Nikolaos Galanakis

Totally Percutaneous Endovascular Aneurysm Repair Using the Preclosing Technique: Towards the Least Invasive Therapeutic Alternative.

Endovascular aneurysm repair (EVAR) offers a minimally invasive approach for the treatment of abdominal aortic aneurysms, whereas arterial closure devices have made totally percutaneous EVAR feasible. This is a retrospective analysis of patients undergoing EVAR in a single institution, between May 2011 and October 2014 using surgical or percutaneous access. Hemostasis after percutaneous access was achieved with 2 Perclose ProGlide suture-mediated devices and a preclosing technique. Technical success, local complications, procedural times, length of hospitalization, and need for analgesics are recorded and compared between groups. Among 82 patients/164 groins, 120/164 (73%) groins underwent percutaneous and 44/146 (27%) surgical access. An average 2.2 devices per access site was used. Technical success was 95% (114/120). Local complications (3.3% vs. 11.4%, P=0.05), procedural times (90 vs. 112 min, P=0.05), hospitalization (2 vs. 5 d, P<0.001), and postoperative analgesics (0.7 vs. 4.4 g IV paracetamol, P=0.01) were significantly reduced after percutaneous access which overall seems safe and effective to perform EVAR.

Embolization or Simple Coverage to Exclude the Internal Iliac Artery During Endovascular Repair of Aortoiliac Aneurysms? Systematic Review and Meta-analysis of Comparative Studies

Purpose: To compare results of simple coverage vs preemptive embolization to exclude the internal iliac artery (IIA) during endovascular repair of aortoiliac aneurysms. Methods: A systematic review of the literature was conducted by searching MEDLINE, CENTRAL, and OpenGray databases until March 2016. Primary outcome measures were safety and efficacy of the 2 strategies. Safety was determined by 30-day mortality and the minor and major complication rates. Efficacy was determined by absence of endoleak from the target IIA. Secondary outcomes of any endoleak, reintervention, operative time, fluoroscopy time, blood loss, contrast volume, and length of hospitalization were also examined. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI). Forest plots and inconsistency (I2) statistics were used to evaluate the heterogeneity of the included studies. Results: Eight observational studies were included in the analysis. Overall, 284 and 255 subjects underwent IIA coverage or embolization, respectively. IIA coverage resulted in a significantly lower major complication rate (6% vs 29%; OR 2.97, 95% CI 1.46 to 6.04, p=0.003; I2=0%) and shorter hospitalization (MD 0.48 days, 95% CI 0.08 to 0.89, p=0.02; I2=0%), while differences in all other outcomes were not statistically significant. Conclusion: In the presence of limited data, available evidence suggests that simple coverage of the IIA may result in significantly fewer major complications compared to preemptive embolization; at the same time, the rates of endoleaks and/or reinterventions are similar between groups.

Improvement of Patient Eligibility with the Use of New Generation Endografts for the Treatment of Abdominal Aortic Aneurysms. A Comparison Study among Currently Used Endografts and literature review.

ABSTRACT Background: Newer generation devices have attempted to accommodate a wider range of aortoiliac anatomies offering endovascular aneurysm repair (EVAR) to more patients with abdominal aortic aneurysms (AAAs). We aim to examine the anatomic suitability for the ultra-low profile Ovation endograft in our AAA patients and to compare them with other contemporary devices. Methods: 158 consecutive AAA patients treated with EVAR or open surgical repair (OSR) were tested for EVAR eligibility according to the most commonly used endografts’ instructions for use. Results: 106 patients underwent EVAR and 52 OSR. EVAR eligibility was higher for the Ovation system (72%) compared to the rest of the devices (Incraft: 63%, Nellix: 60%, Endurant-II: 59%, Excluder: 55%, Zenith-Flex: 36%, Aorfix: 35%, P-value<0.001). Non-suitable proximal neck anatomy followed by access vessel inadequacy were the primary reasons for ineligibility. Conclusion: New generation aortic endografts with innovative proximal sealing mechanisms and ultra-low profile delivery systems are increasing patient eligibility for EVAR.

The role of endovascular therapy in acute mesenteric ischemia

Background Endovascular therapy, including aspiration thrombectomy and local thrombolytic therapy, often associated with angioplasty and stent placement, has been described in the literature. The purpose of this study was to review case series of patients with acute mesenteric ischemia treated with endovascular therapy and evaluate their outcomes. Methods An online review using PubMed was carried out to identify all English articles about this topic in the time interval from 2005 to 2016. The following variables were extracted number of patients, cause of occlusion, symptoms, arteries involved, number of sessions of treatment, technical success, clinical success, recurrence rate, complications, mortality rate, number of patients who underwent diagnostic laparoscopy or surgical resection of ischemic bowel. Results Eighteen papers met the inclusion criteria and were included. Among the patients with arterial mesenteric ischemia treated with endovascular approach, the technical success rate was high (up to 100%) and data regarding clinical success are encouraging, even though they are few and heterogeneous. Technical success rate and clinical success of patients with acute venous mesenteric ischemia approached with endovascular treatment was 74-100% and 87.5-100% respectively. Conclusions Current advances in endovascular therapies have made these treatments feasible for mesenteric ischemia.

