Endovascular Aortic Interventions and Aneurysm Repair: Recent Advances and Future Prospects

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Vascular Medicine".

Deadline for manuscript submissions: closed (15 October 2023) | Viewed by 16735

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Special Issue Editors


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Guest Editor
Department of Vascular Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
Interests: peripheral artery disease (PAD); aortic pathology; endovascular interventions
Special Issues, Collections and Topics in MDPI journals

E-Mail Website
Guest Editor
Department of Vascular Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
Interests: peripheral artery disease (PAD); aortic pathology; endovascular interventions
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

We are the Guest Editors of a new Special Issue entitled “Endovascular Aortic Interventions and Aneurysm Repair: Recent Advances and Future Prospects” to be published in the Journal of Clinical Medicine (JCM, Impact Factor 4.242, ISSN 2077-0383, https://www.mdpi.com/journal/jcm). The treatment of aortic pathologies has changed significantly over the past few decades, fueled by the first endovascular aneurysm repair (EVAR). Gradually, endovascular interventions to treat aortic pathologies have become the first line of treatment in most centers and have been shown to be both safe and effective. Over the years, image guidance, endovascular materials and techniques, and stent grafts have evolved, enabling us to treat a wider range of aneurysms and other aortic diseases. On one hand, endovascular aortic repair opens doors for innovations related to interventional planning, imaging, stent graft development, application of Artificial Intelligence (AI), and patient selection. On the other hand, there are also drawbacks, such as the negative effects of radiation, endoleaks (relevance, detection, and treatment), and cost-effectiveness issues, which evoke new research questions. Endovascular aortic repair has seen and continues to see significant progress, a development which cannot be stopped. This Special Issue will address topics that can keep us in the loop and help us to achieve even faster, more effective, cheaper, and safer repairs.

We would like to invite you to contribute an original research or review article to this Special Issue.

Dr. Martin Teraa
Dr. Constantijn E.V.B. Hazenberg
Guest Editors

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Keywords

  • endovascular aneurysm repair (EVAR)
  • complex EVAR
  • aortic pathology
  • aortic disease
  • aortic aneurysm
  • aneurysm
  • aortic dissection
  • endovascular intervention

Published Papers (13 papers)

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Editorial

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4 pages, 199 KiB  
Editorial
The Current Era of Endovascular Aortic Interventions and What the Future Holds
by Martin Teraa and Constantijn E. V. B. Hazenberg
J. Clin. Med. 2022, 11(19), 5900; https://doi.org/10.3390/jcm11195900 - 06 Oct 2022
Viewed by 1029
Abstract
Today, more than 30 years after the first endovascular aneurysm repair (EVAR) by Juan Parodi and Julio Palmaz [...] Full article

