Randomized Controlled Trial of Oral Tranexamic Acid Intervention for the Prevention of Type II Endoleak after Endovascular Abdominal Aneurysm Repair

Purpose: The purpose of this study was to evaluate tranexamic acid (TA) for the prevention of type II endoleak (EL2) at a high level of evidence by a randomized controlled trial.Methods: Patients who underwent endovascular aneurysm repair (EVAR) between May 2017 and January 2020 were included. Patients in the TA group were given 750 mg of TA daily for a month after EVAR. The incidence of EL2, blood coagulation/fibrinolytic ability, and changes in aneurysm diameter were compared between two groups.Result: On the 7th day after EVAR, EL2 was found in 14 patients (34.1%) in the TA group and in 7 patients (15.9%) in the non-TA group. It was also found in 12 patients (29.3%) in the TA group and 6 patients (13.6%) in the non-TA group at 1 month after EVAR. There was no significant difference in the incidence of EL2 between the two groups (p = 0.051, 0.08). Blood tests revealed that fibrin degradation product and D-dimer were significantly suppressed in the TA group, there was no significant difference in the change of diameter regardless of the TA intake.Conclusion: This study proved anti-fibrinolytic effect of the TA, but it alone had not enough power to decrease EL2 after EVAR.     

Routine Use of Intravascular Ultrasound for Endovascular Aneurysm Repair: Angiography is not Necessary

INTRODUCTION: to assess the outcome of endovascular aortic aneurysm repair (EVAR) using intravascular ultrasound (IVUS) without angiography. MATERIALS/METHODS: eighty consecutive patients (median age 69 years (range 25-90): male 72 (90%), female 8 (10%)) underwent endovascular aneurysm repair (AAA 68 (85%), TAA 12 (15%)) using either angiography in 31/80 patients (39%) or IVUS in 49/80 patients (61%) in accordance to the surgeons preference. RESULTS: hospital mortality was 2/80 (3%), 1/68 for AAA (2%), 1/12 for TAA (8%), 2/31 for angiography (7%), and 0/49 for IVUS (0.0%: NS). Median quantity of contrast medium was 190 ml (range: 20-350) for angiography versus 0 ml for IVUS (p<0.01). Median X-ray exposure time 24 min (range 9-65 min) versus 8 min (range 0-60 min) for IVUS (p<0.05). No coverage of renal or suprarenal artery orifices occurred in either group. Conversion to open surgery was necessary in 4/80 patients (5%), 1/31 for angiography (3%) and 3/49 patients for IVUS (6%: NS). Early endoleaks were observed in 13/80 patients (16%): 8/31 patients for angiography (26%) versus 5/49 for IVUS (10%: p<0.05): 5/13 endoleaks resolved spontaneously (39%) whereas 8/13 (61%) required additional procedures. CONCLUSIONS: IVUS is a reliable tool for EVAR. In most cases, perprocedural angiography is not necessary.     

合并双髂总动脉瘤的腹主动脉瘤的腔内治疗

目的总结腹主动脉瘤合并双髂总动脉瘤的腔内治疗经验。方法2009年1月～2012年3月,126例腹主动脉瘤接受腔内修复术（endovascularaneurysmrepair,EVAR）,其中33例合并双髂总动脉瘤（直径〉18mm）。27例双侧髂总动脉直径〉18-〈25mm,选择合适口径的髂腿移植物完成传统EVAR;6例因-侧髂总动脉直径≥25mm,选择该侧髂外动脉作为锚定区完成EVAR,并行髂内动脉栓塞术。结果所有腔内技术均获得成功,手术时间（115±36）min,出血量（173±65）m1。术中发现即刻内漏7例（21．2％）：I型内漏3例（近端1例,远端2例,均经球囊扩张后内漏消失）;11I型内漏1例,经扩张后内漏消失;II型内漏2例,Ⅳ型内漏1例,经随访瘤体直径未增大,未予处理。33例术后随访6～39个月,平均15．3月,无动脉瘤破裂,无远端迟发型I型内漏发生,髂动脉直径无明显扩张。结论对于部分合并双髂动脉瘤的腹主动脉瘤患者,根据髂总动脉直径选择合适的腔内治疗方法可以达到理想的治疗效果,近期效果满意。     

Results from the Prospective Registry of Endovascular Treatment of Abdominal Aortic Aneurysms (RETA): Mid Term Results to Five Years

