Fabio Verzini

Management of Abdominal Aortic Aneurysms Clinical Practice Guidelines of the European Society for Vascular Surgery

Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands b Imperial College, London, UK University Hospital Innsbruck, Austria Azienda Ospedaliera di Perugia, Italy Hopital Cardiologique, CHRU de Lille, Lille, France f St Thomas’ Hospital, London, UK g St George’s Vascular Institute, London, UK Yale University School of Medicine, New Haven, Connecticut, USA University of Siena, Siena, Italy University of Poitiers, Poitiers, France

Comparison of Surveillance Versus Aortic Endografting for Small Aneurysm Repair (CAESAR): Results from a Randomised Trial

BACKGROUND Randomised trials have failed to demonstrate benefit from early surgical repair of small abdominal aortic aneurysm (AAA) compared with surveillance. This study aimed to compare results after endovascular aortic aneurysm repair (EVAR) or surveillance in AAA <5.5 cm. METHODS Patients (50-79 years) with AAA of 4.1-5.4 cm were randomly assigned, in a 1:1 ratio, to receive immediate EVAR or surveillance by ultrasound and computed tomography (CT) and repair only after a defined threshold (diameter ≥5.5 cm, enlargement >1 cm /year, symptoms) was achieved. The main end point was all-cause mortality. Recruitment is closed; results at a median follow-up of 32.4 months are here reported. RESULTS Between 2004 and 2008, 360 patients (early EVAR = 182; surveillance = 178) were enrolled. One perioperative death after EVAR and two late ruptures (both in the surveillance group) occurred. At 54 months, there was no significant difference in the main end-point rate [hazard ratio (HR) 0.76; 95% confidence interval (CI) 0.30-1.93; p = 0.6] with Kaplan-Meier estimates of all-cause mortality of 14.5% in the EVAR and 10.1% in the surveillance group. Aneurysm-related mortality, aneurysm rupture and major morbidity rates were similar. Kaplan-Meier estimates of aneurysms growth ≥5 mm at 36 months were 8.4% in the EVAR group and 67.5% in the surveillance group (HR 10.49; 95% CI 6.88-15.96; p < 0.01). For aneurysms under surveillance, the probability of delayed repair was 59.7% at 36 months (84.5% at 54 months). The probability of receiving open repair at 36 months for EVAR feasibility loss was 16.4%. CONCLUSION Mortality and rupture rates in AAA <5.5 cm are low and no clear advantage was shown between early or delayed EVAR strategy. However, within 36 months, three out of every five small aneurysms under surveillance might grow to require repair and one out of every six might lose feasibility for EVAR. Surveillance is safe for small AAA if close supervision is applied. Long-term data are needed to confirm these results. CLINICAL TRIAL REGISTRATION INFORMATION This study is registered, NCT Identifier: NCT00118573.

Endovascular treatment of iliac aneurysm : Concurrent comparison of side branch endograft versus hypogastric exclusion

OBJECTIVE To analyze early and mid-term outcome of endovascular treatment in patients with iliac aneurysms, comparing the results of hypogastric revascularization by branch endografting with those of hypogastric occlusion. METHODS Consecutive patients with iliac aneurysms receiving side branch endograft (Group I) were compared with those receiving endograft with hypogastric exclusion (Group II) during the interval from January 2000 to May 2008. Procedural details and outcomes were prospectively collected and were analyzed at one year to avoid mismatch in follow-up length. RESULTS A total of 74 patients (mean age, 75.8 years, 95% males) were treated: 32 in Group I and 42 in Group II. No differences in baseline risk factors and aneurysm diameter (40.2 +/- 7.9 mm in Group I vs. 38.4 +/- 10.8 in Group II) were found. Concurrent treatment of aortic aneurysm was performed in 25/32 (78%) of Group I and 36/42 (86%) of Group II. Fluoro time was 48 minutes (interquartile range [IQR] 31-57) in Group I vs. 31 minutes (IQR 23-38) in Group II (P = .04). The amount of contrast was similar in both Groups: 184 ml (IQR 155-210) in Group I vs. 183 ml (IQR 155-200) in Group II. No intestinal ischemia or deaths occurred. There were no significant differences in failures of hypogastric side branch deployment (2/32) compared with hypogastric coiling (3/42). Limb occlusions all occurring in the external iliac artery side were 2/32 in Group I vs. 3/42 in Group II. Reintervention rates were similar (5/32 vs. 4/42) at one year. Shrinkage of 5 mm or more was detected in 7/23 (30%) of Group I and in 13/37 (34%) of Group II. Iliac endoleak was present in eight patients (19%) in Group II and in one patient in Group I (4%) (P = .1). Similarly, buttock claudication or impotence were more frequent after hypogastric exclusion, recorded in eight patients in Group II and in one patient in Group I (P = .1). CONCLUSIONS Endovascular treatment of iliac aneurysm with hypogastric revascularization through side branched endografts is feasible and safe in the mid-term. When compared with hypogastric embolization, this option leads to similar technical success and reintervention rates. Endoleak and buttock claudication occur frequently in patients with iliac aneurysm treated with hypogastric exclusion, while are uncommon in those with hypogastric revascularization. Side branch endografting for iliac aneurysm may be considered a primary choice in younger, active patients with suitable anatomy, but larger studies and longer postoperative observation periods are needed.

