Objective: To assess the incidence, outcomes, and predictors of type III endoleaks (TIIIELs) in patients treated with different generations of Endologix unibody devices for abdominal aortic aneurysm (AAA). Methods: Patients treated with unibody endografts between 1999 and 2020 in a single unit were prospectively enrolled, retrospectively analyzed, and stratified according to device generation. The primary outcome was the incidence of TIIIEL in patients treated with unibody devices. Secondary outcomes included: (1) TIIIEL incidence among the different device generations; (2) comparison of type IIIa (TIIIaELs) and type IIIb endoleaks (TIIIbELs) incidence, treatment, and complications; (3) risk factor analysis for TIIIEL; (4) overall survival and survival free from TIIIEL. Results: A total of 872 patients who underwent endovascular aortic repair (EVAR) were analyzed. The cumulative incidence of TIIIEL was 4.8% (42/872). The incidence among different generations was 2.4% (10/414), 21.7% (15/69), and 4.6% (16/341), and 2.1% (1/48) for Powerlink, AFXs, AFXd, and AFX2. Freedom from TIIIEL by device generation was significantly lower in the AFXs group (p<0.001). Type III endoleaks was higher in urgent EVAR (p=0.011), large AAA (p<0.001), angulated and calcified necks (p=0.002), and when more than one modular component or non-proprietary extension was used (p<0.001). AFXs was found as independent risk factor for TIIIEL (hazard ratio [HR]=3.1, p=0.003), while the use of a single component decreased the risk (HR=0.3, p=0.005). Finally, every 10-mm increase in AAA diameter resulted in a 2-fold increase in TIIIEL risk (HR=2.0, p<0.001). Conclusion: The first generation of AFX endograft was associated with an increase in TIIIEL risk by 3.1 times, claiming a strict and careful follow-up in patients implanted with this device. Clinical Impact The old-generation of unibody endograft AFXs was associated with an increase in TIIIEL risk by 3.1 times. Angulated and calcified neck, large aneurysms and the use of nonproprietary graft extension were found as independent risk factors for TIIIEL. Patients implanted with these devices and with these anatomical features should be intensively monitored during follow-up.
BACKGROUND: Despite advancements in endovascular materials and techniques, an open conversion (OC) after endovascular aneurysm repair (EVAR) is sometimes still required. The aim of this study was to report the early results of a national registry on OC after EVAR, describing the characteristics of the population that currently requires these technically challenging operations.METHODS: The iConveRt (Italian Conversion Registry) started in January 2022, including 21 vascular centers. All consecutive patients undergoing OC were prospectively included. We collected data pre-operatively, post-operatively, at one-month follow-up, and at each follow-up evaluation. We included all patients operated on until December 2022; we analyzed and reported early and in-hospital results.RESULTS: We included 74 patients with a mean age of 77.81±6.32 years (93.24% males). Median time elapsed from initial EVAR was 74.07 months (IQR 48.93-108). Endovascular repair was attempted in 59.46% (44/74) prior to LOC. Median aneurysm diameter at conversion was 80 mm (IQR 61-89). The main indication for LOC was the presence of an endoleak (62/75, 83.78%). Complex EVAR was present in 6/74 (8.11%) of the patients. Fifty-two patients (70.27%) underwent partial endograft explantation. Overall 30-day death rate was 14.86% (11/74). Thirty-day mortality was 20.83% for urgent cases vs. 12% for elective cases. In-hospital mortality was 17.57% (13/74).CONCLUSIONS: Current OC after EVAR seem to be different if compared to previous reports from 2000s and 2010s. They are performed later, patients present with larger aneurysms, and we are also starting to face the need of complex EVAR explantations.
Our goal was to achieve complete proximal sealing in severe aortic neck angulation (SNA) during endovascular aneurysm repair (EVAR) of a patient with an abdominal aortic aneurysm (AAA) unfit for surgery. An 82-year-old patient with an infrarenal AAA of 9.8 cm with an SNA of 90° was admitted for acute coronary syndrome. Following coronary treatment, the patient was considered unfit for surgery and therefore was evaluated for EVAR. Aneurysm sac exclusion was obtained with the deployment of a Powerlink bifurcated graft (Endologix Inc, Irvine, CA) inside a Relay thoracic endograft (Bolton Medical, Florida) placed just below the most distal renal artery. At 6 months, computed tomographic angiography confirmed correct graft placement, complete aneurysm exclusion, and a reduction in the aneurysmal sac. In AAA patients with an SNA at high risk of EVAR failure, the adaptability of a thoracic endograft could be considered for proximal sealing.
