Marie Josee Van Rijn

Standard endovascular aneurysm repair in patients with wide infrarenal aneurysm necks is associated with increased risk of adverse events

Objective: Endovascular aneurysm repair (EVAR) has progressively expanded to treat more challenging anatomies. Although EVAR in patients with wide infrarenal necks has been reported with acceptable results, there is still controversy regarding the longer‐term outcomes. Our aim is to determine the impact of infrarenal neck diameter on midterm outcome following EVAR with a single endograft with suprarenal fixation. Methods: A retrospective case‐control study was designed using data from a prospective multicenter database. Patients who electively underwent standard EVAR with an Endurant stent graft (Medtronic Ave, Santa Rosa, Calif) for a degenerative abdominal aortic aneurysm from January 2008 to December 2012 in three high‐volume centers in The Netherlands were included. All measurements were obtained using dedicated reconstruction software and center‐lumen line reconstruction. Patients with an infrarenal neck diameter of ≥30 mm were compared with patients with a neck diameter of <30 mm. The primary end point was freedom from neck‐related adverse events (a composite of type Ia endoleak, neck‐related secondary intervention, and endograft migration). Secondary end points were primary clinical success, type Ia endoleak, neck‐related reinterventions, endoleaks, and aneurysm‐related secondary interventions. Results: Four‐hundred twenty‐seven patients were included. Seventy‐four patients (17.3%) with a neck diameter of ≥30 mm were compared with a control group of 353 patients. There were no significant differences at baseline between groups including demographics, comorbidities, baseline aneurysm diameter, infrarenal neck length, suprarenal angulation, or infrarenal neck angulation. Median stent graft oversizing was 12.5% (7.9‐16.1) and 16.6% (12.0‐23.1) in the ≥30‐mm neck‐diameter and control groups, respectively (P < .001). Median follow‐up was 3.1 years (1.2‐4.7) and 4.1 years (2.7‐5.6) for the large neck and control groups, respectively (P < .001). Type Ia endoleaks occurred in 17 patients (4.0%) and were significantly more frequent in patients with ≥30‐mm neck diameter (9.5% vs 2.8%; P = .005). Neck‐related secondary interventions were performed in 20 patients (4.7%) and were also more common among patients with neck diameters of ≥30 mm (9.5% vs 3.7%; P = .04). The 4‐year freedom from neck‐related adverse events were 75% and 95% for the large neck and control groups, respectively (P < .001). On multivariable regression analysis, infrarenal neck diameter of ≥30 mm was an independent risk factor for neck‐related adverse events (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.6‐9.1), type Ia endoleak (OR, 2.7; 95% CI, 1.0‐8.3), and neck‐related secondary interventions (OR, 3.2, 95% CI, 1.1‐9.2). Conclusions: EVAR in patients with large diameter necks is associated with an increased risk of neck‐related adverse events in midterm follow‐up. This may influence the clinical decision regarding choice of repair and toward a more intensive surveillance following EVAR in these patients in the long term.

Midterm results of the fenestrated Anaconda endograft for short-neck infrarenal and juxtarenal abdominal aortic aneurysm repair

Objective: The fenestrated Anaconda endograft (Vascutek, Renfrewshire, Scotland) was introduced in 2010 and showed promising short‐term results with high technical success and low morbidity rates. The aim of this study was to present the midterm results, with a minimum of 12 months follow‐up, for all patients treated with the fenestrated Anaconda endograft in The Netherlands. Methods: Patients treated with the fenestrated Anaconda endograft between May 2011 and February 2015 were included. Follow‐up consisted of computed tomography angiography at 1 month and 1 year, and duplex ultrasound yearly thereafter with additional computed tomography angiography if indicated using a standard protocol. Results: A total of 60 patients were included; 48 patients (80.0%) were treated for juxtarenal aneurysms, and 12 (20.0%) were short‐neck infrarenal aneurysms. Mean aneurysm size was 64 ± 9 mm. A total of 140 fenestrations were incorporated. Median follow‐up was 16.4 months (interquartile range, 11.9‐27.4). The 30‐day mortality was 3.4% (n = 2). Kaplan‐Meier estimates for 1‐year, 2‐year, and 3‐year survival were 91.4%, 89.5%, and 86.3%, respectively, without aneurysm‐related mortality during follow‐up. Main body primary and secondary endograft patencies were 98.3% and 100%, respectively. Target vessel primary and secondary patencies were 95.0% and 98.6%, respectively. Early type IA endoleaks occurred in seven patients (11.7%) and spontaneously resolved in all patients. At 1‐year follow‐up 4 (6.7%) type II endoleaks persisted. One patient experienced aneurysm rupture because of a late type III endoleak attributable to a dislodged renal stent and subsequently underwent successful conversion to open surgery. Conclusions: The fenestrated Anaconda is a viable treatment option for complex abdominal aortic aneurysms. Acceptable mortality and morbidity and low reintervention rates contribute to good midterm results. Occurrence of early type I endoleak was relatively common, but these resolved spontaneously in all patients.

