Frédéric Cochennec

Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition

OBJECTIVE The aim of the study was to determine whether type II endoleak (T2E) after endovascular repair of abdominal aorta (EVAR) is a benign condition (ie, not associated with growth, reintervention, rupture, or death). METHODS Data from patients who underwent EVAR for atherosclerotic infrarenal aortic aneurysms between June 1995 and May 2010 in the Vascular Surgery Department of Henri Mondor Hospital were prospectively collected. Data from patients presenting with at least one T2E on computed tomography scan during their follow-up were compared with those with no T2E. Three subcategories of T2E were studied according to time of occurrence (early or late), persistence (persistent or transient), and recurrence (recurrent or not recurrent). RESULTS Seven hundred patients were included with follow-up ranging from 1 month to 15 years (median, 31.3 months; range, 12.4-61.4); 201 (28.9%) had at least one T2E. Patients with T2Es were significantly older (P < .001), female (P = .015), had larger aneurysms (P = .019), and patent lumbar arteries (P = .003). Patients without T2Es had a higher incidence of current smoking (P < .001) and chronic obstructive pulmonary disease (P < .005). Multivariate analysis showed risk of T2E was increased in older patients (odds ratio [OR], 1.04; confidence interval [CI], 95% 1.02-1.06; P < .001) and in those with patent lumbar arteries (OR, 1.70; CI, 95% 1.16-2.50; P = .007), and was reduced in active smokers (OR, 0.16 CI, 95% 0.04-0.71; P = .015) or patients with coronary artery disease (OR, 0.65; CI, 95% 0.45-0.92; P = .016). Patients with T2Es had more complications (death, rupture, reintervention, or conversion) (P < .001) and greater aneurysm sac enlargement (>5 mm upon follow-up) (P < .001). Multivariate analysis showed T2E was a risk factor for aneurysm diameter growth >5 mm; this risk was increased if T2E persisted more than 6 months (hazard ratio [HR], 3.16; CI, 95% 2.55-6.03; P < .001), was recurrent (HR, 1.88; CI, 95% 1.18-3.01; P = .008), or associated with a type I or III endoleak (HR, 1.96; CI, 95% 1.41-2.73; P < .001). Recurrent T2E was associated with a higher rate of reintervention (P = .04) and conversion to open surgery (P = .028). CONCLUSIONS Not all T2Es are benign. Recurrent as well as persistent T2Es are prone to life-threatening complications.

A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms

OBJECTIVE The benefit of fenestrated endovascular aortic aneurysm repair (FEVAR) compared with open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) is unknown. This study compares 30-day outcomes of these procedures from two high-volume centers where FEVAR was undertaken for high-risk patients. METHODS Patients undergoing FEVAR with commercially available devices and OSR of CAAAs (total suprarenal/supravisceral clamp position) were propensity matched by demographic, clinical, and anatomic criteria to identify similar patient cohorts. Perioperative outcomes were evaluated using univariate and multivariate methods. RESULTS From July 2001 to August 2012, 59 FEVAR and 324 OSR patients were identified. After 1:4 propensity matching for age, gender, hypertension, congestive heart failure, coronary disease, chronic obstructive pulmonary disease, stroke, diabetes, preoperative creatinine, and anticipated/actual aortic clamp site, the study cohort consisted of 42 FEVARs and 147 OSRs. The most frequent FEVAR construct was two renal fenestrations, with or without a single mesenteric scallop, in 50% of cases. An average of 2.9 vessels were treated per patient. Univariate analysis demonstrated FEVAR had higher rates of 30-day mortality (9.5% vs. 2%; P = .05), any complication (41% vs. 23%; P = .01), procedural complications (24% vs. 7%; P < .01), and graft complications (30% vs. 2%; P < .01). Multivariable analysis showed FEVAR was associated with an increased risk of 30-day mortality (odds ratio [OR], 5.1; 95% confidence interval [CI], 1.1-24; P = .04), any complication (OR, 2.3; 95% CI, 1.1-4.9; P = .01), and graft complications (OR, 24; 95% CI, 4.8-66; P < .01). CONCLUSIONS FEVAR, in this two-center study, was associated with a significantly higher risk of perioperative mortality and morbidity compared with OSR for management of CAAAs. These data suggest that extension of the paradigm shift comparing EVAR with OSR for routine AAAs to patients with CAAAs is not appropriate. Further study to establish proper patient selection for FEVAR instead of OSR is warranted before widespread use should be considered.