OBJECTIVES: To assess the mid-term outcomes up to 5 years following endovascular repair of abdominal aortic aneurysms (EVAR), following its initial introduction into practice in the UK. DESIGN: A prospective voluntary Registry of Endovascular Treatment of Aneurysms (RETA) collected demographic and risk factor data, short term (30 day) outcomes and follow up outcomes up to 5 years from the 41 centres that initially undertook EVAR in the UK. RESULTS: Short term outcomes (30 days): 90.4% of aneurysms were successfully excluded, 6.1% had persistent endoleaks and 5.8% of patients had died. Follow up was obtained from 30 days up to 5 years (mean 3.1 years). Returns rates for requested follow up data were 87% at 1 year and 77, 65, 52 and 51% at 2, 3, 4 and 5 years, respectively. Ninety percent of deaths at follow up were unrelated to the stent-graft or aneurysm. Persistent proximal type I endoleak was associated with significant mortality both from attempted open repair or from rupture if untreated. Other endoleaks were more benign. Complications related to the aneurysm or device occurred at an average rate of 15% per annum. The most common complications were secondary endoleaks or graft migration. Endovascular treatment was preferred if treatment was necessary for graft complications. The cumulative freedom from secondary procedure (Kaplan-Meier) were 87, 77, 70, 65 and 62% at 1, 2, 3, 4 and 5 years of follow up, respectively. CONCLUSIONS: Registry data provides useful information to guide the design of more formal trials. Collecting follow up from voluntarily submitted data is difficult. The registry data remains well ahead of the trial data, but indicate that long term follow up is required in these trials, because of the high rate of complications seen at follow up.     

Aneurysm Sac Thrombus Load Predicts Type II Endoleaks after Endovascular Aneurysm Repair

Type II endoleaks are associated with the absence of aneurysm shrinkage after endovascular abdominal aortic aneurysm repair (EVAR). This study aims at determining the predictability of this complication, whose potential risk factors have been the subject of conflicting reports. Preoperative computed tomography (CT) scans of 178 patients who underwent EVAR for true infrarenal abdominal aortic aneurysms between January 20, and April 17, 2003, with a minimum follow-up of 30 days, were reviewed. The following information was retrieved: maximum aneurysm diameter, aneurysm thrombus load (maximum thickness, percentage of sac circumference wall coverage, percentage of maximum sac area occupancy); number, diameter, and nature (lumbar, inferior mesenteric, accessory renal, middle sacral) of patent aortic side-branch arteries; thrombus thickness at each aortic branch ostium, and aneurysm diameter at that level. Postoperative CT and duplex scans supplemented with angiography in selected cases were reviewed for the presence of a type II endoleak observable beyond the 30th postoperative day. Logistic regression was used to assess the association of each variable with this outcome. There were 38 (21.3%) patients with type II endoleaks after the 30th postoperative day. The median follow-up was 12 months (range 1–65 months). By univariate analysis, the following variables significantly decreased the risk of a type II endoleak: thrombus maximum thickness [odds ratio (OR) 0.77 for a 5 mm increase, p = 0.009], mean thrombus thickness at aortic side-branches ostia (OR 0.65 for a 1 mm increase, p = 0.0006), thrombus-occupied percentage of maximum aneurysm area (OR 0.72 for a 10% increase, p < 0.0001), percentage of thrombus-lined aneurysm wall (OR 0.53 for a 25% increase, p < 0.0001). The presence of a patent inferior mesenteric artery (OR 6.84, p < 0.01) and the number of patent aortic side-branches (OR 1.37 for each additional vessel, p = 0.002) significantly increased the risk of detecting a late type II endoleak. Aneurysm and aortic side-branch diameters did not have any impact. In a multiple logistic regression model (whole model p < 0.0001), the thrombus-occupied percentage of maximum aneurysm area (OR 0.74 for a 10% increase, p < 0.0005) and the number of patent aortic side-branches (OR 1.31 for each additional vessel, p = 0.009) remained independent predictors of type II endoleaks. The simple measure of the proportion of maximum aneurysm area occupied by thrombus may be a useful way to identify patients at high risk of a persistent type II endoleak. Patients with low preoperative sac thrombus load should be followed with a high degree of suspicion for this complication.Sérgio M. Sampaio is a recipient of the Edward S. Rogers Vascular Surgery Clinical Research Fellowship.Presented at the 32nd Annual Symposium on Vascular Surgery of the Society for Clinical Vascular Surgery, Rancho Mirage, CA, March 10-13, 2004.