Research

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11 pages, 1531 KiB  
Article
The Correlation of Aortic Neck Angle and Length in Abdominal Aortic Aneurysm with Severe Neck Angulation for Prediction of Intraoperative Neck Complications and Postoperative Outcomes after Endovascular Aneurysm Repair
by Khamin Chinsakchai, Thana Sirivech, Frans L. Moll, Sasima Tongsai and Kiattisak Hongku
J. Clin. Med. 2023, 12(18), 5797; https://doi.org/10.3390/jcm12185797 - 06 Sep 2023
Cited by 1 | Viewed by 1090
Abstract
Objectives: Endovascular aneurysm repair (EVAR) in a hostile neck has been associated with adverse outcomes. We aimed to determine the association of infrarenal aortic neck angle and length and establish an optimal cutoff value to predict intraoperative neck complications and postoperative outcomes. Methods: [...] Read more.
Objectives: Endovascular aneurysm repair (EVAR) in a hostile neck has been associated with adverse outcomes. We aimed to determine the association of infrarenal aortic neck angle and length and establish an optimal cutoff value to predict intraoperative neck complications and postoperative outcomes. Methods: This was a retrospective review of patients with an intact infrarenal abdominal aortic aneurysm (AAA) with severe neck angulation (>60 degrees) who underwent EVAR from October 2010 to October 2018. Demographic data, aneurysm morphology, and operative details were collected. The ratio of neck angle and length was calculated as the optimal cutoff value of the aortic neck angle-length index. The patients were categorized into two distinct groups using latent profile analysis, a statistical technique employed to identify concealed subgroups within a larger population by examining a predetermined set of variables. Intraoperative neck complications, adjunct neck procedures, and early and late outcomes were compared. Results: 115 patients were included. Group 1 (G1) had 95 patients with an aortic neck angle-length index ≤ 4.8, and Group 2 (G2) had 20 patients with an aortic neck angle-length index > 4.8. Demographic data and aneurysm morphology were not significantly different between groups except for neck length (p < 0.001). G2 had more intraoperative neck complications than G1 (21.1% vs. 55%, p = 0.005). Adjunctive neck procedures were more common in G2 (18.9% vs. 60%, p < 0.001). The thirty-day mortality rate was not statistically different. G1 patients had a 5-year proximal neck re-intervention-free rate comparable to G2 patients (93.7% G1 vs. 87.5% G2, p = 0.785). The 5-year overall survival rate was not statistically different (59.9% G1 vs. 69.2% G2, p = 0.891). Conclusions: Patients with an aortic neck angle-length index > 4.8 are at greater risk of intraoperative neck complications and adjunctive neck procedures than patients with an aortic neck angle-length index ≤ 4.8. The 5-year proximal neck re-intervention-free rate and the 5-year survival rate were not statistically different. Based on our findings, this study suggests that the aortic neck angle-length index is a reliable predictor of intraoperative neck complications during EVAR in AAA with severe neck angulation. Full article
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11 pages, 1029 KiB  
Article
Increased Aortic Exclusion in Endovascular Treatment of Complex Aortic Aneurysms
by Merel Verhagen, Daniel Eefting, Carla van Rijswijk, Rutger van der Meer, Jaap Hamming, Joost van der Vorst and Jan van Schaik
J. Clin. Med. 2023, 12(15), 4921; https://doi.org/10.3390/jcm12154921 - 26 Jul 2023
Viewed by 838
Abstract
Purpose: Perioperative risk assessments for complex aneurysms are based on the anatomical extent of the aneurysm and do not take the length of the aortic exclusion into account, as it was developed for open repair. Nevertheless, in the endovascular repair (ER) of complex [...] Read more.
Purpose: Perioperative risk assessments for complex aneurysms are based on the anatomical extent of the aneurysm and do not take the length of the aortic exclusion into account, as it was developed for open repair. Nevertheless, in the endovascular repair (ER) of complex aortic aneurysms, additional segments of healthy aorta are excluded compared with open repair (OR). The aim of this study was to assess differences in aortic exclusion between the ER and OR of complex aortic aneurysms, to subsequently assess the current classification for complex aneurysm repair. Methods: This retrospective observational study included patients that underwent complex endovascular aortic aneurysm repair by means of fenestrated endovascular aneurysm repair (FEVAR), fenestrated and branched EVAR (FBEVAR), or branched EVAR (BEVAR). The length of aortic exclusion and the number of patent segmental arteries were determined and compared per case in ER and hypothetical OR, using a Wilcoxon signed-rank test. Results: A total of 71 patients were included, who were treated with FEVAR (n = 44), FBEVAR (n = 8), or BEVAR (n = 19) for Crawford types I (n = 5), II (n = 7), III (n = 6), IV (n = 7), and V (n = 2) thoracoabdominal or juxtarenal (n = 44) aneurysms. There was a significant increase in the median exclusion of types I, II, III, IV, and juxtarenal aneurysms (p < 0.05) in ER, compared with hypothetical OR. The number of patent segmental arteries in the ER of type I–IV and juxtarenal aneurysms was significantly lower than in hypothetical OR (p < 0.05). Conclusion: There are significant differences in the length of aortic exclusion between ER and hypothetical OR, with the increased exclusion in ER resulting in a lower number of patent segmental arteries. The ER and OR of complex aortic aneurysms should be regarded as distinct modalities, and as each approach deserves a particular risk assessment, future efforts should focus on reporting on the extent of exclusion per treatment modality, to allow for appropriate comparison. Full article