Open vs endovascular repair of abdominal aortic aneurysm involving the iliac bifurcation

INTRODUCTION Aneurysmal involvement of the iliac bifurcation increases the level of difficulty during surgery for abdominal aortic aneurysm (AAA) repair, potentially increasing the risk of early postoperative complications. Three previous randomized trials comparing endovascular aneurysm repair (EVAR) and open repair (OR) for AAAs showed that EVAR is associated with a lower early mortality rate. However, whether these results are valid for AAA involving the iliac bifurcation (AAAIB) remains unclear. The aim of this study was to evaluate early and late results after OR and EVAR for patients with AAA involving the iliac bifurcation. METHODS Of 1116 patients treated for elective AAA repair between January 1998 and January 2008, 131 presented with AAAIB as detected by computed tomography (CT) scan. Sixty-eight patients were treated by EVAR and 63 by OR. Clinical and anatomic data, operative intervention, and outcomes were collected prospectively and analyzed retrospectively. The median duration of follow-up was 38 months for both groups. RESULTS Patients in the EVAR group (72 +/- 10 years) were older than those in the OR group (64 +/- 8 years; P < .0001), but there were no differences in cardiac, renal, or pulmonary comorbidities between the two groups. Inhospital mortality rates were 2.9% vs 6.3% for EVAR and OR groups, respectively (P = .43). Systemic postoperative complications occurred in 7.4% vs 9.5% (P = .76) and postoperative colonic ischemia in 0% vs 6.3% (P = .051) of patients with EVAR and OR, respectively. Survival rates by Kaplan-Meier analysis were 91 +/- 7% for patients with EVAR and 90 +/- 8% for patients with OR at 2 years, and 61% +/- 15 for EVAR and 79% +/- 13 for OR at 5 years. All-cause reoperation rates were 25% with EVAR and 22% with OR (P = .83). Patients with EVAR were more likely to develop buttock claudication (33.3% vs 3.6%; P < .0001), whereas patients with OR were more prone to develop abdominal wall complications (19.6% vs 0%; P < .001). CONCLUSION In this series, the postoperative mortality and systemic complication rates after either EVAR or OR for AAAIB were not statistically different. In the OR group, there were more abdominal wall complications and a trend toward a higher rate of colonic ischemia. In the EVAR group, buttock claudication was more frequent.

Statin therapy is associated with aneurysm sac regression after endovascular aortic repair

BACKGROUND Several anatomic factors have been identified as predictive of sac behavior after endovascular aneurysm repair (EVAR). The effects of statin therapy on aneurysm sac size reduction remain controversial. This study tested the hypothesis that statin therapy enhances aneurysmal sac regression after EVAR. METHODS This monocentric retrospective study included patients with abdominal aortic aneurysms treated by EVAR using the Zenith (Cook, Bloomington, Ind) graft device. We excluded patients presenting with perioperative sac enlargement factors such as endoleaks, endotension, infectious, inflammatory, ruptured, or anastomotic aneurysms. We prospectively assessed standard clinical and anatomic data, as well as statin use, at the time of EVAR and during follow-up. The primary end point was the decrease in the largest transverse aortic diameter at 24 months compared with the preoperative diameter. RESULTS Among 166 patients treated by a Zenith device and meeting the inclusion criteria, 120 were identified as statin users and 46 as nonstatin users, with comparable characteristics. At 24 months of follow-up, statin group patients had a greater aneurysm sac reduction (25% vs 14%; P < .0001). At a threshold of 5 mm in diameter regression, statin use was a positive factor of retraction (odds ratio, 7.93; 95% confidence interval, 3.22-15.52; P < .0001). Multivariate analysis revealed statin use was an independent predictive factor of sac regression (adjusted odds ratio, 9.39; 95% confidence interval, 3.45-25.56). CONCLUSIONS This study showed that statin use was predictive of sac regression after EVAR with the Zenith graft device. This effect needs to be confirmed by larger randomized trials or by large population evaluation.

