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1.
Background
Endovascular aneurysm repair is a minimally-invasive method for the treatment of abdominal aortic aneurysms. For aneurysms that involve the visceral arteries, a custom-made stent graft with fenestrations for the branch arteries is required. The purpose of the current study is to evaluate the structural impact of misaligned fenestrations with respect to luminal patency and proximal aortic neck apposition in an in vitro model.Methods
A custom apparatus was used to evaluate seven Anaconda and three Zenith fenestrated stent grafts. All stent grafts were evaluated at 10° increments of stent/fenestration misalignment up to 80°. Images were captured at each interval and the luminal cross-sectional area and wall apposition were measured.Results
The Anaconda stent graft, which has an unsupported main body, demonstrated a linear reduction in luminal patency at increasing angles of misalignment (P < 0.0001). Stent/fenestration misalignments of 20° and 80° resulted in decreases in mean luminal patency of 14% and 54% respectively. The Zenith stent graft demonstrated a similar decrease in luminal patency, starting at misalignments of ≥40° (P < 0.0001). However, with stent/fenestration misalignments of ≥30°, apposition between the Zenith stent graft and the simulated aortic neck was compromised suggesting the creation of a type Ia endoleak.Conclusions
Both the Anaconda and Zenith devices behave adversely at extreme angles of misalignment with luminal narrowing in the Anaconda device and loss of wall apposition in the Zenith device; however, both stent grafts appear to be equivalent at low angles of misalignment. 相似文献2.
Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians
《Journal of vascular surgery》2020,71(4):1162-1168
ObjectivePatients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up.MethodsRetrospective review of a prospectively collected vascular surgery database was performed to identify all patients who underwent elective repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared using univariate statistics.ResultsThe study cohort was composed of 314 patients 80 years of age or older (median, 83 years; interquartile range, 5 years) who underwent repair (96 open, 218 EVAR). The groups had similar comorbidities, except that EVAR patients were more likely to be male and open repair patients were more likely to have larger aneurysms. Compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (EVAR, 5.8 years; open repair, 5.8 years; P = .98). The 1-year survival was significantly higher for EVAR (92.9%) than for open repair (84.1%; P = .02). The 2-year survival (EVAR, 83.4%; open repair, 74.6%; P = .07) and 5-year survival (EVAR, 57.8%; open repair, 60.3%; P = .98) did not differ between EVAR and open repair. Reintervention rates (EVAR, 18%; open repair, 2%; P = .05) were higher in the endovascular treatment group.ConclusionsEVAR results in an improved 1-year mortality in octogenarians compared with open repair, although 5-year survival is similar between the groups. With average life expectancies of >5 years and an 18% reintervention rate, diligent follow-up is required after EVAR even in elderly patients. 相似文献
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Paolo Perini Mauro Gargiulo Roberto Silingardi Elio Piccinini Patrizio Capelli Antonio Fontana Mattia Migliari Giancarlo Masi Matteo Scabini Nicola Tusini GianLuca Faggioli Antonio Freyrie 《Journal of vascular surgery》2019,69(2):423-431
Objectives
We report a multicenter experience of urgent late open conversion (LOC), with the goal of identifying the mode of presentation, technical aspects, and outcomes of this cohort of patients.Methods
A retrospective analysis of endovascular aneurysm repair (EVAR) requiring LOC (>30 days after implantation) from 1996 to 2016 in six vascular centers was performed. Patients with aneurysm rupture or other conditions requiring urgent surgery (<24 hours) were included. Patient demographics, time interval between EVAR and LOC, endograft characteristics, previous attempts at endovascular correction, indications, operative technique, 30-day mortality and morbidity, and long-term survival were analyzed.Results