PC014. Comparison of Long-term Results for the Endurant and Excluder Stent Graft

Objectives: Because endovascular aneurysm repair has become a predominant alternative, it has a high profile how to train young vascular surgeons in open surgery. The objective was to analyze the learning curve and determine the number needed to treat to establish sufficient surgical skills of open surgery for intact abdominal aortic aneurysm. Methods: This was a retrospective study of a prospectively accumulated database at Asahi General Hospital in Japan between 2003 and 2017. A total of 562 consecutive patients who underwent open repair for intact abdominal aortic aneurysm or iliac artery aneurysms either by an attending surgeon or by six young vascular surgeons (>20 experiences) were included. All young vascular surgeons had accomplished general surgery training. Analysis was conducted by every 10-cases experience performed by young vascular surgeons (Y group) to investigate the learning

Long-term outcomes of standard endovascular aneurysm repair in patients with severe neck angulation

Objective: Severe neck angulation is associated with complications after endovascular aneurysm repair (EVAR). Newer endografts may overcome this limitation, but the literature lacks long‐term results. We studied the long‐term outcomes of EVAR in patients with severe neck angulation. Methods: A retrospective case‐control study of a prospective multicenter database was performed. All measurements were made with dedicated software with center lumen line reconstruction. A study group including patients with neck length >15 mm, infrarenal angle (&bgr;) >75 degrees or suprarenal angle (&agr;) >60 degrees, and neck length 10 to 15 mm with &bgr; >60 degrees or &agr; >45 degrees was compared with a control group matched for demographics and other morphologic neck features. The primary end point was type IA endoleak (EL1A). Secondary end points were freedom from neck‐related secondary interventions, primary clinical success, and overall survival. Results: Forty‐five patients were included in the angulated neck group and compared with 65 matched patients. Median follow‐up was 7.4 years (interquartile range, 4.8‐8.5 years). In the angulated neck group, mean &agr; was 51.4 degrees (±21.1 degrees) and the mean &bgr; was 80.8 degrees (±15.6 degrees); in the nonangulated group, these were 17.9 degrees (±17.0 degrees) and 35.4 degrees (±20.0 degrees), respectively. At 7 years, five patients in the angulated neck group and two nonangulated patients developed EL1A, yielding a freedom from EL1A of 86.1% (n = 14; standard error [SE], 0.069) and 96.6% (n = 34; SE, 0.023), respectively (P = .056). After exclusion of a patient who developed an EL1A secondary to an endograft infection, this difference was significant: 86.1% (n = 14; SE, 0.069) in the angulated neck group and 98.2% (n = 34; SE, 0.018) in the nonangulated group (P = .016). At 7 years, freedom from neck‐related secondary interventions was 91.7% (n = 14; SE, 0.059) and 91.6% (n = 29; SE, 0.029), respectively. The 7‐year primary clinical success estimates were 41.2% (n = 11; SE, 0.085) and 56.6% (n = 20; SE, 0.072) for the angulated neck and nonangulated groups, respectively (P = .12). The 7‐year survival rates were 44.3% (n = 18; SE, 0.076) vs 66.7% (n = 42; SE, 0.059) for the angulated neck and nonangulated groups, respectively (P = .25). Device integrity failure was not observed. Conclusions: Despite satisfactory results early and in the midterm, a higher rate of EL1A was identified among patients with severely angulated necks in the long term. However, mortality was not affected by this difference. These findings suggest that EVAR should be used judiciously in patients with extreme angulation of the proximal neck and highlight the need for close follow‐up of EVAR, especially in the long term and in patients treated outside instructions for use.