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11 pages, 1682 KiB  
Article
Nonsurgical Repair of the Ascending Aorta: Why Less Is More
by Xun Yuan, Xiaoxin Kan, Zhihui Dong, Xiao Yun Xu and Christoph A. Nienaber
J. Clin. Med. 2023, 12(14), 4771; https://doi.org/10.3390/jcm12144771 - 19 Jul 2023
Viewed by 1012
Abstract
Objective: Advanced endovascular options for acute and chronic pathology of the ascending aorta are emerging; however, several problems with stent grafts placed in the ascending aorta have been identified in patients unsuitable for surgical repair, such as migration and erosion at aorta interface. [...] Read more.
Objective: Advanced endovascular options for acute and chronic pathology of the ascending aorta are emerging; however, several problems with stent grafts placed in the ascending aorta have been identified in patients unsuitable for surgical repair, such as migration and erosion at aorta interface. Method: Among the six cases analysed in this report, three were treated with a stent graft in the ascending aorta to manage chronic dissection in the proximal aorta; dimensions of those stent grafts varied between 34 and 45 mm in diameter, and from 77 to 100 mm in length. Three patients, matched by age, sex and their nature of pathology, were subjected to the focal closure of a single communicating entry by the use of an occluding device (Amplatzer ASD and PFO occluders between 14 and 18 mm disc diameter) with similar Charlson comorbidity score. Results: Both conceptually different nonsurgical management strategies were technically feasible; however, with stent grafts, an early or delayed erosion to full re-dissection was documented with stent grafts, in contrast to complete seal, with an induced remodelling and a long-term survival after the successful placing of coils and occluder devices. Moreover, aortic root motion was not impaired by the focal occlusion of a communication with an occluder, while free motion was impeded after stent graft placement. Conclusions: The intriguing observation in our small series was that stent grafts placed in the ascending aorta portends the risk of an either early (post-procedural) or delayed migration and erosion of aortic tissues at the landing site or biological interface between 12 and 16 months after the procedure, a phenomenon not seen with the use of focal occluding devices up to 5 years of follow-up. Obviously, the focal approach avoids the erosion of the aortic wall as the result of minimal interaction with the biological interface, such as a diseased aortic wall. Potential explanations may be related to a reduced motion of the aortic root after the placement of stent graft in the ascending aorta, whereas the free motion of aortic root was preserved with an occluder. The causality of erosion may however not be fully understood, as besides the stiffness and radial force of the stent graft, other factors such as the induced inflammatory reactions of aortic tissue and local adhesions within the chest may also play a role. With stent grafts failing to portend long-term success, they may still have a role as a temporizing solution for elective surgical conversion. Larger datasets from registries are needed to further explore this evolving field of interventions to the ascending aorta. Full article
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17 pages, 10261 KiB  
Article
Three-Dimensional Characterization of Aortic Root Motion by Vascular Deformation Mapping
by Taeouk Kim, Nic S. Tjahjadi, Xuehuan He, JA van Herwaarden, Himanshu J. Patel, Nicholas S. Burris and C. Alberto Figueroa
J. Clin. Med. 2023, 12(13), 4471; https://doi.org/10.3390/jcm12134471 - 04 Jul 2023
Viewed by 1140
Abstract
The aorta is in constant motion due to the combination of cyclic loading and unloading with its mechanical coupling to the contractile left ventricle (LV) myocardium. This aortic root motion has been proposed as a marker for aortic disease progression. Aortic root motion [...] Read more.