There were 42 patients (88.1% men; mean age, 75.8 ± 9.0 years) included. Among the 42 explanted grafts, 33 were bifurcated, 1 tube, 6 aortouni-iliac, and 2 side-branch devices. Suprarenal fixation was present in 78.6%. Twelve patients (28.6%) underwent endovascular reintervention before LOC. Indications for urgent LOC were aneurysm rupture in 24 of the 42 cases (57.1%), endograft infection in 11 (26.2%), endoleak associated with aneurysm growth and pain in 6 (14.3%), and recurrent endograft thrombosis in 2 (4.8%). The proximal aortic cross-clamping site was infrarenal in 38.1% of cases, suprarenal in 19.1%, and supraceliac in 42.9%. Complete removal of the endograft was performed in 32 patients (76.2%) and partial removal in 10 (proximal preservation in 7 of 10). Reconstructions were performed with Dacron grafts in 33 of the 42 cases, cryopreserved arterial allografts in 5, and endograft removal associated with prosthetic axillobifemoral bypass in 4. The 30-day mortality was 23.8%; hemorrhagic shock was an independent risk factor of early mortality (odds ratio, 10.5; 95% confidence interval, 1.5-73.7; P = .018). During a mean follow-up of 23.9 ± 36.0 months, two late aneurysm-related deaths occurred. The estimated 1- and 5-year survival rates were 62.1% and 46.1%, respectively.Conclusions
Urgent LOC after EVAR are associated with high postoperative mortality rates and poor long-term survival. Further studies are necessary to define the timing and the best treatment option for failing EVAR. 相似文献6.
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《Anaesthesia and Intensive Care Medicine》2019,20(5):281-286
The prevalence of abdominal aortic aneurysm (AAA) and the number of patients undergoing aneurysm repair is increasing. The UK has worked tirelessly to reduce its operative mortality rates for elective open AAA repair with the introduction of a quality improvement programme. Reducing death from ruptured aortic aneurysm has been the focus of the national screening programme. Despite the increased prevalence of disease and intervention, the popularity of open repair has diminished since the advent of endovascular repair (EVAR). The short-term benefits of EVAR when compared to open repair are well described; however, the long-term survival benefits, freedom form re-intervention and cost effectiveness of EVAR are not proven. The choice of technique for emergency AAA repair is contentious, with the more traditional approach of open repair being rapidly overtaken by endovascular options. In this article we provide an overview of the evidence supporting the different treatment options, outline current approaches to risk stratification, describe the key physiological changes that occur during open repair and describe an overview of the approach to perioperative management. 相似文献
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《Anaesthesia and Intensive Care Medicine》2022,23(4):222-228
The prevalence of abdominal aortic aneurysm (AAA) has declined in recent years and according to the annual National Vascular Registry reports (2016–20) the number of patients undergoing aneurysm repair has been steadily decreasing over the last five years. The UK has worked tirelessly to reduce its operative mortality rates for elective open AAA repair with the introduction of a quality improvement programme. Reducing death from ruptured aortic aneurysm has been the focus of the national screening programme. The short-term benefits of EVAR when compared to open repair are well described, however, the long-term survival benefits, freedom form re-intervention and cost effectiveness of EVAR have been demonstrated to be dominated by open surgery. That is that people with intact AAA should be offered open surgery if medically suitable. The choice of technique for emergency AAA repair is less contentious, with the more traditional approach of open repair being rapidly overtaken by endovascular options in those who are anatomically suitable for EVAR. Technical analysis by NICE has consistently reported favourable outcomes with EVAR in the emergency setting and that it is a cost-effective treatment. In this article we provide an overview of the evidence supporting the different treatment options, outline current approaches to risk stratification, describe the key physiological changes that occur during open repair and describe an overview of the approach to perioperative management. 相似文献