Predictive factors for limb occlusions after endovascular aneurysm repair

OBJECTIVE Greater flexibility and smaller sizes for introducer sheaths in the newest stent grafts increase the feasibility of endovascular aneurysm repair but raise concerns about long-term limb patency. The aim of the study was to determine the incidence of and predictive factors for limb occlusion after use of the Endurant stent graft (Medtronic Inc, Minneapolis, Minn) for abdominal aortic aneurysm. METHODS The Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) prospectively included 1143 patients treated with bifurcated devices who were observed for up to 2 years. Limb occlusions were evidenced by computed tomography, angiography, or ultrasound. To predict stent graft limb occlusion, a two-step model-building technique was applied. We first identified predictors from a total of 47 covariates obtained at baseline and in the periprocedural period. Subsequently, we reduced the set of potential predictors to key factors that are clinically meaningful. To handle large numbers of covariates, we used the Classification And Regression Tree (CART) method. RESULTS Forty-two stent graft limbs occluded in 39 patients (3.4% of the patients). At 2 years, the rate of freedom from stent graft limb occlusion calculated by Kaplan-Meier plot was 97.9% (standard error [SE], 0.33%). Of the 42 occlusions, 13 (31%) were observed within 30 days and 30 (71%) within 6 months. The strongest independent predictors were distal landing zone on the external iliac artery, external iliac artery diameter ≤10 mm, and kinking. High-risk vs low-risk patients were identified according to a decision tree based on the strongest predictors. Freedom from stent graft limb occlusion was 96.1% (SE, 0.64%) in high-risk patients vs 99.6% (SE, 0.19%) in low-risk patients. CONCLUSIONS After Endurant stent grafting, the incidence of limb occlusion was low. Classifying patients as high risk vs low risk according to the algorithm used in this study may help define specific strategies to prevent limb occlusion and improve the overall results of endovascular aneurysm repair using the latest generation of stent grafts.

Endovascular balloon occlusion is associated with reduced intraoperative mortality of unstable patients with ruptured abdominal aortic aneurysm but fails to improve other outcomes

BACKGROUND Proximal aortic control by endovascular balloon occlusion (EBO) is an alternative to conventional aortic cross-clamping (CAC) in hemodynamically unstable patients presenting with a ruptured abdominal aortic aneurysm (rAAA). The aim of this study was to evaluate the potential clinical benefit of EBO over CAC. METHODS Data from 72 patients with rAAA treated at our institution from 2001 to 2013 were retrospectively analyzed. All patients were hemodynamically unstable (mean arterial blood pressure at admission <65 mm Hg or associated unconsciousness, cardiac arrest, or emergency endotracheal intubation). Clinical end points of hemodynamic restoration, mortality rate, and major postoperative complications were assessed for CAC (group 1) and EBO (group 2). RESULTS At admission, 72 patients were unstable. CAC was performed in 40 and EBO in 32. Intraoperative mortality was 43% in group 1 vs 19% in group 2 (P = .031). In group 1, the approach for CAC (thoracotomy [n = 23] vs laparotomy [n = 17]) did not influence intraoperative mortality (43% vs 41%). There was no significant difference in 30-day (75% vs 62%) and in-hospital (77% vs 69%) mortality rates between groups. After EBO, the treatment-open vs endovascular repair-did not influence the intraoperative mortality rate (31% vs 43%; P = .5). Eight surgical complications were secondary to CAC (1 vena cava injury, 3 left renal vein injuries, 1 left renal artery injury, 1 pancreaticoduodenal vein injury, and 2 splenectomies), but no EBO-related complication was noted (P = .04). Differences in colon ischemia (15% vs 28%) and renal failure (12% vs 9%) were not statistically significant. Abdominal compartment syndrome occurred in four patients in group 2 and in no patients in group 1. CONCLUSIONS Compared with CAC, EBO is a feasible and valuable strategy and is associated with reduced intraoperative mortality of unstable rAAA patients, but not in-hospital mortality, in this retrospective study.

Aortoiliac aneurysms infected by Campylobacter fetus.

PURPOSE Few reports of aortoiliac aneurysms infected by Campylobacter fetus are available. We report five cases and review previous reports, with a view to describing the clinical pattern, treatment options, and outcome of this infection. METHODS During a 10-year period, 21 patients were diagnosed with C fetus infection in the Department of Clinical Microbiology, five of whom had an infected arterial aneurysm. We retrospectively reviewed their medical charts. Diagnosis was made on the basis of clinical presentation, computed tomography scan, perioperative findings, and identification of C fetus in at least one blood culture or culture from an aneurysm specimen. Late outcome of surviving patients was assessed by telephone interview. RESULTS We identified four aortic aneurysms and one hypogastric aneurysm. All patients were seen in an emergency setting. Five had fever and abdominal pain, and three had contained rupture. Campylobacter fetus was found in blood cultures of four patients and in the aneurysm specimen of one patient. Three patients were treated by open repair and two by endovascular repair. One patient treated endovascularly died from septic shock due to C fetus at 2 weeks. One patient treated by open surgery underwent reoperation for persistent infection. The remaining patients were cured, but one died at 5 months of an unrelated cause. All surviving patients received long-term antibiotic therapy. CONCLUSION Campylobacter fetus infection of aortoiliac aneurysms is a serious condition with a high rate of rupture. However, long-term success can be obtained with prompt surgical treatment and an appropriate antibiotic regimen. The benefits of stent grafts remain debatable.

