Endoleak

Abdominal aortic aneurysm (AAA) is a condition where the weakening of the aortic wall leads to its widening and the generation of a thrombus. To prevent a possible rupture of the aortic wall, AAA can be treated non-invasively by means of the endovascular aneurysm repair technique (EVAR), consisting of placing a stent-graft inside the aorta by a cateter to exclude the aneurysm sac from the blood circulation. A major complication is the presence of liquid blood turbulences, called endoleaks, in the thrombus formed in the space between the aortic wall and the stent-graft. In this paper we propose an automatic method for the detection of type II endoleaks in computer tomography angiography (CTA) images. The lumen and thrombus in the aneurysm area are first segmented using a radial model approach. Then, these regions are split into Thrombus Connected Components (TCCs) using a watershed-based segmentation and geometric and image content-based characteristics are obtained for each TCC. Finally, TCCs are classified into endoleaks and non-endoleaks using a multilayer Perceptron (MLP) trained on manual labeled sample TCCs provided by experts.

Open surgical repair is considered the traditional treatment for patients with thoracic aortic aneurysms (TAA). In view of the persistent perioperative mobidity and mortality, endovascular stent-graft placement as a minimally invasive and potentially safer treatment for aneurysm of the descending aorta was introduced in 1992. Since then, progress has been made and several institutions have substantiated the safety and effectiveness of stent grafts in the repair of descending TAAs or type-B aortic dissections. Currently, both custom-designed, home-made, and commercially available stent grafts are used. Prior to placement of the endoprosthesis, three major prerequisites must be considered: the localization and mor-phology of the aneurysm; the distal vascular access of sufficient size; and a limited tortuosity of the abdominal and thoracic aorta. Although short-term results are encouraging, severe complications, including paraplegia, cerebral strokes, and aortic rupture, have been encountered. The long-term durability of currently available stent-graft systems is nonexistent and material fatigue are of major concern to both surgeons and radiologists. Nevertheless, endovascular stent-graft placement could become the procedure of choice in a substantial number of patients with descending TAA.

urpose: To scrutinize registry data on thoracoabdominal repairs performed using the Multilayer Flow Modulator (MFM) outside the indications for use (IFU) and analyze the adverse outcomes. Methods: Of 380 patients from Europe registered in the MFM Global Registry after treatment for thoracoabdominal aortic aneurysm (TAAA) or dissection, 38 (10%) patients (30 men; median age 71 years, range 30-91) treated on a compassionate basis outside the IFU were analyzed. Thirteen patients had chronic Stanford type B dissection with aneurysmal dilatation .6 cm. There were 6 mycotic and 4 saccular aneurysms in addition to 15 primary TAAAs. The mean aneurysm diameter was 7.1 cm. Ten patients presented with rupture, and 23 patients had previous open or thoracic endovascular aortic repair (TEVAR). Results: Although no death, paraplegia, stroke, or renovisceral compromise was documented during the initial hospital stay, technical success was zero. There were 31 (81.6%) cases in which there was failure to land the device in normal aorta. Other violations of the IFU included 12 with inadequate stent overlap and 11 cases involving a small MFM being deployed inside a larger one. Five of the 9 cases in which an undersized device was used resulted in a type I endoleak (failure mode I). During a mean follow-up of 10.066.9 months, all-cause mortality was 89.5% (34/38), of which 27 (71.1%) were aneurysm-related deaths. Overall survival, freedom from aneurysm-related death, and rupture-free survival estimates were 17.5%, 25.0%, 31.5%, respectively, at 18 months. There were 8 visceral branch complications; in all, 14 secondary endovascular interventions were required in 11 patients for endoleak (failure modes I and II) or stent foreshortening. No false lumen was completely thrombosed in the dissecting aneurysms. All aneurysms showed a mean sac growth rate of 0.1260.16 cm/month. Factors having a significance influence on risk of aneurysm-related death included maximum aneurysm diameter (p¼0.025, HR 1.37, 95% CI 1.04 to1.82), previous TEVAR (p¼0.03, HR 2.44, 95% CI 1.10 to 2.08), and inadequate overlap between MFM devices (p,0.002, HR 4.02, 95% CI 1.70 to 9.49). Conclusion: There are clinical scenarios in which the MFM does not perform well. The MFM is not a solution for patients living on borrowed time and should not be used indiscriminately in patients in whom other modalities of aortic repair are not feasible. Its use must adhere to the IFU, and robust clinical data are required before constructing a randomized controlled trial.

Background: Despite the publication of recent guidelines for management of the left subclavian artery (LSA) during endovascular stenting procedures of the thoracic aorta, specific management for those presenting with dissection remains unclear. This systematic review attempts to address this issue. Methods: Systematic assessment of the published data on thoracic aorta dissection was performed identifying 46 studies, which incorporated 1,275 patients. Primary outcomes included the prevalence of left arm ischemia, stroke, spinal cord ischemia, endoleak, stent migration, and mortality. Outcomes were compared between patients with and without LSA coverage and revascularization incorporating factors such as the number of stents used, length of aorta covered, urgency of intervention, and type of dissection (acute or chronic). Statistical pooling techniques, c 2 tests, and Fisher's exact testing were used for group comparisons.

The last few years have seen an increase in popularity of endovascular aneurysm repair because of the improvements made to the endografts design as well as experience gained by physicians, but the long-term results of this procedure are still uncertain. The majority of late complications after an endograft can be treated with an endovascular approach but, in some cases, it may need conversion to open surgery. In this paper, we discuss the case of a male patient who presented with an aorto-duodenal fistula on an endograft requiring explant. After two operations and 20 days in hospital, the patient was discharged and after 1 year he is doing well. In medical literature, there are very few reported cases of aortoenteric fistula complicating endovascular prosthesis, the diagnosis is quite difficult, surgical treatment is fairly complex consisting in endograft removal and we refer to our experience on this difficult and life-threatening operation.

