Jason Constantinou

Results of complex aortic stent grafting of abdominal aortic aneurysms stratified according to the proximal landing zone using the Society for Vascular Surgery classification

BACKGROUND Advances in endovascular technology have led to the successful treatment of complex abdominal aortic aneurysms. However, there is currently no consensus on what constitutes a juxtarenal, pararenal, or suprarenal aneurysm. There is emerging evidence that the extent of the aneurysm repair is associated with outcome. We compare the outcomes of 150 consecutive patients treated with a fenestrated or branched stent graft and present the data stratified according to the Society for Vascular Surgery classification based on proximal anatomic landing zones. METHODS A prospectively collected database of consecutive patients undergoing fenestrated or branched stent graft insertion in a tertiary center between 2008 and 2013 was retrospectively analyzed. Aneurysms were subdivided into zones according to where the area of proximal seal could be achieved in relation to the visceral arteries. Zone 8 covers the renal arteries, zone 7 covers the superior mesenteric artery, and zone 6 covers the celiac axis. Patient demographics, operative variables, mortality, and major morbidity were analyzed by univariate and multivariate analysis to assess for differences between zones. RESULTS During the study period, 150 patients were treated. There were 49 in zone 8, 76 in zone 7, and 25 in zone 6. Prior aortic surgery had been performed in 19 patients, which included 11 patients with previous endovascular aneurysm repairs. There was significantly increased blood loss (P < .001), operative time (P < .0001), total hospital stay (P = .018), and intensive care unit stay (P < .0001) as the zones ascended the aorta. There were 14 inpatient deaths recorded across all zones with a 30-day mortality rate of 8%. Logistic regression analysis for 30 day mortality showed a significant increase as the zones ascended (P = .007). Kaplan-Meier analysis showed that 5-year survival significantly deteriorated as the zones ascended (P = .039), with no significant difference in the freedom from reintervention curves between zones (P = .37). CONCLUSIONS We have shown that the extent of the aneurysm repair as determined by the proximal sealing zone is associated with outcome. Mortality, operative duration, blood loss, and hospital stay all significantly increased as the zones ascended. These data also validate the use of the proposed new classification based on aortic anatomy.

Calcification of a Synthetic Renovascular Graft in a Child

Introduction Vascular grafts, especially in paediatric cases, need to be durable. Common failures such as thrombosis are well documented with research efforts directed towards them. However, there are lesser known causes of graft failure, such as graft calcification, and these also require further research focus. Report A paediatric case is described in which a synthetic renovascular graft, implanted for mid-aortic syndrome, became calcified, necessitating surgical intervention to resolve graft malfunction. Significant calcification in the limb of a bifurcated polyethylene terephthalate graft was found to be the cause of resistant stenosis and refractory hypertension. Histology conducted on the explanted limb showed the presence of multinuclear giant cells, indicating a chronic foreign body response. Discussion Calcification of vascular grafts is probably more common than previously recognised. Stenosis typically resistant to angioplasty may result in the long term and thus leading to surgical intervention. In young children, this is suboptimal as these grafts need to last throughout adulthood. Explanted prosthetic grafts should be sent to specialist registries such as that in Strasbourg to be optimally assessed so that contributory factors can be identified.

Ten-year single-centre experience with type II endoleaks: Intervention versus observation

Our objective was to determine the relative merits of intervention or observation of type II endoleaks (T2Ls). A retrospective analysis was performed on 386 infra-renal endovascular aneurysm repair (IR-EVAR) patients from 2006 to 2015. Annual surveillance imaging of patients undergoing EVAR at our centre were analysed, and all endoleaks were subjected to a multidisciplinary team meeting for consideration and treatment. In the 10-year time frame, 386 patients (79.5±8.7 years) underwent an IR-EVAR. Eighty-one patients (21.0%) developed a T2L and intervention was undertaken in 28 (34.6%): 17 (60.7%) were treated via a transarterial approach (TA) and 11 (39.3%) using the translumbar approach (TL). Fifty-three patients (65.4%) with T2Ls were managed conservatively. Patients who received T2L treatment had a greater proportion of recurrent T2Ls than patients who were conservatively managed (p=0.032). T2Ls associated with aneurysmal growth were more resistant to treatment than those where there was no change or a decrease in aneurysm size during follow-up (0.033). There was no significant difference in the TA and TL approach with respect to endoleak repair success (p=0.525). Treatment of a T2L did not confer a survival advantage compared to conservative management (p=0.449) nor did the choice of either the TA or TL approach (p=0.148). Our study suggests the development of a T2L associated with aneurysm growth may represent an aggressive phenotype that is resistant to treatment. However, this did not lead to an increased risk of mortality over follow-up. Neither a transarterial nor a translumbar approach to treating a T2L conferred superiority.

