Giuseppe Saitta

Treatment of ruptured abdominal aortic aneurysm after endovascular abdominal aortic repair: A comparison with patients without prior treatment.

OBJECTIVE A retrospective analysis of immediate outcomes following aneurysm rupture (rAAA) in two groups: patients previously treated at our center with primary endovascular repair (EVAR) and patients without previous EVAR for abdominal aortic aneurysms (AAA) in an 8-year period. METHODS Fourteen patients with a confirmed rAAA identified throughout the follow-up period following primary EVAR repair at our center (from a population of 820 AAA treated at our center in election) were retrospectively compared with 155 patients without previous EVAR in the same time period, from the introduction of an intention-to-treat protocol with EVAR for rAAA in January 1999. Primary study outcomes included 30-day mortality and severe systemic complications following rAAA correction with both open and EVAR treatments. RESULTS In the 14 patients secondary interventions were necessary throughout follow-up prior to rupture in 43% (6/14). The mean time to rupture was 50.23 months (9-113). The mean increase in maximum aneurysmal diameter at rupture was 18.39 mm. Type of endoleaks observed at rupture: 35.7% I proximal, 35.7% III contralateral stump disconnection, 14.3% I distal, 14.3% III midgraft tear: treatment at rupture included five EVAR corrections with aortouniiliac endografts, four EVAR corrections with extensions, and five surgical conversions. Thirty-day mortality between the two groups, 28.5% (patients with prior EVAR) 38.7% (patients without prior EVAR), and severe systemic complications, 50% vs 37.6%, were not found to be statistically significant. Hemodynamic instability, 36% (patients with prior EVAR) 63% (patients without prior EVAR), was found to be an independent predictor of 30-day mortality (P < .0001), whereas severe systemic complications, 50% vs 33.5%, did not influence the same outcome (P = .852). CONCLUSIONS In terms of mortality, it would be logical to expect a protection from the endograft in patients with previous EVAR. A trend seems to confirm this assumption, but no statistical significance was found, which may be due to the small population size.

Inflammatory abdominal aortic aneurysm endovascular repair into the long-term follow-up.

BACKGROUND To investigate long-term outcomes for inflammatory abdominal aortic aneurysms (IAAA) after endovascular treatment (EVAR). METHODS Between May 1997 and January 2009, 9 male patients (Mean 67 years, range 54-75 years) with IAAA were treated with EVAR using commercially available endografts. Results were assessed using contrast-enhanced computed tomography (CT) at 3 months, 12 months, and biannually thereafter. Echo-color duplex scanning was also recommended at 3, 6, and 12 months after discharge, and annually thereafter. Primary endpoints were aneurysm-related mortality, aneurysm sac evolution, perianeurysmal fibrosis (PAF) thickness, and hydronephrosis progression. RESULTS No aneurysm-related deaths were observed during the long-term follow-up of eight patients (one patient death unknown). Maximum aneurysm sac diameter progressively reduced in eight patients (89%) and remained unchanged in one (11%). The absolute mean reduction of the aneurysm size was 26.2%. PAF regressed in two patients (22%), reduced in five (56%), and remained unchanged in two (22%). The absolute median reduction of the PAF thickness was 55.1%. No endoleak was observed during the follow-up period. Hydronephrosis persisted in all three patients who were preoperatively diagnosed with this pathology. Survival rates were 89%, 66.7%, and 66.7% at 12, 36, and 60 months, respectively. CONCLUSIONS This series suggests that EVAR for IAAA into the long-term is associated with a positive trend for both PAF and aneurysm diameter reduction. EVAR does not seem to offer any benefits for hydronephrosis, but seems to effectively exclude the aneurysm sac in anatomically suitable patients.

Endovascular treatment of abdominal aortic aneurysms with the Powerlink Endograft System: influence of placement on the bifurcation and use of a proximal extension on early and late outcomes.

