Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair

Abstract

BackgroundAneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance.MethodsPatients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6–18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks.ResultsSome 597 EVARs (71·1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47·6 per cent), moderate shrinkage (5–9 mm) in 142 (23·8 per cent) and major shrinkage (at least 10 mm) in 171 patients (28·6 per cent). Four years after the index imaging, the rate of freedom from complications was 84·3 (95 per cent confidence interval 78·7 to 89·8), 88·1 (80·6 to 95·5) and 94·4 (90·1 to 98·7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3·11; P < 0·001). Moderate compared with major shrinkage (HR 2·10; P = 0·022), early postoperative complications (HR 3·34; P < 0·001) and increasing abdominal aortic aneurysm baseline diameter (HR 1·02; P = 0·001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage.ConclusionEarly change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance.

Systematic review of laparoscopic ligation of inferior mesenteric artery for the treatment of type II endoleak after endovascular aortic aneurysm repair

“…This is an important fact as it has been shown that patients with major sac shrinkage have a very low risk of complications for up to 5 years. 35 The main limitation of our study was the low quality of the data because only case reports and one case cohort study exist in the literature. In addition, as these cases were executed in selected centers with profound laparoscopic expertise, the results with this method may not be generalized in daily practice.…”

“…It has been suggested that early change in sac diameter is a strong predictor of late outcome after EVAR. 35 One report suggested that IMA type II endoleak after EVAR may be predictable. 11 Thus, the incidence of IMA type II endoleaks was associated with a larger crosssectional area of the aortic lumen at the level of the IMA ostium before EVAR (P ¼ .001).…”

Management of late main-body aortic endograft component uncoupling and type IIIa endoleak encountered with the Endologix Powerlink and AFX platforms

“…[12][13][14][15] The most serious consequence of type III endoleaks is repeat exposure of the aneurysm sac to direct arterial blood pressure with subsequent aneurysm sac enlargement and death from AAA rupture. Additionally, it has now been recognized that endograft uncoupling can obstruct aortic blood flow resulting in AAA thrombosis and lower extremity ischemia.…”

Management of Aortic Sac Enlargement Following Successful EVAR in a Frail Patient

“…In the absence of any abnormality, the presence of sac shrinkage and the demonstration of adequate proximal and distal sealing zones on the 1 year follow up CTA, very few patients will experience an aneurysm related problem requiring correction. 17 Stratification of follow up may be done depending on the pre-operative anatomical features of the aneurysm and the extent to which the device's instructions for use are accurately followed. The adequacy of proximal and distal fixation together with the anatomical features of the aneurysm (angulation, tortuosity) may predict the likelihood of needing corrective intervention.…”