John K. Karwowski

Midterm outcomes after treatment of type II endoleaks associated with aneurysm sac expansion

Purpose To examine the outcomes following interventions for type II endoleaks in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR). Methods A retrospective review was conducted of all patients who underwent treatment for type II endoleak from July 2001 to September 2010 in a single center. In this time period, 29 (4.7%) patients (22 men; mean age 78.6 years, range 54–87) were identified as having a type II endoleak and enlargement of the aneurysm sac, meeting the criterion for treatment. All patients had at least one attempted percutaneous intervention. Patients were followed both clinically and radiographically, with computed tomographic angiography every 3 to 12 months, over a follow-up period that ranged from 1 to 10 years (mean 3.5). Results Forty-eight interventions were performed on the 29 patients. Of these, 15 (56%) patients underwent multiple (2–4) procedures. Of the 11 endoleaks with an isolated inferior mesenteric artery identified as the source, initial success for transarterial embolization at 2 years was 72%, with 2 of the failures having successful secondary interventions. For the 18 endoleaks with a lumbar source, the success of the initial intervention was 17% at 2 years; repeated embolization attempts produced a 40% secondary success rate. Seven (24%) patients had continued endoleak despite multiple treatment attempts; 3 ultimately required elective aortic graft explantation. There were no ruptures or deaths during the study period. In a comparison of type II endoleak patients who had stable aneurysm sacs and those who had persistent sac expansion, the only significant differences in preoperative anatomical characteristics were a lower prevalence of mural thrombus (p=0.036) and longer right iliac arteries (p=0.012) in the group with sac expansion. Independent predictors of type II endoleak were mural thrombus (p<0.001), patent lumbar arteries (p=0.004), aneurysm length (p=0.011), and iliac artery length (p=0.004) Conclusion This study demonstrates that most patients require multiple reinterventions to treat type II endoleaks; specifically, lumbar artery embolization carries a low midterm success rate.

Endovascular aneurysm repair in nonagenarians is safe and effective

OBJECTIVESnAdvanced age is a significant risk factor that has traditionally steered patients away from open aneurysm repair and toward expectant management. Today, however, the reduced morbidity and mortality of aortic stent grafting has created a new opportunity for aneurysm repair in patients previously considered too high a risk for open surgery. Here we report our experience with endovascular aneurysm repair (EVAR) in nonagenarians.nnnMETHODSnRetrospective chart review identified all patients>90-years-old undergoing EVAR over a 9-year period at our institution. Collected data included preoperative comorbidities, perioperative complications, endoleaks, reinterventions, and long-term survival.nnnRESULTSn24 patients underwent EVAR. The mean age was 91.5 years (range 90-94) among 15 (63%) males and 9 (37%) females. Mean abdominal aortic aneurysm diameter was 6.3±1.1 cm. Eight patients (33%) were symptomatic (pain or tenderness). There were no ruptures. Fourteen patients (58%) had general anesthesia while 10 (42%) had local or regional anesthesia. Mean postoperative length of stay was 3.2±2.4 days (2.8±1.9 days for asymptomatic vs 4.1±3.2 days for symptomatic, P=.29). There was one perioperative mortality (4.2%). There were two local groin seromas (8.3%) and six systemic complications (25%). One patient required reintervention for endoleak (4.2%). There were no aneurysm related deaths beyond the 30-day postoperative period. Mean survival beyond 30 days was 29.7±18.0 months for patients expiring during follow-up. Cumulative estimated 12, 24, and 36-month survival rates were 83%, 64%, and 50%, respectively. Linear regression analysis demonstrated an inverse relationship between the number of preoperative comorbidities and postoperative survival in our cohort (R2=0.701), with significantly decreased survival noted for patients presenting with >5 comorbidities. Those still alive in follow-up have a mean survival of 36.1±16.0 months.nnnCONCLUSIONnThis is the largest reported EVAR series in nonagenarians. Despite their advanced age, these patients benefit from EVAR with low morbidity, low mortality, and mean survival exceeding 2.4 years. Survival appears best in those patients with ≤5 comorbidities. With or without symptoms, patients over the age of 90 should be considered for EVAR.

An interdisciplinary approach to the prevention and treatment of groin wound complications after lower extremity revascularization.

BACKGROUNDnIf not effectively treated, groin wound infections following lower extremity revascularization (LER) may result in graft or limb loss.nnnMETHODSnA retrospective review was performed of all patients who underwent muscle flap transposition by a single surgeon after LER between 2006 and 2010.nnnRESULTSnTwenty-nine muscle transposition flaps were performed in 24 patients (21 sartorius, 6 rectus femoris, and 2 gracilis). Nineteen were for treatment of groin wound infections, two for treatment of lymphocele, one for coverage of exposed graft in the setting of pyoderma gangrenosum, and seven for infection prophylaxis. Two graft losses followed flap placement. The limb loss rate was 4%. When performed for therapeutic purposes, graft salvage rates were 100% for autogenous and 92% for synthetic grafts.nnnCONCLUSIONSnMuscle transposition flaps are an effective means of graft salvage in the setting of groin wound complications following LER and should be considered for infection prophylaxis in high-risk patients.