Female sex is associated with comparable 5-year outcomes after contemporary endovascular aneurysm repair despite more challenging anatomy.

BACKGROUND: Women with abdominal aortic aneurysms less often meet anatomic criteria for endovascular repair and experience worse perioperative and long-term survival. METHODS: We compared long-term survival, aneurysm-related mortality, and rates of endoleaks and reinterventions between male and female patients in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) using 2:1 propensity score matching. RESULTS: There were 1130 male patients and 133 female patients, yielding 399 patients after matching (266 male patients, 133 female patients). Female patients were older, with smaller aneurysms, smaller iliac arteries, and shorter, more angulated necks, and they were more often treated outside the device instructions for use (all P < .001). Through 5 years, female patients experienced overall mortality comparable to that of well-matched male patients (34% vs 38%, respectively; hazard ratio, 0.89 [0.61-1.29]; P = .54) and lower aneurysm-related mortality (0% vs 3%; P = .047). Female patients experienced higher rates of any postoperative type IA endoleak through 5 years (10% vs 1%; P < .001) but comparable rates of secondary endovascular procedures (14% vs 16%; P = .40). Female sex was independently associated with significantly higher risk of long-term type IA endoleaks (hazard ratio, 4.8 [1.2-20.8]; P = .04), even after accounting for anatomic factors. No female patient experienced aneurysm rupture during follow-up, and only one female patient underwent conversion to open repair. CONCLUSIONS: Despite more challenging anatomy, female patients in the ENGAGE registry had long-term outcomes comparable to those of male patients. However, female patients experienced higher rates of type IA endoleaks. Although standard endovascular aneurysm repair remains a viable solution for most women, whether high-risk patients may be better served with open surgery, custom-made devices, EndoAnchors (Aptus Endosystems, Sunnyvale, Calif), or chimneys is worthy of further study.

Patients with large neck diameter have a higher risk of type IA endoleaks and aneurysm rupture after standard endovascular aneurysm repair.

OBJECTIVE: Standard endovascular aneurysm repair (EVAR) is the most common treatment of abdominal aortic aneurysms (AAAs). EVAR has been increasingly used in patients with hostile neck features. This study investigated the outcomes of EVAR in patients with neck diameters ≥30 mm in the prospectively maintained Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE). METHODS: This is a retrospective study comparing patients with neck diameters ≥30 mm with patients with neck diameters <30 mm. The primary end point was type IA endoleak (EL1A). Secondary end points included secondary interventions to correct EL1A, aneurysm rupture, and survival. RESULTS: This study included 1257 patients (mean age, 73.1 years; 89.4% male) observed for a median 4.0 years (interquartile range, 2.7-4.8 years). A total of 97 (7.7%) patients had infrarenal neck diameters ≥30 mm and were compared with the remaining 1160 (92.3%) with neck diameters <30 mm. At baseline, there were no differences between groups regarding demographics and comorbidities other than cardiac disease, which was more frequent in the ≥30-mm neck diameter group (P = .037). There were no significant differences between the groups regarding neck length, angulation, thrombus, or calcification. Mean preoperative AAA diameter was 64.6 ± 11.3 mm in the ≥30-mm neck diameter group and 60.0 ± 11.6 mm in the <30-mm neck diameter group (P < .001). Stent graft oversizing was significantly less in the ≥30-mm neck diameter group (12.2% ± 8.9% vs 22.1% ± 11.9%; P <. 001). Five patients (5.2%) in the ≥30-mm neck diameter group and 30 (2.6%) with neck diameters <30 mm developed EL1A, yielding a 4-year freedom from EL1A of 92.4% vs 96.6%, respectively (P = .09). Oversizing was 21.8% ± 13.0% for patients developing EL1A and 21.3% ± 12.4% for the remaining cohort (P = .99). In adjusting for neck length, AAA diameter, and device oversizing, patients with neck diameter ≥30 mm were at greater risk for development of EL1A (hazard ratio, 3.0; 95% confidence interval, 1.0-9.3; P = .05). Secondary interventions due to EL1A did not differ between groups (P = .36). AAA rupture occurred in three patients with neck diameter ≥30 mm (3.1%) and in eight patients with neck diameter <30 mm (0.7%; hazard ratio, 5.1; 95% confidence interval, 1.4-19.2; P = .016); two cases were EL1A related in each group. At 4 years, overall survival was 61.6% for the ≥30-mm neck diameter group and 75.2% for the <30-mm neck diameter group (P = .009), which remained significant on correcting for sex and AAA diameter (P = .016). CONCLUSIONS: In this study, patients with infrarenal neck diameter ≥30 mm had a threefold increased risk of EL1A and fivefold risk of aneurysm rupture after EVAR as well as worse overall survival. This may influence the choice of AAA repair and underlines the need for regular computed tomography-based imaging surveillance in this subset of patients. Furthermore, these results can serve as standards with which new, possibly improved technology, such as EndoAnchors (Medtronic, Santa Rosa, Calif), can be compared.

Covered stents in iliac artery occlusive disease: what is the evidence?

