Impact of patient demographics and intraoperative characteristics on abdominal aortic aneurysm sac following endovascular repair.

BACKGROUND: Endovascular aortic repair (EVAR) has become the preferred treatment for abdominal aortic aneurysm (AAA). Its main aim is to seal the perfusion of the aneurysmal sac and, thus, induce sac regression and subsequent aortic remodelling. Aneurysmal sac regression has been linked to the short- and long-term clinical outcomes post-EVAR. It has also been shown to be influenced by endograft device choice, with several of these available commercially. This review summarises and discusses current evidence on the influence of pre- and intraoperative factors on sac regression. Additionally, this review aims to highlight the device-specific variations in sac regression to provide an overall holistic approach to treating AAAs with EVAR. METHODS: A comprehensive literature search was conducted using multiple electronic databases to identify and extract relevant data. RESULTS: Female sex, >70 mm original sac diameters, higher pre-procedural fibrinogen levels, smoking and low intra-aneurysmal pressure were found to positively impact sac regression. Whereas renal impairment, ischemic heart disease, high intra-aneurysmal pressure and aneurysm neck thrombus negatively influenced sac regression. Patent lumbar arteries, age, statins and hypercholesterolaemia displayed conflicting evidence regarding sac regression. Regarding the EVAR endografts compared, newer generation devices such as the Anaconda mainly showed the most optimal results. CONCLUSION: Sac regression following EVAR in AAA is an important prognostic factor for morbidity and mortality. Nevertheless, several pre- and intraoperative factors can have an influence on sac regression. Therefore, it is necessary to take them into account when assessing AAA patients for EVAR to optimise outcomes. The choice of EVAR stent-graft can also affect sac regression, with evidence suggesting that the Fenestrated Anaconda is associated with the most favourable results.

Endovascular reintervention after frozen elephant trunk: where is the evidence?

The introduction of the single-step hybrid frozen elephant trunk (FET) procedure for total arch replacement has revolutionized the field of aortovascular surgery. FET has proven to achieve excellent results in the repair of complex thoracic aorta pathologies. However, there remains a risk of reintervention post-FET for a variety of causes. This secondary intervention can either be performed endovascular, with thoracic endovascular aortic repair (TEVAR), or via open surgery. Multiple FET hybrid prosthesis are commercially available, each requiring different rates of endovascular reintervention. The current review will focus on providing an overview of the reintervention rates for main causes in relation to the FET grafts on the market. In addition, strategies to prevent reintervention will be highlighted. A comprehensive literature search was conducted on multiple electronic databases including PubMed, Ovid, Scopus and Embase to highlight the evidence in the literature on endovascular reintervention after FET. The main causes for secondary intervention are distal stent graft-induced new entry (dSINE), endoleak and negative aortic remodeling, and to a much lesser extent, graft kinking and aorto-esophageal fistulae. In addition, it is clear that the Thoraflex Hybrid (Terumo Aortic, Inchinnan, UK) is the superior FET device, showing excellent reintervention rates for all the above causes. Interestingly, the choice of FET device as well as its size and length can help prevent the need for reintervention. The FET procedure is indeed associated with excellent clinical outcomes, however, the need for reintervention may still arise. Importantly, the Thoraflex Hybrid prosthesis has shown excellent results when it comes to endovascular reintervention. Finally, several strategies exist that can prevent reintervention.