Journal of Endovascular Therapy最新文献

Purpose: Fenestrated endovascular aortic repair (FEVAR) is technically more challenging when performed after a failing EVAR procedure (FEVAR after EVAR). This study aims to assess the technical outcome of FEVAR after EVAR and to identify factors that may influence complication rates.

Methods: A retrospective observational study was conducted at a single department of vascular and endovascular surgery. The rate of FEVAR after EVAR compared to primary FEVAR is reported. Complication and primary unconnected fenestration (PUF) rates as well as survival were assessed for the FEVAR after EVAR cohort. PUF rates and operating time were also compared to all primary FEVAR patients. Patient characteristics and technical factors such as number of fenestrations or use of a steerable sheath were assessed as possible influencers on technical success when performing FEVAR after EVAR.

Results: Two hundred and nine fenestrated devices were implanted during the study period (2013 to April 2020). Thirty-five patients (16.7% of all FEVAR patients) had undergone FEVAR after EVAR and were included in the study. Overall survival at last follow-up (20.2±19.1 months) was 82.9% in FEVAR after EVAR patients. Rates of technical failure dropped significantly after 14 procedures (42.9% vs. 9.5%; p=0.03). Primary unconnected fenestrations were seen in 3 cases of FEVAR after EVAR (8.6%) and 14 of 174 primary FEVAR cases (8.0%; p>0.99). Operating time for FEVAR after EVAR was significantly higher than for primary FEVAR (301.1±110.5 minutes vs. 253.9±103.4 minutes; p=0.02). The availability of a steerable sheath was a significant predictor of reduced risk of PUFs, whereas age and gender, number of fenestrations or suprarenal fixation of the failed EVAR did not significantly influence PUF rates.

Conclusion: Fewer technical complications were seen over the study period in FEVAR after EVAR patients. While rates of PUFs were not different from primary FEVAR, operating time was significantly longer in patients undergoing FEVAR for failed EVAR. Fenestrated EVAR can be a valuable and safe tool to treat patients with progression of aortic disease or type Ia endoleak after EVAR but may be more complex to achieve than primary FEVAR.

Clinical impact: This retrospective study assesses the technical outcome of fenestrated endovascular aortic repair (fenestrated EVAR; FEVAR) after prior EVAR. While rates of primary unconnected fenestrations were not different from primary FEVAR, operating time was significantly longer in patients undergoing FEVAR for failed EVAR. Fenestrated EVAR after prior EVAR may be technically more challenging than primary FEVAR procedures, but could be performed with equally good results in this patient cohort. FEVAR offers a feasible treatment option for patients with progression of aortic disease or type Ia endoleak after EVAR.

Objective: Lower serum ionized calcium (iCa²⁺) was reported to be associated with a higher risk of adverse events in patients with cardiovascular diseases. This study aimed to investigate the associations between preoperative serum iCa²⁺ and outcomes of type B aortic dissection (TBAD) patients receiving thoracic endovascular aortic repair (TEVAR).

Methods: Between January 2016 and December 2019, 491 TBAD patients received TEVAR in a single center. Patients with acute or subacute TBAD were included. Serum iCa²⁺ (pH 7.4) was obtained from the arterial blood gas analysis before TEVAR. The study population was grouped into the hi-Ca group (1.11 mmol/L ≤ iCa²⁺ < 1.35 mmol/L) and lo-Ca group (iCa²⁺ < 1.11 mmol/L). The primary outcomes were all-cause mortality. The secondary outcomes were any major adverse clinical events (MACEs), which included all-cause mortality and aortic-related severe complications. To eliminate bias, 1:1 propensity score matching (PSM) was conducted.

Results: Overall, 396 TBAD patients were included in this study. In the total population, there were 119 (30.1%) patients in the lo-Ca group. After PSM, 77 matched pairs were obtained for further analysis. In the matched population, the 30-day mortality and 30-day MACEs between the two groups presented significant differences (p=0.023 and 0.029, respectively). At 5 years, cumulative incidences of mortality (log-rank p<0.001) and MACEs (log-rank p=0.016) were significantly higher in the lo-Ca group than that of the hi-Ca group. Multivariate cox regression analysis indicated that lower preoperative iCa²⁺ (hazard ratio for per 0.1 mmol/L decrease, 2.191; 95% confidence interval, 1.487-3.228, p<0.001) was an independent risk factor for 5-year mortality after PSM.

