Impact of Significant Sac Shrinkage on Endograft Tortuosity at 5 Years Postendovascular Aortic Aneurysm Repair: A Retrospective Analysis.
Significant sac shrinkage after endovascular aortic aneurysm repair (EVAR) is generally considered a positive outcome indicative of durable clinical success. However, its impact on endograft configuration is rarely addressed. Sac remodeling and volume loss due to shrinkage can potentially cause deformation of endograft components, resulting in limb angulation and compression. We investigated the hypothesis that significant sac shrinkage could affect endograft tortuosity at 5 years post-EVAR.
We retrospectively reviewed patients who underwent elective EVAR for infrarenal abdominal aortic aneurysm between June 2007 and December 2018. Patients with early postoperative and 5-year follow-up computed tomography images were included. Patients treated with modular bifurcated endografts (Zenith, Endurant, Excluder, and Incraft) were analyzed. The "shrinkage" group comprised patients with >10 mm diameter reduction, while the "stable" group had ± 5 mm diameter change at 5 years. Tortuosity index (TI) was calculated as the ratio of centerline distance to straight-line distance between proximal and distal endograft edges. The association between sac shrinkage and ≥5% increase of TI (≥5%ΔTI) was analyzed for both ipsilateral and contralateral sides.
Of 136 patients enrolled, 80 were in the shrinkage group and 56 in the stable group. On the ipsilateral side, ≥5%ΔTI was observed in 24 cases (17.6%). The patients with ipsilateral ≥5%ΔTI had significantly shorter median neck lengths (22 mm vs. 30 mm, P = 0.030). Sac shrinkage ≥15 mm was negatively associated with ≥5%ΔTI compared to stable sac (P = 0.027). Logistic regression showing sac shrinkage ≥15 mm had a significant negative correlation with ≥5%ΔTI (P = 0.025, hazard ratio [95% confidence interval]: 0.218 [0.057-0.824]). On the contralateral side, ≥5%ΔTI (19 cases, 14.0%) was associated with shorter neck length but not with sac shrinkage. In the shrinkage group, cross-leg positioning resulted in a significant increase in ipsilateral TI at 5 years compared to straight positioning (median ΔTI: 1.8% vs. 0.0%, P = 0.013). No reinterventions for leg-related events were necessary during the 5-year follow-up period.
Contrary to our initial hypothesis, significant sac shrinkage does not adversely affect endograft configuration and may help stabilize tortuosity on the ipsilateral side. However, in patients with crossed-leg configuration, continued vigilant observation may be warranted even after achieving sac shrinkage, as it could exacerbate tortuosity. Shorter neck length was associated with increased tortuosity on both sides. Further research is needed to confirm these findings and consider potential confounding factors, including the impact of different endograft designs.
Sugimoto M
，Osawa T
，Lee C
，Ikeda S
，Kawai Y
，Niimi K
，Banno H
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Impact of Intraoperative Branch Embolization for Type 2 Endoleak Prevention During Endovascular Abdominal Aortic Repair.
Endovascular abdominal aortic repair (EVAR) has a significantly higher revision rate than open repair, primarily due to type 2 endoleak (2EL). Although 2ELs are considered benign, late open conversion (LOC) due to the expansion of the aneurysm diameter of the 2EL is a concern in the mid- and long-term. In this study, we investigated the impact of embolization of the inferior mesenteric artery (IMA) or lumbar artery (LA) at the time of the initial EVAR and its long-term outcomes.
Between April 2008 and December 2021, 743 EVAR procedures for abdominal aortic aneurysms were performed at our institution. The patients were divided into 2 groups at the time of initial surgery, namely, 215 and 528 patients in the embolization (Group E) and nonembolization (Group N) groups, respectively. Branch embolization was performed in patients with an IMA diameter ≥3 mm and LA diameter ≥2 mm on preoperative computed tomography. Re-embolization with EL was performed in patients with a diameter enlargement ≥10 mm, and LOC was performed in patients with continued enlargement ≥15 mm after re-embolization. The mean follow-up period was 7.0 years.