The aorta is in constant motion due to the combination of cyclic loading and unloading with its mechanical coupling to the contractile left ventricle (LV) myocardium. This aortic root motion has been proposed as a marker for aortic disease progression. Aortic root motion extraction techniques have been mostly based on 2D image analysis and have thus lacked a rigorous description of the different components of aortic root motion (e.g., axial versus in-plane). In this study, we utilized a novel technique termed vascular deformation mapping (VDM(D)) to extract 3D aortic root motion from dynamic computed tomography angiography images. Aortic root displacement (axial and in-plane), area ratio and distensibility, axial tilt, aortic rotation, and LV/Ao angles were extracted and compared for four different subject groups: non-aneurysmal, TAA, Marfan, and repair. The repair group showed smaller aortic root displacement, aortic rotation, and distensibility than the other groups. The repair group was also the only group that showed a larger relative in-plane displacement than relative axial displacement. The Marfan group showed the largest heterogeneity in aortic root displacement, distensibility, and age. The non-aneurysmal group showed a negative correlation between age and distensibility, consistent with previous studies. Our results revealed a strong positive correlation between LV/Ao angle and relative axial displacement and a strong negative correlation between LV/Ao angle and relative in-plane displacement. VDM(D)-derived 3D aortic root motion can be used in future studies to define improved boundary conditions for aortic wall stress analysis. Full article
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15 pages, 2758 KiB  
Article
Incidence and Outcomes of Abdominal Aortic Aneurysm Repair in New Zealand from 2001 to 2021
by Sinead Gormley, Oliver Bernau, William Xu, Peter Sandiford and Manar Khashram
J. Clin. Med. 2023, 12(6), 2331; https://doi.org/10.3390/jcm12062331 - 16 Mar 2023
Cited by 2 | Viewed by 2017
Abstract
Purpose: The burden of abdominal aortic aneurysms (AAA) has changed in the last 20 years but is still considered to be a major cause of cardiovascular mortality. The introduction of endovascular aortic repair (EVAR) and improved peri-operative care has resulted in a steady [...] Read more.
Purpose: The burden of abdominal aortic aneurysms (AAA) has changed in the last 20 years but is still considered to be a major cause of cardiovascular mortality. The introduction of endovascular aortic repair (EVAR) and improved peri-operative care has resulted in a steady improvement in both outcomes and long-term survival. The objective of this study was to identify the burden of AAA disease by analysing AAA-related hospitalisations and deaths. Methodology: All AAA-related hospitalisations in NZ from January 2001 to December 2021 were identified from the National Minimum Dataset, and mortality data were obtained from the NZ Mortality Collection dataset from January 2001 to December 2018. Data was analysed for patient characteristics including deprivation index, repair methods and 30-day outcomes. Results: From 2001 to 2021, 14,436 patients with an intact AAA were identified with a mean age of 75.1 years (SD 9.7 years), and 4100 (28%) were females. From 2001 to 2018, there were 5000 ruptured AAA with a mean age of 77.8 (SD 9.4), and 1676 (33%) were females. The rate of hospitalisations related to AAA has decreased from 43.7 per 100,000 in 2001 to 15.4 per 100,000 in 2018. There was a higher proportion of rupture AAA in patients living in more deprived areas. The use of EVAR for intact AAA repair has increased from 18.1% in 2001 to 64.3% in 2021. The proportion of octogenarians undergoing intact AAA repair has increased from 16.2% in 2001 to 28.4% in 2021. The 30-day mortality for intact AAA repair has declined from 5.8% in 2001 to 1.7% in 2021; however, it has remained unchanged for ruptured AAA repair at 31.6% across the same period. Conclusions: This study highlights that the incidence of AAA has declined in the last two decades. The mortality has improved for patients who had a planned repair. Understanding the contemporary burden of AAA is paramount to improve access to health, reduce variation in outcomes and promote surgical quality improvement. Full article
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11 pages, 841 KiB  
Article
Feasibility and Safety of Percutaneous Axillary Artery Access in a Prospective Series of 100 Complex Aortic and Aortoiliac Interventions
by Tim Wittig, Arsen Sabanov, Andrej Schmidt, Dierk Scheinert, Sabine Steiner and Daniela Branzan
J. Clin. Med. 2023, 12(5), 1959; https://doi.org/10.3390/jcm12051959 - 01 Mar 2023
Viewed by 1147
Abstract
We aimed to review the feasibility and safe use of the percutaneous axillary artery (AxA, 100 patients) approach for endovascular repair (ER) of thoraco-abdominal aortic aneurysms (TAAA, 90 patients) using fenestrated, branched, and chimney stent grafts and other complex endovascular procedures (10 patients) [...] Read more.
We aimed to review the feasibility and safe use of the percutaneous axillary artery (AxA, 100 patients) approach for endovascular repair (ER) of thoraco-abdominal aortic aneurysms (TAAA, 90 patients) using fenestrated, branched, and chimney stent grafts and other complex endovascular procedures (10 patients) necessitating AxA access. Percutaneous puncture of the AxA in its third segment was performed using sheaths sized between 6 to 14F. For closing puncture sites greater than 8F, two Perclose ProGlide percutaneous vascular closure devices (PVCDs) (Abbott Vascular, Santa Clara, CA, USA) were deployed in the pre-close technique. The median maximum diameter of the AxA in the third segment was 7.27 mm (range 4.50–10.80). Device success, defined as successful hemostasis by PVCD, was reported in 92 patients (92.0%). As recently reported results in the first 40 patients suggested that adverse events, including vessel stenosis or occlusion, occurred only in cases with a diameter of the AxA < 5 mm, in all subsequent 60 cases AxA access was restricted to a vessel diameter ≥ 5 mm. In this late group, no hemodynamic impairment of the AxA occurred except in six early cases below this diameter threshold, all of which could be repaired by endovascular measures. Overall mortality at 30 days was 8%. In conclusion, percutaneous approach of the AxA in its third segment is feasible and represents a safe alternative access to open access for complex endovascular aorto-iliac procedures. Complications are rare, especially if the maximum diameter of the access vessel (AxA) is ≥5 mm. Full article
