European Expert Opinion on Infrarenal Sealing Zone Definition and Management in Endovascular Aortic Repair Patients: A Delphi Consensus

Abstract

Purpose: The purpose of the study was to provide a consensus definition of the infrarenal sealing zone and develop an algorithm to determine when and if adjunctive procedure(s) or reintervention should be considered in managing patients undergoing endovascular aortic repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA). Methods: A European Advisory Board (AB), made up of 11 vascular surgeons with expertise in EVAR for AAA, was assembled to share their opinion regarding the definition of preoperative and postoperative infrarenal sealing zone. Information on their current clinical practice and level of agreement on proposed reintervention paths was used to develop an algorithm. The process included 2 virtual meetings and 2 rounds of online surveys completed by the AB (Delphi method). Consensus was defined as reached when ≥ 8 of 11 (73%) respondents agreed or were neutral. Results: The AB reached complete consensus on definitions and measurement of the pre-EVAR target anticipated sealing zone (TASZ) and the post-EVAR real achieved sealing zone (RASZ), namely, the shortest length between the proximal and distal reference points as defined by the AB, in case of patients with challenging anatomies. Also, agreement was achieved on a list of 4 anatomic parameters and 3 prosthesis-/procedure-related parameters, considered to have the most significant impact on preoperative and postoperative sealing zones. Furthermore, the agreement was reached that in the presence of visible neck-related complications, both adjunctive procedure(s) and reintervention should be contemplated (100% consensus). In addition, adjunctive procedure(s) or reintervention can be considered in the following cases (% consensus): insufficient sealing zone on completion imaging (91%) or on the first postoperative computed tomography (CT) scan (91%), suboptimal sealing zone on completion imaging (73%) or postoperative CT scan (82%), and negative evolution of the actual sealing zone over time (91%), even in the absence of visible complications. Conclusions: AB members agreed on definitions of the pre- and post-EVAR infrarenal sealing zone, as well as factors of influence. Furthermore, a clinical decision algorithm was proposed to determine the timing and necessity of adjunctive procedure(s) and reinterventions.

Pre-operative Aortic Neck Characteristics and Post-operative Sealing Zone as Predictors of Type 1a Endoleak and Migration After Endovascular Aneurysm Repair: A Systematic Review and Meta-Analysis

“…These findings are consistent with previous systematic reviews that focused on individual neck characteristics. The higher odds for developing type 1a endoleak in patients with a larger neck diameter were also reported in systematic reviews by Antoniou et al 6 and Kouvelos et al 7 The current results regarding neck angulation were also consistent with findings by Qayyum et al 9 Although neck length is one of the most important neck characteristics for pre-operative planning, 4,11 this variable has not been described much in the literature. An explanation for this could be that patients with a short proximal neck length are almost exclusively treated with open surgical repair or complex (fenestrated, branched, or chimney) EVAR.…”

“…48,58,59 A clinical decision algorithm was recently proposed by 11 European vascular surgeons to decide if and when adjunctive procedures and reinterventions are necessary, based on the real achieved sealing zone. 11 Implementing real achieved sealing zone measurements in clinical practice is a step toward detecting type 1a endoleak and migration at an early stage to decrease post-EVAR mortality.…”

“…The real achieved sealing zone can be defined as the length starting at the proximal end of the endograft fabric and over which the endograft material is in proper apposition to the aortic wall. 11 The pre-operative neck characteristics and proximal real achieved sealing zone had to be measured on a computed tomography angiography (CTA) scan.…”

“…The following post-EVAR definitions and measurement methods for post-operative CTA scans based on existing literature and a Delphi consensus of 11 European vascular surgeons are proposed: 11 Real achieved sealing zone: length starting at the proximal end of the endograft fabric and ending where the endograft material is no longer circumferentially apposed to the aortic wall. Measured over the centreline or as the shortest apposition length (with postprocessing software).…”

“…5e9 Although the literature suggests stratifying the risk of type 1a endoleak with the pre-operative anatomy and also with the postoperative real achieved sealing zone, evidence seems limited and a systematic review on clinical outcome is lacking. 10,11 This systematic review aimed to provide an overview of pre-operative aortic neck characteristics and the postoperative real achieved sealing zone, and their respective risk of developing type 1a endoleak and migration after EVAR.…”