The mean number of branch embolizations was 2.3 ± 1.1. Intraoperatively, the operative time, fluoroscopy time, irradiation dose, and contrast medium use were significantly higher in Group E than in Group N. There was a significant difference between the 2 groups regarding shrinkage (Group E versus Group N: 45.6% versus 37.3%; P = 0.03) and enlargement (Group E versus Group N: 9.3% vs. 19.5%; P < 0.001) of the aneurysm diameter by > 5 mm after EVAR. In the mid- and long-term, the avoidance rate of 2EL reintervention was significantly lower in Group E at 5 years (93.5% vs. 88.6%) and 10 years (87.5% vs. 76.4%; P = 0.04). LOC prevention was 5 years; Group E: 100% vs. 96.9% for Group N and 10 years; Group E: 98.8% vs. 92.5% for Group N, significantly lower in Group E (P = 0.02).
The impact of branch embolization at the time of the initial EVAR is believed to prevent enlargement of the aneurysmal sac and LOC. However, prolonged operation time, increased radiation exposure, and the use of contrast medium have been debated. To improve the long-term results of EVAR, embolisms of both the IMA and LA are required.
Takazawa A
，Asakura T
，Nakazawa K
，Tokunaga C
，Yoshitake A
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Comparison of Two Modern Survival Prediction Tools, SORG-MLA and METSSS, in Patients With Symptomatic Long-bone Metastases Who Underwent Local Treatment With Surgery Followed by Radiotherapy and With Radiotherapy Alone.
Survival estimation for patients with symptomatic skeletal metastases ideally should be made before a type of local treatment has already been determined. Currently available survival prediction tools, however, were generated using data from patients treated either operatively or with local radiation alone, raising concerns about whether they would generalize well to all patients presenting for assessment. The Skeletal Oncology Research Group machine-learning algorithm (SORG-MLA), trained with institution-based data of surgically treated patients, and the Metastases location, Elderly, Tumor primary, Sex, Sickness/comorbidity, and Site of radiotherapy model (METSSS), trained with registry-based data of patients treated with radiotherapy alone, are two of the most recently developed survival prediction models, but they have not been tested on patients whose local treatment strategy is not yet decided.
(1) Which of these two survival prediction models performed better in a mixed cohort made up both of patients who received local treatment with surgery followed by radiotherapy and who had radiation alone for symptomatic bone metastases? (2) Which model performed better among patients whose local treatment consisted of only palliative radiotherapy? (3) Are laboratory values used by SORG-MLA, which are not included in METSSS, independently associated with survival after controlling for predictions made by METSSS?
Between 2010 and 2018, we provided local treatment for 2113 adult patients with skeletal metastases in the extremities at an urban tertiary referral academic medical center using one of two strategies: (1) surgery followed by postoperative radiotherapy or (2) palliative radiotherapy alone. Every patient's survivorship status was ascertained either by their medical records or the national death registry from the Taiwanese National Health Insurance Administration. After applying a priori designated exclusion criteria, 91% (1920) were analyzed here. Among them, 48% (920) of the patients were female, and the median (IQR) age was 62 years (53 to 70 years). Lung was the most common primary tumor site (41% [782]), and 59% (1128) of patients had other skeletal metastases in addition to the treated lesion(s). In general, the indications for surgery were the presence of a complete pathologic fracture or an impending pathologic fracture, defined as having a Mirels score of ≥ 9, in patients with an American Society of Anesthesiologists (ASA) classification of less than or equal to IV and who were considered fit for surgery. The indications for radiotherapy were relief of pain, local tumor control, prevention of skeletal-related events, and any combination of the above. In all, 84% (1610) of the patients received palliative radiotherapy alone as local treatment for the target lesion(s), and 16% (310) underwent surgery followed by postoperative radiotherapy. Neither METSSS nor SORG-MLA was used at the point of care to aid clinical decision-making during the treatment period. Survival was retrospectively estimated by these two models to test their potential for providing survival probabilities. We first compared SORG to METSSS in the entire population. Then, we repeated the comparison in patients who received local treatment with palliative radiation alone. We assessed model performance by area under the receiver operating characteristic curve (AUROC), calibration analysis, Brier score, and decision curve analysis (DCA). The AUROC measures discrimination, which is the ability to distinguish patients