To describe early experience with the use of iliac branch grafts (IBGs) in aortoiliac aneurysm repair. (25 months), 14 patients (13 men, one woman) with a mean age of 70.1 years (range, 59.3-80.0 y) were treated with IBGs. Indications were abdominal aneurysm with common iliac artery (CIA) involvement (n ϭ 11), juxtarenal aortic aneurysm with CIA involvement (n ϭ 1), and bilateral CIA and internal iliac artery (IIA) aneurysms (n ϭ 1). Postoperative endoleaks and patency rate were determined with computed tomography within 1 month of implantation and 1 year thereafter, with concurrent clinical evaluation for pelvic ischemia. Mean follow-up period was 18.7 months (range, 6 -35 mo).

urpose: To report the bench-top evaluation and initial clinical use of an instrument for onsite fenestration of aortic stent-grafts. Methods: A stainless steel thermal cautery instrument was designed to create circular stentgraft fenestrations from 3 to 10 mm in diameter. Three operators independently benchtested the instrument on thoracic stent-graft samples to evaluate size, shape, location, and quality of fenestrations created. For clinical use, on-site fenestration was performed 2 days before the endovascular procedure in a sterile room without access to supplemental oxygen. A fenestrator 1 or 2 mm smaller in diameter than the target vessel was used; the edges of the fenestrations were strengthened using flexible radiopaque nitinol wire. The aortic stent-graft was then re-sheathed and sterilized for added safety. Eighteen patients (17 men; mean age 51 years, range 18-80) with a variety of thoracic and juxtarenal pathologies were treated using Zenith TX2, Valiant Captivia, Zenith AAA, and Endurant stent-grafts modified in this manner. Results: After successful bench testing, the instrument was used to create 34 fenestrations in aortic stent-grafts deployed in the 18 patients. Size and location of fenestrations obtained were as desired. Subsequent catheterization of the fenestration/target vessel and covered stent deployment were successfully achieved in 31 (91%) fenestrations; 2 fenestrations had type III endoleaks and 1 fenestration was unused. There was no perioperative mortality, stroke, embolization, vessel dissection, renal failure, or graft infection. Follow-up to 1 year in the majority of patients has revealed no new fenestration-related problems. Conclusion: This simple-to-use instrument makes on-site creation of aortic stent-graft fenestrations easy, accurate, and precise. The instrument is inexpensive, robust, and easily sterilized.

Endovascular repair is a standard of treatment for patients with abdominal aortic aneurysm who are unfit for open surgery. Type 1A endoleak (T1A-E) is defined as persistent blood flow outside the lumen of the endograft due to a failure of the graft to seal the proximal landing zone adequately. Accordingly, T1A-E treatment is mandatory, and endovascular options, when possible, consist of standard adjuncts as cuffs and stents or sometimes mere ballooning. Alternatively, different embolization techniques have been described in little or case series. We describe a successful management of large T1A-E with solely coil embolization of the isolated leakage area.

Objective: The objective of this study was to describe our experience with endovascular aneurysm repair (EVAR) with the use of chimney grafts for branch vessel preservation. Methods: Patients treated with a chimney graft procedure between October 2009 and May 2015 were included for analysis. Patients who were not considered eligible for open surgical repair or for conventional, branched, or fenestrated endovascular repair were selected. A standardized operating procedure with left brachial or axillary artery cutdown access for the chimney grafts and bilateral femoral artery cutdown access for the aortic main device was used. Outcomes were noted according to the Society for Vascular Surgery reporting standards. In addition, evolution of gutter area over time was determined. Estimated rates of survival, freedom from aneurysm growth, and clinical success at 24 months of follow-up were calculated. Results: Thirty-three patients (mean age, 77.6 6 6.8 years; 87.9% male) with a mean preoperative maximum aneurysm diameter of 71.7 6 13.5 mm were included. A total of 54 of an intended 54 chimney grafts were deployed. Primary technical success and 30-day secondary clinical success rates were 87.9% and 84.8%, respectively. The early mortality rate was 6.1% (n ¼ 2). The early type IA endoleak rate was 6.1% (n ¼ 2), and the chimney graft occlusion rate was 6.1% (n ¼ 2). Median follow-up duration was 26 months (interquartile range, 14.8-37.3 months). The estimated 2-year actuarial survival rate was 78.1% (standard error, 67.4%). Late complications included type IA endoleak (n ¼ 1), chimney graft occlusion (n ¼ 2), type II endoleak with aneurysm growth (n ¼ 4), and distal stent graft limb kinking and occlusion (n ¼ 1). Late reinterventions included coil or glue embolization (n ¼ 3), distal limb extension (n ¼ 2), open endoleak ligation (n ¼ 2), Palmaz stent placement (n ¼ 1), repeated EVAR (n ¼ 1), and femorofemoral bypass graft (n ¼ 1). At 2 years, the estimated secondary clinical success and freedom from aneurysm growth rates were 80.5% (67.2%) and 84.4% (67.2%). Gutter size showed a small but significant decrease over time at the level of the proximal markers and at 10 mm distal from the markers. Conclusions: Midterm results show that a standardized procedure for EVAR using chimney grafts for branch vessel preservation is an acceptable option for high-risk patients with large, complex aneurysms who are unfit for open repair and who have been excluded from fenestrated EVAR. Gutter size decreases over time, but the rate of branch vessel loss and reinterventions demonstrate that this approach should remain reserved for those who are at truly prohibitive risk for open or fenestrated stent graft repair.

Objective: This study was conducted to provide insight into the safety, applicability, and outcomes of thoracic endovascular aortic repair (TEVAR) with the chimney graft technique. Methods: Original data regarding the chimney technique in TEVAR in the emergent and elective setting were collected from MEDLINE, Embase, and Scopus databases. All variables were systematically extracted and included in a database. Patient and procedural characteristics, details, and outcomes were analyzed. Results: In total, 94 patients with 101 chimney-stented aortic arch branches were analyzed, consisting of the brachiocephalic artery in 20, the left common carotid artery in 48, and the left subclavian artery in 33. Balloon-expandable stents were used in 36% and self-expandable stents in 64% for the aortic side branch. The interventions were elective in 72% and emergent in 28%. Technical success was achieved in 98% in elective and emergent settings combined. Endoleaks were described in 18%; with type Ia being most frequently reported in 6.4% overall and in 6.5% in the elective setting. Stroke was reported in 5.3% of the patients, of which 40% were fatal. The overall perioperative mortality was 3.2%. Median follow-up time was 11 months, and chimney stents remained patent in all patients. Conclusions: TEVAR with the chimney technique is a viable treatment option and may expand treatment strategies for patients with challenging thoracic aortic pathology and anatomy in the emergent and elective setting. Patency of the thoracic chimney stents appears to be good during short-term follow-up. Other complications, such as endoleak and stroke, deserve attention by future research to further improve treatment strategies and the prognosis of these patients. (J Vasc Surg