Patients with large neck diameter have a higher risk of type IA endoleaks and aneurysm rupture after standard endovascular aneurysm repair

Objective Standard endovascular aneurysm repair (EVAR) is the most common treatment of abdominal aortic aneurysms (AAAs). EVAR has been increasingly used in patients with hostile neck features. This study investigated the outcomes of EVAR in patients with neck diameters ≥30 mm in the prospectively maintained Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE). Methods This is a retrospective study comparing patients with neck diameters ≥30 mm with patients with neck diameters <30 mm. The primary end point was type IA endoleak (EL1A). Secondary end points included secondary interventions to correct EL1A, aneurysm rupture, and survival. Results This study included 1257 patients (mean age, 73.1 years; 89.4% male) observed for a median 4.0 years (interquartile range, 2.7‐4.8 years). A total of 97 (7.7%) patients had infrarenal neck diameters ≥30 mm and were compared with the remaining 1160 (92.3%) with neck diameters <30 mm. At baseline, there were no differences between groups regarding demographics and comorbidities other than cardiac disease, which was more frequent in the ≥30‐mm neck diameter group (P = .037). There were no significant differences between the groups regarding neck length, angulation, thrombus, or calcification. Mean preoperative AAA diameter was 64.6 ± 11.3 mm in the ≥30‐mm neck diameter group and 60.0 ± 11.6 mm in the <30‐mm neck diameter group (P < .001). Stent graft oversizing was significantly less in the ≥30‐mm neck diameter group (12.2% ± 8.9% vs 22.1% ± 11.9%; P <. 001). Five patients (5.2%) in the ≥30‐mm neck diameter group and 30 (2.6%) with neck diameters <30 mm developed EL1A, yielding a 4‐year freedom from EL1A of 92.4% vs 96.6%, respectively (P = .09). Oversizing was 21.8% ± 13.0% for patients developing EL1A and 21.3% ± 12.4% for the remaining cohort (P = .99). In adjusting for neck length, AAA diameter, and device oversizing, patients with neck diameter ≥30 mm were at greater risk for development of EL1A (hazard ratio, 3.0; 95% confidence interval, 1.0‐9.3; P = .05). Secondary interventions due to EL1A did not differ between groups (P = .36). AAA rupture occurred in three patients with neck diameter ≥30 mm (3.1%) and in eight patients with neck diameter <30 mm (0.7%; hazard ratio, 5.1; 95% confidence interval, 1.4‐19.2; P = .016); two cases were EL1A related in each group. At 4 years, overall survival was 61.6% for the ≥30‐mm neck diameter group and 75.2% for the <30‐mm neck diameter group (P = .009), which remained significant on correcting for sex and AAA diameter (P = .016). Conclusions In this study, patients with infrarenal neck diameter ≥30 mm had a threefold increased risk of EL1A and fivefold risk of aneurysm rupture after EVAR as well as worse overall survival. This may influence the choice of AAA repair and underlines the need for regular computed tomography‐based imaging surveillance in this subset of patients. Furthermore, these results can serve as standards with which new, possibly improved technology, such as EndoAnchors (Medtronic, Santa Rosa, Calif), can be compared.

Unexplained rupture after endovascular aneurysm repair

We present a case of a 70-year-old man who was admitted with rupture of an abdominal aneurysm 4 years after endovascular aneurysm repair. He was compliant with yearly follow-up computed tomography angiography. One month earlier, his computed tomography angiogram showed perfect exclusion of the aneurysm and no endoleak. We explanted the stent graft and confirmed effective sealing, and the graft was intact. We found no signs of infection during 2 years of follow-up. This rupture is nonpredictable and unexplained and illustrates that unremarkable imaging does not guarantee prevention of rupture. This case shows that the ultimate failure of endovascular aneurysm repair cannot be prevented despite surveillance protocols.

FT07. Anatomical Predictors of Long-Term Mortality After Standard EVAR

AAA, Abdominal aortic aneurysm; CI, confidence interval; eGFR, estimated glomerular filtration rate; HR, hazard ratio. Anatomical Predictors of Long-Term Mortality After Standard EVAR Nelson F. G. Oliveira, MD, Frederico Bastos-Gonçalves, MD, Marie Josee Van Rijn, MD, José Oliveira-Pinto, MD, Frans Moll, MD, Sander Ten Raa, MD, Sanne Hoeks, MD, Hence Verhagen, MD. Hospital do Divino Espírito Santo, Ponta Delgada, Portugal; Hospital de Santa Marta, Libson, Portugal; Erasmus University Medical Center, Rotterdam, The Netherlands; University Medical Center, Utrecht, The Netherlands