Nelson Oliveira

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.

Leriche Syndrome in a Patient with Situs Inversus Totalis

Situs inversus is a rare congenital defect defined by a mirror image anatomic variation of the thoracic and abdominal organs. In this situation, abdominal aortic surgery may become particularly challenging. This is the case of a 51-year-old man, who presented with an incapacitating lower limb claudication. On his workup, a complete occlusion of the infrarenal aorta requiring surgical revascularization was found. Additionally, a situs inversus totalis was identified along with a single horseshoe kidney. The patient underwent uneventfully a surgical aortobifemoral interposition. The sole modification to the standard procedure regarded the graft limbs tunneling, which was performed in a prerenal pathway in the retroperitoneal space, thus avoiding iatrogenic injury to the anteriorly positioned iliac veins. Although challenging, conventional aortic surgery can be safely accomplished in patients with situs inversus totalis.

Sepsis-induced purpura fulminans caused by Pasteurella multocida.

A 52-year-old man was admitted with a cutaneous rash associated with septic shock and multiorganic failure, 6 days after a dog bite. He was started on empiric antibiotherapy and supportive measures. The patients condition aggravated, with need for invasive mechanical ventilation and intermittent haemodialysis, and evolution from a petechiae-like rash to purpura and gangrene, culminating in bilateral lower limb amputation. The blood cultures revealed only Pasteurella multocida, after 10 days of incubation. P multocida infection is a rare cause of soft tissue infection that subsides with oral antibiotherapy. Infections causing sepsis are rare and appear in immunocompromised patients. Purpura fulminans induced by sepsis is a rare, life-threatening disorder. This syndrome should be recognised promptly, so early treatment is instituted. We found no case reports of purpura fulminans caused by Pasteurella infections in our literature review.

Iliac artery pseudoaneurysm: a rare complication following allograft nephrectomy.

Our aim is to present a case of a common iliac artery pseudoaneurysm, which complicated an allograft nephrectomy. A 27-year-old woman presented with acute abdominal pain and a palpable pulsatile mass in the right iliac fossa, 1 year after a right pelvic allograft nephrectomy. An iliac pseudoaneurysm was suspected and confirmed on triplex ultrasound and CT angiography. The patient underwent a pseudoaneurysm resection with direct repair of the previous allograft Carrell patch suture dehiscence. The intervention and recovery were uneventful and after a follow-up of 6 months, the patient remains asymptomatic with no clinical or imaging recurrence of the pseudoaneurysm.Vascular complications following allograft nephrectomy are rare but may present significant morbidity and mortality. Endovascular exclusion is currently the preferred option for the management of pseudoaneurysms following allograft nephrectomy; however, open surgical approach remains an alternative for selected patients.

A primary arterial–ureteral fistula after an aortic-bifemoral bypass

INTRODUCTION Primary arterial-ureteral fistula is a rare and diagnostically challenging condition which may present with massive hematuria. PRESENTATION OF CASE A case of primary arterial-ureteral fistula (AUF) is presented in a patient with a previous prosthetic aortic-bifemoral bypass. The AUF treated with arterial and ureteral resection, arterial ligation and ureteral reconstruction. DISCUSSION Primary AUF are more frequently associated with aneurysmal degeneration of the arterial wall. The development of a primary fistula due to an iliac artery aneurysm many years after an aortic-bifemoral bypass performed due to atherosclerotic obstructive disease is a very unusual presentation of this entity. Multiple surgical strategies can be employed in achieving hemorrhage and infection control, urinary tract continuity, and vascular reconstruction. CONCLUSION A multidisciplinary approach and the achievement of a pre-operative diagnosis are essential for an effective management of this condition with prognostic implications.

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.

IF12. Standard EVAR for Aneurysms With Large Neck Diameter Results in Higher Risk of Type IA Endoleak and Rupture

and 29% vs 72% at 6 months. The primary patency rates of stent graft vs balloon groups at 3 months, 6 months, and 12 months were 91.7%, 83.2%, and 46.9% vs 65.3%, 27.8%, and 7.8%. The mean primary patency after treatment was 380.22 6 28.54 days for the stent graft group and 151.08 6 16.79 days for balloon group. Conclusions: Stent graft provides a better solution over plain balloon angioplasty on hemodialysis graft outlet stenosis treatment, with a lower postintervention restenosis rate and longer primary patency.

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