Endovascular aneurysm repair (EVAR) will fail over time in a percentage of patients. Mechanical failure of the device, progression of aortic disease, or interface complications between the device and the native vasculature may contribute. Our aim was to evaluate the role of fenestrated and branched endografts as treatment options for failed devices. Between January 2001 and June 2013, 970 patients were enrolled into a physician-sponsored investigational device exemption (PSIDE) study and treated with a fenestrated/branched endograft. All patients treated for nonurgent proximal neck failure of an infrarenal endoprosthesis previously implanted during EVAR comprised the study group. Patients treated for a primary aneurysm within the PSIDE were evaluated as a comparison group to identify preoperative risk factors for failure. A retrospective review was undertaken to determine the details of the initial EVAR, whereas the prospective PSIDE database was used to assess outcomes of secondary...

Despite improvements in endograft devices, operator technique, and patient selection, endovascular repair has not achieved the long-term durability of open surgical aneurysm repair. Persistent or recurrent aneurysm sac flow from failed proximal sealing, component failure, or branch vessel flow underpins a significant rate of reintervention after endovascular repair. The Nellix device (Endologix, Irvine, Calif) employs a unique design with deployment of polymer-filled EndoBags surrounding the endograft flow lumens, sealing the aneurysm sac space and potentially reducing complications from persistent sac flow. This retrospective analysis represents the initial experience in consecutive patients treated with the device in real-world practice. This study was performed at six clinical centers in Europe and one in New Zealand during the initial period after commercialization of the Nellix device. Patients underwent evaluation with computed tomography and other imaging modalities following...

Background: This study presents the short-term and midterm results of direct percutaneous sac injection (DPSI) for postoperative endoleak treatment after endovascular aortic aneurysm repair (EVAR). Methods: Between March 1994 and November 2011, EVAR was performed in 986 patients. The median follow-up was 63 ؎ 45 months (range, 0-211 months). A retrospective analysis was performed. DPSI was used in 21 patients for 19 type II endoleaks and two endoleaks of undefined origin (EOUO), of which 12 (57%) were after failure of a previous endovascular treatment attempt. Results: DPSI using thrombin (n ‫؍‬ 16), coils (n ‫؍‬ 7), gelfoam (n ‫؍‬ 6), or glue (n ‫؍‬ 3), or a combination, was technically feasible in all patients. Saccography during DPSI revealed a previously undetected type I endoleak in three patients. Immediate DPSI success was achieved in 16 of 18 procedures (88.9%), with two complications. Glue incidentally intravasated in the inferior vena cava, causing a clinically nonsignificant subsegmental pulmonary artery embolism in one patient, and the temporary development of a type III endoleak, possibly from graft puncture, in another. During a median follow-up of 39 months (interquartile range, 13-88 months) after DPSI, recurrent endoleaks were observed in nine patients (50.0%), one type I endoleak due to graft migration, five type II endoleaks, and three EOUO. The occurrence of a re-endoleak during follow-up was significantly associated with dual-antiplatelet medication (0% in patients without re-endoleak vs 44.4% in patients with re-endoleak; P ‫؍‬ .023) and with a nonsignificant trend for the use of aspirin alone (33.3% in patients without re-endoleak vs 80% in patients with re-endoleak; P ‫؍‬ .094). Re-endoleak occurred in 33.3% of the patients without antiplatelet medication and in 100% of patients with dual-antiplatelet medication (P ‫؍‬ .026). Thrombin was used as the sole embolic agent during the initial DPSI in all patients with dual-antiplatelet therapy. No other factor was significantly associated with re-endoleaks. Reintervention was deemed necessary in six patients within a median of 10 months (interquartile range, 4-16 months) after DPSI, including six additional DPSI treatments in four patients with type II re-endoleaks, cuff placements in one type I endoleak, and endograft relining in one EOUO. Conclusions: This initial experience suggests that DPSI is feasible as a technique for endoleak treatment after EVAR. However, complications and endoleak recurrence remain a concern. The role of antiplatelet therapy and different embolic agents on long-term embolization success needs to be studied in more detail. ( J Vasc Surg 2012;56:965-72.)

Endovascular treatment for arteriocaval fistula (ACF) has become the preferred alternative to open repair. However, endoleaks sometimes occur and maintain the ACF. A 64-year-old man presented with persistent fistula after placement of a bifurcated stent-graft for ACF complicating an aortoiliac aneurysm that was maintained by endoleaks from the inferior mesenteric and lumbar arteries. Transarterial embolization of the aneurysm sac and inferior mesenteric artery successfully resolved the problem without any complications observed over 16 months of follow-up. A literature review and discussion of the management options for this entity are presented. A combination of inflow and outflow control is important to obtain better long-term outcomes.