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10 pages, 2393 KiB  
Article
Dynamic Morphology of the Ascending Aorta and Its Implications for Proximal Landing in Thoracic Endovascular Aortic Repair
by Denis Skrypnik, Marius Ante, Katrin Meisenbacher, Dorothea Kronsteiner, Matthias Hagedorn, Fabian Rengier, Florian Andre, Norbert Frey, Dittmar Böckler and Moritz S. Bischoff
J. Clin. Med. 2023, 12(1), 70; https://doi.org/10.3390/jcm12010070 - 21 Dec 2022
Viewed by 1259
Abstract
In this study, we assessed the dynamic segmental anatomy of the entire ascending aorta (AA), enabling the determination of a favorable proximal landing zone and appropriate aortic sizing for the most proximal thoracic endovascular aortic repair (TEVAR). Methods: Patients with a non-operated AA [...] Read more.
In this study, we assessed the dynamic segmental anatomy of the entire ascending aorta (AA), enabling the determination of a favorable proximal landing zone and appropriate aortic sizing for the most proximal thoracic endovascular aortic repair (TEVAR). Methods: Patients with a non-operated AA (diameter < 40 mm) underwent electrocardiogram-gated computed tomography angiography (ECG-CTA) of the entire AA in the systolic and diastolic phases. For each plane of each segment, the maximum and minimum diameters in the systole and diastole phases were recorded. The Wilcoxon signed-rank test was used to compare aortic size values. Results: A total of 100 patients were enrolled (53% male; median age 82.1 years; age range 76.8–85.1). Analysis of the dynamic plane dimensions of the AA during the cardiac cycle showed significantly higher systolic values than diastolic values (p < 0.001). Analysis of the proximal AA segment showed greater distal plane values than proximal plane values (p < 0.001), showing a reversed funnel form. At the mid-ascending segment, the dynamic values did not notably differ between the distal plane and the proximal segmental plane, demonstrating a cylindrical form. At the distal segment of the AA, the proximal plane values were larger than the distal segmental plane values (p < 0.001), thus generating a funnel form. Conclusions: The entire AA showed greater systolic than diastolic aortic dimensions throughout the cardiac cycle. The mid-ascending and distal-ascending segments showed favorable forms for TEVAR using a regular cylindrical endograft design. The most proximal segment of the AA showed a pronounced conical form; therefore, a specific endograft design should be considered. Full article
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10 pages, 1760 KiB  
Article
Effectiveness and Minimal-Invasiveness of Zone 0 Landing Thoracic Endovascular Aortic Repair Using Branched Endograft
by Tomoaki Kudo, Toru Kuratani, Yoshiki Sawa and Shigeru Miyagawa
J. Clin. Med. 2022, 11(23), 6981; https://doi.org/10.3390/jcm11236981 - 26 Nov 2022
Viewed by 1271
Abstract
Background: Zone 0 landing thoracic endovascular aortic repair (TEVAR) for the treatment of aortic arch diseases has become a topic of interest. This study aimed to verify whether branced TEVAR (bTEVAR) is an effective and a more minimally invasive treatment by comparing the [...] Read more.
Background: Zone 0 landing thoracic endovascular aortic repair (TEVAR) for the treatment of aortic arch diseases has become a topic of interest. This study aimed to verify whether branced TEVAR (bTEVAR) is an effective and a more minimally invasive treatment by comparing the outcomes of bTEVAR and hybrid TEVAR (hTEVAR) in landing zone 0. Methods: This retrospective, single-center, observational cohort study included 54 patients (bTEVAR, n = 25; hTEVAR, n = 29; median age, 78 years; median follow-up period, 5.4 years) from October 2012 to June 2018. The logistic Euro-SCORE was significantly higher in the bTEVAR group than in the hTEVAR group (38% vs. 21%, p < 0.001). Results: There was no significant difference the in-hospital mortality between the bTEVAR and hTEVAR groups (0% vs. 3.4%, p = 1.00). The operative time (220 vs. 279 min, p < 0.001) and length of hospital stay (12 vs. 17 days, p = 0.013) were significantly shorter in the bTEVAR group than in the hTEVAR group. The 7-year free rates of aorta-related deaths (bTEVAR [95.5%] vs. hTEVAR [86.9%], Log-rankp = 0.390) and aortic reintervention (bTEVAR [86.3%] vs. hTEVAR [86.9%], Log-rankp = 0.638) were not significantly different. Conclusions: The early and mid-term outcomes in both groups were satisfactory. bTEVAR might be superior to hTEVAR in that it is less invasive. Therefore, bTEVAR may be considered an effective and a more minimally invasive treatment for high-risk patients. Full article
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Review