Retrograde Stenting Under Transmesenteric Angiographic Guidance of an Occluded Superior Mesenteric Vein to Treat Life-Threatening Hemorrhage

Midgut carcinoid tumors (MCTs) are responsible for a range of mesenteric vascular complications and may rarely manifest with gastrointestinal (GI) hemorrhage. Endovascular approaches are particularly useful for this population, as surgery is often technically difficult. We report a case of life-threatening upper GI bleeding in a 50-year-old man previously diagnosed with an MCT in the small bowel mesentery. Computed tomography angiogram revealed an MCT obstructing the superior mesenteric vein (SMV) associated with multiple large collateral vessels. The patient underwent retrograde stenting of the obstructed SMV using a combined open and endovascular approach to successfully terminate the persistent GI bleeding.

Temporary Perfusion Branches to Decrease Spinal Cord Ischemia in the Endovascular Treatment of Thoraco-Abdominal Aortic Aneurysms

BASED ON A PRESENTATION AT THE 2013 VEITH SYMPOSIUM, NOVEMBER 19-23, 2013 (NEW YORK, NY, USA): BACKGROUND: : Spinal cord ischemia (SCI) is one of the most feared complications following the repair of thoraco- abdominal aortic aneurysms (TAAA). Endovascular repair of TAAA is now possible with branched stent grafts, but spinal cord ischaemia rates are still unacceptably high. A number of techniques have been utilized to reduce these levels, however, SCI remains a challenge to endovascular repair of TAAA. The use of sac perfusion branches aims to reduce the incidence of this catastrophic complication. METHODS A retrospective analysis of all patients undergoing branched endovascular aortic repair for all thoraco-abdominal aneurysms (TAAA) using custom made devices during January 2008 to August 2014. We describe a two staged technique in which perfusion of segmental vessels is maintained by a temporary endoleak through an open perfusion branch, incorporated within the branched stent graft, followed by a closure of this branch at a later date to complete exclusion of the aneurysm. RESULTS Forty-seven patients underwent TAAA repair. Twenty-five (53%) had a two-stage procedure using either a sac perfusion branch or a target vessel to perfuse the sac. Nine patients (19.15%) suffered some form of SCI with eight patients having temporary SCI (lasting less than 72 hours) and one patient having permanent SCI. Of eight patients that had temporary spinal cord ischemia, all had a perfusion strategy. There was one case of permanent SCI (2.13%). CONCLUSION Sac perfusion branches provide a safe method for preventing SCI, however this needs to be used in conjunction with controlling MAP and CSF drainage.BACKGROUND Spinal cord ischemia (SCI) is one of the most feared complications following the repair of thoraco- abdominal aortic aneurysms (TAAA). Endovascular repair of TAAA is now possible with branched stent grafts, but spinal cord ischaemia rates are still unacceptably high. A number of techniques have been utilized to reduce these levels, however, SCI remains a challenge to endovascular repair of TAAA. The use of sac perfusion branches aims to reduce the incidence of this catastrophic complication. METHODS A retrospective analysis of all patients undergoing branched endovascular aortic repair for all thoraco-abdominal aneurysms (TAAA) using custom made devices during January 2008 to August 2014. We describe a two staged technique in which perfusion of segmental vessels is maintained by a temporary endoleak through an open perfusion branch, incorporated within the branched stent graft, followed by a closure of this branch at a later date to complete exclusion of the aneurysm. RESULTS Forty-seven patients underwent TAAA repair. Twenty-five (53%) had a two-stage procedure using either a sac perfusion branch or a target vessel to perfuse the sac. Nine patients (19.15%) suffered some form of SCI with eight patients having temporary SCI (lasting less than 72 hours) and one patient having permanent SCI. Of eight patients that had temporary spinal cord ischemia, all had a perfusion strategy. There was one case of permanent SCI (2.13%). CONCLUSION Sac perfusion branches provide a safe method for preventing SCI, however this needs to be used in conjunction with controlling MAP and CSF drainage.