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《Journal of vascular surgery》2023,77(3):770-777.e2
ObjectivePrior reports of the low profile Zenith Alpha abdominal graft (Cook Medical Inc, Bloomington, IN) have shown impaired limb graft patency to be the primary causes of reintervention. Special notices from the manufacturer have indicated certain instructions for use (IFU) violations as the main reasons for these complications. In the present study, we assessed the incidence of limb graft occlusion (LGO) and analyzed the effects of the detailed anatomic risk factors for LGO highlighted in the IFU and previously reported studies.MethodsA retrospective study was performed of 241 patients treated with the low profile Zenith Alpha at a single institution from October 1, 2015 to September 30, 2018. All computed tomography angiograms were analyzed using three-dimensional software. Data were extracted from the electronic medical records until the end of the study period (December 31, 2020). The cumulative incidence of LGO and LGO-related reinterventions were assessed. A regression analysis was performed to evaluate the possible risk factors associated with the development of LGO at specified time points. These included aortic and iliac diameters, graft component oversizing, iliac tortuosity and calcification, overlap of graft components, proximal alignment of ipsilateral and contralateral legs, and sealing zone in the external iliac artery. Reader agreement of iliac calcification and tortuosity was assessed in patients with LGO.ResultsA total of 33 limbs (7%) in 27 patients (11%) had become occluded. The cumulative incidence of LGO was 7% (95% confidence interval [CI], 5%-9%) per limb up to 3 years postoperatively. The previously described risk factors for LGO were studied using regression analysis; however, no positive association with LGO was identified. Heavily calcified common iliac arteries (CIAs) and external iliac arteries were protective against LGO compared with noncalcified vessels up to 3 years postoperatively (decreased risk, 17% [95% CI, ?27% to ?7%]; P = .001; and 15% [95% CI, ?26 to ?5]; P = .005, respectively). The reader agreement of iliac calcification and tortuosity showed substantial agreement (CIA intrareader kappa = 0.75; CIA interreader kappa = 0.62) and almost perfect agreement (intrareader kappa = 0.85; interreader kappa = 0.84), respectively.ConclusionsThe cumulative incidence of LGO after endovascular aneurysm repair with the Zenith Alpha graft was 7% per limb up to 3 years postoperatively. None of the analyzed risk factors suggested by the IFUs or current literature were positively associated with LGO. 相似文献
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Nicole A. Kennedy Lisa M. Flynn M.D. F.A.C.S. Richard M. Berg M.D. F.A.C.S. David R. Lorelli M.D. F.A.C.S. Kumara Rama M.D. F.A.C.S. Youssif Rizk D.O. F.A.C.O.S. 《American journal of surgery》2010,199(3):369-371
Background
This study evaluates the relationship between body mass index (BMI) and other comorbidities on the overall morbidity and mortality of abdominal aortic aneurysm (AAA) repair.Methods
A database of all nonemergent open and endovascular AAA repairs performed at our center from 2004 to 2008 was created. The outcomes at the predefined time intervals were then evaluated for each group of patients.Results
One hundred forty-three patients qualified for this study with a 3:2 stent graft-to-open ratio. A trend relating patient BMI with early mortality was noted. Age >80 years was a strong predictor of mortality in all time intervals.Conclusions
The outcomes for this population show a significant trend toward early mortality in open AAA repair patients with an elevated preoperative BMI. Appropriate patient selection and preoperative optimization are recommended for all AAA repair candidates; however, some innate characteristics such as patient age, may play the largest role in determining outcomes. 相似文献12.
