Thorarinn Kristmundsson

Outcomes of fenestrated endovascular repair of juxtarenal aortic aneurysm

OBJECTIVE To evaluate late outcomes after fenestrated endovascular aortic repair (f-EVAR) in a tertiary European referral center. METHODS In 2009, we published short- and midterm results after f-EVAR in the first 54 patients treated with this technique at our center between September 2002 and June 2007. In this paper, we provide long-term follow-up of the same patient cohort with the main focus on target vessel (TV) patency, renal function, reinterventions, and survival. RESULTS A total of 54 patients were included in this study. Median age was 72 years (interquartile range [IQR], 68-76 years) at primary operation, and 85% were men. Median preoperative aneurysm diameter was 60 mm (IQR, 53-66 mm). One hundred thirty-four vessels were targeted (mean, 2.5 per patient), and 96 TV stents were placed. The median clinical follow-up was 67 months (IQR, 37-90 months), and computed tomography follow-up was 60 months (IQR, 35-72 months). Aneurysm diameter decreased ≥ 5 mm in 39% ± 7% at 12 months, 64% ± 8% at 36 months, and 71% ± 8% at 60 months. Primary TV patency was 94% ± 2% at 12 months, 91% ± 3% at 36 months, and 90% ± 3% at 60 months. Glomerular filtration rate decreased by 17% at 59 months (IQR, 26-73 months) follow-up (60 [IQR, 46-79] vs 50 [IQR, 38-72] mL/min/1.73 m(2); P < .001), and one patient became dialysis-dependent secondary to a renal stent occlusion. Reintervention-free survival was 88% ± 5% at 12 months, 69% ± 7% at 36 months, and 56% ± 5% at 60 months. At least one reintervention was done in 37% of patients, of which 29% were endoleak-related, 26% TV-related, 13% graft-limb-related, and 32% due to other causes. The majority of reinterventions (68%) were based on complications detected on routine follow-up. Estimated overall survival was 93% ± 4% at 12 months, 76% ± 6% at 36 months, and 60% ± 7% at 60 months. In total, 54% of the patients died during the 10-year study period, where 9% died of aneurysm-related causes. CONCLUSIONS Long-term mortality after f-EVAR is high, but most patients die from nonaneurysmal causes. Aneurysm-related mortality is associated with technical complications that can be reduced with increased experience. Reinterventions are common, and most complications are detected on routine follow-up.

Anatomic suitability for endovascular repair of abdominal aortic aneurysms and possible benefits of low profile delivery systems

The aim of the study was to evaluate the anatomic suitability for endovascular abdominal aneurysm repair (EVAR) according to instructions for use (IFUs) of three commercially available bifurcated stent graft devices and explore the possible benefits of low-profile delivery systems. Computed tomography scans of 241 patients with abdominal aortic aneurysm (AAA) were evaluated for suitability of Zenith Flex®, Gore Excluder® and Endurant® bifurcated stent graft systems according to their IFUs. The most common exclusion criteria and possible benefits of smaller diameter delivery systems were analyzed. When choosing the most suitable graft model for each patient, the overall suitability was 49.4%. By brand, the suitability was 28.6% for Zenith®, 25.7% for Gore Excluder® and 48.1% for Endurant®. By step wise accepting iliac diameters of ≥6 mm, ≥5 mm and ≥4 mm the overall suitability increased to 56.7, 58.9 and 60.2%, respectively (P < 0.001). Diameters below 4 mm had no additional effect on suitability as combinations of other anatomical features, with or without narrow iliacs, accounted for the remaining excluding factors. In conclusion, Less than half of patients with AAAs are suitable for EVAR according to current IFUs. Low-profile delivery systems may allow for endovascular treatment in up to 60% of patients.