Predictive factors and clinical consequences of proximal aortic neck dilatation in 230 patients undergoing abdominal aorta aneurysm repair with self-expandable stent-grafts.

OBJECTIVE Several studies have suggested that proximal aortic neck dilatation (AND) is a frequent event after balloon-expandable endografting. Yet few data are available on AND after repair with self-expandable stent grafts. To investigate incidence, predictive factors, and clinical consequences of AND, computed tomography (CT) scans obtained at intervals during follow-up of 230 patients who had undergone endoluminal abdominal aortic aneurysm (AAA) repair with self-expandable stents were reviewed. SUBJECTS Between April 1997 and March 2001, 318 patients underwent endoluminal AAA repair with a self-expandable endograft at our unit. CT scans obtained at 1 and 12 months after surgery and yearly thereafter were prospectively stored in a computer imaging data base. Two hundred thirty patients were available for minimum 1-year assessment. Two vascular surgeons with tested interobserver agreement reviewed 686 CT scans. Diameter of the proximal aortic neck was measured as the minor axis of the first CT section that contained at least half of the proximal portion of the endograft. For endografts with suprarenal attachment the first scan below the lowest renal artery was considered. Diameter change of 3 mm or more between the CT scan at 1 month and subsequent evaluations was defined as AND. Nine possible independent predictors of AND were analyzed with Cox regression analysis. RESULTS Median follow-up was 24 months (range, 12-54 months). In 2 patients, AAA ruptured during follow-up. CT scans for 65 patients (28%) showed AND. Thirteen patients with AND (5.6%) underwent repeat intervention, including positioning of the proximal cuff in 8 patients and late conversion to open repair in five patients. Of the nine variables examined with multivariate analysis, only 3, ie, presence of neck circumferential thrombus (hazard ratio [HR], 2.51; 95% confidence interval [CI], 1.26-5.01; P =.008), preoperative proximal neck diameter (HR, 1.21; 95% CI, 1.07-135; P =.001), and preoperative AAA diameter (HR, 1.03; 95% CI, 1.00-1.06; P =.046) were positive independent predictors of AND, whereas the other 6, ie, neck angulation more than 60 degrees, neck length, suprarenal fixation, oversizing more than 15%, endoleak at 30 days, and increased AAA diameter during follow-up, showed no significant correlation. Probability of AND at 48 months was 59 +/- 6.1 at analysis with the Kaplan-Meier method. CONCLUSIONS AND is a frequent sequela of endoluminal repair in the mid-term. Severe AND developed in a small percentage of our patients, compromising integrity of AAA repair. Patients with large aneurysms and aortic necks and patients with aortic neck circumferential thrombus are at high risk for aortic neck enlargement after endoluminal repair of AAA.

Mechanisms of symptomatic spinal cord ischemia after TEVAR: insights from the European Registry of Endovascular Aortic Repair Complications (EuREC).

Purpose To test the hypothesis that simultaneous closure of at least 2 independent vascular territories supplying the spinal cord and/or prolonged hypotension may be associated with symptomatic spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). Methods A pattern matching algorithm was used to develop a risk model for symptomatic SCI using a prospective 63-patient single-center cohort to test the positive predictive value (PPV) of prolonged intraoperative hypotension and/or simultaneous closure of at least 2 of 4 the vascular territories supplying the spinal cord (left subclavian, intercostal, lumbar, and hypogastric arteries). This risk model was then applied to data extracted from the multicenter European Registry on Endovascular Aortic Repair Complications (EuREC). Between 2002 and 2010, the 19 centers participating in EuREC reported 38 (1.7%) cases of symptomatic spinal cord ischemia among the 2235 patients in the database. Results In the single-center cohort, direct correlations were seen between the occurrence of symptomatic SCI and both prolonged intraoperative hypotension (PPV 1.00, 95% CI 0.22 to 1.00, p=0.04) and simultaneous closure of at least 2 independent spinal cord vascular territories (PPV 0.67, 95% CI 0.24 to 0.91, p=0.005). Previous closure of a single vascular territory was not associated with an increased risk of symptomatic spinal cord ischemia (PPV 0.07, 95% CI 0.01 to 0.16, p=0.56). The combination of prolonged hypotension and simultaneous closure of at least 2 territories exhibited the strongest association (PPV 0.75, 95% CI 0.38 to 0.75, p<0.0001). Applying the model to the entire EuREC cohort found an almost perfect agreement between the predicted and observed risk factors (kappa 0.77, 95% CI 0.65 to 0.90). Conclusion Extensive coverage of intercostal arteries alone by a thoracic stent-graft is not associated with symptomatic SCI; however, simultaneous closure of at least 2 vascular territories supplying the spinal cord is highly relevant, especially in combination with prolonged intraoperative hypotension. As such, these results further emphasize the need to preserve the left subclavian artery during TEVAR.