Transcatheter arterial chemoembolization combined with radiofrequency or microwave ablation for hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is the sixth most common type of malignancy. Several therapies are available for HCC and are determined by stage of presentation, patient clinical status and liver function. Local–regional treatment options, including transcatheter arterial chemoembolization, radiofrequency ablation or microwave ablation, are safe and effective for HCC but are accompanied by limitations. The synergistic effects of combined transcatheter arterial chemoembolization and radiofrequency ablation/microwave ablation may overcome these limitations and improve the therapeutic outcome. The purpose of this article is to review the current literature on these combined therapies and examine their efficacy, safety and influence on the overall and recurrence-free survival in patients with HCC.

Spontaneous Type Ia Endoleak Sealing in Patients Undergoing Endovascular Aneurysm Repair With the Ovation Stent Graft

BACKGROUND Type Ia endoleak may lead to continuous sac pressurization and late rupture after endovascular aneurysm repair (EVAR). Nevertheless, there have been scarce reports suggesting that these endoleaks may occasionally present spontaneous sealing. Taking into account the original sealing mechanism of the Ovation endograft that exploits 2 polymer-filled O-rings, we hypothesize that spontaneous type Ia endoleak sealing may sometimes incur following implantation of this device. We aim to report our experience with spontaneous type Ia endoleak sealing in patients treated with the Ovation endograft. METHODS This is a retrospective observational study which included all patients undergoing EVAR with the Ovation endograft in a single institution during a 6-year period. Patients with an intraoperative type Ia endoleak were identified. The primary endpoint was rate of spontaneous sealing. Secondary endpoints were migration, sac expansion, need for reinterventions, secondary type Ia endoleaks, and aneurysm-related and overall mortality. Adherence to the instructions for use (IFU) was evaluated to examine relation with occurrence of endoleak and rates of spontaneous sealing. RESULTS Among 147 patients treated, 8 (5%) left the operation theater with a type Ia endoleak. In 6 patients, the endoleak spontaneously resolved during a maximum of 3 months of follow-up. Among those, 5 cases were treated outside the IFU (2 short necks and 3 with severe angulation), while the sixth was a patient treated inside the IFU but was anticoagulated. In 2 patients, the endoleak did not spontaneously resolve. One presented a conical neck of marginal length and the other circumferential calcifications. Type Ia endoleak was significantly more common among patients treated in an off-label fashion. CONCLUSIONS Spontaneous sealing of type Ia endoleak is common after EVAR with the Ovation endograft. Nonadherence to the IFU results in more endoleaks, but it does not seem to reduce possibilities for spontaneous sealing.

Has Anatomic Complexity of Abdominal Aortic Aneurysms Undergoing Open Surgical Repair Changed after the Introduction of Endovascular Treatment? Systematic Review and Meta-analysis of Comparative Studies

BACKGROUND At a time when endovascular aneurysm repair (EVAR) is increasingly used to treat abdominal aortic aneurysms (AAAs), lesions undergoing open surgical repair (OSR) may present significant differences compared with those treated before wide EVAR availability. We aim to record discrepancies in AAAs surgically treated before and after the introduction of EVAR. METHODS We conducted a systematic review of the literature and meta-analysis of comparative studies. The MEDLINE, CENTRAL, and OpenGrey databases were searched up to October 2017. Outcome measures were anatomic complexity, procedural details, and postoperative outcomes. The random-effects model was used to calculate combined overall effect sizes. Data are presented as odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs). RESULTS Five observational studies were included. These involved 1,091 patients treated in the pre-EVAR era and 802 in the post-EVAR era. In general, patients undergoing OSR during the first period presented more comorbidities. Increased anatomic complexity was found among patients in the second group as demonstrated by the increased rate of suprarenal clamping (10.5% vs. 22.3%; OR, 0.34; 95% CI, 0.24-0.50), left renal vein division (10.3% vs. 18.8%; OR, 0.46; 95% CI, 0.25-0.88), iliac aneurysm (28.3% vs. 44.9%; OR, 0.48; 95% CI, 0.37-0.64), and iliac occlusive disease (13.1% vs. 20.2%; OR, 0.59; 95% CI, 0.39-0.88). Intraoperative use of blood products was greater during the latter period, but this difference did not reach statistical significance. Procedural duration was slightly increased in the same group. Morbidity and mortality were similar among the groups. CONCLUSIONS After the wide availability of endoluminal grafting, more compromised patients tend to be managed with EVAR, leaving a fitter patient population to undergo OSR. At the same time, anatomic complexity of AAAs undergoing open surgery has considerably increased, requiring advanced proximal aortic surgical expertise to deal with these complex aortic pathologies Overall, morbidity and mortality remained unchanged, possibly due to the counterbalancing effects of these factors.

