F. Bastos Gonçalves

Severe Proximal Aneurysm Neck Angulation: Early Results Using the Endurant Stentgraft System

OBJECTIVE Angulation of the proximal aneurysm neck has been associated with adverse outcome after EVAR. We aim to investigate the influence of angulation on early results when using the Endurant Stentgraft System. METHODS A retrospective analysis of a prospective multicentre database identified 45 elective patients treated with the Endurant stentgraft with severe angulation of the proximal neck, which were compared to a control group without significant angulation. Endpoints were early technical and clinical success, deployment accuracy and differences in operative details. RESULTS Mean age was 74 with 86.4% males. Mean infrarenal angle (β) was 80.8° ± 16 and mean suprarenal angle (α) was 51.4° ± 21. Patients in the angulated group had larger aneurysms (mean 309 cc vs. 187 cc), shorter necks (mean 27 mm ± 14 vs. 32.6 mm ± 13) and 74% (vs. 56%) were ASA III/IV. Technical success was 100%, with one patient requiring an unplanned proximal extension. No differences were found regarding early type-I endoleaks (0% vs. 0%), major postoperative complications (6.7% vs. 6.2%; p = 0.77) or early survival (97.8% vs. 96.9%, p = 0.79). Distance from lowest renal artery to prosthesis was 2.4 mm ± 2.7 vs. 2.3 mm ± 4.8, p = 0.9. Operative details were equivalent for both groups. CONCLUSIONS Treatment with the Endurant stentgraft is technically feasible and safe, with satisfactory results in angulated and non-angulated anatomies alike. No sealing length was lost in extremely angulated cases, confirming the devices high conformability. Mid- and long-term data are awaited to verify durability, but early results are promising and challenge current opinion concerning neck angulation.

Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair

Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance.

Editor's Choice - Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS).

DedicationThese guidelines are dedicated to Paola De Rango, University of Perugia, Italy. She participated very actively in the process of developing these guidelines, in particular the important chapters on chronic arterial and venous mesenteric ischaemia. Six days after the second meeting of the task force she died unexpectedly, to our great despair and loss. We honour her dedication and scientific integrity by completing these guidelines. Among many other commitments she was a very productive reviewer and an associate editor of this journal. You can read more about Paolas important contributions to science and to the vascular community in the April 2016 issue of the European Journal of Vascular and Endovascular Surgery. 1 Dr Paola De Rango, July 28, 1966 – February 21, 2016

Spontaneous Delayed Sealing in Selected Patients with a Primary Type-Ia Endoleak After Endovascular Aneurysm Repair

OBJECTIVE Direct additional therapy is advised for type-Ia endoleaks detected on completion angiography after endovascular aneurysm repair (EVAR). Additional intraoperative endovascular procedures are, however, often challenging or not possible, and direct open conversion is unattractive. The results of a selective, conservative strategy for patients with primary type-Ia endoleak has been analysed. METHODS This was a retrospective, single-centre study (UMC, Utrecht, NL). From 2004 to 2008, all patients with a primary type-Ia endoleak and suitable anatomy for EVAR, stentgraft oversizing ≥15%, and optimal deployment were included. Complications during follow-up were studied and all sequential CTA scans were reviewed. These were compared with the remaining patients, treated during the same period. RESULTS Fifteen patients were included (14 male, median age 77, range 67-85) with a median aneurysm diameter of 60 mm (48-80), an aneurysm neck diameter of 26 mm (21-32), a neck length of 29 mm (11-39), and infrarenal angulation of 49° (31-90). One patient suffered rupture 2 days after EVAR - leading to the only AAA-related death. Eight of the 15 type-Ia endoleaks disappeared spontaneously on the first postoperative CTA, obtained within 1 week of EVAR. On the second postoperative CTA, obtained a median of 5 months (1-12) after EVAR, all remaining endoleaks had sealed. One recurrence occurred at 4.85 years. During a median follow-up of 3.3 years, there were five secondary interventions. Compared with controls, there were more secondary (or recurrent) type-1a endoleaks (13% vs. 4%), endograft migrations (13% vs. 3%), sac growths (33% vs. 16%), and secondary interventions (33% vs. 23%). None of these differences however, were statistically significant. CONCLUSIONS All but one of the primary type-Ia endoleaks sealed spontaneously. Until sealing, the risk of rupture persisted, but subsequently only one recurrence of type-Ia endoleak was seen. In selected patients, a conservative approach for primary type-Ia endoleaks may be justified.

Treatment of Post-implantation Aneurysm Growth by Laparoscopic Sac Fenestration: Long-term Results

OBJECTIVES Sac growth after endovascular aneurysm repair (EVAR) is an important finding, which may influence prognosis. In case of a type II endoleak or endotension, clipping of side branches and subsequent sac fenestration has been presented as a therapeutic alternative. The long-term clinical efficacy of this procedure is unknown. METHODS The study included eight patients who underwent laparoscopic aortic collateral clipping and sac fenestration for enlarging aneurysms following EVAR. Secondary interventions and clinical outcome were retrieved from hospital records. Sac behaviour was evaluated measuring volumes on periodical computed tomography angiography (CTA) imaging using dedicated software. RESULTS Follow-up had a median length of 6.6 (range 0.6-8.6) years. During this time, only three patients successfully achieved durable aneurysm shrinkage (n = 2) or stability (n = 1). The remaining patients suffered persistent (n = 2) or recurrent sac growth (n = 3), all regarded as failure of fenestration. A total of six additional interventions were performed, comprising open conversion (n = 2), relining (n = 1) and implantation of iliac extensions (n = 3). All additional interventions were successful at arresting further sac growth during the remainder of follow-up. CONCLUSIONS Despite being a less invasive alternative to conversion and open repair, the long-term outcome of sac fenestration is unpredictable and additional major procedures were often necessary to arrest sac growth.

Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS)

DedicationThese guidelines are dedicated to Paola De Rango, University of Perugia, Italy. She participated very actively in the process of developing these guidelines, in particular the important chapters on chronic arterial and venous mesenteric ischaemia. Six days after the second meeting of the task force she died unexpectedly, to our great despair and loss. We honour her dedication and scientific integrity by completing these guidelines. Among many other commitments she was a very productive reviewer and an associate editor of this journal. You can read more about Paolas important contributions to science and to the vascular community in the April 2016 issue of the European Journal of Vascular and Endovascular Surgery. 1 Dr Paola De Rango, July 28, 1966 – February 21, 2016

Commentary on 'ADSORB: A Study on the Efficacy of Endovascular Grafting in Uncomplicated Acute Dissection of the Descending Aorta'

behind the primary endpoint, it may seem that the trial is designed to favour stengrafting. Finally, a reflection is required regarding the dramatic change in sample size, based on data from false lumen thrombosis (which was published long after the initial ADSORB-trial design). Is a trial still required to show such a large difference in the rates of false lumen thrombosis in medical vs. stent graft groups (target effect size ¼ 0.58)? In other words, is there still equipoise to justify a randomized trial? Naturally, if more “conventional” endpoints had been chosen (such as long-term freedom from rupture, dissection-related complications, re-intervention or death) much larger numbers would be required, but more definitive and clinically relevant data would be obtained. The vascular community is eagerly looking for final answers on how to manage uncomplicated type B dissections, but it is still unclear if ADSORB will deliver these.

Editor's choice: Management of the diseases of mesenteric arteries and veins

DedicationThese guidelines are dedicated to Paola De Rango, University of Perugia, Italy. She participated very actively in the process of developing these guidelines, in particular the important chapters on chronic arterial and venous mesenteric ischaemia. Six days after the second meeting of the task force she died unexpectedly, to our great despair and loss. We honour her dedication and scientific integrity by completing these guidelines. Among many other commitments she was a very productive reviewer and an associate editor of this journal. You can read more about Paolas important contributions to science and to the vascular community in the April 2016 issue of the European Journal of Vascular and Endovascular Surgery. 1 Dr Paola De Rango, July 28, 1966 – February 21, 2016

Review: Quality of life in lower limb peripheral vascular surgery

Purpose Vascular intervention studies generally consider patency and limb salvage as primary outcomes. However, quality of life is increasingly considered an important patient-oriented outcome measurement of vascular interventions. Existing literature was analyzed to determine the effect of different treatments on quality of life for patients suffering from either claudication or critical limb ischemia. Basic methods A review of the literature was undertaken in the Medline library. A search was performed on quality of life in peripheral arterial disease. Results were stratified according to treatment groups. Principal findings Twenty-one articles described quality of life in approximately 4600 patients suffering from peripheral arterial disease. Invasive treatment generally results in better quality of life scores (at a maximum of 2 years of follow-up), compared with non-invasive treatment. In patients with critical limb ischemia, successful revascularization improves quality of life scores. Only one study reported long-term results. Conclusions Increase in quality of life scores can be found for any intervention performed for peripheral arterial disease. However, there is scarce information on long-term quality of life after vascular intervention.

Comments regarding “The Wonders of New Available Post-Analysis CT Software in the Hands of Vascular Surgeons”

The authors of this manuscript present a case where an endoleak was detected in a growing aneurysm sac, after endovascular aneurysm repair. This was presumed to be a type-II EL, and it was not until reconstructions with open source post-processing software were made that they discovered device failure as the origin of the endoleak. This case report clearly underlines the added value of reconstruction software, as it altered the diagnosis from a type II endoleak e the optimal management of which is still debatable e to a type III endoleak, which constitutes a serious and threatening complication requiring expeditious intervention. Although the value of using post-processing software to improve insight in the anatomy and to provide more accurate diameter and length measurements is undisputable, advocating the wide use of OsiriX open-source version has some important pitfalls not highlighted by the authors. First of all, this has not been approved for primary clinical use to our knowledge. This may pose serious ethical and medicolegal issues. Fortunately, there are several commercially available FDA approved alternatives, including OsiriX MD. 1 Second, before adopting reconstruction software in clinical practice, education in post-processing is paramount, as deficient use of these tools may result in misleading information and generate errors in patient management. Apart from the arguments in favor of reconstruction software, the clinical case that was presented also provided some food for thought. The final diagnosis was graft failure as a result of graft material discontinuity in the main body, although no cause of this could be traced. This finding is worrying, especially since the implantationwas only sixteen months before. Mandatory reporting of graft failures should be part of standard care to improve overall quality. Last but not least, this case emphasizes that finding a type II endoleak in a patient with a growing aneurysm should never preclude the search for an alternative, more serious cause for growth. It is of utmost importance to make sure that growth is not caused by a type I a/b or III endoleak. Assuring a generous proximal and distal seal is key in this. Furthermore, contrast-enhanced magnetic resonance using a blood pool agent can help identifying the cause of growth as well, as it has demonstrated that many growing aneurysms without detectable endoleaks on CTA may actually have occult endoleaks.2 Only if one is convinced that no other cause than type II endoleak is present, conservative treatment may be advisable.