Diletta Loschi

Abdominal Aortic Endografting Beyond the Trials: A 15-Year Single-Center Experience Comparing Newer to Older Generation Stent-Grafts

Purpose To evaluate the late results of endovascular aneurysm repair (EVAR) with the endografts currently in use and compare outcomes to older devices. Methods Clinical, demographic, and imaging data on consecutive patients undergoing elective EVAR from January 1997 to December 2011 at a single center were retrieved from an electronic database and reviewed. Newer stent-grafts (NSG) were defined as those introduced after 2004 (second-generation Excluder and Anaconda) or currently in use without modifications (Zenith, Endurant). Of the 1412 consecutive patients (1290 men; mean age 73 years) who underwent elective EVAR in a tertiary university hospital, 882 were treated with NSGs and 530 with older stent-grafts (OSGs). Results In the NSG group, the abdominal aortic aneurysms (AAA) were larger (55.7 vs. 53.2 mm, p<0.0001) and the patients were older (p<0.0001) and less frequently smokers or had pulmonary disease, while hypertension and diabetes were more frequent (all p<0.0001). Thirty-day mortality was 0.8% in the NSG group vs. 1.1% in the OSG group (p=NS). Follow-up ranged from 1 to 174 months (mean 54.1±42.4); the OSG patients had longer mean follow-up compared to the NSG group (80.2±47.9 vs. 38.4±29.1 months, p<0.0001). All-cause survival rates were comparable in both groups. Freedom from late conversion (96.1% vs. 89.1% at 7 years, p<0.0001) or reintervention (83.6% vs. 74.2% at 7 years, p=0.015) and freedom from AAA diameter growth >5 mm (p=0.022) were higher in the NSG group. In adjusted analyses, the use of a new-generation device was a negative independent predictor of reintervention [hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.49 to 0.93, p=0.015] and aneurysm growth (HR 0.63, 95% CI 0.45 to 0.89, p=0.010). Conclusion Newer-generation endografts can perform substantially better than the older devices. In the long term, incidences of reintervention, conversion, and AAA growth are decreased in patients treated with devices currently in use. However, the need for continuous surveillance is still imperative for all endografts.

Quality of life in patients with small abdominal aortic aneurysm: the effect of early endovascular repair versus surveillance in the CAESAR trial.

OBJECTIVE To evaluate and compare changes over time in health-related quality of life reported by patients with small (4.1-5.4 cm) abdominal aortic aneurysms (AAAs) undergoing endovascular aortic aneurysm repair (EVAR) or surveillance. METHODS Participants were randomly assigned to receive either early EVAR or surveillance within a multicentre, randomised clinical trial on small AAA (Comparison of surveillance vs. Aortic Endografting for Small Aneurysm Repair, CAESAR). Patient-reported health-related quality of life was assessed before randomisation, at 6 months and yearly thereafter using the Short Form 36 (SF-36) Health Survey. RESULTS Between 2004 and 2008, 360 patients (345 males, mean age 68.9 years) were randomised, 182 to early EVAR and 178 to surveillance. There was one perioperative death. Mean follow-up was 31.8 months. No significant difference in survival was found. At baseline, comparable quality of life scores were recorded in both treatment groups: Total SF-36: 73.0 versus 75.5 (p = 0.18), Physical domain: 71.4 versus 73.3 (p = 0.33); Mental health domain: 70.9 versus 72.7 (p = 0.33), in the EVAR arm versus the surveillance arm, respectively. Six months after randomisation, Total SF-36 and Physical and Mental domain scores were all significantly higher with respect to baseline in the EVAR group, while patients of the surveillance group scored lower. The differences between EVAR and surveillance arms in score changes at 6 months were significant and in favour of EVAR: Total score: difference 5.4; p = 0.0017; Physical: difference 3.8; p = 0.02; and Mental: difference 6.0; p = 0.0005. Differences between EVAR and surveillance diminished over time. At the last assessment, patients in both groups had decreased scores with a significant drop with respect to the baseline (-3.9 in EVAR, -6.3 in surveillance). There were no significant differences between the EVAR and surveillance arms: Total score: p = 0.25; Physical: p = 0.47; and Mental: p = 0.38. CONCLUSIONS Patients with small AAA under surveillance compared with early EVAR had significant impaired functional health at 6 months after assignment. After a mean of 31.8 months, SF-36 health-related quality of life in patients allocated to early EVAR and surveillance was similar.

