Javairiah Fatima

Fate of Aneurysmal Common Iliac Artery Landing Zones Used for Endovascular Aneurysm Repair

Purpose: To determine outcomes of aneurysmal common iliac arteries (aCIA) used for landing zones (LZs) during endovascular aneurysm repair (EVAR). Methods: This single-center study retrospectively compared 57 EVAR patients (mean age 72±8 years; 56 men) with 70 aCIAs (diameter ≥20 mm) to 25 control EVAR subjects (mean age 73±7 years; 20 men) with 50 normal (≤15-mm) CIA LZs treated consecutively during the same time interval. The CIA LZ measurements were analyzed using random effects linear mixed models to determine diameter change over time. Life tables were used to estimate freedom from endoleak, reintervention, and all-cause mortality. Results: The mean maximum preoperative CIA diameter in the aCIA LZ group was 24.8±4.5 mm (range 20.0–47.3, median 23.9) vs 13.6±1.5 mm (range 9.2–15.0, median 13.9; p<0.001) in the controls. Nineteen aCIA LZs were treated outside the instructions for use of the device. Median follow-up in the aCIAs LZ cohort was 39.2 months [interquartile range (IQR) 15, 61] vs 49.3 months (IQR 36, 61) in the controls (p=0.06). The rate of aCIA LZ change (0.09 mm/mo, 95% CI 0.07 to 0.1) was significantly greater than controls (0.03 mm/mo, 95% CI −0.009 to 0.07; p<0.0001). No type Ib endoleaks developed in either group; however, aCIA LZ patients had 6 (11%) iliac limb–related reinterventions. There were significantly more endograft-related reinterventions in the aCIA LZ patients (n=10, 14%) compared with controls (n=2, 4%; p=0.06). There was no difference in mortality or freedom from any post–hospital discharge endoleak. Conclusion: Aneurysmal CIA LZs used during EVAR experience greater dilatation compared with normal LZs, but no significant difference in outcome was noted in midterm follow-up. However, an increased incidence of graft limb complications or endograft-related reintervention may be encountered. Use of aCIA LZs appears to be safe; however, greater patient numbers and longer follow-up are needed to understand the clinical implications of morphologic changes in these vessels when used during EVAR.

Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients

Background: Aortic arch disease is a challenging clinical problem, especially in high‐risk patients, in whom open repair can have morbidity and mortality rates of 30% to 40% and 2% to 20%, respectively. Aortic arch chimney (AAC) stents used during thoracic endovascular aortic repair (TEVAR) are a less invasive treatment strategy than open repair, but the current literature is inconclusive about the role of this technology. The focus of this analysis is on our experience with TEVAR and AAC stents. Methods: All TEVAR procedures performed from 2002 to 2015 were reviewed to identify those with AAC stents. Primary end points were technical success and 30‐day and 1‐year mortality. Secondary end points included complications, reintervention, and endoleak. Technical success was defined as a patients surviving the index operation with deployment of the AAC stent at the intended treatment zone with no evidence of type I or type III endoleak on initial postoperative imaging. The Kaplan‐Meier method was used to estimate survival. Results: Twenty‐seven patients (age, 69 ± 12 years; male, 70%) were identified, and all were described as being at prohibitive risk for open repair by the treating team. Relevant comorbidity rates were as follows: coronary artery disease/myocardial infarction, 59%; oxygen‐dependent emphysema, 30%; preoperative creatinine concentration >1.8 mg/dL, 19%; and congestive heart failure, 15%. Presentations included elective (67%; n = 18), symptomatic (26%; n = 7), and ruptured (7%; n = 2). Eleven patients (41%) had prior endovascular or open arch/descending thoracic repair. Indications were degenerative aneurysm (49%), chronic residual type A dissection with aneurysm (15%), type Ia endoleak after TEVAR (11%), postsurgical pseudoaneurysm (11%), penetrating ulcer (7%), and acute type B dissection (7%). Thirty‐two brachiocephalic vessels were treated: innominate (n = 7), left common carotid artery (LCCA; n = 24), and left subclavian artery (n = 1). Five patients (19%) had simultaneous innominate‐LCCA chimneys. Brachiocephalic chimney stents were planned in 75% (n = 24), with the remainder placed for either LCCA or innominate artery encroachment (n = 8). Overall technical success was 89% (one intraoperative death, two persistent type Ia endoleaks in follow‐up). The 30‐day mortality was 4% (n = 1; intraoperative death of a patient with a ruptured arch aneurysm), and median length of stay was 6 (interquartile range, 4‐9) days. Seven (26%) patients experienced a major complication (stroke, three [all with unplanned brachiocephalic chimney]; respiratory failure, three; and death, one). Nine (33%) patients underwent aorta‐related reintervention, and no chimney occlusion events occurred during follow‐up (median follow‐up, 9 [interquartile range, 1‐23] months). The 1‐year and 3‐year survival is estimated to be 88% ± 6% and 69% ± 9%, respectively. Conclusions: TEVAR with AAC can be performed with high technical success and acceptable morbidity and mortality in high‐risk patients. Unplanned AAC placement during TEVAR results in an elevated stroke risk, which may be related to the branch vessel coverage necessitating AAC placement. Acceptable midterm survival can be anticipated, but aorta‐related reintervention is not uncommon, and diligent follow‐up is needed.