Jump to: Editorial, Research, Other

17 pages, 8154 KiB  
Review
Review of Clinical Applications of Dual-Energy CT in Patients after Endovascular Aortic Repair
by Wojciech Kazimierczak, Natalia Kazimierczak and Zbigniew Serafin
J. Clin. Med. 2023, 12(24), 7766; https://doi.org/10.3390/jcm12247766 - 18 Dec 2023
Cited by 2 | Viewed by 765
Abstract
Abdominal aortic aneurysms (AAAs) are a significant cause of mortality in developed countries. Endovascular aneurysm repair (EVAR) is currently the leading treatment method for AAAs. Due to the high sensitivity and specificity of post-EVAR complication detection, CT angiography (CTA) is the reference method [...] Read more.
Abdominal aortic aneurysms (AAAs) are a significant cause of mortality in developed countries. Endovascular aneurysm repair (EVAR) is currently the leading treatment method for AAAs. Due to the high sensitivity and specificity of post-EVAR complication detection, CT angiography (CTA) is the reference method for imaging surveillance in patients after EVAR. Many studies have shown the advantages of dual-energy CT (DECT) over standard polyenergetic CTA in vascular applications. In this article, the authors briefly discuss the technical principles and summarize the current body of literature regarding dual-energy computed tomography angiography (DECTA) in patients after EVAR. The authors point out the most useful applications of DECTA in this group of patients and its advantages over conventional CTA. To conduct this review, a search was performed using the PubMed, Google Scholar, and Web of Science databases. Full article
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18 pages, 1848 KiB  
Review
Systematic Review and Meta-Analysis of the Incidence of Rupture, Repair, and Death of Small and Large Abdominal Aortic Aneurysms under Surveillance
by Nicola Leone, Magdalena Anna Broda, Jonas Peter Eiberg and Timothy Andrew Resch
J. Clin. Med. 2023, 12(21), 6837; https://doi.org/10.3390/jcm12216837 - 29 Oct 2023
Viewed by 902
Abstract
Background: The ultimate goal of treating patients with abdominal aortic aneurysms (AAAs) is to repair them when the risk of rupture exceeds the risk of repair. Small AAAs demonstrate a low rupture risk, and recently, large AAAs just above the threshold (5.5–6.0 cm) [...] Read more.
Background: The ultimate goal of treating patients with abdominal aortic aneurysms (AAAs) is to repair them when the risk of rupture exceeds the risk of repair. Small AAAs demonstrate a low rupture risk, and recently, large AAAs just above the threshold (5.5–6.0 cm) seem to be at low risk of rupture as well. The present review aims to investigate the outcomes of AAAs under surveillance through a comprehensive systematic review and meta-analysis. Methods: PubMed, Embase, and the Cochrane Central Register were searched (22 March 2022; PROSPERO; #CRD42022316094). The Cochrane and PRISMA statements were respected. Blinded systematic screening of the literature, data extraction, and quality assessment were performed by two authors. Conflicts were resolved by a third author. The meta-analysis of prevalence provided estimated proportions, 95% confidence intervals, and measures of heterogeneity (I2). Based on I2, the heterogeneity might be negligible (0–40%), moderate (30–60%), substantial (50–90%), and considerable (75–100%). The primary outcome was the incidence of AAA rupture. Secondary outcomes included the rate of small AAAs reaching the threshold for repair, aortic-related mortality, and all-cause mortality. Results: Fourteen publications (25,040 patients) were included in the analysis. The outcome rates of the small AAA group (<55 mm) were 0.3% (95% CI 0.0–1.0; I2 = 76.4%) of rupture, 0.6% (95% CI 0.0–1.9; I2 = 87.2%) of aortic-related mortality, and 9.6% (95% CI 2.2–21.1; I2 = 99.0%) of all-cause mortality. During surveillance, 21.4% (95% CI 9.0–37.2; I2 = 99.0%) of the initially small AAAs reached the threshold for repair. The outcome rates of the large AAA group (>55 mm) were 25.7% (95% CI 18.0–34.3; I2 = 72.0%) of rupture, 22.1% (95% CI 16.5–28.3; I2 = 25.0%) of aortic-related mortality, and 61.8% (95% CI 47.0–75.6; I2 = 89.1%) of all-cause mortality. The sensitivity analysis demonstrated a higher rupture rate in studies including <662 subjects, patients with a mean age > 72 years, >17% of female patients, and >44% of current smokers. Conclusion: The rarity of rupture and aortic-related mortality in small AAAs supports the current conservative management of small AAAs. Surveillance seems indicated, as one-fifth reached the threshold for repair. Large aneurysms had a high incidence of rupture and aortic-related mortality. However, these data seem biased by the sparse and heterogeneous literature overrepresented by patients unfit for surgery. Specific rupture risk stratified by age, gender, and fit-for-surgery patients with large AAAs needs to be further investigated. Full article
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15 pages, 1294 KiB  
Review
Chimney vs. Fenestrated Endovascular vs. Open Repair for Juxta/Pararenal Abdominal Aortic Aneurysms: Systematic Review and Network Meta-Analysis of the Medium-Term Results
by Petar Zlatanovic, Aleksa Jovanovic, Paolo Tripodi and Lazar Davidovic
J. Clin. Med. 2022, 11(22), 6779; https://doi.org/10.3390/jcm11226779 - 16 Nov 2022
Cited by 4 | Viewed by 1555
Abstract
Introduction: This systematic review with network meta-analysis aimed at comparing the medium-term results of open surgery (OS), fenestrated endovascular repair (FEVAR), and chimney endovascular repair (ChEVAR) in patients with juxta/pararenal abdominal aortic aneurysms (JAAAs/PAAAs). Materials and methods: MEDLINE, SCOPUS, and Web of Science [...] Read more.
Introduction: This systematic review with network meta-analysis aimed at comparing the medium-term results of open surgery (OS), fenestrated endovascular repair (FEVAR), and chimney endovascular repair (ChEVAR) in patients with juxta/pararenal abdominal aortic aneurysms (JAAAs/PAAAs). Materials and methods: MEDLINE, SCOPUS, and Web of Science were searched from inception date to 1st July 2022. Any studies comparing the results of two or three treatment strategies (ChEVAR, FEVAR, or OS) on medium-term outcomes in patients with JAAAs/PAAAs were included. Primary outcomes were all-cause mortality, aortic-related reintervention, and aortic-related mortality, while secondary outcomes were visceral stent/bypass occlusion/occlusion, major adverse cardiovascular events (MACEs), new onset renal replacement therapy (RRT), total endoleaks, and type I/III endoleak. Results: FEVAR (OR = 1.53, 95%CrI 1.03–2.11) was associated with higher medium-term all-cause mortality than OS. Sensitivity analysis including only studies that analysed JAAA showed that FEVAR (OR = 1.65, 95%CrI 1.08–2.33) persisted to be associated with higher medium-term mortality than OS. Both FEVAR (OR = 8.32, 95%CrI 3.80–27.16) and ChEVAR (OR = 5.95, 95%CrI 2.23–20.18) were associated with a higher aortic-related reintervention rate than OS. No difference between different treatment options was found in terms of aortic-related mortality. FEVAR (OR = 13.13, 95%CrI 2.70–105.2) and ChEVAR (OR = 16.82, 95%CrI 2.79–176.7) were associated with a higher rate of medium-term visceral branch occlusion/stenosis compared to OS; however, there was no difference found between FEVAR and ChEVAR. Conclusions: An advantage of OS compared to FEVAR and ChEVAR after mid-term follow-up aortic-related intervention and vessel branch/bypass stenosis/occlusion was found. This suggests that younger, low-surgical-risk patients might benefit from open surgery of JAAA/PAAA as a first approach. Full article
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Other