Aorto-bronchial and aorto-pulmonary fistulation after thoracic endovascular aortic repair: an analysis from the European Registry of Endovascular Aortic Repair Complications.

OBJECTIVES To learn upon incidence, underlying mechanisms and effectiveness of treatment strategies in patients with central airway and pulmonary parenchymal aorto-bronchial fistulation after thoracic endovascular aortic repair (TEVAR). METHODS Analysis of an international multicentre registry (European Registry of Endovascular Aortic Repair Complications) between 2001 and 2012 with a total caseload of 4680 TEVAR procedures (14 centres). RESULTS Twenty-six patients with a median age of 70 years (interquartile range: 60-77) (35% female) were identified. The incidence of either central airway (aorto-bronchial) or pulmonary parenchymal (aorto-pulmonary) fistulation (ABPF) in the entire cohort after TEVAR in the study period was 0.56% (central airway 58%, peripheral parenchymal 42%). Atherosclerotic aneurysm formation was the leading indication for TEVAR in 15 patients (58%). The incidence of primary endoleaks after initial TEVAR was n = 10 (38%), of these 80% were either type I or type III endoleaks. Fourteen patients (54%) developed central left bronchial tree lesions, 11 patients (42%) pulmonary parenchymal lesions and 1 patient (4%) developed a tracheal lesion. The recognized mechanism of ABPF was external compression of the bronchial tree in 13 patients (50%), the majority being due to endoleak formation, further ischaemia due to extensive coverage of bronchial feeding arteries in 3 patients (12%). Inflammation and graft erosion accounted for 4 patients (30%) each. Cumulative survival during the entire study period was 39%. Among deaths, 71% were attributed to ABPF. There was no difference in survival in patients having either central airway or pulmonary parenchymal ABPF (33 vs 45%, log-rank P = 0.55). Survival with a radical surgical approach was significantly better when compared with any other treatment strategy in terms of overall survival (63 vs 32% and 63 vs 21% at 1 and 2 years, respectively), as well as in terms of fistula-related survival (63 vs 43% and 63 vs 43% at 1 and 2 years, respectively). CONCLUSIONS ABPF is a rare but highly lethal complication after TEVAR. The leading mechanism behind ABPF seems to be a continuing external compression of either the bronchial tree or left upper lobe parenchyma. In this setting, persisting or newly developing endoleak formation seems to play a crucial role. Prognosis does not differ in patients with central airway or pulmonary parenchymal fistulation. Radical bronchial or pulmonary parenchymal repair in combination with stent graft removal and aortic reconstruction seems to be the most durable treatment strategy.

Results of aberrant right subclavian artery aneurysm repair

OBJECTIVE The objective of this multicenter registry was to review current treatments and late results of repair of aneurysm of aberrant right subclavian artery (AARSA). METHODS All consecutive AARSA repairs from 2006 to 2013 in seven centers were reviewed. End points were 30-day and late mortality, reintervention rate, and AARSA-related death. RESULTS Twenty-one AARSA repairs were included (57% men; mean age, 67 years); 3 ruptures (14%) required emergent treatment; 12 (57%) were symptomatic for dysphagia (33%), dysphonia (24%), or pain (19%). Eight cases (38%) presented with thoracic aortic aneurysm, two with intramural hematoma, and one with acute type B aortic dissection. Mean AARSA diameter was 4.2 cm; a single bicarotid common trunk was present in 38% of cases. The majority of patients underwent hybrid intervention (n = 15; 71%) consisting of single (n = 2) or bilateral (n = 12) subclavian to carotid transposition or bypass or ascending aorta to subclavian bypass (n = 1) plus thoracic endovascular aortic repair (TEVAR); 19% of cases underwent open repair and 9% simple TEVAR with AARSA overstenting. Perioperative death occurred in two patients (9%): in one case after TEVAR in ruptured AARSA, requiring secondary sternotomy and aortic banding; and in an elective case due to multiorgan failure after a hybrid procedure. Median follow-up was 30 (interquartile range, 15-46) months. The Kaplan-Meier estimate of survival at 36 months was 90% (standard error, 0.64). Late AARSA-related death in one case was due to AARSA-esophageal fistula presenting with continuing backflow from distal AARSA and previous TEVAR. At computed tomography controls, one type I endoleak and one type II endoleak were detected; the latter required reintervention by aneurysm wrapping and ligature of collaterals. AARSA-related death was more frequent after TEVAR, a procedure reserved for ruptures, compared with elective open or hybrid repair. CONCLUSIONS Hybrid repair is the preferred therapeutic option for patients presenting with AARSA. Midterm results show high rates of clinical success with low risk of reintervention. Simple endografting presents high risk of related death; these findings underline the importance of achieving complete sealing to avoid treatment failures.

