Payman Majd

Repeated contrast medium application after endovascular aneurysm repair and not the type of endograft fixation seems to have deleterious effect on the renal function

Objective: The influence of endovascular aneurysm repair (EVAR) on renal function is of high concern. The question whether stent graft fixation type plays a significant role in renal outcome after EVAR is still debated. However, other factors, such as repeated contrast medium exposure, should also be considered. Methods: We performed a two‐center, stratified‐cohort case control study to evaluate the influence of last‐generation abdominal endografts with suprarenal (SR) vs infrarenal (IR) fixation on renal function. Results: From a total of 276 patients, 134 were treated with IR fixation (group A) and 142 with SR fixation (group B) stent grafts. There was no significant difference in intraoperative contrast medium use (mean 120.0 mL group A vs 104.8 mL; P = .087) between the two cohorts. Overall, 11.2% of the patients (31/276) showed a relevant decline (≥20%) of estimated glomerular filtration rate (eGFR) postoperative and 11.5% (31/269) after 12 months. Furthermore, 19/134 (14.2%) patients in group A and 12/142 (8.5%) patients in group B showed a postoperative decrease of eGFR ≥20% (P = .132). Comparing the 12‐month follow up, there was also no significant difference between the two groups (group A, n = 18/134; group B, n = 13/135; P = .329). Patients with only one contrast‐enhanced computed tomography scan postoperatively (4/102; 3.9%) showed significant less renal deterioration after 12 months compared with the rest of the study collectively (27/166; 16.9%; P = .002). Comparing IR vs SR fixation in these patients, there was no significant difference between the two groups. One patient (1/35; 2.9%) with IR fixation (group A) and 3/67 (4.5%) with SR fixation (group B) showed a decline in eGFR values of ≥20% after 12 months (P = 1.0). Conclusions: Our study showed no significant difference in renal impairment between SR and IR fixation in EVAR for IR abdominal aortic aneurysm. However, significantly more renal deterioration was observed in patients with increased postoperative contrast medium expose. Therefore, alternatives such as contrast‐ enhanced duplex ultrasound or magnetic resonance imaging for EVAR surveillance should be considered.

Impairment of erectile function after elective repair of abdominal aortic aneurysm.

The purpose of the present study was to compare the functional change of erectile dysfunction after endovascular repair (EVAR) and open repair (OR) of abdominal aortic aneurysm. Between April 2009 and December 2011, male patients admitted for elective treatment of an asymptomatic infrarenal abdominal aortic aneurysm were included. The erectile function was evaluated by using a validated KEED questionnaire. All patients filled out the questionnaire preoperatively and postoperatively after one year. The number of patients with an increase of erectile dysfunction was 8 (26.6%) to 16 (53.3%) in open repair group vs. 30 (42.6%) to 40 (58.8%) in endovascular aneurysm repair. There was no statistically significant difference between open repair and endovascular aneurysm repair groups in order of new incidence of erectile dysfunction (p = 0.412). The study showed an increase in the mean value of Erectile Dysfunction -Score postoperatively in both the groups as well. The present study showed an increase of erectile dysfunction postoperatively, but the difference between the two groups was not statistically significant.

Clinical outcome after surgical and endovascular treatment of symptomatic persistent sciatic artery with review of the literature and reporting of three cases.

A persistent sciatic artery is a very rare vascular anomaly with an estimated incidence of 0.025–0.06% and with less than 200 described cases in the literature. During early embryonic development, the sciatic artery delivers the major blood supply to the lower limb and usually disappears when the superficial femoral artery has developed properly. The usual form of presentation in adults is the aneurysmal degeneration of the sciatic artery or less frequently with another complication (thrombosis, embolism, neuralgia). We describe three cases of a complete sciatic artery (two cases are bilateral and one is unilateral) associated with lower limb ischemia caused by embolism from the aneurysmal degeneration of the sciatic artery at the buttock level in two cases and atherosclerotic degeneration of the lower limb arteries in the third case. We also describe two combined therapy methods consisted of limb revascularization with vein-graft bypass and endovascular embolization of the aneurysm with vascular plug in the first case, in the second case combination of localized thrombolysis therapy followed by a bypass and an ilio-pedal vein bypass in the third one. And we discuss later the reported clinical outcome after surgical and endovascular treatment of this anomaly in the literature.