Editor's Choice – Management of Descending Thoracic Aorta Diseases : Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

Editors Choice - Management of Descending Thoracic Aorta Diseases : Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).

Epidural anesthesia reduces length of hospitalization after endoluminal abdominal aortic aneurysm repair

PURPOSE The low invasiveness of endoluminal abdominal aneurysm repair (EAAR) appears optimal for the use of epidural anesthesia (EA). However, reported series on EAAR show that general anesthesia (GA) is generally preferred. To evaluate the feasibility and problems encountered with EA for EAAR, patients undergoing EAAR with EA and patients undergoing EAAR with GA were examined. METHODS From April 1997 through October 1998, EAAR was performed on 119 patients at the Unit of Vascular Surgery at Policlinico Monteluce in Perugia, Italy. Four patients (3%) required conversion to open repair and were excluded from the analysis because they were not suitable candidates for evaluating the feasibility of EA. The study cohort thus comprised 115 patients undergoing abdominal aortic aneurysm (AAA) repair with the AneuRx Medtronic stent graft. The incidence of risk factors and anatomical features of the aneurysm were compared in patients selected for EA or GA on the basis of intention-to-treat analysis. Intraoperative and perioperative data were compared and analyzed on the basis of intention-to-treat and on-treatment analysis. RESULTS Sixty-one patients (54%) underwent the surgical procedure with EA (group A), and 54 (46%) underwent the surgical procedure with GA (group B). Conversion from EA to GA was required in four patients (3 of 61 patients, 5%). There were no statistically significant differences between the two study groups in demographics, clinical characteristics, and American Society of Anesthesiology classification (ASA). There was no perioperative mortality. Major morbidity occurred in 3% of patients (group B). According to intention-to-treat analysis, no significant differences were observed between the two groups in mean operating time, fluoro time, blood loss, amount of contrast media used, mean units of transfused blood, need of intensive care unit, mean postoperative hospital stay, and postoperative endoleak. Conversely, significant differences were found by means of on-treatment analysis in the need of intensive care unit (0 vs 5 patients; P =.02), and length of hospitalization (2.5 vs 3.2 days; P =.04). Multivariate logistic regression analysis showed that GA and ASA 4 were positive independent predictors of prolonged (more than 2 days) postoperative hospitalization (hazard ratio, 2.5; 95% CI, 1.1 to 5.8; P =.03, and hazard ratio, 5.1; 95% CI, 1.5 to 17.9; P =.007, respectively). CONCLUSION EA for EAAR is feasible in a high percentage of patients in whom it is attempted, and it ensures a technical outcome comparable with that of patients undergoing EAAR with GA. Successful completion of EAAR with EA is associated with a short period of hospitalization.

Outcome of Carotid Stenting Versus Endarterectomy A Case-Control Study

Background and Purpose— To compare perioperative and midterm results of carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in similar cohorts of patients, a retrospectively matched case-control study was performed. Methods— Three hundred and one case subjects undergoing CAS with cerebral protection and 301 concurrent matched-controls undergoing CEA were examined. Matching was by sex, age (±2 years), symptoms and coronary disease. Results— The 30-day disabling stroke/death rate was 2.6% in the CAS group versus 1.3% in the CEA group (odds ratio [OR] 2; 95% CI, 0.54 to 9.35; P=0.4). CAS patients had a significantly higher risk of periprocedural stroke (7.9% versus 2.3%; OR, 5.2; 95% CI, 1.7 to 18; P=0.001) than CEA patients. However, there was a decreasing trend in 30-day neurological event rates for the last 201 CAS matched cases: 5.4% versus 1.9% (OR 2.8; 95% CI, 0.8 to 10.2; P=0.1). Fifty percent of CAS disabling strokes occurred during cannulation of epiaortic vessels before placement of cerebral protection. Conditional multivariate analysis revealed CAS as a predictor of 30-day stroke (hazard ratios [HR] 3.9; 95% CI, 1.6 to 9.4; P=0.002) but not of 30-day disabling stroke/death (HR 3.6; 95% CI, 0.93 to 13.9; P=0.06). Restenosis free intervals at 36 months were 93.6% versus 92.1% for CAS and CEA, respectively, (P=0.6). Conclusions— When comparing CAS with CEA, the risk of any neurological events is still higher, particularly during catheterism and ballooning. The effect of the learning curve related to technical expertise and patient selection may influence the outcome of CAS versus CEA. In the midterm the restenosis rate of CAS compares favorably to CEA.