Early versus late experience in fenestrated endovascular repair for abdominal aortic aneurysm

OBJECTIVE The objective of this study was to evaluate operative results and 1-year outcomes in early vs late experience after fenestrated endovascular aortic repair. METHODS All patients treated in Malmö, Sweden, and in Lille, France, with fenestrated endovascular repair for abdominal aortic aneurysm were prospectively enrolled in a computerized database. Early experience was defined as the first 50 patients treated at each center. Data from early and late experience were retrospectively analyzed and compared for differences in operative results and 1-year outcomes. RESULTS Early experience covered 4.7 years in Malmö and 4.5 years in Lille; late experience covered 5.6 years in Malmö and 3.7 years in Lille. A total of 288 patients were included. In the later phase, stent graft configuration was more complex because of increased number of fenestrations/scallops incorporated in the graft design (2.7 ± 0.8 vs 3.2 ± 0.7; P < .001). Despite this, volume of contrast material and radiation time decreased by 27% and 20%, respectively, whereas procedure time remained unchanged. At 1 year, a trend toward decreasing abdominal aortic aneurysm diameter was observed in the late group, but no differences were found in mortality, endoleaks, or target vessel patency between the groups. CONCLUSIONS With increasing experience, fenestrated endovascular aneurysm repair design has become more complicated, with more visceral vessels targeted for better proximal seal, while operative risk still remains low. Simultaneously, radiation time and volume of contrast material have been reduced, with possible long-term benefits for the patient.

Transurethral Bladder Tumor Resection Can Cause Seeding of Cancer Cells into the Bloodstream

PURPOSE Transurethral bladder tumor resection is the initial diagnostic procedure for bladder cancer. Hypothetically tumor resection could induce seeding of cancer cells into the circulation and subsequent metastatic disease. In this study we ascertain whether transurethral bladder tumor resection induces measurable seeding of cancer cells into the vascular system. MATERIALS AND METHODS Patients newly diagnosed with suspected invasive bladder cancer and planned for transurethral resection of bladder tumor in 2012 to 2013 were enrolled in the study. Before transurethral bladder tumor resection a vascular surgeon placed a venous catheter in the inferior vena cava via the femoral vein. Blood samples were drawn before and during the resection from the inferior vena cava and a peripheral vein, and analyzed for circulating cancer cells using the CellSearch® system. The number of circulating tumor cells identified was compared in preoperative and intraoperative blood samples. RESULTS The circulating tumor cell data on 16 eligible patients were analyzed. In 6 of 7 positive inferior vena cava samples (86%) the number of circulating tumor cells was increased intraoperatively (28 vs 9, 28 vs 0, 28 vs 5, 3 vs 0, 4 vs 0, 1 vs 0), and results were similar, although less conclusive, for the corresponding peripheral vein samples. CONCLUSIONS Our study confirms that tumor cells can be released into the circulation during transurethral bladder tumor resection. It is currently unknown whether this will increase the risk of metastatic disease.

Adult UrologyOncology: Adrenal/Renal/Upper Tract/BladderTransurethral Bladder Tumor Resection Can Cause Seeding of Cancer Cells into the Bloodstream

PURPOSE Transurethral bladder tumor resection is the initial diagnostic procedure for bladder cancer. Hypothetically tumor resection could induce seeding of cancer cells into the circulation and subsequent metastatic disease. In this study we ascertain whether transurethral bladder tumor resection induces measurable seeding of cancer cells into the vascular system. MATERIALS AND METHODS Patients newly diagnosed with suspected invasive bladder cancer and planned for transurethral resection of bladder tumor in 2012 to 2013 were enrolled in the study. Before transurethral bladder tumor resection a vascular surgeon placed a venous catheter in the inferior vena cava via the femoral vein. Blood samples were drawn before and during the resection from the inferior vena cava and a peripheral vein, and analyzed for circulating cancer cells using the CellSearch® system. The number of circulating tumor cells identified was compared in preoperative and intraoperative blood samples. RESULTS The circulating tumor cell data on 16 eligible patients were analyzed. In 6 of 7 positive inferior vena cava samples (86%) the number of circulating tumor cells was increased intraoperatively (28 vs 9, 28 vs 0, 28 vs 5, 3 vs 0, 4 vs 0, 1 vs 0), and results were similar, although less conclusive, for the corresponding peripheral vein samples. CONCLUSIONS Our study confirms that tumor cells can be released into the circulation during transurethral bladder tumor resection. It is currently unknown whether this will increase the risk of metastatic disease.