Background: This study presents the short-term and midterm results of direct percutaneous sac injection (DPSI) for postoperative endoleak treatment after endovascular aortic aneurysm repair (EVAR). Methods: Between March 1994 and November 2011, EVAR was performed in 986 patients. The median follow-up was 63 ؎ 45 months (range, 0-211 months). A retrospective analysis was performed. DPSI was used in 21 patients for 19 type II endoleaks and two endoleaks of undefined origin (EOUO), of which 12 (57%) were after failure of a previous endovascular treatment attempt. Results: DPSI using thrombin (n ‫؍‬ 16), coils (n ‫؍‬ 7), gelfoam (n ‫؍‬ 6), or glue (n ‫؍‬ 3), or a combination, was technically feasible in all patients. Saccography during DPSI revealed a previously undetected type I endoleak in three patients. Immediate DPSI success was achieved in 16 of 18 procedures (88.9%), with two complications. Glue incidentally intravasated in the inferior vena cava, causing a clinically nonsignificant subsegmental pulmonary artery embolism in one patient, and the temporary development of a type III endoleak, possibly from graft puncture, in another. During a median follow-up of 39 months (interquartile range, 13-88 months) after DPSI, recurrent endoleaks were observed in nine patients (50.0%), one type I endoleak due to graft migration, five type II endoleaks, and three EOUO. The occurrence of a re-endoleak during follow-up was significantly associated with dual-antiplatelet medication (0% in patients without re-endoleak vs 44.4% in patients with re-endoleak; P ‫؍‬ .023) and with a nonsignificant trend for the use of aspirin alone (33.3% in patients without re-endoleak vs 80% in patients with re-endoleak; P ‫؍‬ .094). Re-endoleak occurred in 33.3% of the patients without antiplatelet medication and in 100% of patients with dual-antiplatelet medication (P ‫؍‬ .026). Thrombin was used as the sole embolic agent during the initial DPSI in all patients with dual-antiplatelet therapy. No other factor was significantly associated with re-endoleaks. Reintervention was deemed necessary in six patients within a median of 10 months (interquartile range, 4-16 months) after DPSI, including six additional DPSI treatments in four patients with type II re-endoleaks, cuff placements in one type I endoleak, and endograft relining in one EOUO. Conclusions: This initial experience suggests that DPSI is feasible as a technique for endoleak treatment after EVAR. However, complications and endoleak recurrence remain a concern. The role of antiplatelet therapy and different embolic agents on long-term embolization success needs to be studied in more detail.

Background: We report a rare case of severe spinal cord ischemia with neurological consequences in a patient who presented after endovascular treatment of a type II endoleak following endovascular aneurysm repair. Methods and Results: An enlarging abdominal aortic aneurysm post-endovascular aneurysm repair was detected owing to a persistent type II endoleak caused by a communication between the iliolumbar and L4 lumbar artery for which the patient underwent supraselective embolization with particles and coils. Immediately after the procedure, the patient experienced an acute onset of neurological symptoms in the right lower limb while limb arterial perfusion remained unaffected. Magnetic resonance imaging-magnetic resonance angiography revealed an acute ischemic process at the L2-L4 level. Further follow-up revealed persistence of the endoleak, and the patient was referred to our institution for open surgical treatment. Conclusions: To the best of our knowledge, this is the first report of severe spinal cord ischemia after transcatheter embolization of the feeding iliolumbar branches of a type II endoleak. Care must be taken during embolization of the feeding artery of type II endoleaks, which may also supply the spinal cord, to minimize the risk of possible spinal cord ischemia.

We present the case of a patient with a persisting type II endoleak after endovascular repair of an iliac aneurysm with an iliaco-caval fistula. We describe the pathophysiological mechanism behind this phenomenon and discuss why conservative treatment is unlikely to seal this type of endoleak. A more aggressive treatment strategy is therefore advocated.

Objective: Recent reports showed that the Endurant stent graft (Medtronic Cardiovascular, Santa Rosa, Calif) is safe and effective for endovascular repair of abdominal aortic aneurysms (AAAs). However, due to its relatively recent introduction, only short-term follow-up data are available. This study presents the 4-year results using this device. Methods: All clinical data, including detailed anatomic information of the first 100 consecutive patients treated with the Endurant stent graft for an infrarenal AAA in three Dutch high-volume hospitals, were prospectively collected. Computed tomography angiography was routinely performed before the procedure, #1 month, and at 1 year postendovascular aneurysm repair. Thereafter, the imaging modality during yearly follow-up was individualized (duplex ultrasound imaging or computed tomography angiography). Patients were classified as within or outside the instructions for use (IFU) for analysis. Study end points were primary clinical success, overall and AAA-related mortality, and sac morphology changes and endoleak during follow-up. Estimates were obtained using Kaplan-Meier plots. Results: The study included 100 consecutive patients (88 men) with a median age of 74 years (interquartile range [IQR], 67-79 years) and median AAA diameter of 58 mm (IQR, 55-65 mm), between December 2007 and March 2009. Twenty patients (20%) were treated outside the IFU (18, outside proximal neck IFU, one outside iliac IFU, and one outside both IFUs). Median follow-up was 48 months (IQR, 36-53 months), and no patients were lost. One contained rupture was observed after 1.5 months due to graft infection. No patients had graft migration. Two type Ia endoleaks, 5 type Ib endoleaks, and 15 type II endoleaks were found. Primary clinical success was 97%, 90%, 84% and 77% at 1, 2, 3, and 4 years, respectively. Primary clinical success was comparable for patients treated within or outside IFU (P [ .20), although both patients outside iliac IFU needed a secondary iliac intervention. Over time, maximum aneurysm diameter decreased $5 mm, remained stable, and increased $5 mm in 58%, 32%, and 10% of the patients, respectively. All-cause mortality was 20% at 4 years, with a 3% AAA-related mortality. Conclusions: The 4-year follow-up data of the Endurant stent graft for AAA treatment shows its use results in a low AAArelated mortality with adequate prevention of rupture or aneurysm growth. Although patients with very challenging anatomy were treated in our series, primary clinical success rates were comparable for patients treated within and outside the IFU. However, both patients outside the iliac IFU needed a secondary iliac intervention. The knowledge of the present results may aid in improving outcomes in the future.

Objective: Late thoracic aneurysms develop in 5% to 12% of patients having undergone open repair for coarctation of the aorta (CoA). We report our early results for thoracic endovascular aortic repair for pseudoaneurysms after CoA repair. Methods: From 2008 to 2013, data regarding demographics, aneurysm morphology, procedure, and follow-up were collected prospectively on all patients treated for pseudoaneurysms after CoA repair. Retrospective analysis of identified patients was then performed. Results: Thirteen patients (six men, seven women) were treated. Patients were a median age, 45 years (interquartile range (IQR), 39-56; range, 27-66 years, and the median time after CoA repair to aneurysm treatment was 34 years (IQR, 24-40 years). All patients had saccular pseudoaneurysms of the aortic arch, with a median aneurysm size of 4.1 cm (IQR, 3.4-5.1 cm). The left subclavian artery (LSCA) was involved in 10 patients and was occluded at presentation in three. Four patients had concurrent LSCA revascularization with carotid-subclavian bypass, one had aortic arch hybrid repair, and the LSCA was intentionally covered in two patients. Patients underwent thoracic endovascular aortic repair using the conformable TAG (6 of 13; W. L. Gore & Associates, Flagstaff, Ariz), Valiant device (4 of 13; Medtronic, Minneapolis, Minn), and a custom-made Relay endograft with LSCA scallop (4 of 13; Bolton Medical, Barcelona, Spain). Technical success was 100%, with satisfactory deployment of the stent grafts in all patients. There was no 30-day mortality, stroke, or paraplegia. Median follow-up was 15 months (IQR, 9-19 months; range, 1-67 months). Two type II endoleaks from an intercostal artery were managed conservatively, and one type Ib endoleak was treated successfully with distal stent extension. Conclusions: In this cohort, new-generation stent grafts have good early clinical and radiologic outcomes, avoiding the need for redo open surgery. Management of the LSCA can be tailored to individual patients with new stent graft technology. Long-term follow-up of these patients is crucial to understanding whether endovascular management of this cohort is acceptable.

