Outcomes of persistent intraoperative type Ia endoleak after standard endovascular aneurysm repair.

OBJECTIVE: This study analyzed outcomes for patients with persistent intraoperative type Ia endoleaks after standard endovascular aneurysm repair (EVAR). METHODS: The study group was identified from a consecutive cohort of 209 patients undergoing EVAR in a tertiary center in the United Kingdom during a 2-year period. Data prospectively collected on departmental computerized databases were retrospectively analyzed. Primary outcome parameters were defined as freedom from type Ia endoleak, EVAR-related reintervention, aneurysm rupture, and aneurysm-related mortality. RESULTS: A completion angiogram identified 44 patients (21%) as having a type Ia endoleak, and 33 (75%) had a persistent endoleak after intraoperative adjunctive procedures, including repeated balloon moulding, aortic cuff extension, and Palmaz stent (Cordis, Miami Lakes, Fla) deployment. In the 11 patients (25%) whose endoleak was successfully abolished intraoperatively, there was no recurrence of type Ia endoleak or secondary intervention to treat type 1a endoleak during a median follow-up period of 27 months. Of the 33 patients with persistent endoleak, 31 (94%) demonstrated resolution of the endoleak on first surveillance computed tomography angiography. One patient was lost to follow-up. Embolization of the endoleak in another patient was successful using Onyx (Micro Therapeutics, Inc, Irvine, Calif) 8 days after the initial procedure. No type Ia endoleak was identified after this on any surveillance imaging, and the patient was alive 28 months later with a stable aneurysm size. In the rest of the patients, no recurrence of the endoleak in any subsequent imaging was noticed, and no secondary intervention was required during follow-up. No aneurysm-related deaths occurred, and 91% of the patients had a stable or shrinking aneurysm. CONCLUSIONS: Despite adjunctive intraoperative maneuvers, persistent type Ia endoleaks can be relatively common. Our study indicates that they may be observed in selected patients. Further research is required to investigate the natural course and management of type Ia endoleaks identified intraoperatively.

Defining a role for contrast-enhanced ultrasound in endovascular aneurysm repair surveillance.

OBJECTIVE: Endovascular aneurysm repair (EVAR) surveillance includes duplex ultrasound, abdominal radiography, and computed tomography angiography. Contrast-enhanced ultrasound (CEUS) has emerged as an additional modality whose role remains undefined. We evaluated whether a potential role for CEUS was the elucidation of unresolved issues following standard surveillance modalities. METHODS: All patients undergoing EVAR at a tertiary referral center had surveillance based on plain abdominal radiograph and duplex ultrasound, with single arterial phase computed tomography angiography reserved for abnormalities or nondiagnostic imaging. In this prospective evaluation, from April 2010 to July 2011, discordance between imaging modalities or unresolved surveillance issues prompted CEUS. Cases and imaging were discussed in a multidisciplinary setting and outcomes recorded. RESULTS: During the study period, 539 patients underwent EVAR surveillance, of whom 33 (6%) had CEUS for unresolved issues (median age, 79; range, 66-90; 28 male). Median follow-up after EVAR was 23 months (range, 0-132). In all cases, CEUS was able to resolve the clinical issue, resulting in secondary intervention in 10 patients (30%). The remaining patients were returned to surveillance. Within the cohort of 33 patients, the clinical issues were categorized into three groups. Group 1: Endoleak of uncertain classification (n = 27: 21 type II, four type I, two had endoleak excluded). Group 2: Significant aneurysm expansion (≥ 5 mm) without apparent endoleak (n = 4: one type II, three had endoleak excluded). Group 3: Target vessel patency following fenestrated EVAR (n = 2: patency confirmed in both). CONCLUSIONS: CEUS can enhance EVAR surveillance through clarification of endoleak and target vessel patency when standard imaging modalities are not diagnostic.

Comparison of fenestrated endovascular and open repair of abdominal aortic aneurysms not suitable for standard endovascular repair.

BACKGROUND: Abdominal aortic aneurysms that are unsuitable for a standard endovascular repair (EVAR) could be considered for fenestrated endovascular repair (f-EVAR). The aim of this study was to conduct a risk-adjusted retrospective concurrent cohort comparison of f-EVAR and open repair for such aneurysms. METHODS: All patients who underwent repair of an abdominal aortic aneurysm that was unsuitable for a standard EVAR due to inadequate neck within one institution between January 2006 and December 2010 were identified. Case notes were retrieved for clinical data, Vascular Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (V-POSSUM) score, and aneurysm morphology. Computed tomography scans were reviewed to establish aneurysm morphology. RESULTS: A total of 107 patients were identified. The open surgery cohort included 54 patients (35 men) who were a median age of 72 years (interquartile range [IQR], 9.5; range, 60-86 years). The aortic cross-clamp was infrarenal in 20 patients, suprarenal or above in 21, and inter-renal in eight. Postoperatively, 63 major complications were noted in 30 patients, nine of whom required 16 reinterventions. Cumulative hospital stay of the cohort was 1170 days (median, 12; IQR, 13; range, 1-205 days) of which 234 days (median, 28; IQR, 36; range, 1-77 days) were in the intensive therapy unit (ITU). Perioperative mortality was 9.2% (n = 5), exactly as estimated by V-POSSUM. The f-EVAR cohort included 53 patients (47 men) who were a median age of 76 years (IQR, 11.50; range, 55-87 years). Two fenestrations and one scallop was the most frequent configuration (n = 31). Postoperatively, 37 major complications were noted in 18 patients, six requiring reintervention. Hospital stay was 559 days (median, 7; IQR, 4.5; range, 4-64 days), of which 31 days (median, 4; IQR, 10.5; range, 1-15 days) were in the ITU. Two patients died perioperatively (3.7%), resulting in an observed crude absolute risk reduction of 5.5% compared with open repair. The V-POSSUM estimated perioperative death in five patients (9.4%) in the f-EVAR cohort. In a hypothetic scenario of the f-EVAR cohort undergoing open repair, V-POSSUM estimated seven deaths (13.2%), resulting in an estimated risk-adjusted absolute risk reduction due to f-EVAR of 9.5%. CONCLUSIONS: In this group of patients, f-EVAR reduced mortality and morbidity substantially compared with open repair and also reduced total hospital stay and ITU utilization.