OBJECTIVE We evaluated the influence of placement of the bifurcated Powerlink endograft (Endologix Inc, Irvine, Calif) on the aortic bifurcation, with the addition of a proximal extension, in the endovascular treatment (EVAR) of selected patients with atherosclerotic abdominal aortic aneurysms (AAAs). METHODS From September 1999 to June 2007, 205 patients were treated with the bifurcated Powerlink endograft for atherosclerotic AAA at two Italian centers with shared protocols. Patients were retrospectively divided in two groups according to treatment with the bifurcated graft only (n = 126), or its placement on the bifurcation with the addition of a proximal extension (n = 79) at the initial procedure. Study end points included postoperative complications, secondary procedures, immediate and late conversion, migration, endoleak, death, and aneurysmal sac behavior. RESULTS Overall technical success was 98.5%. Additional procedures were performed in 18%, and postoperative complications occurred in 11.2% (systemic, 8.3%; local, 2.9%). Median follow-up was 42.4 months (range, 6-94 months). Secondary procedures were recorded in 11.2%, migration in 3.9%, type I proximal endoleak in 7.8%, and late conversions in 2.4%. Placement on the bifurcation and the addition of an extension were associated with a higher incidence of postoperative complications (7.1% vs 17.7%, P = .020). A reduced incidence of endoleak (19% vs 8.9%, P = .048), secondary procedures (14.3% vs 6.3%, P = .04), and migration (6.3% vs 0%, P = .024) were observed in the group with a proximal extension. Analysis of single variables reveals that migration was significantly influenced by placement of the graft on the bifurcation (47% vs 0%, P < .001). Both placement on the bifurcation and the addition of an extension positively influenced the type I proximal endoleak rate (3.8% vs 35.3% P < .001) and the need for a secondary intervention (6.3% vs 35.3% P < .001) Two aneurysm ruptures and five cases of late conversion occurred in the group treated with a bifurcated graft only (4%, P = .52, P = .159). Analysis of aneurysm sac behavior was not statistically significant: enlargement, 4.1% vs 1.3% (P = .158); reduction, 34.1% vs 40.5% (P = .542). CONCLUSION The placement of the bifurcated Powerlink endograft on the aortic bifurcation with a proximal extension for complete sealing seems to improve late outcomes, particularly secondary procedures, migration, and endoleak development. Larger prospective studies with longer follow-up are necessary to confirm these promising results.

Single-Center Experience with the Talent LPS Endograft in Patients with at Least 5 Years of Follow-up

Purpose: To evaluate long-term results in patients undergoing elective endovascular aneurysm repair (EVAR) using the Talent LPS endograft to treat abdominal aortic aneurysm (AAA). Methods: Fifty patients (49 men; median age 72 years, range 54–89) were treated electively between 1997 and 2001 with the Talent LPS endograft chosen for various anatomical reasons, including short (≤15 mm) aortic neck (32.5%), iliac ectasia (≥18 mm) in at least 1 iliac artery (32%), angulated (30°–60°) aortic neck (16%), large (≥28 mm) aortic neck (6%), and tapered, reversed tapered, or bulging aortic neck (14%). A quarter of patients were preoperatively classified as unfit for AAA open repair, and 58% were high risk (ASA III or IV). The primary endpoints were immediate success, aneurysm-related and non-aneurysm-related mortality, secondary interventions, graft-related complications, graft migration (≥5 mm), and structural failure. Results: Implantation success was achieved in 96% (48/50). Four (8%) patients died within 30 days; in follow-up, the mortality rate was 51% over a mean 47.7±27.4 months (minimum of 5 years). Aneurysm-related mortality was 12% (6/50); 3 (6%) patients were converted. The overall reintervention rate was 16% (8/50). There were 9 (18%) endoleaks in 8 patients: 4 type I (2 proximal, 2 distal), 3 type II, and 2 type III. The migration rate was 4% (1 ruptured AAA, 1 endoleak). Individual cases of graft kinking and stent fracture occurred in this series. Conclusion: Despite the small population, trends in our results suggest that the Talent stent-graft performs well over the long term. Surveillance, especially with regard to migration and graft integrity, remains of great importance.