Objective: The Endurant (Medtronic, Minneapolis, Minn) is a new stent graft specifically designed to make more patients anatomically eligible for endovascular aneurysm (EVAR). This study presents the 1-year results of 100 consecutive patients with abdominal aortic aneurysms (AAAs) treated with the Endurant stent graft in real-life practice. Methods: All clinical preoperative, operative, postoperative, and 1-year follow-up data of patients with the Endurant stent graft from three tertiary centers were prospectively collected. Patients underwent computed tomographic angiography (CTA) preoperatively, at 1 month, and at 1-year post-EVAR. The first 100 patients with an implantation date at least 1 year before our date of analysis and complete information were included. Clinical data, AAA characteristics, presence of endoleaks, graft migration, and other EVAR-related complications were noted. All values are stated as mean ؎ SD (range). Results: This study included 100 patients with AAAs (88 men) with a mean age of 73 ؎ 8 years (47 to 87 years), an AAA size of 61 ؎ 10 mm (31 to 93 mm), an AAA volume of 210 ؎ 122 mL (69 to 934 mL), a proximal neck length of 33 ؎ 14 mm (9 to 82 mm), and an infrarenal angulation of 44 ؎ 25°(0°-108°). Nineteen of the 100 included patients had at least one anatomic characteristic that was considered a violation of the instructions for use (IFU) of the Endurant stent graft. A primary technical success was achieved in 98% of the patients (one additional stent placement in renal artery was required; one unplanned aorto-uni-iliac device placed), with no primary type I or III endoleaks or conversions. A secondary technical success was achieved in all cases. The 30-day mortality was 2% and the first postoperative CTA documented 16 endoleaks (16%; 16 type II). One-year follow-up showed three iliac limb occlusions (3%), one infected stent graft (causing a type Ia endoleak), and five endovascular reinterventions (5%; three to treat iliac limb occlusions, one proximal extension cuff; and one stent in the renal artery). The 1-year all-cause mortality rate was 12% (12 patients) and the AAA-related mortality was 3%. The mean AAA size was significantly smaller after 1 year (diameter, 54 ؎ 11.8 [32-80] mm; P < .01; volume, 173 ؎ 119 [42-1028] mL; P < .01), and one graft migration >5 mm and 13 endoleaks were noted (12 type II, 1 type I [neck dilatation]). Conclusion: The treatment of patients with AAAs with the Endurant stent graft seems to be successful and durable during the first year after EVAR. Despite the wider inclusion criteria for the Endurant, and with 19% of our patients treated outside the IFU, the AAA-related mortality, number of type I or III endoleaks, and reintervention rates are comparable to the results of other stent grafts.

Background: Early morbidity and mortality are generally lower after endovascular aortic repair (EVAR), than after open repair but re-interventions and late complications are more common. The aim of the present study was to make a detailed description of re-interventions after EVAR-including incidence, indications, procedures, and outcome-with special reference to non-access-related re-interventions. Methods: This is a retrospective single-center cohort study of re-interventions after standard EVAR with special reference to non-access-related re-interventions. Consecutive patients (n = 405) treated with standard EVAR for non-ruptured (n = 337) or ruptured (n = 68) infrarenal aneurysms between 2005 and 2013 were analysed. Median follow-up was 29 months (range 0-108). Results: Eighty-nine patients (22 %) underwent 113 re-interventions during follow-up. Twenty-seven patients (7 %) had 28 access related re-intervention, 65 patients (16 %) had 85 non-access related reinterventions. Non-access related re-interventions were more common in ruptured aneurysms than in unruptured aneurysms (22 vs. 15 %, p = 0.002). The most frequent indications were endoleak type I (n = 19), type II (n = 21), or type III (n = 5); stent graft migration (n = 9); and thrombosis (n = 14). The most frequent procedures were embolization of endoleak type II (n = 21), additional iliac stent graft (n = 19), proximal extension (n = 12), thrombolysis (n = 8), iliac limb bare-metal stenting (n = 6), and stent graft relining (n = 7). Endovascular technique was used in 83 % of re-interventions. Thirty-day mortality after non-access-related re-interventions was 15 % when initiated from symptoms (rupture or infection) and 0 % when initiated from follow-up findings (p = 0.014). Cumulative survival five years after EVAR was 72 % in patients with a re-intervention and 59 % in patients without (p = 0.21). Conclusions: Non-access-related re-intervention rates are still considerable after EVAR and more frequent after ruptured aneurysms. Endoleak embolization is the most frequent procedure, followed by additional iliac stent grafts. Outcomes after re-interventions are generally good, except when initiated by rupture or infection.

Background: The chimney graft technique has been proposed as an alternative endovascular treatment of juxtarenal aortic aneurysms, extending the landing zone and enabling successful exclusion of the aneurysm with standard endograft devices. Methods: A prospective observational study assigning patients with juxtarenal aortic aneurysm treated with single renal chimney grafts in a tertiary vascular center in the United Kingdom was conducted. Primary outcome endpoints were defined as technical success, perioperative morbidity and mortality, and freedom from any type of endoleak, reintervention, and aneurysm-related death. Results: Nine patients were enrolled. Successful aortic and chimney graft implantation was achieved in all patients. A proximal type I endoleak noticed on completion angiogram was treated with an aortic extension cuff. None of the patients died within 30 days of treatment. Two patients developed a type IA endoleak during follow-up, resulting in aneurysm rupture and death. Both patients had had uneventful chimney procedures, and no endoleak was evident on previous surveillance computed tomographic scans. All chimney grafts remained patent, and none of the patients developed renal impairment during the follow-up period. Conclusions: Proximal type I endoleak constitutes a weak point of chimney graft interventions. Increased vigilance in surveillance of such patients to prevent late aneurysm-related complications is required. Additional research to identify potential poor prognostic morphologic indicators is expected.

