Editor's Choice - Ten-year Experience with Endovascular Repair of Thoracoabdominal Aortic Aneurysms: Results from 166 Consecutive Patients.

OBJECTIVE: To present a 10 year experience with endovascular thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent grafts. MATERIALS AND METHODS: Consecutive patients with TAAA treated with fenestrated and branched stent grafts within the period January 2004-December 2013. Data were collected prospectively. RESULTS: 166 patients (125 male, 41 female, mean age 68.8 ± 7.6 years) were treated. The mean TAAA diameter was 71 ± 9.3 mm. Types of TAAA were: type I, n = 12 (7.2%), type II, n = 50 (30.1%), type III, n = 53 (31.9%), type IV, n = 41 (24.8%), and type V, n = 10 (6%). Fifteen (9%) patients had an acute TAAA (11 contained rupture, 4 symptomatic). One hundred and eight (65%) patients were refused for open surgery earlier. Seventy eight (47%) patients had previously undergone one or more open/endovascular aortic procedures. Technical success was 95% (157/166). Thirty day operative mortality was 7.8% (13/166), with an in hospital mortality of 9% (15/166). Peri-operative spinal cord ischemia (SCI) was observed in 15 patients (9%), including permanent paraplegia in two (1.2%). Mean follow up was 29.2 ± 21 months. During follow up 40 patients died, two of them probably from aneurysm related cause. Re-intervention, mostly by endovascular means, was needed in 40 (24%) patients. Estimated survival at 1, 2, and 5 years was 83% ± 3%, 78% ± 3.5%, and 66.6% ± 6.1%, respectively. Estimated target vessel stent patency at 1, 2, and 5 years was 98% ± 0.6%, 97% ± 0.8%, and 94.2% ± 1.5%, respectively. Estimated freedom from re-intervention at 1 and 3 years was 88.3% ± 2.7%, and 78.4% ± 4.5%, respectively. CONCLUSIONS: Endovascular repair of TAAA with fenestrated and branched stent grafts in high volume centers appears safe and effective in the mid-term in a high risk patient cohort. A considerable reintervention rate should be acknowledged, however.

Fenestrated stent-grafts for salvage of prior endovascular abdominal aortic aneurysm repair.

OBJECTIVES: To review our experience with fenestrated endovascular aneurysm repair (F-EVAR) to treat complications after previous standard infrarenal endovascular aneurysm repair (EVAR). METHODS: A prospectively maintained database including all consecutive patients with juxtarenal abdominal aortic aneurysm that were treated with F-EVAR after failed previous EVAR within the period March 2002 to November 2012 at the University Medical Center of Groningen, Netherlands (up to October 2009), and the Klinikum Nürnberg Süd, Germany (from November 2009) was analyzed. Evaluated outcomes included initial technical success, operative mortality and morbidity, and late procedure-related events with regard to survival, target vessel patency, endoleak, renal function, and reintervention. RESULTS: A total of 26 patients (24 male, mean age 73.2 ± 6.5 years) were treated. All patients had proximal anatomies precluding endovascular reintervention with standard techniques. In 23 patients a fenestrated proximal cuff was used, and in three patients a bifurcated fenestrated stent graft. Technical success was achieved in 24 (92.3%) patients. One patient required on-table open conversion because of impossibility to retrieve the top cap as a result of twist of the ipsilateral limb. In the second patient the right kidney was lost due to inadvertent stenting in a smaller branch of the renal artery. Catheterization difficulties, all related to the passage through the limbs or struts of the previous stent graft, were encountered in 11 (42.3%) cases, including five (19.2%) patients with iliac access problems and six (23.1%) with challenging renal catheterization. Operative target vessel perfusion success rate was 94.6% (70/74). Operative mortality was 0%. Mean follow-up was 26.8 ± 28.5 months. No proximal type I endoleak was present on first postoperative CTA. The mean aneurysm maximal diameter decreased from 73 ± 20 mm to 66.7 ± 21 mm (p < .05). There were six late deaths, one of them aneurysm related. Estimated survival rates at 1 and 2 years were 94.1 ± 5.7% and 87.4 ± 8.4%, respectively. Patency during follow-up for the target vessels treated successfully with a fenestrated stent graft was 100% (70/70). Reintervention was required in four cases, including one acute conversion due to rupture, one for iliac limb occlusion and two for type Ib and II endoleak. Renal function deterioration was observed solely in the two cases of primary technical failure. CONCLUSIONS: F-EVAR represents a feasible option for the repair of juxtarenal abdominal aortic aneurysm after prior EVAR failure. It is advantageous in terms of mortality and less morbid than open surgery, but is associated with increased technical challenges because of the previously placed stent graft. Outcome seems related to initial technical success.

