Search Results (110)

Background/Objective: Sarcopenia is a predictor of poor surgical outcomes in older adults. The Psoas Muscle Index (PMI), calculated from routine preoperative CT scans, has been proposed as an imaging-based marker of physiological reserve, but its diagnostic utility in vascular surgery remains unclear. We aimed to assess the predictive value of PMI for early complications following elective abdominal aortic aneurysm (AAA) repair in two European centers. Methods: We retrospectively analyzed 245 patients who underwent open or endovascular AAA repair between 2018 and 2022 in Poland and The Netherlands. PMI was measured at the level of third lumbar vertebrae (L3) level, normalized to height, and stratified into center-specific tertiles. Early complications were compared across tertiles, procedures, and centers. Multivariate logistic regression was used to adjust for age, comorbidities, and procedure type. Results: Low PMI was significantly associated with early complications in EVAR patients at the Polish center (p = 0.004). No associations were found in open repair or at the Dutch center. Mean PMI values did not differ significantly between centers. Conclusions: PMI may serve as a context-dependent imaging biomarker for early risk stratification following AAA repair, particularly in endovascular cases. Its predictive value is influenced by institutional and procedural factors, highlighting the need for prospective validation and standardization before clinical adoption. Full article

Background/Objectives: There are no reports about the nationwide trends in abdominal aortic aneurysm (AAA) repair and mortality rates. This study aims to evaluate the trend in AAA treatment and related mortality, including ruptured AAAs (rAAAs) and intact AAAs (iAAAs) over the last 13 years. Methods: This serial, cross-sectional study investigated the time trends in patients who were treated for an AAA and underwent an aneurysm repair between 2010 and 2022. Data from the Health Insurance Review and Assessment Service (HIRA) and Statistics Korea were used. A linear-by-linear association and Poisson regression analysis were performed to determine the changes in the treatment of AAAs and related mortality. Results: The number of patients with an rAAA increased from 462 in 2010 to 770 in 2022 (relative risk, RR 1.57; p < 0.0001). The number of patients with an iAAA increased from 3685 to 12,399 in the same period (RR 3.16; p < 0.0001). Endovascular aneurysm repair (EVAR) has been more commonly performed since 2011. During the study period, EVAR increased from 406 to 1161 (RR 2.68; p < 0.0001). Although the annual mortality rates after iAAA treatment decreased from 1.4% to 0.7% (mean mortality rate, 1.1%), the mortality rates after rAAA treatment were similar, ranging from 34.6% to 34.2%, during the study period (mean mortality rate, 35.2%). Conclusions: During the last 13 years, the annual number of patients with rAAAs and iAAAs has increased. Since 2011, EVAR has been more commonly performed. The annual iAAA-related mortality rate decreased along with the increasing trend in EVAR. However, the annual rAAA-related mortality rate did not change. Full article

Background/Objectives: Physician-modified endografts (PMEGs) have emerged as a treatment option for complex aortic pathologies. Uncertainty remains regarding the modification techniques and the most suitable materials for customization of fenestrated endografts. The aim of this study was to evaluate CE-marked endovascular aortic repair (EVAR) devices and suitable materials for device modification in PMEGs for juxtarenal and pararenal aortic pathologies. Methods: This single-center observational study included patients treated with the physician-modified TREO (Terumo Aortic, Inchinnan, UK) device between April and December 2024. All patients had aortic ruptures or symptomatic aneurysms and unfavorable anatomy or severe comorbidities, making standard EVAR and open repair unsuitable. Procedural data were recorded and analyzed, including in-hospital outcomes. The “wire visibility” and “sheath–wire contrast” of endografts were assessed under fluoroscopy, and different resheathing techniques were compared. Results: Technical success was achieved in all five patients. The number of fenestrations per patient was 2.6 (range: 1–4). In one patient (1/5), type Ib and type IIIc endoleaks were observed postoperatively, requiring reintervention. No in-hospital mortality occurred. The ICU and hospital stay were 24 h (range: 18–40 h) and 8 days (range: 6–20 days), respectively. Moreover, the One SNARE wire was identified as the wire with the highest “wire visibility”, and Endurant II showed the best “sheath–wire contrast”. Resheathing with the dedicated crimping device was superior to the tape-assisted method. Conclusions: The TREO platform, in synergy with suitable additional materials, offers a viable solution for urgent aortic pathologies requiring PMEGs. Continued refinement of materials and procedural standardization could enhance the long-term outcome. Full article