Fourteen-year outcomes of abdominal aortic endovascular repair with the Zenith stent graft

Objective: Long‐term results of abdominal aortic aneurysm (AAA) endovascular repair are affected by graft design renewals that tend to improve the performance of older generation prostheses but usually reset the follow‐up times to zero. The present study investigated the long‐term outcomes of endovascular AAA repair (EVAR) using the Zenith graft, still in use without major modification, in a single center experience. Methods: Between 2000 and 2011, 610 patients underwent elective EVAR using the Zenith endograft (Cook Inc, Bloomington, Ind) and represent the study group. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA‐related death. Secondary outcomes included freedom from late (>30 days) reintervention, freedom from late (>30 days) conversion to open repair, freedom from aneurysm sac enlargement >5.0 mm and freedom from EVAR failure, defined as a composite of AAA‐related death, AAA rupture, AAA growth >5 mm, and any reintervention. Results: Mean age was 73.2 years. Mean aneurysm diameter was 55.3 mm. There were five perioperative deaths (0.8%) and three intraoperative conversions. At a mean follow‐up of 99.2 (range, 0‐175) months, seven AAA ruptures occurred, all fatal except one. Overall survival was 92.8% ± 1.1% at 1 year, 70.1% ± 1.9% at 5 years, 37.8% ± 2.9% at 10 years, and 24 ± 4% at 14 years. Freedom from AAA‐rupture was 99.8% ± 0.02 at 1 year (one case), 99.4% ± 0.04 at 5 years (three cases), and 98.1% ± 0.07 at 10 and 14 years. Freedom from late reintervention and conversion was 98% ± 0.6 at 1 year, 87.7% ± 1.5 at 5 years, 75.7% ± 3.2 at 10 years, and 69.9% ± 5.2 at 14 years. Freedom from aneurysm sac growth >5.0 mm was 99.8% at 1 year, 96.6% ± 0.7 at 5 years, 81.0% ± 3.4 at 10 years, and 74.1% ± 5.8% at 14 years. EVAR failure occurred in 132 (21.6%) patients at 14 years. At multivariate analysis, independent predictors of EVAR failure resulted type I and III endoleak (hazard ratio [HR], 6.7; 95% confidence interval [CI], 4.6‐ 9.7; P < .001], type II endoleak (HR, 2.3; 95% CI, 1.6‐3.4; P < .001), and American Society of Anesthesiologists grade 4 (HR, 1.6; 95% CI, 1.0‐2.6; P = .034). Conclusions: EVAR with Zenith graft represents a safe and durable repair. Risk of rupture and aneurysm‐related death is low, whereas overall long‐term survival remains poor. Novel endograft models should be tested and evaluated considering that one‐fourth of the operated patients will still be alive after 14 years.

Sarcoma of the Thigh: Radical Excision with Arterial Reconstruction Using the Contralateral Saphenous Vein.

Soft tissue sarcomas are a heterogeneous group of malignant mesenchymal neoplasms that frequently affect large muscle of the thigh. A conservative limb-salvage surgery involving en bloc resection of the whole tumor with surrounding healthy tissue can sometimes be considered instead of amputation to achieve good local disease control while preserving a satisfying function of the affected limb. The massive vascular encasement, once regarded as a contraindication to limb-salvage surgery, can sometimes be encompassed thanks to vascular axis reconstruction. Although no doubt exists about the need for reconstruction of the femoral artery with quite good reported results, the venous replacement is a controversial issue with unclear patency rates, yet this replacement is mandatory when superficial and deep femoral veins are removed together with the saphenous vein. The femoral artery is commonly replaced with an autologus reversed saphenous vein graft because of its resistance to infections and its excellent patency rates compared with artificial grafts. We present a case of thigh sarcoma involving the femoral vascular axis with complete clogging of the femoral vein due to massive deep thrombosis. The video illustrates the features of the case and highlights the steps of a wide compartment resection with arterial reconstruction by autologus reversed saphenous vein graft.