The last two decades have seen a revolution in the treatment of aortoiliac occlusive disease (AIOD). Acceptable safety and durability outcomes have now been realized with endovascular treatments, which is increasingly finding a place in the treatment of AIOD. Evolution of stent technologies and endovascular techniques is seeing an expansion of AIOD lesions indicated for primary endovascular treatment. The literature evidence basis is continuously evolving, and questions remain as to the optimal form of vessel treatment. Covered stents have been increasingly promoted for their long-term durability, particularly in extensive, challenging AIOD lesions. Here, we explore the seminal evidence basis for covered stents in the treatment of AIOD, and aim to provide a sound evidence based argument for their use.

Stenting for carotid artery stenosis: fractures, proposed etiology and the need for surveillance.

PURPOSE: Carotid artery stenting is a relatively new intervention for the treatment of carotid artery stenosis, and the long-term outcomes and complications are therefore yet to be determined. In one surgeon's practice, it was found that a stent fracture was the etiological factor for recurrent stenosis. A retrospective study was therefore performed with the hypothesis that carotid stent fractures are common. The aims were to determine prevalence of fractures in this surgeon's series, risk factors, and most importantly, clinical relevance. METHODS: Patients from one surgeon's private practice who had carotid stenosis deemed suitable for intervention (>80% asymptomatic, >70% symptomatic, 50% to 70% if an ulcerated lesion) and had suitable aortic and carotid morphology for carotid stenting between March 2004 and December 2006 were included. To enhance the quality of the measurement, two vascular surgeons and one radiologist examined the films independently to determine if there was a fracture present. Given that this was a retrospective study, there was no preconceived sample size determined. RESULTS: Fracture prevalence was found to be 29.2% or 14 out of 48 stents. Restenosis occurred in 21% of those stents with a detected fracture, after an average follow-up of 15 months. Several anetiological factors are proposed, with a finding in this series, of a strong and significant association between the presence of calcified vessels and the presence of fractures (odds ratio 7.7; standard error 5.6; 95% confidence interval 1.9-32.0, P =.003). CONCLUSIONS: Although this is a small study, it demonstrates that carotid stent fractures do exist, and importantly, not all of them are benign. Therefore, the authors recommend regular surveillance with plain radiography in addition to duplex ultrasonography to enable early detection of fracturing. Following detection, institution of increased surveillance frequency and/or any appropriate intervention can be implemented, to aid in the prevention of complications resulting from restenosis should it become apparent.

Open endarterectomy of the SPT segment: an experience.

The purpose of the study was to evaluate the results of open endarterectomy in short atherosclerotic occlusions of the SPT segment (superficial femoral, popliteal, and tibioperoneal arteries). Retrospectively, records from July 1999 to June 2004 of patients who underwent open endarterectomy of lower limb arteries were verified; 63 patients with 66 lesions had open endarterectomy of the SPT segment as a primary procedure. At the time of this study, there were 57 patients alive and six dead, with the cause of death being unrelated to the procedure. The patients had a mean age of 71 +/- 10.73 years, and there were 18 females and 45 males. All patients underwent routine follow-up at 1, 3, 6, and 12 months and yearly thereafter. Routine clinical examination and ultrasound were done to assess the outcome. The mean length of endarterectomized superficial femoral artery was 7.42 +/- 3.66 cm (range 2-15). The lesions involved were the superficial femoral, popliteal, and tibioperoneal arteries (SPT segment). The primary cumulative patency rate by means of life-table analysis was 48.8% at 5 years (mean 12.7 months, range 1-60). During follow-up, percutaneous transluminal angioplasty was necessary in nine patients, for a primary assisted patency rate of 85.1% at 5 years. The location of recurrent stenoses after endarterectomy was usually at one of the ends of the endarterectomy site. Once a preferred technique, endarterectomy is now overshadowed by bypass procedures. Our clinical experience suggests that, in a select group of patients with SPT segment occlusions, open endarterectomy is technically feasible and should be used in cases with insufficient vein for bypass grafting. It also can be used as an alternative to allow the long saphenous vein to be reserved for a bypass procedure in the future.

Pulsating varicose veins!! The diagnosis lies in the heart.

Right heart failure is associated with increased systemic venous pressure, which can be diagnosed clinically with the findings of elevated jugular venous pressure, pulsatile liver and distinctive cardiac murmurs (precordial systolic). Severe tricuspid regurgitation (TR) has occasionally been known to lead to marked pulsation of varicose veins. We report three cases that were referred to the vascular clinic of Royal Perth Hospital in which the patients involved had unilateral (right leg) varicose veins and chronic venous ulcers. On clinical examination all three patients had pulsations along the course of the varicose long saphenous vein up to the mid calf. The main differential diagnosis was arterio-venous malformation, which was excluded by compression of the sapheno-femoral junction and demonstrating absence of pulsation in the long saphenous vein. A venous duplex scan showed a grossly incompetent sapheno-femoral junction with abnormal wave forms. Two of the cases were managed conservatively with compression dressing. The option of sapheno-femoral junction ligation was reserved in one patient who had unsettling cellulitis and oedema of the lower limb in spite of compression dressing and optimal conservative management. All three patients had improvement in ulcer size at 3-month follow up with compression therapy. This article highlights that in cases of right heart failure the venous pressures can be felt as low as the mid calf level and that can be a cause of the venous ulcers. There should be a high suspicion of right heart failure in patients with late onset venous insufficiency.