A Novel Method to Estimate Iliac Tortuosity in Evaluating EVAR Access

Purpose To subjectively and objectively evaluate the methods used for preoperative assessment of iliac artery tortuosity in patients with abdominal aortic aneurysms (AAA). Methods Iliac artery tortuosity was assessed retrospectively in 188 patients (160 men; mean age 73 years) diagnosed with AAA at our clinic in 2006 and 2007. All patients underwent preoperative computed tomography (CT) with predominantly thin-slice acquisitions. CT data were analyzed in a dedicated 3-dimensional workstation to perform centerline-of-flow measurements on 376 iliac arteries. Iliac tortuosity was evaluated using the following methods: (1) subjective grading (none, mild, moderate, severe) by 2 experienced observers, (2) calculating the modified iliac tortuosity index based on the published reporting standards for endovascular aneurysm repair, and (3) using the shortest distance between the aortic bifurcation and the common femoral artery (CFA) on axial CT scans as a surrogate for the tortuosity index. Correlation between the objective methods was assessed, and all 3 methods were evaluated for intra- and interobserver agreement. Results (1) The intra- and interobserver agreement was substantial (κ=0.71 and κ=0.65, respectively) for subjective grading, but few variations were found in the calculated tortuosity indexes between the subjective groups. (2) Intra- and interobserver correlations when measuring the iliac tortuosity index were strong (r=0.94 and r=0.79, respectively), with good intra- and interobserver agreement. (3) The new method had a strong correlation with iliac tortuosity index (r=0.78); segregating the iliac arteries into 3 length categories (<10 cm, 10–15 cm, >15 cm), the mean iliac tortuosity indexes were 2.0±0.37, 1.6±0.21, and 1.1±0.27, respectively (p<0.001). This strong correlation was not seen when measuring the iliac artery length in CLF reconstruction (r=0.31), proving little variation in CLF length among patients. Conclusion Subjective grading of iliac artery tortuosity had substantial agreement between investigators but cannot be recommended as a surrogate for the tortuosity index in access evaluation. The iliac artery tortuosity index is most accurate, but complex and time-consuming. As the CLF length varies only slightly among patients, the new method using the shortest aortic bifurcation-CFA distance on an axial CT scan is a good substitute for the iliac tortuosity index and can often replace it clinically.

Laser Generated In situ Fenestrations in Dacron Stent Grafts.

OBJECTIVE/BACKGROUND To evaluate if the creation of laser generated in situ fenestrations in polyester/Dacron stent grafts causes embolization. METHODS In seven pigs, Dacron stent grafts were implanted from the infrarenal aorta to the right iliac artery. Prior to placing the stent graft, a carotid artery protection filter, with a pore size of 70-200 μm, was placed in the proximal left common iliac artery. An excimer laser catheter was then advanced antegradely through the stent graft and positioned at the level of origin of the left iliac artery. A fenestration was then created with the laser probe. The carotid filter was retrieved and inspected macroscopically with magnifying glasses, for emboli and clot. RESULTS Seven pigs with a median weight of 90 kg (range 78-98 kg) were tested. The median operating time was 170 minutes. All laser fenestrations were successfully completed. No emboli or clot could be detected in the protection filters. CONCLUSION Creation of laser generated, in situ fenestrations do not produce macroscopically visible emboli/clot. This might indicate safe usage of laser created fenestrations for endovascular arch repair and left subclavian artery revascularization.

Is Repeat PTA of a Failing Hemodialysis Fistula Durable

Purpose. Our objective was to evaluate the outcome of percutaneous transluminal angioplasty (PTA) and particularly rePTA in a failing arteriovenous fistula (AV-fistula). Are multiple redilations worthwhile? Patients and Methods. All 159 stenoses of AV fistulas that were treated with PTA, with or without stenting, during 2008 and 2009, were included. Occluded fistulas that were dilated after successful thrombolysis were also included. Median age was 68 (interquartile range 61.5–78.5) years and 75% were male. Results. Seventy-nine (50%) of the primary PTAs required no further reintervention. The primary patency was 61% at 6 months and 42% at 12 months. Eighty (50%) of the stenoses needed at least one reintervention. Primary assisted patency (defined as patency after subsequent reinterventions) was 89% at 6 months and 85% at 12 months. The durability of repeated PTAs was similar to the durability of the primary PTA. However, an early primary PTA carried a higher risk for subsequent reinterventions. Successful dialysis was achieved after 98% of treatments. Nine percent of the stenoses eventually required surgical revision and 13% of the fistulas failed permanently. Conclusion. The present study suggests that most failing AV-fistulas can be salvaged endovascularly. Repeated PTA seems similarly durable as the primary PTA.