Thomas F.X. ODonnell Sarah E. Deery Laura T. Boitano Jeffrey J. Siracuse Marc L. Schermerhorn Salvatore T. Scali Andres Schanzer Robert T. Lancaster Virendra I. Patel 《Journal of vascular surgery》2019,69(2):414-422
Background
The early survival advantage of endovascular aneurysm repair (EVAR) compared with open repair reverses over time, possibly because of higher rates of reintervention related to endoleaks and aneurysm sac expansion. Therefore, we sought to examine the association between sac behavior, endoleaks, reintervention, and long-term survival.Methods
We reviewed all patients undergoing EVAR in the Vascular Quality Initiative between 2003 and 2017 with an imaging study at 1 year postoperatively (±6 months). We defined aneurysm sac changes by Society for Vascular Surgery guidelines (change ≥5 mm) and determined independent predictors of sac behavior, new endoleak, and reintervention using hierarchical logistic regression. We employed Cox regression to examine the association between sac behavior and long-term survival. We performed propensity matching between patients with sac regression and those with failure to regress as a secondary analysis.Results
Of 30,074 EVAR patients, 14,817 (49%) had a 1-year imaging study and were included in this study. At 1 year, 40% of sacs regressed, 35% remained stable, and 25% expanded. Factors independently associated with sac expansion were age (by decade: odds ratio [OR], 1.07; 95% confidence interval [CI], 1.01-1.13; P = .02), appearance of new endoleak (OR, 1.23; 95% CI, 1.10-1.37; P = .001), smaller aortic diameter (diameter <5 cm: OR, 1.37; 95% CI, 1.21-1.55; P < .001), anemia (OR, 1.47; 95% CI, 1.20-1.80; P < .001), rupture (OR, 1.33; 95% CI, 1.07-1.65; P = .01), and chronic kidney disease (OR, 1.15; 95% CI, 1.05-1.25; P < .01), whereas former smoking (OR, 0.86; 95% CI, 0.76- 0.96; P < .01), cerebrovascular disease (OR, 0.82; 95% CI, 0.67-0.99; P = .04), and statin therapy at discharge (OR, 0.83; 95% CI, 0.75-0.91; P < .001) were associated with lower risk of expansion. Both sac expansion (OR, 2.3; 95% CI, 2.0-2.7; P < .001) and a stable sac (OR, 3.1; 95% CI, 2.7-3.5; P < .001) were associated with the development of new endoleaks. Any failure of the aneurysm sac to regress was associated with long-term mortality compared with sac regression (stable sac size: hazard ratio, 1.2; 95% CI, 1.03-1.4; P = .02; sac expansion: hazard ratio, 1.6; 95% CI, 1.3-2.1; P < .001). This association persisted in patients without documented endoleaks and remained robust after accounting for reinterventions and endoleaks seen in follow-up or on completion angiography. In the propensity-matched cohort, patients with failure to regress experienced lower long-term survival (77% at 10 years compared with 82% for patients with sac regression; P = .01).Conclusions
After EVAR, aneurysm sac behavior is associated with the development of new endoleaks, reintervention, and long-term mortality. Not only sac expansion but any failure of the sac to regress is associated with higher long-term mortality, independent of reinterventions or endoleaks, and may be modified by statin therapy. Further study is needed to establish whether patients with stable sacs could benefit from selective reintervention. 相似文献13.
《Journal of vascular surgery》2020,71(5):1809-1812
Both the U.S. Preventive Services Task Force and the UK National Institute for Health and Care Excellence are re-evaluating their screening paradigms for abdominal aortic aneurysms (AAAs). Currently, most countries that screen for AAA do so only in male ever-smokers between the ages of 65 and 75 years and in patients with a family history of AAA. However, these recommendations are based primarily on screening trials predating the endovascular era. The wider applicability of endovascular aneurysm repair and its safety profile, especially in the elderly, have changed the risk-benefit of repair and, by extension, screening. This is despite the decreasing prevalence of AAA thanks to improved medical therapies and lower smoking rates. This evidence summary critically examines the evidence behind screening and the potential for expanded screening. 相似文献