ObjectiveTo report outcomes of urgent juxtarenal/pararenal aneurysms (J/P-AAAs) managed by off-the-shelf multibranched thoracoabdominal endografts (Cook, T-branch).MethodsIn this observational, multicenter, retrospective study, patients with J/P-AAAs treated by urgent endovascular repair by T-branch in 23 European aortic centers, from 2013 to 2023, were analyzed. Contained J/P-AAAs rupture, presence of related symptoms, and aneurysm diameter of >70 mm were considered as indication for urgent repair. Technical success (TS), spinal cord ischemia (SCI), and 30-day/hospital mortality were assessed as early outcomes. Survival, freedom from reinterventions, and target artery instability (TAI) were evaluated during follow-up.ResultsOverall, 197 patients (J-AAAs, n = 64 [33%]; P-AAAs, n = 95 [48%]; previous failed endovascular aneurysm repair (EVAR), n = 38 [19%]) were analyzed. The mean age and aneurysm diameter was 75 ± 8 years and 76 ± 4 mm, respectively. The American Society of Anesthesiologists score was 3 and 4 in 118 (60%) and 79 (40%) patients. Rupture, symptoms, and diameter of >70 mm were present in 51 (26%), 110 (56%), and 53 (27%) patients, respectively. An adjunctive proximal thoracic endograft was used in 28 cases (14%). The mean aortic coverage between the upper portion of the endograft and the lowest renal artery was 154 ± 49 mm. Single-stage repair and cerebrospinal fluid drainage were reported in 144 (73%) and 53 (27%) cases, respectively. TS was achieved in 182 (92%) cases (rupture, 84% vs no rupture, 95%; P = .02). Failures consist of TA loss (11 [6%]: renal artery, 9; celiac trunk, 2), type I to III endoleaks (2 [1%]), and 24-h mortality (2 [1%]). Rupture was a risk factor for technical failure (P = .02; odds ratio [OR], 3.8; 95% confidence interval [CI], 1.1-12.1). Overall, 15 patients (8%) had persistent SCI (rupture, 14% vs no rupture, 5%) with 11 (6%) , of paraplegia (rupture, 10% vs no rupture, 5%; P = .001). Rupture (P = .04; OR, 3.1; 95% CI, 1.1-8.9) and adjunctive proximal thoracic endograft (P = .01; OR, 4.1; 95% CI, 1.3-12.9) were risk-factors for SCI. Twenty-two patients (11%) died within 30 days or during a prolonged hospitalization. Previous failed EVAR (P = .04; OR, 3.6; 95% CI, 1.1-12.3), paraplegia (P < .001; OR, 9.9; 95% CI, 1.6-62.2) and postoperative mesenteric complications (P = .03; OR, 10.4; 95% CI, 1.2-93.3), as well as cardiac (P = .03; OR, 8.2; 95% CI, 2.0-33.0) and respiratory (P < .001; OR, 10.1; 95% CI, 2.9-35.2) morbidities were associated with 30-day/hospital mortality. The mean follow-up was 19 ± 5 months. The estimated 3-year survival and freedom from reinterventions was 58% and 77%, respectively. TAI occurred in 27 patients (14%) (occlusion, 15; endoleak, 14) with an estimated 3-year freedom from TAI of 72%.ConclusionsUrgent repair of J/P-AAAs by T-branch is feasible and effective with satisfactory TS and 30-day/hospital mortality in high-risk patients. However, extensive aortic coverage is necessary, leading to a non-negligible SCI rate, especially in case of aortic rupture or when adjunctive thoracic endografts are necessary. Previous failed EVAR and postoperative mesenteric complications, as well as cardiac and respiratory morbidities were associated with 30-day/hospital mortality and should be subjected to more research for the purposes of improving outcomes.
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