Midterm Outcomes of the Nellix Endovascular Aneurysm Sealing System A Dual-Center Experience

Purpose: To report midterm outcomes of the Nellix Endovascular Aneurysm Sealing (EVAS) System in the treatment of abdominal aortic aneurysm (AAA). Methods: Between September 2013 and July 2014, 64 AAA patients (mean age 76.6±6.8 years; 61 men) were treated with the EVAS system at 2 centers (only procedures performed at least 12 months prior to the analysis were included). Most patients were treated for a stable AAA, while 1 patient was treated for a ruptured aneurysm. Mean aneurysm diameter was 57.3±9.3 mm. The proximal neck measured a mean 21.5±3.3 mm in diameter and 27.0±12.1 mm long; the neck angle was 16.9°±19.3°. Eleven (17.2%) patients were treated outside the instructions for use (IFU). Results: Technical success was achieved in 63 (98.4%) of 64 patients; 1 type Ia endoleak was treated intraoperatively. One (1.6%) aneurysm-related death occurred at 4 months due to a secondary aortoenteric fistula. Overall, endoleaks occurred in 3 (4.7%) patients (2 type Ia, 1 type II). The estimated rates for 18-month overall survival, freedom from aneurysm-related death, and freedom from secondary interventions were 92.7%, 98.4%, and 95.0%, respectively. Patients treated outside the IFU had a significantly higher incidence of device-related complications (p=0.03). Conclusion: The use of the Nellix device in everyday clinical practice is safe and offers promising midterm results. The risk of secondary aortoenteric fistula requires further analysis. Longer follow-up is needed to assess the actual efficacy of the device, although the risk of migration with late endoleak seems low.

Thoracic Endograft for Abdominal Aortic Aneurysms, an Unusual Application for Severe Neck Angulation: Case Report and Literature Review

Our goal was to achieve complete proximal sealing in severe aortic neck angulation (SNA) during endovascular aneurysm repair (EVAR) of a patient with an abdominal aortic aneurysm (AAA) unfit for surgery. An 82-year-old patient with an infrarenal AAA of 9.8 cm with an SNA of 90° was admitted for acute coronary syndrome. Following coronary treatment, the patient was considered unfit for surgery and therefore was evaluated for EVAR. Aneurysm sac exclusion was obtained with the deployment of a Powerlink bifurcated graft (Endologix Inc, Irvine, CA) inside a Relay thoracic endograft (Bolton Medical, Florida) placed just below the most distal renal artery. At 6 months, computed tomographic angiography confirmed correct graft placement, complete aneurysm exclusion, and a reduction in the aneurysmal sac. In AAA patients with an SNA at high risk of EVAR failure, the adaptability of a thoracic endograft could be considered for proximal sealing.

Treatment of a Ruptured Abdominal Aortic Aneurysm with an Adverse Anatomy Using the Nellix Endovascular Aneurysm Sealing System

Editor: Endovascular aneurysm sealing (EVAS) with the Nellix device (Endologix, Inc, Irvine, California) has been described for the treatment of abdominal aortic aneurysm (AAA) (1,2). The device comprises two stainless steel balloon-expandable stents (endoframes) that are deployed below the renal arteries and land in the common iliac arteries. The endoframe is surrounded by a polytetrafluoroethylene bag that is filled with a liquid polymer at high pressure (up to 200 mm Hg), which cures to a solid to exclude the aneurysm permanently and maintain the frames in position (2). The specific design of the Nellix device can potentially be used to treat patients outside the traditional anatomic requirements of endovascular aortic repair (1). The present instructions for use (IFU) are similar to other stent grafts and do not include ruptured AAAs. We report the case of a ruptured AAA treated with the Nellix device. Institutional review board approval was not required for the present report. An 80-year-old woman was admitted at our institution with a 60-mm ruptured AAA. Computed tomography angiography showed a small tapered proximal neck (16 mm at the renal arteries, 13 mm in the segment before the aneurysm sac), with a tight kink (angles 4 701) (Figs 1, 2). The external iliac arteries had a 5.5-mm diameter, with diffused calcifications (Fig 3). Because of severe comorbidities, endovascular aortic repair under local anesthesia was undertaken. Procedural steps have been described in previous publications (1,2). Briefly, under local anesthesia, bilateral percutaneous femoral access was obtained and