The incidence and fate of endoleaks vary between ruptured and elective endovascular abdominal aortic aneurysm repair.

The number of ruptured abdominal aortic aneurysm (r-AAA) patients who are treated by endovascular means is increasing as ruptured endovascular aneurysm repair (r-EVAR) enters the mainstream. However, even today, data on the incidence and behavior of endoleaks after r-EVAR are scarce. This study analyzed whether endoleaks behave differently after EVAR for rupture vs elective AAA repair. From 2002 to 2013, there were 2052 patients who underwent EVAR for treatment of rupture (n = 166 [8.1%]) and elective repair (n = 1886 [91.9%]) of infrarenal AAA. Follow-up included computed tomography angiography at 1 month, at 6 months, and yearly thereafter. All type I and type III endoleaks were treated at the time of or shortly after the diagnosis. Persistent type II endoleaks at >6 months after EVAR without a decrease in AAA sac underwent translumbar or transfemoral embolization procedures. Data were prospectively collected in a vascular database. During a mean follow-up of 30 months, patients had a significantly lower incidence of type II endoleaks after r-EVAR compared with elective endovascular aneurysm repair (e-EVAR; n = 15 [9.0%] vs n = 380 [20.2%]; P < .01). Although the incidence of type I endoleaks is similar after r-EVAR (n = 9 [5.4%] and e-EVAR (n = 83 [4.4%]; P = .68), the r-EVAR patients required stent graft explantation more frequently (n = 9 [5.4%] vs n = 20 [1.1%]; P < .01). Whereas the need for secondary intervention was comparable in both r-EVAR (n = 33 [19.9%]) and e-EVAR (n = 439 [23.3%]; P = .37) groups, patients undergoing percutaneous embolization procedures trended toward significance between the two groups (n = 11 [6.6%] vs n = 216 [11.5%]; P = .06) with endoleaks. Compared with e-EVAR, patients who undergo r-EVAR experience a similar incidence of type I endoleaks and a significantly lower incidence of type II endoleaks. The endoleaks in both e-EVAR and r-EVAR patients can frequently be managed by endovascular means. However, r-EVAR patients with type I and type II endoleaks are at a significantly higher risk for stent graft explantation.

Quinn AA ，Mehta M ，Teymouri MJ ，Keenan ME ，Paty PSK ，Zhou Y ，Chang BB ，Feustel P ... -  《-》

A 15-Year Single-Center Experience of Endovascular Repair for Elective and Ruptured Abdominal Aortic Aneurysms.

To evaluate the differences in technical outcomes and secondary interventions between elective endovascular aneurysm repair (el-EVAR) procedures and those for ruptured aneurysms (r-EVAR). Of the 906 patients treated with primary EVAR from September 1998 until July 2012, 43 cases were excluded owing to the use of first-generation stent-grafts. Among the remaining 863 patients, 773 (89.6%) patients (mean age 72 years; 697 men) with asymptomatic or symptomatic abdominal aortic aneurysms (AAAs) were assigned to the el-EVAR group; 90 (10.4%) patients (mean age 73 years; 73 men) were assigned to the r-EVAR group based on blood outside the aortic wall on preoperative imaging. The primary study outcome was technical success; secondary endpoints, including freedom from secondary interventions and late survival, were examined with Kaplan-Meier analyses. At baseline, r-EVAR patients had larger aneurysms on average (p<0.001) compared to el-EVAR patients. Technical success was comparable (p=0.052), but there were more type Ia endoleaks at completion angiography in the r-EVAR group (p=0.038). As anticipated, more patients died in the first month in the r-EVAR group (18.9% vs 2.2% el-EVAR, p<0.001). At 5 years, there was an overall survival of 65.1% for the el-EVAR patients vs 48.1% in the r-EVAR group (p<0.001). The freedom from AAA-related mortality was 95.7% for el-EVAR and 71.0% for r-EVAR (p<0.001). Five-year freedom from type I/III endoleaks was significantly lower in the r-EVAR group (78.7% vs 90.0%, p=0.003). Five-year freedom from secondary intervention estimates were not significantly different (el-EVAR 84.2% vs r-EVAR 78.2%, p=0.064). Within our cohort of primary EVAR patients, r-EVAR cases showed comparable stent-graft-related technical outcome. Although there was a higher incidence of type Ia endoleaks on completion angiography in the r-EVAR group, the overall secondary intervention rate was comparable to el-EVAR.