Prospective study of the E-liac Stent Graft System in patients with common iliac artery aneurysms: 30-Day results:

Objectives To study the safety and feasibility of the E-liac Stent Graft System® in patients with aorto/iliac aneurysms. Methods A prospective multicentric European registry of patients receiving the E-liac Stent Graft System® was conducted. Endpoints of the study included the technical success as well as periprocedural events and 30-day endoleaks, reinterventions, internal and external iliac artery patency and mortality. Results Between July 2014 and June 2016, a total of 45 patients (93% men, mean age 72 years, range 53–90 years) were enrolled at 11 sites in four European countries. Five patients received an isolated iliac treatment. Thirty-seven patients were treated with a combination of an abdominal stent graft and a unilateral E-liac and three in combination with bilateral E-liac. All E-liac Stent Grafts (48) were implanted in the intended position and the internal iliac arteries were successfully bridged. Two patients did not receive clinical success, due to endoleak type Ia of the aortic stent graft. At 30-day follow-up, clinical success rate was 96%. Three successful endovascular reinterventions were performed within the 30-day follow-up: one due to a type Ia endoleak in the common iliac artery, one due to type Ia endoleak of the aortic stent graft, and one due to bilateral lower limb claudication provoked by stent graft limb stenosis. At 30-day, a 100% survival rate and complete absence of pelvic or buttock ischemia/claudication were reported. Primary patency at 30 days was 100% for the internal iliac artery and 98% for the external iliac artery with an assisted patency of 100% in the latter. Conclusions The high clinical success rate, low rates of device-related reinterventions (2%), and excellent patency rate demonstrate the safety and feasibility of the E-liac Stent Graft System. Long-term results are awaited to state efficacy and durability. Clinical Trials.gov. Identifier no. NCT02209194.

Impact of meteorological conditions on the incidence of acute aortic dissection

Background: There is still much controversy about whether meteorological conditions influence the occurrence of acute aortic dissection (AAD). The aim of the present study was to investigate the possible correlation between atmospheric pressure, temperature, lunar cycle and the event of aortic dissection in our patient population. Methods: The clinical data for 348 patients with AAD (73% type Stanford A) were confronted with the meteorological data provided by the Cologne weather station over the same period. Results: There were no statistically significant differences between meteorological parameters on days of AAD events compared with control days. A logistic regression model showed that air pressure (odds ratio [OR] 1.004, 95% confidence interval [CI] 0.991–1.017, p = 0.542), air temperature (OR 0.978, 95% CI 0.949–1.008, p = 0.145), season (p = 0.918) and month of the event (p = 0.175) as well as presence of full moon (OR 1.579, 95% CI 0.763–3.270, p = 0.219) were not able to predict AAD events. Also, no predictive power of meteorological data and season was found on analysing their impact on different types of AAD events. Conclusions: Our study did not reveal any dependence of atmospheric pressure, air temperature or the presence of full moon on the incidence of different types of AAD.

Impact of preoperative elevated serum creatinine on long-term outcome of patients undergoing aortic repair with Stanford A dissection: a retrospective matched pair analysis