with the event of interest (such as death at a particular time point) from those without. AUROC typically ranges from 0.5 to 1.0, with 0.5 indicating random guessing and 1.0 a perfect prediction, and in general, an AUROC of ≥ 0.7 indicates adequate discrimination for clinical use. Calibration refers to the agreement between the predicted outcomes (in this case, survival probabilities) and the actual outcomes, with a perfect calibration curve having an intercept of 0 and a slope of 1. A positive intercept indicates that the actual survival is generally underestimated by the prediction model, and a negative intercept suggests the opposite (overestimation). When comparing models, an intercept closer to 0 typically indicates better calibration. Calibration can also be summarized as log(O:E), the logarithm scale of the ratio of observed (O) to expected (E) survivors. A log(O:E) > 0 signals an underestimation (the observed survival is greater than the predicted survival); and a log(O:E) < 0 indicates the opposite (the observed survival is lower than the predicted survival). A model with a log(O:E) closer to 0 is generally considered better calibrated. The Brier score is the mean squared difference between the model predictions and the observed outcomes, and it ranges from 0 (best prediction) to 1 (worst prediction). The Brier score captures both discrimination and calibration, and it is considered a measure of overall model performance. In Brier score analysis, the "null model" assigns a predicted probability equal to the prevalence of the outcome and represents a model that adds no new information. A prediction model should achieve a Brier score at least lower than the null-model Brier score to be considered as useful. The DCA was developed as a method to determine whether using a model to inform treatment decisions would do more good than harm. It plots the net benefit of making decisions based on the model's predictions across all possible risk thresholds (or cost-to-benefit ratios) in relation to the two default strategies of treating all or no patients. The care provider can decide on an acceptable risk threshold for the proposed treatment in an individual and assess the corresponding net benefit to determine whether consulting with the model is superior to adopting the default strategies. Finally, we examined whether laboratory data, which were not included in the METSSS model, would have been independently associated with survival after controlling for the METSSS model's predictions by using the multivariable logistic and Cox proportional hazards regression analyses.
Between the two models, only SORG-MLA achieved adequate discrimination (an AUROC of > 0.7) in the entire cohort (of patients treated operatively or with radiation alone) and in the subgroup of patients treated with palliative radiotherapy alone. SORG-MLA outperformed METSSS by a wide margin on discrimination, calibration, and Brier score analyses in not only the entire cohort but also the subgroup of patients whose local treatment consisted of radiotherapy alone. In both the entire cohort and the subgroup, DCA demonstrated that SORG-MLA provided more net benefit compared with the two default strategies (of treating all or no patients) and compared with METSSS when risk thresholds ranged from 0.2 to 0.9 at both 90 days and 1 year, indicating that using SORG-MLA as a decision-making aid was beneficial when a patient's individualized risk threshold for opting for treatment was 0.2 to 0.9. Higher albumin, lower alkaline phosphatase, lower calcium, higher hemoglobin, lower international normalized ratio, higher lymphocytes, lower neutrophils, lower neutrophil-to-lymphocyte ratio, lower platelet-to-lymphocyte ratio, higher sodium, and lower white blood cells were independently associated with better 1-year and overall survival after adjusting for the predictions made by METSSS.
Based on these discoveries, clinicians might choose to consult SORG-MLA instead of METSSS for survival estimation in patients with long-bone metastases presenting for evaluation of local treatment. Basing a treatment decision on the predictions of SORG-MLA could be beneficial when a patient's individualized risk threshold for opting to undergo a particular treatment strategy ranged from 0.2 to 0.9. Future studies might investigate relevant laboratory items when constructing or refining a survival estimation model because these data demonstrated prognostic value independent of the predictions of the METSSS model, and future studies might also seek to keep these models up to date using data from diverse, contemporary patients undergoing both modern operative and nonoperative treatments.
Level III, diagnostic study.
Lee CC
，Chen CW
，Yen HK
，Lin YP
，Lai CY
，Wang JL
，Groot OQ
，Janssen SJ
，Schwab JH
，Hsu FM
，Lin WH
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ResearchGate
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钛学术
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