Purpose : To report the use of a endograft to manage a type IB endoleak in a patient with a juxtarenal aortic aneurysm previously treated with a multylayer stent Case report : Under compassionate use a 68 years old patient with a juxtarenal aortic aneurysm and multiple comorbidities was treated with a multilayer flow modulating stent. Twelve months later a new CT scan identified a type Ib endoleak with an increase of the aortic aneurysm size due to extension of the aneurysmal disease to the aortic carrefour . A new endovascular procedure was then performed , deploying an aorto bisiliac endoprosthesis . After 18 months serial echocolor duplex and CT scans have shown normal visceral arteries patency, no signs of endoleak and sac shrinkage of 5 mm Conclusion: In this case, MARS failed to treat the AAA and required a reoperation with conventional covered stentgraft for distal sealing, which may be considered a feasible solution to manage potential endoleaks

Objective: Endovascular aneurysm repair (EVAR) decreases 30-day mortality for patients with ruptured abdominal aortic aneurysms (r-AAAs) compared with open surgical repair (OSR). However, which patients benefit or whether there is any long-term survival advantage is uncertain. Methods: From 2002 to 2011, 283 patients with r-AAA underwent EVAR (n [ 120 [42.4%]) or OSR (n [ 163 [57.6%]) at Albany Medical Center. All data were collected prospectively. Patients were analyzed on an intention-to-treat basis, and outcomes were evaluated by a logistic regression multivariable model. Kaplan-Meier analysis was used to compare long-term survival. Results: The EVAR patients had a significantly lower 30-day mortality than did the OSR patients (29/120 [24.2%] vs 72/163 [44.2%]; P < .005) and better cumulative 5-year survival (37% vs 26%; P < .005). Men benefited more from EVAR (mortality: 20.9% for EVAR vs 44.3% for OSR; P < .001) than did women (mortality: 32.4% vs 43.9%; P [ .39). Age $80 years was a significant predictor of death for EVAR (odds ratio [OR], 1.07; P [ .003) but not for OSR (OR, 1.04; P [ .056). Preexisting hypertension was a significant predictor of survival for both EVAR (OR, 0.17; P < .001) and OSR (OR, 0.48; P [ .021). Almost one fourth of EVAR patients (21/91 [23.1%]) required secondary interventions. Survival advantage was maintained for EVAR patients to 5 years.

Background: Since the introduction of endovascular aneurysm repair (EVAR), long-term follow-up studies reporting single-device results are scarce. In this study, we focus on EVAR repair with the Talent stent graft (Medtronic, Santa Rosa, Calif). Methods: Between July 2000 and December 2007, 365 patients underwent elective EVAR with a Talent device. Patient data were gathered prospectively and evaluated retrospectively. By American Society of Anesthesiologists category, 74% were categories III and IV. Postoperative computed tomography (CT) scanning was performed before discharge, at 3, 12 months, and yearly thereafter. Data are presented according to reporting standards for EVAR. Results: The mean proximal aortic neck diameter was 27 mm (range, 16-36 mm), with a neck length <15 mm in 31% (data available for 193 patients). Deployment of endografts was successful in 361 of 365 patients (99%). Initially, conversion to laparotomy was necessary in four patients. Primary technical success determined by results from computed tomography (CT) scans before discharge was achieved in 333 patients (91%). Proximal type I endoleaks were present in 28 patients (8%) during follow-up, and 14 of these patients needed additional treatment for type I endoleak. The 30-day mortality for the whole Talent group was 1.1% (4 of 365). Follow-up to 84 months is reported for 24 patients. During follow-up, 122 (33%) patients died; in nine, death was abdominal aortic aneurysm (AAA)-related (including 30-day mortality). Kaplan-Meier estimates revealed primary clinical success rates of 98% at 1 year, 93% at 2 years, 88% at 3 years, 79% at 4 years, 64% at 5 years, 51% at 6 years, and 48% at 7 years. Secondary interventions were performed in 73 of 365 patients (20%). Ten conversions for failed endografts were performed. Life-table yearly risk for AAA-related reintervention was 6%, yearly risk for conversion to open repair was 1.1%, yearly risk for total mortality was 8.9%, and yearly risk for AAA-related mortality was 0.8%. Conclusion: Initially, technical success of endovascular aneurysm repair (EVAR) using the Talent endograft is high, with acceptable yearly risk for AAA-related mortality and conversion. However, a substantial amount of mainly endovascular reinterventions is necessary during long-term follow-up to achieve these results. ( J Vasc Surg 2010;ⅢⅢ:ⅢⅢⅢ.)

Background: Since the introduction of endovascular aneurysm repair (EVAR), long-term follow-up studies reporting single-device results are scarce. In this study, we focus on EVAR repair with the Talent stent graft (Medtronic, Santa Rosa, Calif). Methods: Between July 2000 and December 2007, 365 patients underwent elective EVAR with a Talent device. Patient data were gathered prospectively and evaluated retrospectively. By American Society of Anesthesiologists category, 74% were categories III and IV. Postoperative computed tomography (CT) scanning was performed before discharge, at 3, 12 months, and yearly thereafter. Data are presented according to reporting standards for EVAR. Results: The mean proximal aortic neck diameter was 27 mm (range, 16-36 mm), with a neck length <15 mm in 31% (data available for 193 patients). Deployment of endografts was successful in 361 of 365 patients (99%). Initially, conversion to laparotomy was necessary in four patients. Primary technical success determined by results from computed tomography (CT) scans before discharge was achieved in 333 patients (91%). Proximal type I endoleaks were present in 28 patients (8%) during follow-up, and 14 of these patients needed additional treatment for type I endoleak. The 30-day mortality for the whole Talent group was 1.1% (4 of 365). Follow-up to 84 months is reported for 24 patients. During follow-up, 122 (33%) patients died; in nine, death was abdominal aortic aneurysm (AAA)-related (including 30-day mortality). Kaplan-Meier estimates revealed primary clinical success rates of 98% at 1 year, 93% at 2 years, 88% at 3 years, 79% at 4 years, 64% at 5 years, 51% at 6 years, and 48% at 7 years. Secondary interventions were performed in 73 of 365 patients (20%). Ten conversions for failed endografts were performed. Life-table yearly risk for AAA-related reintervention was 6%, yearly risk for conversion to open repair was 1.1%, yearly risk for total mortality was 8.9%, and yearly risk for AAA-related mortality was 0.8%. Conclusion: Initially, technical success of endovascular aneurysm repair (EVAR) using the Talent endograft is high, with acceptable yearly risk for AAA-related mortality and conversion. However, a substantial amount of mainly endovascular reinterventions is necessary during long-term follow-up to achieve these results. ( J Vasc Surg 2010;ⅢⅢ:ⅢⅢⅢ.)