Conclusions: Lower preoperative serum iCa²⁺ might have an association with 5-year mortality in TBAD patients after TEVAR. Serum iCa²⁺ monitoring in this population may facilitate the identification of critical conditions.

Clinical impact: Our present study found that the cutoff value of preoperative serum iCa²⁺ 1.11 mmol/L, which is slightly lower than the lower limit of the normal range of 1.15-1.35 mmol/L, worked relatively well for discerning the high-risk and low-risk TBAD patients at 5 years. Serum iCa²⁺ monitoring in TBAD patients receiving TEVAR may facilitate the identification of critical conditions.

Background: There are little available data about the impact of geriatric nutritional risk index (GNRI) on clinical outcomes following endovascular therapy (EVT) in chronic limb-threatening ischemia (CLTI) regarding the severities of renal dysfunction (RD).

Aims: The aim of this study is to evaluate the impact of GNRI on clinical outcomes following EVT in CLTI regarding the severities of RD.

Methods: We enrolled 705 consecutive CLTI cases treated with EVT between January 2010 and December 2019 at our hospital. The GNRI on admission was calculated as follows: [14.89 × albumin (g/dL)] + [41.7 × (body weight/ideal body weight)]. Study population were divided into 2 groups based on the median GNRI: low group (GNRI < 92) and high group (GNRI ≥ 92). Next, study population was divided to 3 groups according to estimate glomerular filtration rate (eGFR), which was defined as early RD group (60 ≤ eGFR), advanced RD group (15 ≤ eGFR < 60), and end-stage renal dysfunction (ESRD) group (eGFR < 15). The primary endpoint was 2-year amputation-free survival (AFS).

Results: The median follow-up duration was 25.2 months. Amputation-free survival was significantly lower in the low GNRI group regardless of any severities of RD (59.1% vs 90.2%, Log Rank P<0.001 in early RD group, 59.6% vs 80.8%, Log Rank P=0.011 in advanced RD group, 32.8% vs 61.1%, Log Rank P<0.001 in ESRD group).

Conclusion: The decrease of GNRI could predict clinical outcomes in CLTI following EVT regardless of any severities of RD based on eGFR.

Clinical impact: The decrease of geriatric nutritional risk index was associated with worse outcomes in chronic limb-threatening ischemia following endovascular therapy regardless of any severities of renal dysfunction. Because both renal dysfunction and chronic limb-threatening ischemia could potentially have any inflammation, the geriatric nutritional risk index, which can reflect both nutrition-related risks and inflammation severity, can be a plausible marker in predicting adverse events after endovascular therapy in chronic limb-threatening ischemia patients with renal dysfunction.

Objective: The objective of this study is to assess the feasibility of endovascular coiling combined with tissue glue embolism for the treatment of iliac arteriovenous fistula (AVF) secondary to deep vein thrombosis (DVT) of the lower extremities. In addition, we aim to summarize the treatment methods and enhance understanding of the disease.

Methods: This research analyzes the clinical data and medical imaging materials of 20 cases with iliac AVF secondary to lower extremity DVT, ranging from December 2014 to December 2020, at our hospital. The patients underwent endovascular coiling and tissue glue embolism during their hospital stay. We collected and summarized the clinical and imaging data, evaluated the efficacy of treatment methods, assessed the incidence of complications, and conducted long-term follow-up observations.

Results: All 20 surgeries were successful. Endovascular coiling combined with tissue glue embolism significantly relieved limb swelling. The diameter difference above the patella in patients before and after treatment was 9.38±3.58 versus 4.13±1.64 cm, P<0.001. No serious complications occurred during treatment, and no patients showed signs of AVF recurrence during follow-up after surgery.

Conclusion: Endovascular coiling combined with tissue glue embolism can be used to treat iliac AVF secondary to DVT of the lower extremities, which has high clinical value and is safe.

Clinical impact: For clinicians, AVF secondary to DVT is a complication that cannot be ignored. It also needs to be treated aggressively to improve patients' quality of life. We presented a minimally invasive method to treat iliac arteriovenous fistula secondary to deep vein thrombosis of lower extremities, which is also an innovative intervention technique. Endovascular coiling combined with tissue glue embolism can achieve better embolic blockade in this type of iliac arteriovenous fistula. This will move the management of postoperative complications in the direction of minimally invasive.