Broos PP ，'t Mannetje YW ，Stokmans RA ，Houterman S ，Corte G ，Cuypers PW ，Teijink JA ，van Sambeek MR ... -  《-》

Long-term follow-up of type II endoleak embolization reveals the need for close surveillance.

Aneurysm growth after endovascular aneurysm repair (EVAR) in patients with type II endoleak is associated with adverse outcomes. This study evaluated the long-term success of embolization of type II endoleaks in preventing aneurysm sac growth. We retrospectively reviewed outcomes of patients who underwent infrarenal EVAR who were treated for a type II endoleak between 2000 and 2008. Computed tomography scans were evaluated for aneurysm sac growth or shrinkage from the time of treatment of the endoleak. The embolization material used, graft type, target vessel embolized, and comorbidities were evaluated for their association with sac growth or shrinkage. Ninety-five patients underwent 140 embolization procedures. The mean time from EVAR to embolization was 26.1 ± 22.2 months, and the average increase in size of the aneurysm sac from EVAR to treatment was 0.7 × 0.5 cm. Patients underwent an average of 1.6 ± 0.8 embolization procedures after EVAR. Thirteen patients underwent initial simultaneous embolization of two targets. Embolization was with glue (61%), coils (29%), glue and coils (7%), and Gelfoam (3%; Pfizer Inc, New York, NY). No abdominal aortic aneurysms (AAA) ruptured. Eight patients (8.4%) underwent graft explant and open repair; 19 (20%) required two or more embolization procedures. There was no difference in the target vessel treated or the treatment used in halting sac expansion (>5 mm). Coil embolization alone resulted in more second procedures. The 5-year cumulative survival was 65% (95% confidence interval [CI], 52%-77%), freedom from explant was 89% (95% CI, 81%-97%), freedom from second embolization was 76% (95% CI, 66%-86%), and freedom from sac expansion >5 mm was 44% (95% CI 30%-50%). Univariable analysis identified continued tobacco use (hazard ratio [HR], 2.30; 95% CI, 1.02-5.13; P = .04) was associated with continued sac expansion, and hyperlipidemia (HR, 9.64; 95% CI, 2.22-41.86) was associated with patients requiring a second embolization procedure. Embolization of type II endoleaks is successful early in preventing aneurysm sac growth and rupture after EVAR. However, a significant number of patients require more than one procedure, and at 5 years, many patients who underwent embolization of a type II endoleak continued to experience sac growth. Patients with hyperlipidemia who undergo coil embolization are more likely to require a second embolization procedure, and patients who smoke have a higher likelihood of AAA sac expansion after embolization. Continued long-term surveillance is necessary in this cohort of patients.

Sarac TP ，Gibbons C ，Vargas L ，Liu J ，Srivastava S ，Bena J ，Mastracci T ，Kashyap VS ，Clair D ... -  《-》

Does Palmaz XL stent deployment for type 1 endoleak during elective or emergency endovascular aneurysm repair predict poor outcome? A multivariate analysis of 1470 patients.