Type II endoleak is an enigmatic and unpredictable marker of worse outcome after endovascular aneurysm repair

BACKGROUND This study analyzed predictors and the long-term consequence of type II endoleak in a large series of elective endovascular abdominal aneurysm repairs (EVARs). METHODS Baseline characteristics and operative and follow-up data of consecutive patients undergoing EVAR were prospectively collected. Patients who developed type II endoleak according to computed tomography angiography and those without type II endoleak were compared for baseline characteristics, mortality, reintervention, conversion, and aneurysm growth after repair. RESULTS In 1997-2011, 1412 consecutive patients (91.4% males; mean age, 72.9 years) underwent elective EVAR and were subsequently followed up for a median of 45 months (interquartile range, 21-79 months). Type II endoleak developed in 218. Adjusted analysis failed to identify significant independent predictors for type II endoleak with the exception of age (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P = .003) and intraluminal thrombus (odds ratio, 0.69; 95% confidence interval, 0.53-0.92; P = .010). Type II endoleak rates were comparable regardless of the device model. Late aneurysm-related survival was comparable (98.4% vs 99.5% at 60 months; P = .73) in patients with and without type II endoleak. However, at 60 months after EVAR, rates of aneurysm sac growth >5 mm (35.3% vs 3.3%; P < .0001) were higher in patients with type II endoleak. Cox regression identified type II endoleak as an independent predictor of aneurysm growth along with age and cardiac disease. The presence of type II endoleak led to reinterventions in 40% of patients and conversion to open surgery in 8%. However, assessment of these patients after reintervention showed similar 60-month freedom rates of persisting type II endoleak (present in more than two after computed tomography angiography scan studies) among those with and without reinterventions (49.8% vs 45.6%; P = .639). Aneurysm growth >5 mm persisted with comparable rates in type II endoleak patients after reintervention and in those who remained untreated (42.9% vs 57.4% at 60 months; P = .117). CONCLUSIONS Reintervention for type II endoleak was common in our practice, yet such intervention did not reliably prevent the continued expansion of the abdominal aortic aneurysm. Our data indicate type II endoleak appears to be a marker of EVAR failure that is difficult to predict and treat effectively.

Effects of statins on early and late results of carotid stenting

OBJECTIVES Increasing data suggest that statins can significantly decrease cardiovascular and cerebrovascular events due to a plaque stabilization effect. However, the benefit of statins in patients undergoing carotid angioplasty and stenting (CAS) for carotid stenosis is not well defined. The aim of this study was to investigate whether statins use was associated with decreased perioperative and late risks of stroke, mortality, and restenosis in patients undergoing CAS. METHODS All patients undergoing CAS for primary carotid stenosis from 2004 to 2009 were reviewed. The independent association of statins and perioperative morbidity was assessed using multivariable analysis. Survival curves and Cox regression models were used to assess late morbidity and restenosis. Propensity score adjustment was employed. RESULTS A total of 1083 consecutive CAS were performed (29% females, mean age 71.5 years; 24.7% symptomatic); 465 (43%) were on statins medication before treatment that was not discontinued at discharge. Statins use was associated with a reduction of perioperative stroke and death (odds ratio [OR] 0.327, 95% confidence interval [CI] 0.13-0.80, P = .016) according to multivariable analysis. Statins effect was more significant in reducing stroke and death in symptomatic patients (OR 0.13; P = .032) and in males (OR 0.27, P = .01). At 5 years, survival (87.2% vs 78.3%; P = .009) and ischemic stroke-free interval (88.9% vs 99.7%; P = .02) rates were higher in the statins group of patients. Adjusting for propensity score and covariates in Cox regression analyses, statins use was independently associated with reduced long-term mortality risk (HR 0.56, 95% CI 0.32-0.97; P = .039) and borderline associated with decreased late ischemic stroke risk (HR 0.14; 95% CI 0.018-1.08, P = .059). There was no effect on restenosis rates. CONCLUSIONS These data suggest that statins use is associated with decreased perioperative and late ischemic strokes risk and reduced mortality rates in patients undergoing CAS. Statins therapy should be considered part of the best medical treatment in current CAS practice.