Type 2 diabetes mellitus is associated with an imbalance in circulating endothelial and smooth muscle progenitor cell numbers.

AIMS/HYPOTHESIS: Individuals with type 2 diabetes mellitus have increased rates of macrovascular disease (MVD). Endothelial progenitor cells (EPCs), circulating angiogenic cells (CACs) and smooth muscle progenitor cells (SMPCs) are suggested to play a role in the pathogenesis of MVD. The relationship between vasoregenerative EPCs or CACs and damaging SMPCs and the development of accelerated MVD in diabetes is still unknown. We tried to elucidate whether EPC, CAC and SMPC numbers and differentiation capacities in vitro differ in patients with and without diabetes or MVD. METHODS: Peripheral blood was obtained from individuals with and without diabetes and MVD (coronary or peripheral artery disease). EPC and SMPC numbers were determined with flow cytometry. Furthermore, CAC and SMPC numbers were quantified after in vitro culture. Their in vitro differentiation capacity was investigated with real-time RT-PCR and quantitative immunofluorescence. RESULTS: In diabetic patients both EPC and CAC levels were reduced (1.3-fold [p < 0.05] and 1.5-fold [p < 0.05], respectively). CAC outgrowth from diabetic patients with MVD was reduced 1.5-fold compared with diabetic patients without MVD (p < 0.05). SMPC levels were similar between diabetic patients and healthy controls. The CAC/SMPC ratio of in vitro cultured progenitor cells was reduced 2.3-fold in samples from diabetic patients (p < 0.001). The differentiation capacity of CACs and SMPCs in vitro remained similar independently of diabetes or MVD. CONCLUSIONS/INTERPRETATION: The ratio between EPCs or CACs and SMPCs is disturbed in type 2 diabetes in favour of SMPCs. This may translate into reduced vascular repair capacity, thereby promoting MVD in type 2 diabetes.

[Results of endovascular repair of TAAA in the first 50  patients]. / Bericht über die ersten 50 endovaskulären thorako-abdominellen Behandlungen mit Seitenarmprothesen.

BACKGROUND: Developments with fenestrated and branched stent grafts have opened the way to treat complex aortic aneurysms involving the visceral arteries. First reports on endovascular treatment of thoracoabdominal aneurysms have demonstrated the feasibility of the technique. METHODS: A literature review and results of first 50  patients treated with a custom-made Zenith device with fixed branches are presented. Most of the patients were refused open surgery mainly for the extent of the disease combined with co-morbidity, which included in most patients a combination of several risk factors. Mean aneurysm size was 71 mm and extent of the aneurysm was type  I (n = 9), type  II (n = 13), type  III (n = 19), and type  IV (n = 9), respectively. RESULTS: Primary and primary assisted technical successes in our series were 88 % (44 / 50) and 92 % (46 / 50), respectively. One patient died on day  1 from an intraoperative aneurysm rupture. In two patients a renal artery was lost, one due to rupture and one due to malpositioning of the bridging stent graft. In a fourth patient, a celiac artery could not be catheterised and was lost. Finally, in two more patients, catheterisation of in total three renal arteries proved impossible. This was solved by a retrograde approach for two renal arteries via laparotomy in one patient, and a spleno-renal bypass in the other patient. Thirty-day mortality was 8 %. Estimated survival at 6  months, 1  year, and 2  years was 91.2 %, 79.8 %, and 69.7 %, respectively. Freedom of reintervention of all kinds at 1 and 2  years was 81.9 % and 73.7 %, respectively. CONCLUSION: Results of fully endovascular repair of thoracoabdominal aneurysms in a high-risk cohort are promising. A learning curve should be expected. Although longer term results need to be awaited, it is likely that endovascular repair of thoracoabdominal aneurysms will become a preferential treatment option for many patients in the future.

Mortality of ruptured abdominal aortic aneurysm with selective use of endovascular repair.

The aim of this review was to examine the results over a seven-year period of treatment for ruptured abdominal aortic aneurysm (RAAA). From 2002 on, our tertiary referral centre offered both open and endovascular (EVAR) treatment modalities for RAAA. All patients with a proven RAAA who were admitted into our hospital were included. Primary outcome measure was surgical mortality. In total 261 patients were admitted with suspicion of acute AAA. Of these, 175 (67%) had a RAAA, confirmed by computed tomography-scanning or at laparotomy. One hundred and fifty-nine patients (90.9%) were treated, 114 by open repair and 45 by EVAR. Overall mortality of patients treated was 25.2%, with an open repair mortality of 27.2%, and EVAR mortality of 20%. EVAR was used more often in patients who were hemodynamically more stable. Evaluation for EVAR and treatment by EVAR increased during the study period. Overall mortality rate for treatment of RAAA in our centre was 25% over the seven-year study period.