14 pages, 626 KiB  
Systematic Review
A State-of-the-Art Review of Intra-Operative Imaging Modalities Used to Quality Assure Endovascular Aneurysm Repair
by Petra Z. Bachrati, Guglielmo La Torre, Mohammed M. Chowdhury, Samuel J. Healy, Aminder A. Singh and Jonathan R. Boyle
J. Clin. Med. 2023, 12(9), 3167; https://doi.org/10.3390/jcm12093167 - 28 Apr 2023
Cited by 1 | Viewed by 1434
Abstract
Endovascular aortic aneurysm repair (EVAR) is the preferred method for elective abdominal aortic aneurysm (AAA) repair. However, the success of this technique depends greatly on the technologies available. Intra-operative imaging is essential but can come with limitations. More complex interventions lead to longer [...] Read more.
Endovascular aortic aneurysm repair (EVAR) is the preferred method for elective abdominal aortic aneurysm (AAA) repair. However, the success of this technique depends greatly on the technologies available. Intra-operative imaging is essential but can come with limitations. More complex interventions lead to longer operating times, fluoroscopy times, and greater contrast doses. A number of intra-operative imaging modalities to quality assure the success of EVAR have been developed. A systematic literature search was performed with separate searches conducted for each imaging modality in the study: computed tomography (CT), digital subtraction angiography (DSA), fusion, ultrasound, intra-operative positioning system (IOPS), and non-contrast imaging. CT was effective at detecting complications but commonly resulted in increased radiation and contrast dose. The effectiveness of DSA can be increased, and radiation exposure reduced, through the use of adjunctive technologies. We found that 2D-3D fusion was non-inferior to 3D-3D and led to reduced radiation and contrast dose. Non-contrast imaging occasionally led to higher doses of radiation. Ultrasound was particularly effective in the detection of type II endoleaks with reduced radiation and contrast use but was often operator dependent. Unfortunately, no papers made it past full text screening for IOPS. All of the imaging techniques discussed have advantages and disadvantages, and clinical context is relevant to guide imaging choice. Fusion and ultrasound in particular show promise for the future. Full article
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