Objective. To evaluate frequency, causes and results of conversion to Open repair (OR) after endovascular repair (EVAR) in a single centre during an 8-year period. Design. Six hundred and forty-nine consecutive patients undergoing EVAR were followed up prospectively for endograftrelated complications. Outcomes. Early conversion was any OR during or within 30 days from the primary EVAR. Late conversion was any OR with removal of the endograft after 30 days since a completed EVAR procedure. Results. Median patient follow-up was 38 months (1-93 months). Conversion to OR was performed in 38 patients; nine early and 29 late. Most (7/9) early conversions were due to extensive vessel calcification. Peri-operative mortality was 22% (2/9). Late conversions occurred at a median of 33 months after primary EVAR: 29 were elective and 4 urgent. During the same interval, 79 secondary endovascular interventions were performed, 7 of which failed. The risk of conversion to OR was 9% at 6 years. At multivariate logistic regression analysis, no single factor (short, large or angulated neck, suprarenal fixation, large pre-operative diameter, iliac aneurysms, ASA score risk) was associated with the risk of late failure requiring conversion to OR. Conclusion. The risk of death after early conversion should be recognized, to avoid forcing morphological indications for primary EVAR. Occurrence of late conversion after EVAR is not negligible, affecting almost 1 out of 10 patients after 6 years. In the presence of an expanding aneurysm after EVAR, especially after a failed secondary endovascular correction, an aggressive attitude in fit patients allows outcomes at similar to those of primary OR.

Objective: In order to prevent postoperative migrations and endoleaks after endovascular aneurysm repair (EVAR), we developed a tissue-engineered vascular graft that integrates with the aortic wall by recruiting the host tissue into the graft scaffold. In this study, we assessed the mechanical properties of the new graft, and evaluated the integration between the graft and the aortic wall histologically and mechanically in canine models.

Background: An increasing number of abdominal aortic aneurysms with unfavorable proximal neck anatomy are treated with standard endograft devices. Skepticism exists with regard to the safety and efficacy of this practice. Methods: A systematic review of the literature was undertaken to identify all studies comparing the outcomes of endovascular aneurysm repair (EVAR) in patients with hostile and friendly infrarenal neck anatomy. Hostile neck conditions were defined as conditions that were not consistent with the instructions for use of the endograft devices employed in the selected studies. Outcome data were pooled, and combined overall effect sizes were calculated using fixed or random effects models. Results: Seven observational studies reporting on 1559 patients (hostile anatomy group, 714 patients; friendly anatomy group, 845 patients) were included. Patients with hostile anatomy required an increased number of adjunctive procedures to achieve proximal seal compared with patients with friendly anatomy (odds ratio [OR], 3.050; 95% confidence interval [CI], 1.884-4.938). Although patients with unfavorable neck anatomy had an increased risk of developing 30-day morbidity (OR, 2.278; 95% CI, 1.025-5.063), no significant differences in the incidence of type I endoleak and reintervention rates within 30 days of treatment between the two groups were identified (OR, 2.467 and 1.082; 95% CI, 0.562-10.823 and 0.096-12.186). Patients with hostile anatomy had a fourfold increased risk of developing type I endoleak (OR, 4.563; 95% CI, 1.430-14.558) and a ninefold increased risk of aneurysm-related mortality within 1 year of treatment (OR, 9.378; 95% CI, 1.595-55.137). Conclusions: Insufficient high-level evidence for or against performing standard EVAR in patients with hostile neck anatomy exists. Our analysis suggests EVAR should be cautiously used in patients with anatomic neck constraints.

Purpose This prospective study was designed to assess the diagnostic value of magnetic resonance angiography (MRA) with blood-pool contrast agent (gadofosveset) in the detection of type-II endoleak after endovascular aortic repair (EVAR). Methods Thirty-two patients with aortic aneurysms who had undergone EVAR were included in this study. All patients were examined by dual-phase computed tomography angiography (CTA) as well as MRA with gadofosveset in the first-pass and steady-state phases. Two independent readers evaluated the images of CTA and MRA in terms of endoleak type II, feeding vessel, and image quality. Results Median follow-up-time after EVAR was 22 months (range 4 to 59). Endoleak type II was detected by CTA in 12 of 32 patients (37.5%); MRA detected endoleak in all of these patients as well as in another 9 patients (n = 21, 65.6%), of whom the endoleaks in 6 patients showed an increasing diameter. Most endoleaks were detected in the steady-state phase (n = 14). The decrease in diameter of the aneurysmal sac was significantly greater in the patients without a visible endoleak that was visible on MRA (P = 0.004). In the overall estimation of diagnostic accuracy, MRA was judged superior to CTA in 66% of all examinations. Conclusion MRA with gadofosveset appeared superior to CTA, and has higher diagnostic accuracy, in the detection of endoleak after EVAR.