Introduction: Abdominal aortic aneurysms (AAA) are major causes of morbidity and mortality in the elderly population. Endovascular aneurysm repair (EVAR) is associated with lower complications rates than conventional treatment; however, rigorous follow-up with contrast imaging is required to confirm aneurysmal sac exclusion. The main objective of this study was to quantify and evaluate miRNA expression response to EVAR based on serum dosages at the 6-month follow-up.

Population and method: 47 patients with indication for EVAR were recruited and 10 patients without comorbidities. miRNA-181b and miRNA-21 were selected for this study and their serum dosages were measured at two time points: preoperatively and after 6 months of follow-up, and only once in the control group. Demographic profiles, clinical follow-ups, and imaging examinations with angiotomography performed preoperatively and after 6 months were collected.

Results: Overexpression of miRNA-181b and miRNA-21 was observed in the whole blood of patients with AAA. EVAR of patients with AAA resulted in decreased expression of the studied miRNAs, indicating that exclusion of the aneurysmal sac alters the expression of these markers. In addition, the expressions of miRNAs did not correlate with endoleaks or the diameter of the aneurysm or with the different types of devices used for the EVAR.

Conclusions: The overexpression of miRNA-181b, miRNA-21 with its reduction after EVAR, may suggest the use of these molecules as potential biomarkers in the follow-up of these patients. However, miRNAs were not able to identify possible endoleaks or discriminate them into subtypes.

Clinical impact: The clinical application of the use of biomarkers in other areas such as oncology is already well established. In endovascular surgery it is still incipient although with great potential in daily practice, in order to anticipate or schedule possible interventions in patients with endoleak. In addition, understand the mechanisms of action of miRNAs in Atherosclerotic diseases and aortic syndromes could provide a better understanding of the pathophysiology as well as pharmacological development for AAA prevention as well as remodeling of the aneurysm sac after EVAR.

Introduction: Vascular trainees are required to have a comprehensive training program, encompassing the completion of clinical, surgical, and research tasks. To fulfill their surgical abilities and performance, sufficient supervised operating time is mandatory. After open vascular procedures, it has been observed that trainee involvement does not lead to detrimental outcomes. On the contrary, its impact during endovascular procedures, which require distinct technical skills, is scarcely reported. The authors aim to analyze the impact of primary operator experience on the outcomes of elective infrarenal endovascular aneurysm repair (EVAR) performed within a teaching institution over a 14-year period.

Methods: This is a single-center, retrospective, comparative study. All consecutive patients submitted to elective EVAR (2011-2023) were considered. Two groups were defined: supervised trainee (ST) and consultant (C), according to the experience of the primary operator. The primary outcome was the incidence of 30-day major adverse events (MAEs). The secondary outcomes were contrast usage, operative time, bleeding, length of stay (LOS), return to operating room (OR), and freedom from aortic-related interventions up to 2 years.

Results: Overall, 507 patients were included (62.1% ST vs 32.5% C). Seventy-two MAEs occurred in 8.1%, with no differences across groups (7.0% ST vs 9.9% C, p=0.31, adjusted odds ratio [aOR]=0.94, 95% confidence interval [CI]=0.46-1.91 for ST-performed procedures), even when MAE components were depicted individually. After adjustment for confounders, no significant differences were found in contrast usage ≥120 mL (aOR=0.89, 95% CI=0.50-1.56), operative time ≥160 minutes (aOR=0.73, 95% CI=0.45-0.18), bleeding (aOR=1.13, 95% CI=0.60-2.12), intensive care unit admission (aOR=0.68, 95% CI=0.40-1.17), prolonged LOS (aOR=0.93, 95% CI=0.60-1.43), return to OR (aOR=0.91, 95% CI=0.37-2.20), and mid-term freedom from aortic-related interventions (adjusted hazard ratio [aHR]=1.39, 95% CI=0.69-2.79).

Conclusion: In carefully selected cases, elective EVAR performed by supervised trainees seems as safe and effective at mid-term as operations performed by consultants. These findings may have important implications for training programs. Further studies to confirm and clarify our findings are required.

Clinical impact: In carefully selected cases, elective EVAR performed by supervised trainees seems safe, when compared to operations performed by consultants. Short-term major adverse events, contrast usage, operative time, bleeding, secondary interventions and length of stay appear similar. Mid-term freedom-from aortic interventions is comparable. These findings may have important implications for vascular training programs.