Background: The aim of the present study was to determine whether raised preoperative serum creatinine affected the long-term outcome in patients undergoing surgical aortic repair for Stanford A acute aortic dissection (AAD). Methods: A total of 240 patients diagnosed with Stanford A AAD underwent surgical repair from January 2006 to April 2015. A propensity score matching was applied, resulting in 73 pairs consisting of one group with normal and one group with preoperative elevated creatinine levels. The cohorts were well balanced for baseline and preoperative clinical characteristics. Both groups were compared regarding their early postoperative variables, as well as estimated survival with up to 9-year follow up. Also, the impact of acute postoperative kidney injury and its severity on long-term survival was analyzed. Results: The proportion of patients suffering Stanford A AAD with raised creatinine levels was 31.3% (n = 75). After propensity matching, there were no statistically significant differences regarding demographics, comorbidities, preoperative baseline and clinical characteristics. Postoperatively matched patients with elevated creatinine had longer intensive care unit (p < 0.001) and total hospital stay (p = 0.002), prolonged intubation times (p = 0.014), higher need for hemofiltration (p < 0.001), higher incidence of temporary neurological disorders (p = 0.16), infection (p = 0.005), and trend toward higher incidence of sepsis (p = 0.097). However, there were no significant differences regarding 30-day mortality (20.5% versus 20.5%, p = 1.000) and long-term overall survival. Further, neither the incidence nor the different stages of acute kidney injury according to the Acute Kidney Injury Network showed any statistically significant differences in terms of long-term survival for both groups [log rank p = 0.636, Breslow (generalized Wilcoxon) p = 0.470, Tarone–Ware p = 0.558]. Conclusions: Patients with elevated creatinine levels undergoing surgical repair for Stanford A AAD demonstrate higher rate of early postoperative complications. However, 30-day mortality and long-term survival in this patient cohort is not significantly impaired.

Image fusion using the two-dimensional-three-dimensional registration method helps reduce contrast medium volume, fluoroscopy time, and procedure time in hybrid thoracic endovascular aortic repairs

Objective The objective of this study was to evaluate the effect of image fusion (IF) technology in thoracic endovascular aortic repair (TEVAR) on reducing radiation exposure (dose and time), amount of injected iodinated contrast medium needed, and procedure time. Methods We performed a review of our institutional endovascular aortic database of patients who had undergone TEVAR between 2008 and 2016 before and after the installation of a three‐dimensional (3D) IF computed tomography system in our hybrid operating room. All patients were operated on using the same radiologic equipment with or without IF. Results The 146 patients who had undergone elective or emergent TEVAR with preoperative computed tomography angiography done in 1‐mm‐thick slices were divided into two groups: the IF group (98 patients), in which TEVAR was performed using intraoperative IF with the two‐dimensional‐3D registration method; and 48 controls without the use of IF. The IF group received a significantly reduced dose of contrast material, with a median of 70 mL (interquartile range [IQR], 50‐101 mL) compared with controls receiving 104 mL (IQR, 69‐168 mL; P < .001).Patients who underwent hybrid TEVAR had a significantly reduced procedure time under IF guidance (n = 25) compared with controls (n = 11; median, 162 minutes [IQR, 139‐199 minutes] vs 213 minutes [IQR, 189‐298 minutes]; P = .015). In addition, the intraoperative fluoroscopy time was reduced to 9 minutes (IQR, 6‐13 minutes) vs 23 minutes (IQR, 12‐45 minutes; P < .005). However, the radiation dose (dose‐area product) was similar for the two groups (P = .37).In patients who underwent plain TEVAR (n = 74) without a carotid‐subclavian bypass, the IF group needed significantly less contrast material (median, 64 mL [IQR, 43‐81 mL]) compared with the control group (median, 98 mL [IQR, 60‐180 mL]; P = .003), whereas intraoperative radiation exposition, procedure time, and fluoroscopy time did not statistically significantly differ between the two groups. Conclusions The IF technology using the two‐dimensional‐3D registration method was associated with reduced intraoperative contrast material volume in performing TEVAR. IF seemed to shorten the operation and radiation times in the more complicated (hybrid) TEVAR cases. However, a prospective study is needed to look at the dose‐area product, fluoroscopy time, and procedure time in a larger cohort of patients.

