Outcomes of persistent intraoperative type Ia endoleak after standard endovascular aneurysm repair

Hass

Journal of the American College of Surgeons

et al. 2017

BACKGROUND Post-endovascular aortic aneurysm repair (EVAR) endoleaks and the need for reintervention are challenging. Additional endovascular treatment is advised for type Ia endoleaks detected on post-EVAR completion angiogram. This study analyzed management and late outcomes of these endoleaks. STUDY DESIGN This was a retrospective review of prospectively collected data from EVAR patients during a 10-year period. All post-EVAR type Ia endoleaks on completion angiogram were identified (group A) and their early (30-day) and late outcomes were compared with outcomes of patients without endoleaks (group B). Kaplan-Meier analysis was used for survival analysis, sac expansion, late type Ia endoleak, and reintervention. RESULTS Seventy-one of 565 (12.6%) patients had immediate post-EVAR type Ia endoleak. Early intervention (proximal aortic cuffs and/or stenting) was used in 56 of 71 (79%) in group A vs 31 of 494 (6%) in group B (p < 0.0001). Late type Ia endoleak was noted in 9 patients (13%) in group A at a mean follow-up of 28 months vs 10 patients (2%) in group B at a mean follow-up of 32 months (p < 0.0001). Late sac expansion and reintervention rates were 9% and 10% for group A vs 5% and 3% for group B (p = 0.2698 and p = 0.0198), respectively. Freedom rates from late type Ia endoleaks at 1, 3, and 5 years for group A were 88%, 85%, and 80% vs 98%, 98%, and 96% for group B (p < 0.001); and for late intervention, were 94%, 92%, and 77% for group A, and 99%, 97%, and 95% for group B (p = 0.007), respectively. Survival rates were similar. CONCLUSIONS Immediate post-EVAR type Ia endoleaks are associated with higher rates of early interventions, late endoleaks and reintervention, which will necessitate strict post-EVAR surveillance.

Section: Discussionmentioning

confidence: 88%

Section: Discussionmentioning

confidence: 92%

See 1 more Smart Citation

Management of Immediate Post-Endovascular Aortic Aneurysm Repair Type Ia Endoleaks and Late Outcomes

Hass

Journal of the American College of Surgeons

et al. 2017

Curr Treat Options Cardio Med

“…Two-year follow-up results on 36 patients showed no AAA rupture, stent fracture or migration, and no type I, III, or IV endoleak. Type II leak was noted in 33 % of patients, with associated sac enlargement in only one patient [21].…”

Section: Device Planningmentioning

confidence: 96%

“…In one study, adjunctive procedures such as repeated balloon inflation or addition of a cuff or Palmaz stent (Cordis, Miami Lakes, FL, USA) were shown to resolve the leak only 25 % of the time. However, on follow-up CTA, 94 % of these patients had resolution of the leak [21]. Determining which patients with type I leak do not need further intervention at the end of the procedure needs further study.…”

Section: N/a Secondary Endograft or Explantmentioning

confidence: 99%

Endovascular Management of Abdominal Aortic Aneurysms: the Year in Review

O’Mara

Bersin

2016

Endovascular aneurysm repair (EVAR) has become the predominant method of treatment for abdominal aortic aneurysms (AAA). The use of conscious sedation with local anesthesia and percutaneous femoral access has further decreased the morbidity of the procedure. Current devices can more effectively manage increasingly "hostile" aneurysm necks, while chimney grafts or dedicated fenestrated stent-grafts can be used for juxta-renal disease with favorable results. However, endovascular repair does present a new set of challenges, and endoleaks remain an area of concern. While there is general consensus that type I and type III endoleaks require treatment, type II endoleaks are the topic of ongoing research and debate. Development of devices and techniques to prevent and treat endoleak continues to progress. Advances in contrast-enhanced ultrasound are reducing reliance on computed tomography for post-operative monitoring. This is an important step in this population at high risk for the development of kidney failure. Despite these many innovations, further research is needed to optimize the care of patients with AAA.

British Journal of Surgery

Long-term follow-up of fenestrated endovascular repair for juxtarenal aortic aneurysm

Roy

Millen

Jones

et al. 2017

BackgroundFenestrated endovascular aneurysm repair (FEVAR) is increasingly being used for juxtarenal aortic aneurysms. The aim of this study was to review long‐term results and assess the importance of changing stent‐graft design on outcomes.MethodsThis was a retrospective review of all patients who underwent FEVAR within a single unit over 12 years (February 2003 to December 2015). Kaplan–Meier analysis of survival, and freedom from target vessel loss, aneurysm expansion, graft‐related endoleak and secondary intervention was performed. Comparison between outcomes of less complex grafts (fewer than 3 fenestrations) and more complex grafts (3 or 4 fenestrations) was undertaken.ResultsSome 173 patients underwent FEVAR; median age was 76 (i.q.r. 70–79) years and 90·2 per cent were men. Median aneurysm diameter was 63 (59–71) mm and median follow‐up was 34 (16–50) months. The adjusted primary technical operative success rate was 95·4 per cent. The in‐hospital mortality rate was 5·2 per cent; there was no known aneurysm‐related death during follow‐up. Median survival was 7·1 (95 per cent c.i. 5·2 to 8·1) years and overall survival was 60·1 per cent (104 of 173). There was a trend towards an increasing number of fenestrations in the graft design over time. In‐hospital mortality appeared higher when more complex stent‐grafts were used (8 versus 2 per cent for stent‐grafts with 3–4 versus fewer than 3 fenestrations; P = 0·059). Graft‐related endoleaks were more common following deployment of stent‐grafts with three or four fenestrations (12 of 90 versus 6 of 83; P < 0·001).ConclusionFenestrated endovascular aneurysm repair for juxtarenal aneurysm is associated with few aneurysm‐related deaths in the long term. Significant numbers of secondary interventions are required, but the majority of these can be performed using an endovascular approach.