Sander Ten Raa

Clinical outcome and morphologic analysis after endovascular aneurysm repair using the Excluder endograft

OBJECTIVE Long-term follow-up after endovascular aneurysm repair (EVAR) is very scarce, and doubt remains regarding the durability of these procedures. We designed a retrospective cohort study to assess long-term clinical outcome and morphologic changes in patients with abdominal aortic aneurysms (AAAs) treated by EVAR using the Excluder endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz). METHODS From 2000 to 2007, 179 patients underwent EVAR in a tertiary institution. Clinical data were retrieved from a prospective database. All patients treated with the Excluder endoprosthesis were included. Computed tomography angiography (CTA) scans were retrospectively analyzed preoperatively, at 30 days, and at the last follow-up using dedicated tridimensional reconstruction software. For patients with complications, all remaining CTAs were also analyzed. The primary end point was clinical success. Secondary end points were freedom from reintervention, sac growth, types I and III endoleak, migration, conversion to open repair, and AAA-related death or rupture. Neck dilatation, renal function, and overall survival were also analyzed. RESULTS Included were 144 patients (88.2% men; mean age, 71.6 years). Aneurysms were ruptured in 4.9%. American Society of Anesthesiologists classification was III/IV in 61.8%. No patients were lost during a median follow-up of 5.0 years (interquartile range, 3.1-6.4; maximum, 11.2 years). Two patients died of medical complications ≤ 30 days after EVAR. The estimated primary clinical success rates at 5 and 10 years were 63.5% and 41.1%, and secondary clinical success rates were 78.3% and 58.3%, respectively. Sac growth was observed in 37 of 142 patients (26.1%). Cox regression showed type I endoleak during follow-up (hazard ratio, 3.74; P = .008), original design model (hazard ratio, 3.85; P = .001), and preoperative neck diameter (1.27 per mm increase, P = .006) were determinants of sac growth. Secondary interventions were required in 32 patients (22.5%). The estimated 10-year rate of AAA-related death or rupture was 2.1%. Overall life expectancy after AAA repair was 6.8 years. CONCLUSIONS EVAR using the Excluder endoprosthesis provides a safe and lasting treatment for AAA, despite the need for maintained surveillance and secondary interventions. At up to 11 years, the risk of AAA-related death or postimplantation rupture is remarkably low. The incidences of postimplantation sac growth and secondary intervention were greatly reduced after the introduction of the low-permeability design in 2004.

Conservative management of persistent aortocaval fistula after endovascular aortic repair

Endovascular repair is a valid alternative for patients with abdominal aortic aneurysms. However, in patients with concomitant aortocaval fistulas, type II endoleaks may result in a persistent communication between the aneurysm sac and the inferior vena cava. In these patients, prompt closure of the persistent fistula has been advocated. We present a patient with an abdominal aortic aneurysm, with aortocaval fistula, who was managed endovascularly. Aneurysm sac shrinkage was observed despite persistent aortocaval communication due to type II endoleak. This case demonstrates that conservative management of type II endoleaks associated with persistent aortocaval fistulas is possible and may result in favorable aneurysm sac remodelling.

One-Year Follow-Up After Hybrid Thoracoabdominal Aortic Repair: Potentially Important Issue for Preoperative Decision-Making

Background: Compared to open thoracoabdominal aortic aneurysm (TAAA) repair, hybrid repair is thought to be less invasive with better perioperative outcomes. Due to the extent of the operation and long recovery period, studying perioperative results may not be sufficient for evaluation of the true treatment effect. The aim of this study is to evaluate 1-year mortality and morbidity in patients with TAAA undergoing hybrid repair. Methods: In a retrospective cohort study, all medical records of patients undergoing hybrid repair for TAAA at the Erasmus University Medical Center between January 2007 and January 2015 were studied. Primary outcome measures were 30-day and 1-year mortality. Secondary outcome measures included major in-hospital postoperative complications. Results: A total of 15 patients were included. All-cause mortality was 33% (5 of the 15) at 30 days and 60% (9 of the 15) at 1 year. Aneurysm-related mortality was 33% (5 of the 15) and 53% (8 of the 15) at 30-day and 1-year follow-up, respectively, with colon ischemia being the most common cause of death. Major complication rate was high: myocardial infarction in 2 (13%) cases, acute kidney failure in 5 (33%) cases, bowel ischemia in 3 (20%) cases, and spinal cord ischemia in 1 (7%) case. Conclusion: The presumed less invasive nature of hybrid TAAA repair does not seem to result in lower complication rates. The high mortality rate at 30 days continues to rise dramatically thereafter, suggesting that 1-year mortality is a more useful clinical parameter to use in preoperative decision-making for this kind of repair.

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