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<正>患者男,68岁,体检发现腹主动脉瘤,左肾动脉狭窄9个月。查体:脐周偏右可触及搏动性包块,呈橄榄型,约5cm×13cm。腹主动脉CTA:动脉粥样硬化,腹主动脉瘤(肾下型)伴附壁血栓形成,左肾动脉起始部中度狭窄伴局限性混合斑块(图1)。入院后全麻行腹主动脉瘤覆膜支架腔内隔绝术,主体支架24mm×12mm×170mm,右髂支16 mm×12 mm×100mm。先用4.5 mm×12.0mm球囊预扩张左肾动脉狭窄处,在其内保留导丝;释放主动 相似文献
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《Journal of vascular surgery》2023,77(1):69-77
ObjectiveIn the present study, we used a national database to identify racial differences in the presentation and outcomes for patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (EVAR) and identified areas for improving their care.MethodsWe queried the EVAR-targeted National Surgical Quality Improvement Program database (2016-2019) to identify patients who had undergone EVAR for both ruptured and nonruptured AAAs. The patients were categorized according to race (White, Black, and Asian). Patients with a history of abdominal aortic surgery or an indication other than AAAs were excluded. The data was analyzed using the χ2 and Kruskal-Wallis tests, presented as frequencies and percentages or median and interquartile range (IQR) for categorical and continuous variables, respectively.ResultsWe identified 3629 patients (16.6% female), including 3312 White (91.3%), 248 Black (6.8%), and 69 Asian (1.9%) patients. Black patients were more frequently women (27.0%) compared with White patients (15.9%) and were younger (median age, 71 years; IQR, 64-77 years) than White (median age, 73 years; IQR, 67-79 years) and Asian (median age, 76 years; IQR, 67-81 years) patients (P < .001 for both). The incidence of smoking, congestive heart failure, and dialysis dependency was highest for Black patients, and the incidence of obesity was lowest for Asian patients. The AAAs in Black patients extended more frequently beyond the aortic bifurcation (P = .047). In Asian patients, the internal iliac arteries were more involved (P = .040). For Black patients, 29.8% of the EVARs were performed in a nonelective setting compared with 20.2% for the White and 15.9% for the Asian patients (P < .001). The aneurysm diameter, nonruptured symptomatic rate, and rupture rate were similar across the groups (P = .807). The operative time was prolonged for Black (median, 128 minutes; IQR, 96-177 minutes) compared with White (median, 114 minutes; IQR, 84-162 minutes) patients (P < .001). Postoperatively, Black patients were more likely to require blood transfusion (16.5%) and had prolonged length of hospital stay (median, 2 days; IQR, 1-4 days) compared with White (10.0%; median, 1 day; IQR, 1-3 days) and Asian (4.3%; median, 1 day; IQR, 1-3 days) patients (P = .001 and P < .001, respectively). Black patients also had a higher 30-day readmission rate (P = .038). On multivariate analysis, Black race was an independent factor for length of stay >1 day after both elective and nonelective EVAR and 30-day readmission for elective EVAR, but not 30-day mortality after elective and nonelective EVAR.ConclusionsIn the present nationwide sample of EVAR cases, Black patients were more often women and younger. Despite similar rates of symptomatic and ruptured AAAs at presentation and 30-day mortality, Black patients more often presented and were treated during the same nonelective admission; they also had associated increased length of hospital stay and readmission. These findings signal a missed opportunity to diagnose, optimize, and treat this particular group of patients in an elective setting. 相似文献
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《Journal of vascular surgery》2020,71(4):1179-1189
BackgroundWomen with abdominal aortic aneurysms less often meet anatomic criteria for endovascular repair and experience worse perioperative and long-term survival.MethodsWe 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.ResultsThere 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.ConclusionsDespite 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. 相似文献
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Kanhua Yin Satinderjit S. Locham Marc L. Schermerhorn Mahmoud B. Malas 《Journal of vascular surgery》2019,69(1):64-73
Objective