Patients Older Than 80 Years Can Reach Their Normal Life Expectancy After Abdominal Aortic Aneurysm Repair: A Comparison Between Endovascular Aneurysm Repair and Open Surgery

Purpose: To investigate the long-term outcomes of endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of infrarenal abdominal aortic aneurysm in octogenarian patients and to compare them with the overall expected survival based on a sex- and age-matched German population. Methods: A total of 177 patients (median age 82 years; 149 men) ≥80 years old (range 80–92) who underwent primary elective repair of an infrarenal aortic aneurysm (≥5 cm) between 1998 and 2015 were identified in a database search. Two groups of patients were formed based on the type of procedure: 131 EVAR patients (median age 83 years; 114 men) and 46 OSR patients (median age 82 years; 35 men). Results: The median follow-up was 5 years for the OSR group and 4.5 years for the EVAR group. Kaplan-Meier analysis showed no significant difference in survival between the EVAR and OSR groups at 78 months. The observed survival of all study patients was not statistically different from the expected survival of a sex- and age-matched German population, which was true separately for women and men. Conclusion: The patients in this study seemed to reach normal life expectancy in comparison to the age- and sex-matched general population with a similar cumulative survival in both study groups over 5 years of follow-up.

A current systematic evaluation and meta-analysis of chimney graft technology in aortic arch diseases

Objective The aim of this study was to provide a review of the literature on the use of chimney graft (CG) technique in treating arterial diseases of the aortic arch and to extrapolate conclusions by summarizing the reported outcomes in a meta‐analysis. Methods An extensive electronic search was made using PubMed/MEDLINE, Science Direct Databases, and the Cochrane Library. Included in this meta‐analysis were all papers published up to February 2016 on endovascular chimney technique in the arch vessels with or without adjunct extra‐anatomic debranching, in any language, providing data about at least one of the essential outcomes: early and late type I endoleak, 30‐day mortality rate, development of perioperative stroke, patency, and retrograde aortic dissection. Results Of the 478 reports yielded by the electronic search, a total of 11 publications (on 373 patients and 387 CGs) fulfilled the inclusion criteria and were included in this study. The overall estimated proportion of technical success was 91.3% (95% confidence interval [CI], 87.4%‐94.0%). Of the 373 patients, 26 (7%) experienced a type Ia endoleak in the perioperative period. The overall estimated proportion of early type Ia endoleak was 9.4% (95% CI, 6.5%‐13.4%). Among the 10 studies that provided data, a retrograde type A dissection was observed in 2 of 351 patients, resulting in an overall estimated proportion of 1.8% (95% CI, 0.8%‐4.0%). The pooled 30‐day mortality rate was 7.9% (95% CI, 4.6%‐13.2%). The pooled estimation for reintervention was 10.6% (95% CI, 5%‐21%); for major stroke, 2.6% (95% CI, 1.3%‐5.0%); for early patency, 97.9% (95% CI, 95.8%‐99%); and for late patency, 92.9% (95% CI, 87.3%‐96%). Conclusions Treatment of aortic diseases involving the aortic arch poses a great challenge. The CG technique has been applied as an alternative treatment option. This meta‐analysis shows that endovascular repair of aortic arch disease using a CG technique in the aortic arch vessels is technically feasible and effective but not without major risk of complications.

Transfemoral transcatheter aortic valve implantation in a patient with multiple endovascular aortic stents – a case report

BackgroundIn patients undergoing transfemoral transcatheter aortic valve implantation, previous endovascular interventions bear a risk for the valve frame to get stucked to the aortic stents.Case PresentationWe report on a 75-year-old frail patient with severe aortic stenosis and a rapid increase of an infra-renal aneurysm. He had a history of multiple endovascular interventions on the aorta. Due to his frail preoperative status we decided to perform a transfemoral transcatheter aortic valve implantation in combination with a simultaneous surgical abdominal aneurysm repair. To allow an atraumatic passage of the Edwards SAPIEN 3 valve across the endovascular stents we used a special technique.ConclusionsThe transfemoral approach in patients with previous endovascular stenting can be performed successfully by a partial inflation of the distal balloon.