Satisfactory short-term outcomes of the STABILISE technique for type B aortic dissection

Objective: The aim of this study was to evaluate the perioperative and short‐term results in a cohort of patients treated during the last year at our institution with the stent‐assisted balloon‐induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique for acute complicated aortic dissection. Methods: Between June 2016 and June 2017, 10 patients (all male; mean age, 62.6 ± 7.4 years) received treatment for acute complicated aortic dissection with the STABILISE technique. After a standard provisional extension to induce complete attachment procedure using the commercially available endovascular dissection system (Cook Medical, Bloomington, Ind), the distal stent graft area and the bare stent area were ballooned to completely exclude the thoracic false lumen (FL) and to obtain a single‐channeled abdominal aorta. Computed tomography was routinely performed within the first postoperative week before discharge and then at 3 months, at 6 months, and yearly thereafter. The technical and clinical success rates were analyzed. Results: The 30‐day technical and clinical success rates were 100%, with complete thrombosis of the thoracic FL and no type I endoleak. Malperfusion was resolved in all cases. No aortic ruptures were recorded, and no open conversion was required. One case of delayed spinal cord ischemia fully resolved within the discharge period. Predischarge computed tomography showed complete thrombosis of the thoracic FL in all cases. In two cases, some degree of patency of the abdominal FL was observed. At short‐term follow‐up, the overall aortic diameters remained stable with no further dilation. Conclusions: The STABILISE technique was safe and feasible in this cohort of patients, with complete thrombosis of the thoracic FL and creation of a single‐channeled aorta in most cases. Further studies are needed to ascertain the long‐term behavior of the treated aorta.

Preliminary Outcomes of the LifeStream Balloon-Expandable Covered Stent in Fenestrated and Branched Thoracoabdominal Endovascular Repairs:

Purpose: To evaluate the 1-year outcomes of thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent-grafts and a novel balloon-expandable covered stent. Methods: Between March 2015 and January 2017, 18 patients (median age 74.7 years; 14 men) received 43 LifeStream balloon-expandable covered stents in conjunction with Zenith fenestrated/branched stent-grafts to bridge 11 celiac trunks, 8 superior mesenteric arteries, and 24 renal arteries (total 32 fenestrations and 11 branches). Results: Stent delivery and deployment was successful in all cases. At 30 days, 5 patients presented with perifenestration endoleaks (type IIIc) secondary to inadequate sealing of the LifeStream covered stent in 7 (22%) of 32 fenestrations. No type IIIc endoleaks were reported in the branched cases. Four patients had a secondary endovascular reintervention with proximal relining by means of a bare balloon-expandable stent at the perifenestration transition area, with complete resolution of the endoleak at 1-year follow-up. One patient refused reintervention. The last 4 fenestrated stent-grafts of this series had prophylactic perifenestration bare stent relining with no evidence of type IIIc endoleaks at imaging. At a median follow-up of 14.1 months (interquartile range 11, 22), the 12-month LifeStream patency rate was 100%. Conclusion: This single-center preliminary experience with the LifeStream balloon-expandable covered stent in fenestrated/branched stent-grafts for TAAA repairs demonstrated good patency; however, an unexpectedly high rate of type IIIc endoleaks was observed. These endoleaks were resolved with reintervention or during the index procedure by proximal relining with a bare balloon-expandable stent, achieving adequate perifenestration sealing.

How to best treat infectious complications of open and endovascular thoracic aortic repairs

Infectious complications of open and endovascular procedures for descending thoracic aortic disease are relatively rare, affecting 1% to 6% of treated patients. However, the number of thoracic aortic procedures, especially endovascular, is increasing continuously, and infectious complications involving the graft or endograft have been observed more frequently in recent years. Several causative factors may play a role in thoracic aortic prosthetic infections, including hematogenous seeding, local bacterial translocation, and iatrogenous contamination. In addition, the development of a fistula between the aortic graft and the esophagus or the bronchial tree is a common associated finding, representing a dramatic event that further increases mortality rates and requires multidisciplinary management. Treatment of these conditions is demanding, often including a number of pharmacological, surgical, and endovascular options. Because there are several different surgical strategies and timing modalities that are chosen according to the surgeons experience, the results of different treatment options are difficult to summarize, and no consensus exists on a standardized paradigm of treatment. In this review, published reports regarding clinical outcomes related to thoracic graft and endograft infections are discussed, including our personal experience with surgical and endovascular management of this condition.