Screening Programs for Abdominal Aortic Aneurysms: Luxury or Necessity?

Controversial Issues Regarding AAA Screening Programs As the authors mention, since January 1, 2007, provisions of the Screening Abdominal Aortic Aneurysm Very Efficiently Act in the United States have provided free, one-time, ultrasound AAA screening for qualified Medicare beneficiaries as part of their Welcome to Medicare examination. Men who have smoked at least 100 cigarettes during their life, as well as both men and women with a family history of AAA qualify. The UK Multicenter Aneurysm Screening Study (MASS) demonstrated that a one-time screening program for men leads to an incremental cost-effectiveness ratio of £7600 (roughly US

Late Branch-Related Complications and Management

10 500) per quality-adjusted life-year gained at 10 years. The long-term results of the MASS trial showed that 216 men need to be invited to screening to save 1 AAArelated death. Other studies have also reported favorable cost-effectiveness of offering AAA screening to men. Despite the lower prevalence of AAAs in women, screening women for AAAs may also be cost-effective because of the higher AAA rupture rate in women (and at smaller AAA diameters). A single screening ultrasound for AAA in asymptomatic men aged >65 years has been shown to be cost-effective in the United Kingdom and through Markov modeling. In the United Kingdom, the cost per life-year saved with screening men >50 years was US

Successful stent graft repair of multiple thoracoabdominal mycotic aortic aneurysms in the presence of Kommerell diverticulum and complicated by aortoesophageal fistula

1173, which is less than for breast, cervical, and colorectal cancer screening programs. Despite the robust data on the benefit of AAA screening programs and their cost-effectiveness, there is evidence that such screening programs are underutilized. Analysis of the Medicare data revealed that <10% of eligible patients undergo screening with abdominal ultrasonography. Extrapolating screening benefits from 2007 to 2012 through 2025 showed that an additional 291 000 life-years can be saved by 2025 (or 131 life-years per 1000 persons screened) if screening rates increased from the 2007 to 2012 (<10%) to 80% by the end of 2018. Despite this large body of evidence, others support that not only AAA screening programs are not beneficial but they also cause more harm than good. According to this interpretation, “for every 10,000 people invited to screening, 46 men avoid dying from a ruptured AAA. But for every avoided death, 4 men are diagnosed with an AAA that would never have been detected or caused health problems in their lifetime without screening; they have been overdiagnosed, which causes substantial physical and psychological harms for many of them”. Admittedly, this interpretation may apply to specific categories of patients, such as those who are frail, who have several comorbidities, and/or who are at high risk for surgery. In a recent report, 112 patients with AAA turned down for elective repair were followed up for a minimum of 2 years. Within 2 years, 64 (57.1%) of 112 had died. Of these, 30 of 64 had a recorded cause of death. Ruptured AAA was the cause of death in only 11 (36.7%) of 30 patients. In other words, the majority of this group of frail patients with an AAA who were turned down for elective repair because of their comorbidities did not die of a ruptured AAA, but as a result of their comorbidities. Another, independent study retrospectively analyzed 692 patients with AAA over a period of 20 years. Overall, 214

Commentary on 'The best conditions for parallel stenting during EVAR: an in vitro study'.

Current endovascular devices offer treatment options to patients with increasingly complex aortic diseases. EVAR is less invasive than open surgical repair, but it is not free of complications. These can potentially result in severe morbidity or even mortality, stressing the need for early detection and subsequent treatment. In this chapter, some of the most common branch-related complications are described. It is clear that thorough knowledge of the potential complications and appropriate treatment are mandatory to reduce morbidity or even mortality in this complex group of patients.

A Comparison of Accuracy of Image- versus Hardware-based Tracking Technologies in 3D Fusion in Aortic Endografting

We describe the management of a woman who presented with synchronous mycotic aortic aneurysms of the aortic arch in the presence of Kommerell diverticulum, the distal thoracic, and the juxtarenal aorta. A staged stent graft repair was undertaken due to rapid expansion of the aneurysms, which involved placement of multiple thoracic quadruple-fenestrated and infrarenal bifurcated stent grafts. Despite complications of an aortoesophageal fistula and transitory spinal cord ischemia, she has been managed successfully and is doing well at 36 months. This case illustrates that stent graft repair of mycotic aneurysms can offer a successful treatment option in selected patients.