Conservative management of type 2 endoleaks is not associated with increased risk of aneurysm rupture.

OBJECTIVE: Endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) has led to a reduction in the perioperative mortality when compared with open repair. However, re-intervention for complications, such as endoleak, may be required in up to 20% of the cases. Controversy exists over the management of type 2 endoleaks. This study examined the outcomes of patients with type 2 endoleaks treated conservatively to inform the ongoing management debate. METHODS: All patients with a confirmed type 2 endoleak after EVAR for an infrarenal AAA were included in the study. Data regarding device details, endoleak and time point, aneurysm sac growth, intervention and outcome were collected retrospectively from case notes and the vascular research database. RESULTS: Forty-one type 2 endoleaks were seen in 369 EVARs performed for infrarenal AAA between March 1994 and June 2006. Twenty-five were isolated type 2 endoleaks and 16 occurred in conjunction with other endoleaks. Of the 25 isolated type 2 endoleaks, 18 (72%) patients demonstrated no increase in sac size, six (24%) patients showed an enlargement of the sac and one patient was lost to follow-up. Only one patient underwent intervention for an isolated type 2 endoleak. After a mean follow-up period of 4 years, approximately half of the patients (48%) remain under observation (with an enlarging or stable sac), whilst the others (48%) have spontaneously sealed. Only five patients under surveillance (20%) have an enlarging sac. There were no ruptured aneurysms or aneurysm-related deaths and no patients required conversion to open repair. CONCLUSIONS: In this study, a policy of regular surveillance for type 2 endoleaks was not associated with any adverse events. We therefore advocate the conservative approach for type 2 endoleaks.

Should Asian men be included in abdominal aortic aneurysm screening programmes?

INTRODUCTION: A national AAA screening programme for men aged 65 is shortly to be implemented in England. Trials that have provided evidence for this screening programme have not included information on ethnicity. Hence their findings may not be applicable to ethnically diverse populations. REPORT: This study retrospectively looked at the prevalence of AAA in men aged 65, from different ethnic backgrounds in our city's current screening programme.19014 men (Caucasians n=18,431, Asian n=446, others n=137) were screened. Prevalence was 4.69% (4.39-5% 95% CI), and 0.45% (0.054-1.161% 95% CI) in Caucasians and Asians respectively (Fisher's exact test: P<0.0001). DISCUSSION: Prevalence of AAAs in men aged 65 of Asian origin appears to be low and so increases uncertainty about cost-effectiveness of screening Asian men.

An observational cohort study of the management and outcomes of vascular trauma.

OBJECTIVES: To evaluate aetiology, presentation, management and mortality following iatrogenic and non-iatrogenic vascular trauma in a regional vascular centre. METHODS: Retrospective observational cohort study of patients presenting with vascular trauma during a seven year period between January 2000 and December 2006. RESULTS: 182 cases of vascular trauma were identified (averaging 26 cases p.a.). The majority (n=132, 73%) were iatrogenic and tended to occur in patients aged >45 years, while 50 (27%) were penetrating/blunt, non-iatrogenic and predominantly occurred in younger males. The majority of iatrogenic vascular injuries (80/132) (61%) followed a cardiac intervention (angiography n=56, angioplasty n=23, pacemaker insertion n=1) and are now increasingly treated by non-operative therapies (thrombin, coils and covered stents). Overall, non-iatrogenic vascular trauma was associated with 4% mortality, compared with 7% following iatrogenic injury. However, while iatrogenic trauma of cardiological origin was associated with a mortality of only 1.3% (1/80), iatrogenic trauma of non-cardiological origin incurred a mortality of 17% (9/52). CONCLUSIONS: The commonest cause of vascular trauma (and with the lowest mortality rate) was cardiological related iatrogenic injury. However, while non-cardiological iatrogenic injury occurred with the same incidence as penetrating/blunt trauma, it was associated with a fourfold excess mortality.

A systematic review and meta-analysis of endovascular repair (EVAR) for ruptured abdominal aortic aneurysm.

BACKGROUND: Endovascular abdominal aortic aneurysm (EVAR) repair has become a well-established technique in the treatment of elective abdominal aortic aneurysms (AAAs) due to proven benefits in mortality, hospital stay and operation time compared to open repair. The aim of this study was to estimate the mortality rate from EVAR due to ruptured abdominal aortic aneurysm (RAAA). METHODS AND MATERIALS: A systematic review and meta-analysis of all English language literature with information on mortality rates from EVAR for RAAA was conducted. RESULTS: The pooled mortality rate from RAAA after EVAR across 31 studies concerning 982 patients was 24% (95% confidence interval (CI) 20-28%). The pooled morbidity from 21 studies was 44% (95% CI 33-55%). The average procedure time was 155.1 min, with an intra-operative blood loss of 523 ml and hospital stay of 10.1 days. There is evidence of publication bias suggesting the mortality rate may be under-estimated. CONCLUSIONS: Mortality from EVAR for RAAA appears to be lower than that which is reported for open repair of RAAA. However, the high level of publication bias cannot be ignored and may actually indicate higher mortality rates.

Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair.

Coil embolization of the internal iliac artery (IIA) is used to extend the application of endovascular aneurysm repair (EVAR) in cases of challenging iliac anatomy. Pelvic ischemia is a complication of the technique, but reports vary as to the rate and severity. This study reports our experience with IIA embolization and compares the results to those of other published series. The vascular unit database of the Leicester Royal Infirmary was used to identify patients who had undergone IIA coil embolization prior to EVAR. Data were collected from hospital case notes and by telephone interviews. Thirty-eight patients were identified; 29 of these were contactable by telephone. A literature search was performed for other studies of IIA embolization and the results were pooled. In this series buttock claudication occurred in 55% (16 of 29 patients) overall: in 52% of unilateral embolizations (11 of 21) and 63% of bilateral embolizations (5 of 8). New erectile dysfunction occurred in 46% (6 of 13 patients) overall: in 38% of unilateral embolizations (3 of 8) and 60% of bilateral embolizations (3 of 5). The literature review identified 18 relevant studies. The results were pooled with our results, to give 634 patients in total. Buttock claudication occurred in 28% overall (178 of 634 patients): in 31% of unilateral embolizations (99 of 322) and 35% of bilateral embolizations (34 of 98) (p = 0.46, Fisher's exact test). New erectile dysfunction occurred in 17% overall (27 of 159 patients): in 17% of unilateral embolizations (16 of 97) and 24% of bilateral embolizations (9 of 38) (p = 0.33). We conclude that buttock claudication and erectile dysfunction are frequent complications of IIA embolization and patients should be counseled accordingly.