Purpose: To evaluate the feasibility and efficacy of transarterial sac embolization with a mixture of N-butyl cyanoacrylate and ethiodized oil (Lipiodol; Guerbet Japan, Tokyo, Japan) (NBCA-LPD) for type II endoleaks after endovascular aortic repair (EVAR) using a double coaxial microcatheter technique. Materials and Methods: A retrospective review was performed of 20 consecutive cases of type II endoleaks treated by transarterial embolization using the technique from August 2010 to June 2013. The treatment indication was persistent type II endoleak over 6 months after EVAR associated with aneurysm expansion Z 5 mm in maximum diameter. A 1.9-F nontapered microcatheter was advanced to the aneurysmal sac through a 2.7-F microcatheter, which was coaxially introduced through a catheter. The endpoint of the procedure was intrasaccular filling with NBCA-LPD and occlusion of the feeder of the type II endoleak. The technical success rate was defined as success in transarterial intrasaccular approach followed by embolization of the intrasaccular channel and inflow arteries. Clinical success was defined as aneurysmal sac shrinkage or stabilization (freedom from sac expansion 4 5 mm in maximum diameter). Results: Technical success was achieved in 18 of 20 cases. During a mean follow-up period of 18.5 months, complete sac occlusion was observed in 13 cases (65%). Clinical success was achieved in 16 cases (80%). No serious complications were observed. Conclusions: The transarterial intrasaccular approach with a double coaxial microcatheter technique can be successfully performed in most cases, and transarterial aneurysm sac embolization using NBCA-LPD has been proven to be feasible. ABBREVIATIONS DSA = digital subtraction angiography, EVAR = endovascular aortic repair, NBCA-LPD = N-butyl cyanoacrylate and ethiodized oil (Lipiodol)

Objectives: Whether abdominal aortic aneurysm (AAA) enlargement after endovascular aneurysm repair (EVAR), without an identifiable endoleak, is a risk factor for AAA rupture remains controversial. To our knowledge, studies including large patient numbers investigating this topic have not been done. Therefore, a considerable number of conversions to open AAA repair have been performed in this patient group. This study evaluated AAA rupture risk in patients without detectable endoleaks but with AAA enlargement after EVAR treatment. Methods: Baseline characteristics and follow-up data were collected prospectively by case record forms. Follow-up visits were scheduled at 1, 3, 6, 12, 18, and 24 months, and annually thereafter. The follow-up assessment included clinical examination and imaging studies. Patients were divided into three groups according to the degree of shrinkage or enlargement of the aneurysm. Group A included patients with >8 mm aneurysm shrinkage, group B consisted of patients with <8 mm shrinkage to <8 mm enlargement, and group C patients had an aneurysm enlargement of >8 mm. Results: The basis for this analysis was 6337 patients who were enrolled prospectively in the European Collaborators on Stent-Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) database between 1996 and 2006. Group A included 691 patients; group B, 5307 patients; and group C, 339 patients. Ruptures occurred in 3 patients in group A, in 14 patients in group B, and in 9 patients in group C. The annual rate of rupture in group C was <1% in the first 4 years but accelerated to 7.5% up to 13.6% in the years thereafter. The mortality rate of elective conversion to open AAA repair was 6.0%. Conclusions: The risk of rupture in patients with an AAA enlargement of 8 mm after EVAR, without detectable endoleaks, is <1% in the first 4 years. No ruptures were seen in patients with AAA enlargement without detectable endoleaks who were not treated with Vanguard stent grafts (Boston Scientific Corp, Natick, Mass) and had AAA diameters <70 mm. For this group, conversion to open repair might not be mandatory, and regular follow-up can be advised instead. After 4 years of follow-up, this study observed an increased annual rupture risk, which might indicate the need for conversion; however, groups are small, and follow-up bias could play a role.

The optimal treatment for type II endoleaks remains unclear. The present report describes a case of ischemic skin ulceration after glue embolization of a type II endoleak with challenging access in a multiply comorbid 82-year-old woman with an expanding aneurysm sac 3 years after endovascular aneurysm repair. Embolization was performed from a proximal position with an n-butyl cyanoacrylate/Ethiodol mixture to allow flow into the endoleak because direct sac puncture was hazardous. One week after intervention, an eschar, which progressed to superficial necrosis as a result of partial nontarget delivery of sclerosant, developed over the left iliac crest. The eschar was self-limiting, with complete resolution by 6 months.

The aim of this paper was to evaluate the influence of a challenging neck on mid-term results using the Endurant I stent-graft system in high risk patients. A retrospective study was conducted on a prospectively compiled database of 72 elective patients with challenging neck treated with the Endurant I system (Endurant Stent Graft, Medtronic AVE, Santa Rosa, CA, USA). These patients were compared to a control group (65 patients) without significant neck problems. The endpoints were mid-term 2-years technical, clinical success and the event free survival of all treated patients. Mean age was 76.12 years; 76.6% of patients were males. Risk factors and preoperative variables did not differ significantly between the two groups. Only 4 (5.5%) patients of the study group vs. 2 (3.1%) in the control group developed type I endoleak during the follow-up. Three (4.1%) study group patients developed type III endoleak vs. 2 (3.1%) in the control group. All these patients required an adjunct pro...

Methods. From 1997 to 2010, 72 patients (median age, 67 years) presented with penetrating atherosclerotic ulcers (symptomatic, 58%; rupture, 36%). Median logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 32. Mean follow-up was 42 months (range, 19 to 56 months). In-hospital mortality, occurrence of endoleaks, reinterventions, and survival were recorded.

Objectives: Hybrid aortic arch repair procedure was introduced to reduce invasiveness in high-risk patients with aortic arch pathology. The good results are expanding its application, but endoleak, particularly type I, remains its Achilles' heel. Design: We describe our experience with hybrid treatment of aortic arch diseases focussing on techniques and results to avoid type I endoleak. Materials and Methods: A total of 15 high-risk patients with zone 0e2 aortic arch pathology underwent supra-aortic debranching on ascending aorta and proximal aortic arch reinforcement with a Dacron prosthesis. Metachronously, the procedure was completed with endovascular stent grafting (ESG). Results: Median age was 70 years with a mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 12.7 AE 6.8. One patient died between aortic debranching and ESG. Mean time between surgical debranching and ESG was 32 AE 27.7 days. No major neurological events occurred. Mean length of the landing zone for ESG was 3.8 AE 0.8 cm. Computed tomography (CT) angiography scan performed soon after operation, and at 3, 6, and 12 months did not show any type I endoleak.