A comparison of total laparoscopic and open repair of abdominal aortic aneurysms

OBJECTIVE The feasibility of total laparoscopic abdominal aortic aneurysm (AAA) repair has been well established. In a previous case-control study, we showed that the postoperative courses of total laparoscopic and open AAA repairs were similar. The purpose of this study was to compare the long-term results of these techniques in the same cohort of patients. METHODS Thirty patients with AAAs treated by total laparoscopic repair between July 2003 and December 2004 (group I) were matched in a case-control fashion by morphology and American Society of Anesthesiologists class with 30 patients who underwent open AAA repair between April 1997 and May 2004 (group II). Patients who survived the intervention were followed up during 5 years. Follow-up consisted of physical examination and duplex ultrasonography at 1 month and yearly thereafter. Group I patients had an additional control computed tomography scan within the first 3 months postoperatively. RESULTS Five-year cumulative survival rates were similar (group I: 83% ± 7% vs group II: 79% ± 7%; log-rank test, P = .69). No late aneurysm-related death occurred during the follow-up period. Incisional hernias were more likely to occur in group II patients (group I: 0% vs group II: 15.4%; P = .047). Incidence of postoperative sexual dysfunction was similar in both groups (group I: 22.2% vs group II: 25.0%; P = not significant [NS]). No late reintervention was recorded in group I, whereas 2 patients in group II had incisional hernia repair. At 5 years, no graft sepsis or anastomotic pseudoaneurysm was reported. CONCLUSIONS This study suggests that total laparoscopic AAA repair provides good long-term results, comparable to those of open repair in terms of aneurysm-related mortality and morbidity. It may reduce the incidence of laparotomy-related complications.

Feasibility and safety of renal and visceral target vessel cannulation using robotically steerable catheters during complex endovascular aortic procedures.

Purpose: To evaluate the safety and success of target vessel cannulation in the visceral aortic segment using the Magellan robotic catheter system (RCS) during complex endovascular aortic procedures. Methods: Robotic navigation was attempted for access to 37 target vessels in 15 patients (14 men; mean age 75±10 years) during 16 fenestrated and/or branched stent-grafting procedures and 1 endovascular repair requiring the chimney technique. For each target vessel, robotic navigation was attempted for a maximum of 15 minutes; if cannulation was unsuccessful in that time, manual catheters were employed. Safety was evaluated by recording intraoperative adverse events, intraoperative complications related to robotic navigation, and postoperative complications. Technical success of robotic cannulation, wire cannulation times, and times for inserting the leader over the wire in the target vessels were recorded to assess RCS performance. Results: Successful robotic cannulation was achieved for 30 (81%) of the 37 target vessels, with a median wire cannulation time of 263 seconds (range 40–780) and a median 15 seconds (range 5–450) for inserting the leader over the wire. No intraoperative complications related to robotic navigation were observed. Seven of 27 arteries accessed via 7 fenestrations could not be cannulated within 15 minutes; all were cannulated successfully using conventional catheters (mean cannulation time 31±7 minutes). All 10 target vessels accessed via branches and chimney stents were successfully cannulated with the RCS. Conclusion: Cannulation of target vessels with the RCS during complex endovascular aortic procedures is feasible and safe. The robotic system was particularly effective for branched and chimney stents.

High Neutrophil to Lymphocyte Ratio Is Associated With Symptomatic and Ruptured Thoracic Aortic Aneurysm

The predictive value of the neutrophil to lymphocyte ratio (NLR) has been demonstrated in several cardiovascular diseases. The aim of our study was to investigate the association between the preoperative NLR and aneurysm characteristics as well as 30-day postoperative morbidity and mortality in patients with thoracic aortic aneurysm (TAA) undergoing aortic surgical repair. Consecutive patients (n = 75) with TAA were retrospectively included over a 10-year period. Clinical characteristics, aneurysm characteristics, and 30-day postoperative outcome were recorded. The median age of patients was 71 (67-80) years. The median preoperative NLR was 3.5 (2.3-5.8). The proportion of asymptomatic TAA was significantly lower in patients with an NLR > 3.5 compared with those with an NLR < 3.5 (52.6% vs 75.7%; P = .054). The proportion of patients with pain or with ruptured TAA was significantly higher in patients with an NLR > 3.5 compared with those with NLR < 3.5 (42.1% vs 16.2%; P = .022 and 26.3% vs 2.7%; P = .007, respectively). No significant difference was observed regarding the 30-day overall postoperative mortality and morbidity. The preoperative NLR did not correlate with TAA diameter. A high preoperative NLR is significantly associated with symptomatic and ruptured TAA, suggesting a potential interest as a marker and/or player in the disease.