Implications of Secondary Aortic Intervention After Thoracic Endovascular Aortic Repair for Acute and Chronic Type B Dissection

interval, 1.8-17.8; P 1⁄4 .002) were independent predictors for the development of neurologic impairment. An interaction term between cLEIT and CIA lumen of 8 mm or less was significant statistically (P 1⁄4 .042), indicating that the presence of small CIA lumen modifies the effect of cLEIT. As shown in the Fig, in patients with CIA lumen of 8 mm or less, the risk of neurologic impairment increases rapidly after 2.5 hours of LE ischemia and becomes nearly certain after 4 hours of ischemia time. In contrast, patients with a larger CIA can tolerate a longer duration of ischemia and demonstrate a less steep rise in the risk for LE neurologic impairment. Conclusions: LE neurologic impairment after FEVAR is strongly associated with cLEIT and patent CIA lumen of 8 mm or less. Our data indicate that when cLEIT is expected to exceed 2.5 hours (in patients with small CIA) or 3 hours (in patients with CIA lumen >8 mm), measures to ensure perfusion of LEs should be undertaken.

Outcomes of antegrade and retrograde open mesenteric bypass for acute mesenteric ischemia

Background: Acute mesenteric ischemia (AMI) is a challenging clinical problem associated with significant morbidity and mortality. Few contemporary reports focus specifically on patients undergoing open mesenteric bypass (OMB) or delineate outcome differences based on bypass configuration. This is notable, because there is a subset of patients who are poor candidates for endovascular intervention including those with flush mesenteric vessel occlusion, long segment occlusive disease, and a thrombosed mesenteric stent and/or bypass. This analysis reviewed our experience with OMB in the treatment of AMI and compared outcomes between patients undergoing either antegrade or retrograde bypass. Methods: A single‐center, retrospective review was performed to identify all patients who underwent OMB for AMI from 2002 to 2016. A preoperative history of mesenteric revascularization, demographics, comorbidities, operative details, and outcomes were abstracted. The primary end point was in‐hospital mortality. Secondary end points included complications, reintervention, and overall survival. Kaplan‐Meier estimation and Cox proportional hazards regression were used to analyze all end points. Results: Eighty‐two patients (female 54%; age 63 ± 12 years) underwent aortomesenteric bypass (aortoceliac/superior mesenteric, n = 44; aortomesenteric, n = 38) for AMI. A history of prior stent/bypass was present in 20% (n = 16). A majority (76%; n = 62) underwent antegrade bypass and the remainder received retrograde infrarenal aortoiliac inflow. Patients receiving antegrade OMB were more likely to be male (53% vs 25%; P = .02), have coronary artery disease (48% vs 25%; P = .06), chronic obstructive pulmonary disease (52% vs 25%; P = .03), and peripheral arterial disease (60% vs 35%; P = .05). Concurrent bowel resection was evenly distributed (antegrade, 45%; retrograde, 45%; P = .9) and 37% (n = 30) underwent subsequent resection during second look operations. The median duration of stay was 16 days (interquartile range, 9‐35 days) and 78% (n = 64) experienced at least one major complication with no difference in rates between antegrade/retrograde configurations. In‐hospital mortality was 37% (n = 30; multiple organ dysfunction, 22; bowel infarction, 4; hemorrhage/anemia, 2; arrhythmia, 1; stroke, 1; 30‐day mortality, 26%). The median follow‐up was 8 months (interquartile range, 1‐26 months). The 1‐ and 3‐year primary patency rates were both 82% ± 6% (95% confidence interval, 71%‐95%), with 10 patients requiring reintervention. Estimated survival at 1 and 5 years was 57% ± 6% and 50% ± 6%, respectively. Bypass configuration was not associated with complication rates (P > .10), in‐hospital mortality (log‐rank, P = .3), or overall survival (log‐rank, P = .9). However, a higher risk of reintervention was observed in patients undergoing retrograde bypass (hazard ratio, 3.0; 95% confidence interval, 0.9‐11.0; P = .08). Conclusions: OMB for AMI results in significant morbidity and mortality, irrespective of bypass configuration. Antegrade OMB is associated with comparable outcomes as retrograde OMB. The bypass configuration choice should be predicated on patient presentation, anatomy, physiology, and surgeon preference; however, an antegrade configuration may provide a lower risk of reintervention.