Purpose: To report a case series on using a novel semi-branch feature in custom-made stent-grafts in the endovascular treatment of complex aortic aneurysms and summarize the contemporary usage of this technology.

Case series: Four patients underwent endovascular aortic aneurysm repair (EVAR) with a custom-made semi-branch stent-graft (Semi-Branch Endovascular Aortic Aneurysm Repair [SBEVAR]). Two male patients, 75- and 76-year-old, were treated due to failed EVAR with late-type Ia endoleak, and the other two, 80- and 55-year-old male patients, due to a juxta-renal aortic abdominal aneurysm (JRAAA). In 3 cases, the celiac trunk (CT) vessel was targeted through an inner semi-branch; in the other case, all target vessels were bridged through inner semi-branches. Intra-operative technical success was accomplished in all 4 patients. Post-operative recovery was uneventful in all cases. The 30-day computed tomography angiography (CTA) follow-up for each patient showed patent target vessels, excellent apposition of the bridging stent to the semi-branch, and complete exclusion of the aneurysm.

Conclusion: The present report and the literature review demonstrate that introducing this novel semi-branch technology for the endovascular treatment of complex aortic aneurysms is feasible and holds great potential. The encouraging outcomes in cases of JRAAA and failed EVAR with late-type Ia endoleak inspire further studies to explore additional uses of this new tool in treating aortic pathologies.

Clinical impact: The inner semi-branch is a novel technology for the incorporation of the renal and mesenteric vessels during complex endovascular aortic aneurysm repair. This new feature allows the use of a branched stent graft with a shorter length of the proximal sealing zone, reducing, consequently, the aortic coverage. It efficiently treats pathologies in which fenestrations could be inappropriate because precise stent graft placement might be difficult and in which tiny diameters leave inadequate room for typical inner branches. Although encouraging findings have been reported, long-term outcomes in target vessel stability have yet to be described.

Purpose: To perform a systematic review and meta-analysis of the outcomes of Anaconda fenestrated endograft for the treatment of complex abdominal aortic aneurysms (cAAA).

Material and methods: A systematic search of all the literature reported until May 2024 was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The pooled 30-day mortality rate, technical success rate, reintervention rate as well as bridging stent occlusion rate, and corresponding 95% confidence intervals (CIs) were estimated using fixed or random effect methods.

Results: A total of 526 study titles were identified by the initial search strategy, of which 6 were considered eligible for inclusion in the meta-analysis. A total of 782 patients (89% male) were identified among the eligible studies. The pooled 30-day mortality rate was 4.8% (95% CI, 3.5%-6.5%) while the reintervention rate was 7.9% (95% CI, 4.3%-14.1%) and 10.2% (95% CI, 5.8%-17.4%) in the early and late period, respectively. The pooled bridging stents occlusion was 2.7% (95% CI, 1.5%-4.9%) during 30 days and 3.5% (95% CI, 1.6%-7.6%) during follow-up. Overall technical success was 86.1% (95% CI, 62.9%-95.8%).

Conclusions: The use of the Anaconda fenestrated endograft in treatment of complex aortic aneurysms involving the abdominal visceral vessels has low early and late mortality. Low rate of bridging stent occlusion occurs early postoperatively and during follow-up, mostly involving the renal arteries. Reinterventions during follow-up are mostly induced by limb occlusion. Lower early technical success rate is explained by the presence of a type Ia endoleak on final angiography, which however resolves spontaneously early postoperatively.

Clinical impact: The present systematic review and meta-analysis of observational studies provide evidence-based data regarding the safety and efficacy of the fenestrated Anaconda device for the primary treatment of cAAA in the perioperative period and at long-term follow-up. Six studies with an overall 782 patients were included. The technical success in patients with cAAA treated with Anaconda fenestrated endograft was 86% while the reintervention rate was 7.9% and 10.2 during the perioperative and long-term follow up period. The pooled 30-day occlusion rate for the bridging stents was 2.7% while the late pooled occlusion rate for the bridging stents among the studies was 3.5%. The use of the Anaconda fenestrated endograft in treatment of complex aortic aneurysms involving the abdominal visceral vessels seems feasible with promising outcomes. The lower early technical success is obscured by the presence of type Ia endoleak which, resolves spontaneously early postoperatively.