Perfusion computed tomography imaging of abdominal aortic aneurysms may be of value for patient specific rupture risk estimation

Abdominal aortic aneurysm (AAA) continues to pose a significant cause of unexpected mortality in the developed countries with its incidence constantly rising. The indication of elective surgical repair is currently based on the maximum diameter and growth rate criteria which represent an oversimplification of the Law of Laplace stating that the stress exerted in a cylinder or sphere is proportional to its radius. These criteria fail to capture the complex pathophysiology of the aneurismal disease thus often leading to therapeutic inaccuracies (treating large AAAs with a very low actual rupture risk while observing smaller ones with a much greater risk). Aneurysmal disease is mainly a degenerative process leading to loss of structural integrity of the diseased aortic wall which cannot withhold the stresses due to systemic pressurization. Moreover aortic wall degeneration has been shown to be a localized phenomenon and rupture depends on the pointwise comparison of strength and stress rather than a global aortic wall weakening. Ex-vivo mechanical studies have related vessel wall hypoxia to loss of structural endurance and reduced wall strength. Therefore a module to capture in vivo variation of aortic wall blood supply and oxygenation would be of value for the evaluation of AAA rupture risk. Perfusion computed tomography (PCT) imaging represents a novel technique which has been already used to estimate tissue vascularity in several clinical conditions but not aneurismal disease. We hypothesize that PCT could be used as an adjunct tool during AAA diagnostics in order to evaluate aortic wall oxygenation in vivo, therefore providing a possible means to identify weak spots making the lesion amenable to rupture.

Commentary: Preoperative Aortic Morphology Identifies Patients at High Risk for Late Failure of Endovascular Aneurysm Repair

Since its introduction, endovascular aneurysm repair (EVAR) has led to a tremendous paradigm shift in the management of abdominal aortic aneurysms (AAA), currently representing the treatment of choice for infrarenal AAAs. Technical and technological innovations over the past 20 years have greatly improved early and late outcomes after EVAR. This has led to the apparent advantages of lower morbidity and mortality compared to traditional open surgical repair according to several randomized clinical trials and meta-analyses. However, the mounting long-term data have tempered the initial enthusiasm. In fact, the detection of several failure modes resulting in a higher complication rate, need for reintervention, and late aneurysm-related mortality has spawned concerns regarding durability, efficacy, and safety of the method in the long run. Endoleaks along with migration are the main adverse events that may result in late treatment failures. Among them, type I endoleak requires immediate treatment because of high aneurysm sac pressurization, enlargement, and an increased risk of rupture. Similarly, caudal movement of the endograft has been associated with loss of device fixation and should be repaired to prevent late aneurysm rupture. A recent systematic review suggested that about 2% of patients undergoing EVAR will need conversion at a later time, which is accompanied by a mortality rate as high as 10%. The difference between this latter value and data reported from contemporary series of elective open surgical AAA repair (mortality as low as 1.3%) highlights the need for proper patient selection of those who will benefit the most from EVAR. Reserving open surgery for those likely to present complications is probably a more appropriate treatment strategy than just employing an endovascular-first approach for every case. Accordingly, there has been a considerable effort in the literature to identify indices that may predict poor outcome after EVAR. Since endovascular graft fixation depends mainly on the integrity and long-term structural stability of the aortic neck, unfavorable neck anatomy is strongly suspected to confer a higher risk of complications and treatment failures. Indeed, data from the EUROSTAR registry indicated that short and angulated aortic necks fared significantly worse compared to those with more favorable characteristics. Specifically, an angulation >60° was related to higher rates of proximal endoleak, secondary interventions, and neck dilatation >4 mm. At the same time, all-cause mortality, aneurysm-related mortality, and rupture of the aneurysm were not affected. Similarly, a neck length <15 mm resulted in a 3-fold rate of type I endoleaks compared with a neck length >15 mm. AbuRahma et al compared outcomes in patients with friendly anatomy or a hostile neck (defined as any or all of the following: length <10 mm, angle >60°, diameter >28 mm, >50% circumferential thrombus, >50% calcified neck, or reverse taper). The authors indicated that a hostile neck was associated with higher rates of early (intraoperative) type I endoleak (about 2.5-fold risk) and need for secondary interventions, while the midterm outcomes were similar to patients with friendly neck anatomy. On the other hand, contradictory reports suggest that EVAR may be safely performed even in the presence of unfavorable anatomy. Notably, Lee et al reported that high neck angulation treated outside the manufacturer’s instructions for use presented similar rates of migration, endoleak, need for reintervention, sac regression, and freedom from 704627 JETXXX10.1177/1526602817704627Journal of Endovascular TherapyKontopodis et al research-article2017