Results of F-EVAR in Octogenarians

BACKGROUND To evaluate the clinical outcomes after fenestrated endovascular aortic aneurysm repair (F-EVAR) in octogenarians. METHODS Between 2002 and 2012, all data from patients treated with custom-made fenestrated endografts for elective juxtarenal or pararenal aortic aneurysms in 2 high-volume centers (Malmö, Sweden & Lille, France) were prospectively entered in a computer database. Demographics and perioperative and follow-up results of patients aged ≥80 years (group 1) and patients aged <80 (group 2) were compared. RESULTS A total of 288 patients (33 in group 1 and 255 in group 2) were treated with fenestrated endografts during the study period. Except for median age, tobacco use, and maximal transaortic diameter (P = 0.001), both groups were comparable. The number of fenestrations, procedure duration, contrast media volume, length of stay, and number of secondary interventions were comparable. The 30-day mortality rate was higher in the octogenarian group (9% vs. 1.6%, P = 0.041). Median follow-up was 25 months. Two-year survival rate according to Kaplan-Meier method was 77.8% in group 1 (95% confidence interval, 61.8-93.9) and 89.0% in group 2 (P = 0.121). Overall mortality during the follow-up period was significantly higher in octogenarians (P < 0.006). CONCLUSIONS F-EVAR in octogenarians is associated with a higher 30-day mortality rate but has similar midterm outcomes compared with younger patients and should be considered as an acceptable therapeutic option in patients with satisfactory life expectancy.

Outcome of visceral chimney grafts after urgent endovascular repair of complex aortic lesions.

OBJECTIVE Endovascular abdominal aortic repair requires an adequate sealing zone. The chimney graft (CG) technique may be the only option for urgent high-risk patients who are unfit for open repair and have no adequate sealing zone. This single-center experience provides long-term results of CGs with endovascular repair for urgent and complex aortic lesions. METHODS Between July 2006 and October 2012, 51 patients (16 women) with a median age of 77 years (interquartile range, 72-81 years), were treated urgently (within 24 hours [61%]) or semiurgently (within 3 days [39%]) with endovascular aortic repair and visceral CGs (n = 73). Median follow-up was 2.3 years (interquartile range, 0.8-5.0 years) for the whole cohort, 3 years for 30-day survivors, and 4.8 years for patients who are still alive. RESULTS Five patients (10%) died within 30 days. All of them had a sacrificed kidney. All-cause mortality was 57% (n = 29), but the chimney- and procedure-related mortality was 6% (n = 3) and 16% (n = 8), respectively. Chimney-related death was due to bleeding, infection, renal failure, and multiple organ failure. There were two postoperative ruptures; both were fatal although not related to the treated disease. The primary and secondary long-term CG patencies were 89% (65 of 73) and 93% (68 of 73), respectively. Primary type I endoleak (EL-I) occurred in 10% (5 of 51) of the patients, and only one patient had recurrent EL-I (2%; 1 of 51). No secondary endoleak was observed. Chimney-related reintervention was required in 16% (8 of 51) of the patients because of EL-I (n = 3), visceral ischemia (n = 4), and bleeding (n = 2). The reinterventions included stenting (n = 5), embolization (n = 3), and laparotomy (n = 2). Thirty-one visceral branches were sacrificed (9 celiac trunks, 9 right, and 13 left renal arteries). Among the 30-day survivors, 8 of 17 patients (47%) with a sacrificed kidney required permanent dialysis; of these, seven underwent an urgent index operation. The aneurysm sac shrank in 63% (29 of 46) of cases. CONCLUSIONS The 6% chimney-related mortality and 93% long-term patency seem promising in urgent, complex aortic lesions of a high-risk population and may justify a continued yet restrictive applicability of this technique. Most endoleaks could be sealed endovascularly. However, sacrifice of a kidney in this elderly cohort was associated with permanent dialysis in 47% of patients.