Endovascular aneurysm repair (EVAR) is now the standard of care for elective infrarenal and ruptured abdominal aortic aneurysms (AAAs). Difficult proximal necks often require adjuvant measures to seal type 1 endoleaks. We believed this was a predictor of increased 30-day morbidity and mortality and reduced long-term survival. We reviewed outcomes for all patients entered into our database between 2003 and 2010 who had EVAR for elective or ruptured AAAs. Patient demographics and operative indications were recorded. Operative procedures, including adjuvant procedures, such as Palmaz XL stent deployment, were documented. All postoperative deaths and morbidity were recorded. Long-term survival was calculated using life table analysis. Multivariate analysis was performed to determine significant predictors of early mortality. Between 2003 and 2010, 1470 patients underwent EVAR for AAA (1378 [93.7%] elective; 92 [6.3%] ruptured or emergent). Elective EVAR patients required Palmaz stent placement in 146 of 1378 (10.6%) cases; in emergent cases, Palmaz stents were required in 16 of 92 (17.4%) cases. This was not significantly different (P=0.06). Thirty-day mortality for elective EVAR was 1.6% (22/1378) compared with 21.7% (20/92) for emergent repair (P<0.0001). Thirty-day mortality among the 146 elective patients undergoing Palmaz stenting was 3.4% compared with 1.4% in the 1232 non-Palmaz stent elective EVAR patients (P=0.085). In emergency cases, the 30-day mortality for the 16 Palmaz patients was 25% compared to 21% for the 76 non-Palmaz stent patients (P=0.76). Among 30-day survivors, there were 428 of 1356 (31.6%) endoleaks identified in the elective patient group and 36 of 72 (50%) in the emergency group (P<0.005). Of the 146 elective patients requiring insertion of a Palmaz stent, 65 (44%) developed endoleaks, significantly more than the 370 of 1232 (30%) in non-Palmaz elective patients (P=0.0004). Among the emergency group, there were also significantly more endoleaks among the 30-day survivors who had a Palmaz stent deployed. In elective EVAR requiring Palmaz XL stents, 14% still had type 1 endoleaks at the end of their procedure; 13% still had type 1 endoleaks in the rupture EVAR Palmaz group. Multivariate analysis of all patients found that while female sex, AAA diameter, and estimated blood loss predicted 30-day mortality, deployment of a Palmaz stent did not. Long-term survival among Palmaz patients was not significantly different from non-Palmaz patients in the elective or emergent setting, although Palmaz patients required more secondary interventions. During EVAR, deployment of a Palmaz stent is more frequently required in patients with rupture, female sex, and larger sac size. However, Palmaz stent deployment itself is not an independent predictor of increased 30-day mortality in either the elective or emergency setting or of poorer long-term survival. However, they are associated with a greater number of postoperative endoleaks, especially type 1 endoleaks, and predict a greater need for secondary interventions.

Byrne J ，Mehta M ，Dominguez I ，Paty PS ，Roddy SP ，Feustel P ，Sternbach Y ，Darling RC ... -  《-》

Fourteen-year outcomes of abdominal aortic endovascular repair with the Zenith stent graft.

Long-term results of abdominal aortic aneurysm (AAA) endovascular repair are affected by graft design renewals that tend to improve the performance of older generation prostheses but usually reset the follow-up times to zero. The present study investigated the long-term outcomes of endovascular AAA repair (EVAR) using the Zenith graft, still in use without major modification, in a single center experience. Between 2000 and 2011, 610 patients underwent elective EVAR using the Zenith endograft (Cook Inc, Bloomington, Ind) and represent the study group. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA-related death. Secondary outcomes included freedom from late (>30 days) reintervention, freedom from late (>30 days) conversion to open repair, freedom from aneurysm sac enlargement >5.0 mm and freedom from EVAR failure, defined as a composite of AAA-related death, AAA rupture, AAA growth >5 mm, and any reintervention. Mean age was 73.2 years. Mean aneurysm diameter was 55.3 mm. There were five perioperative deaths (0.8%) and three intraoperative conversions. At a mean follow-up of 99.2 (range, 0-175) months, seven AAA ruptures occurred, all fatal except one. Overall survival was 92.8% ± 1.1% at 1 year, 70.1% ± 1.9% at 5 years, 37.8% ± 2.9% at 10 years, and 24 ± 4% at 14 years. Freedom from AAA-rupture was 99.8% ± 0.02 at 1 year (one case), 99.4% ± 0.04 at 5 years (three cases), and 98.1% ± 0.07 at 10 and 14 years. Freedom from late reintervention and conversion was 98% ± 0.6 at 1 year, 87.7% ± 1.5 at 5 years, 75.7% ± 3.2 at 10 years, and 69.9% ± 5.2 at 14 years. Freedom from aneurysm sac growth >5.0 mm was 99.8% at 1 year, 96.6% ± 0.7 at 5 years, 81.0% ± 3.4 at 10 years, and 74.1% ± 5.8% at 14 years. EVAR failure occurred in 132 (21.6%) patients at 14 years. At multivariate analysis, independent predictors of EVAR failure resulted type I and III endoleak (hazard ratio [HR], 6.7; 95% confidence interval [CI], 4.6- 9.7; P < .001], type II endoleak (HR, 2.3; 95% CI, 1.6-3.4; P < .001), and American Society of Anesthesiologists grade 4 (HR, 1.6; 95% CI, 1.0-2.6; P = .034). EVAR with Zenith graft represents a safe and durable repair. Risk of rupture and aneurysm-related death is low, whereas overall long-term survival remains poor. Novel endograft models should be tested and evaluated considering that one-fourth of the operated patients will still be alive after 14 years.

Verzini F ，Romano L ，Parlani G ，Isernia G ，Simonte G ，Loschi D ，Lenti M ，Cao P ... -  《-》