) of uncomplicated abdominal aortic aneurysm (AAA) is dependent on the risk/benefit ratio, particularly in patients >80 years old with possible short life expectancy. The aim was to evaluate the survival of patients >80 years old after EVAR and analyse predictors of late mortality, in order to analyse the efficacy of the EVAR treatment in these patients.

IF07. The Impact of Branches and Fenestrations on Early and Long-Term Visceral Vessel Patency in Complex Aortic Endograft Revascularization

Objective: The majority of late endovascular aneurysm repair (EVAR) complications can be easily managed by endovascular means. Nevertheless, a late open conversion (LOC) is sometimes required. The aim of the study was to report the outcomes and technical aspects of a multicenter experience of LOC after EVAR performed electively. Methods: All LOCs performed from 1996 to 2016 in 10 Italian Vascular Centers were reviewed. LOC was defined as a total or partial endograft explantation >30 days after the initial EVAR. Patients’ demographics, clinical risk factors, time elapsing from EVAR, type of endograft, previous attempts of endovascular correction, indication for LOC, operative technique (clamping site, partial or complete graft removal), 30-day mortality, and postoperative major complications were analyzed. Long-term survival was evaluated by Kaplan-Meier method. Results: During the study period, 175 patients underwent LOC. Among these, 121 were operated on electively and were therefore analyzed. Mean age at conversion was 73.5 6 7.5 years; 90% were male. Grafts were excised after a median of 40.2 months (range, 1.2-150.1 months). The number of LOCs increased significantly during the period of the study (correlation R 1⁄4 0.66; P 1⁄4 .0015). Types of explanted endografts were 109 bifurcated, 5 aortouni-iliac, 4 tubes, 2 chimney grafts, and 1 iliac side branch device. An endovascular attempt to repair the failing EVAR was performed in 40 of 121 patients before LOC. The reason for LOC was endoleak (83%), endograft infection (12%), and graft thrombosis (5%). Proximal aortic cross-clamping site was infrarenal in 42% of the cases, suprarenal in 17%, supraceliac in 39%, and thoracic in 2%. Complete removal of the stent graft was performed in 68% of the patients. Reconstructions were performed with Dacron grafts in 110 of 121 cases, cryopreserved arterial allografts in 6 of 121, endograft removal associated with prosthetic axillobifemoral bypass in 4 of 121, and autologous superficial femoral vein in 1 of 121. Overall 30-day mortality was 7.4%. Infected EVAR was significantly associated with a higher morbidity (P 1⁄4 .022), and longer length of stay (24.9 6 14.8 vs 13.9 6 10 days; P 1⁄4 .0023). During the median follow-up of 24.5 months (range, 0-212.1 months), five aneurysm-related deaths occurred (two reinfections, two allograft ruptures, one rupture of an aortic stump). The estimated 1and 5-year survival rates were 83.2% and 61.9%, respectively. Long-term survival was significantly lower for infected endografts (57.4% vs 87.3% at 1 year; log-rank P 1⁄4 .0028). Conclusions: Number of LOCs after EVAR increased significantly over time. Elective LOC has satisfactory postoperative and long-term outcomes. LOCs for infected endografts are associated with a complicated postoperative period and poor long-term survival.