Significant research efforts have been made to improve the safety and efficacy of endovascular aneurysm repair (EVAR) in treating abdominal aortic aneurysm. This study aimed to examine the trends of perioperative outcomes of EVAR in the recent decade using a national validated database.Methods
Patients who underwent EVAR for intact abdominal aortic aneurysm between 2006 and 2015 were identified from the National Surgical Quality Improvement Program and divided into early (2006-2010) and late (2011-2015) periods. The primary outcome of the study was 30-day mortality. Secondary outcomes included operative time, length of hospital stay, and 30-day major complications (renal, cardiopulmonary, and wound infection).Results
A total of 30,076 patients were identified, with 11,539 in the early period and 18,537 in the late period. The 30-day mortality was kept at a low level in both periods (1.2% vs 1.2%; P = .98), whereas both the mean operation time (155.5 ± 72.6 minutes vs 141.9 ± 73.7 minutes; P < .001) and length of hospital stay (3.24 ± 5.32 days vs 2.81 ± 4.30 days; P < .001) were decreased in the late period. The 30-day major complication rate was reduced by 19.6% (5.1% vs 4.1%; P < .0001), with decreased renal failure (1.4% vs 1.0%; P = .003), cardiopulmonary complications (2.2% vs 1.7%; P = .006), and wound complications (2.5% vs 1.8%; P < .001). All the decreasing trends of mortality, any 30-day complication, and each type of major complication were statistically significant. Being treated in the late period was independently associated with decreased 30-day major complications (odds ratio, 0.75; 95% confidence interval, 0.65-0.87; P < .001), and this effect was confirmed in the propensity score-matched cohort (odds ratio, 0.76; 95% confidence interval, 0.66-0.90; P < .001).Conclusions
Although the 30-day mortality remains similar, postoperative complications in EVAR have decreased significantly during the recent decade. The continuous improvement in endograft technology and surgical skills has resulted in decreased operative time, marked reduction in surgical complications, and shorter hospital length of stay after endovascular repair. 相似文献18.
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目的:探讨腔内隔绝术治疗腹主动脉瘤术中短支对接困难的处理方法。方法:对本中心自1997年3月至2004年6月间施行的腹主动脉瘤腔内隔绝术进行回顾性研究。共有51例出现短支对接困难。其中,出现导丝进入主体短支产生困难的50例次,对侧单支导入主体短支产生困难的12例次。术中采用了多角度透视法、对侧导丝导引法、左肱动脉穿刺近端漂流法、导丝上下贯通法、球囊扩张法、超硬导丝回撤法和导丝牵张法。结果:多角度透视法应用于50例病人,对侧导丝导引法14例,左肱动脉穿刺近端漂流法10例,导丝上下贯通法3例,球囊扩张法2例,超硬导丝回撤法10例,导丝牵张法5例。51例病人均获成功对接,使分叉型移植物成功地隔绝了腹主动脉瘤。结论:短支对接是放置分叉型移植物手术操作过程中的难点,短支对接困难会造成手术的时间延长甚至失败。利用多种血管腔内技术可以解决这一问题。 相似文献
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《Asian journal of surgery / Asian Surgical Association》2022,45(1):346-352
BackgroundOperative mortality after endovascular aneurysm repair (EVAR) has been reported as lower than open surgical repair (OSR) for abdominal aortic aneurysm (AAA) in randomized controlled trials. However, many cohort studies have demonstrated similar mortality rates for both procedures. We compared operative mortality between EVAR and OSR, at our institution.MethodsAll AAA operations from 2012 to 2017 were reviewed, and baseline characteristics were collected. Outcomes included 30-day mortality, operative data, complications, length of hospital stay (LOS), costs, re-intervention, and survival rates were compared. A multivariable analysis with unbalanced characteristics was performed.ResultsWe had a total of 162 patients, 100 having OSR and 62 for EVAR. The EVAR group was older, with higher ASA classification. Thirty-day mortality rate did not significantly differ (0/100 for OSR and 2/62 (3%) for EVAR; p = 0.145), while the EVAR group had less blood loss, shorter operative times, and LOS, but higher re-intervention rates (adjusted hazard ratio 6.4 (95%CI: 1.4, 26.8)). Survival rates did not significantly differ between the groups. EVAR cost approximately 1-million yen more.ConclusionsOSR had low 30-day mortality rate in selected low-risk patients whereas EVAR had less blood loss, shorter operative times, LOS and could be done in high-risk patients with low 30-day mortality but with higher re-intervention rate. 相似文献