Technical Aspects and Results of Hybrid Iliac Revascularization

Hybrid iliac revascularization combines endovascular aortoiliac repair with extra-anatomic construction of the internal iliac artery, with or without replacement of the external iliac artery. The procedure may be indicated in patients with unilateral or bilateral common iliac artery aneurysms who are not candidates for total endovascular repair or when the external iliac artery segment is too small to take even a 16Fr sheath, which is the minimal profile for current iliac branch devices. Iliac revascularization is typically done using a flank retroperitoneal approach. There is paucity of data in the literature on results of this technique, which seems to add some morbidity and prolonged recovery compared to standard EVAR done using trans-femoral access. Nonetheless, hybrid iliac revascularization should be in the armamentarium of surgeons performing complex aortic repair. This chapter summarizes some of the technical aspects and results of hybrid iliac repair.

PC014 Challenging Iliac Anatomy in Fenestrated Endovascular Aortic Aneurysm Repair

occurring in the province of Ontario from 2005 to 2014. Surgeon annual volume was classified by quintiles, with the highest annual volume acting as the reference category for the analysis. Multivariable logistic regression modeling was used, adjusting for patient factors (age, sex, comorbidities, year of procedure, income), surgeon years of experience and clustering amongst institutions, to investigate the relationship between surgeon annual volume and 30-day mortality, 30-day complications (myocardial infarction, stroke, hemorrhage, infection, pneumonia, deep vein thrombosis/pulmonary embolism, acute renal failure), 30-day reoperations (related to index procedure), 1-year mortality, and 1-year reoperations. The potential effects of annual surgeon composite volume and surgeon years of experience on postoperative outcomes were also explored. Results: A total of 7211 elective open AAA repairs performed by 101 surgeons were included. Most of the operations were performed by vascular surgeons (81.5%), followed by cardiac (12.1%) and general surgeons (6.1%). Median number of procedures in the low quintile group was three repairs per year, while the very high quintile group performed 54 repairs per year. Overall 30-day mortality was 3%, with no effect of surgeon volume when comparing lowest volume to highest volume quintiles (P 1⁄4 .21). The lowest volume group exhibited a higher 30-day complication rate (28.0% vs 20.4%; odds ratio, 1.54; 95% confidence interval, 1.15-2.06) and 30-day reoperation rate (10.53% vs 6.73%; odds ratio, 1.63; 95% confidence interval, 1.18-2.26) when compared to the highest volume group. No effect of surgeon volume on 1-year mortality, or 1-year reoperation was observed. Similarly, composite volume and surgeon years of experience did not significantly impact postoperative mortality. Conclusions: Higher surgeon annual volume resulted in lower postoperative complication and reoperation rates, while having no effect on postoperative mortality. Surgeon years of experience did not influence outcomes suggesting that annual volume is more important than surgeon seniority in dictating outcomes after elective open AAA repair.