Late ruptures of abdominal aortic aneurysms post-endovascular aneurysm repair present a significant risk, occurring in about 0.9% of cases. The typical timeframe leading to rupture is roughly 37 months, with the primary factors often linked to endoleaks, especially types I and III, which sustain pressure within the aneurysm sac. The approaches to managing late ruptures consist of endovascular approaches, open surgical interventions, and conservative care, each customised to the patient’s specific characteristics. When feasible endovascular repair is favoured, additional stent grafts are deployed to seal endoleaks and offer lower perioperative mortality rates compared to those for open surgery. Open repair is considered when endovascular solutions fail or are not feasible. Conservative management with active monitoring and supportive treatment can be considered for haemodynamically stable non-surgical patients. Endovascular repair methods like fenestrated/branched EVAR (F/BEVAR) and parallel grafting (PGEVAR) are effective for complicated anatomies and show high technical success with reduced morbidity compared to that with open repairs. Chimney techniques and physician-modified endografts may help regain and broaden the sealing zone. Limb extensions with or without embolisation, interposition endografting, and whole-body relining are helpful options for type IB and type 3–5 endoleaks. Open surgical repair carries a higher perioperative mortality but may be essential in preventing death due to rupture following failed EVAR. The choice depends on the patient’s clinical stability and fitness for surgery in the absence of a viable endovascular alternative. This article discusses the available options for treating late rupture after EVAR, emphasising the importance of individualised treatment plans and the need for rigorous postoperative surveillance to prevent such complications. Full article

Background/Objectives: Wide and conical-shaped infrarenal necks are risk factors for neck-related complications after Endovascular Aorta Aneurysm Repair (EVAR). The aim of this study is to investigate the performance of the Endurant endoprosthesis in wide/conical-shaped aortic neck anatomies compared to its performance in a normal infrarenal neck (reference group). Methods: A single-center, retrospective observational cohort study was performed, including consecutive subjects with an infrarenal abdominal aortic aneurysm, treated electively with an Endurant endoprosthesis. The primary endpoint was the freedom from aneurysm-related reinterventions through 1 year. Secondary endpoints included proximal fixation failure, type IA endoleak, stent migration, aneurysm sac remodeling, aneurysm-related mortality, freedom from reinterventions throughout available follow-up, and rupture. Results: A total of 268 patients were included, with a mean age of 73.3 years, and 85.1% were male. Freedom from aneurysm-related reinterventions was significantly lower in the wide-neck group (60.0%) compared to the reference group (81.1%; p = 0.018) but not for the conical-neck group (70.3%; p = 0.286). Median time to first reintervention was 1.7 (IQR 0.8; 4.4 years) in the reference group, 2.9 years (IQR 0.3; 5.0 years) in the wide-neck group (p = 0.547) and 3.8 years (IQR 0.4; 6.5) in the conical-neck group (p = 0.123). The proximal fixation failure rate was 7.4% in the wide-neck group compared to 3.3% in the reference group (p = 0.155) and 1.7% in the conical-neck group (p = 0.525). The type IA endoleak rate was 4.9% in the wide-neck group versus 3.3% in the reference group (p = 0.250). Conclusions: In the group with wide necks, reintervention-free survival was lower compared to the reference group, which seems to be driven by proximal fixation failure. Full article

Background/Objectives: Aortic stiffness is a strong independent factor in cardiovascular outcomes. The method of choice for evaluating aortic stiffness is the measurement of aortic pulse wave velocity (PWV). Endovascular aortic repair (EVAR) increases aortic rigidity and thus aortic stiffness. The aim of this study is to investigate the correlation between endograft length and post-operative increases in PWV in patients with abdominal aortic aneurysms (AAAs) subjected to EVAR. Methods: A prospective observational study enrolling 107 patients from February to December 2025 was conducted. Patient demographics and comorbidities were recorded. The length of the endografts was calculated by studying computed tomography angiograms (CTAs) and digital subtraction angiographies (DSAs) of the patients. PWV was measured pre-operatively and post-operatively during the first 24 h after EVAR, and the difference in PWV (dPWV) was calculated. Results: The mean age of the patients was 72 ± 7.5 years, and 93.5% of them were males. The mean transverse AAA diameter was 5.7 ± 1.1 mm, and the mean endograft length was 169.7 ± 26.9 mm. An extension to the external iliac artery was deployed in 10 patients (9.3%). A strong positive correlation was observed between dPWV and endograft length, indicating that each additional 1 mm in graft length corresponded to a 0.541% increase in dPWV. Patients with an extension to external iliac arteries exhibited a significantly higher mean dPWV (9.95 ± 2.08% vs. 27.12% ± 12.15%, t = −4.463, p = 0.002). No statistically significant differences in dPWV between the different endograft types were found (p = 0.74). Conclusions: Endograft length is strongly related to PWV elevation during the immediate post-operative time after EVAR, especially when the endograft is extended to the external iliac arteries. Full article

Background/Objectives: Endovascular aneurysm repair (EVAR) of the aorta may trigger an inflammatory response that affects coagulation. In the EVAR of para-renal and thoraco-abdominal aortic aneurysms, the implants are more complex and the duration of surgery is longer. However, the exact pathophysiological mechanisms of coagulation activation are not yet well understood. The primary aim of this study is to investigate the effects of complex EVAR of para-renal and thoraco-abdominal aortic aneurysms on the coagulation status of patients. Methods: This prospective observational study (STROBE), approved and registered by the Ethics Committee of the University Hospital of Larissa (UHL) (NCT06432387), will enroll consecutive patients undergoing elective EVAR of para-renal and thoraco-abdominal aortic aneurysms. Exclusion criteria: Refusal to participate, previous surgery within 3 months, American Society of Anesthesiologists physical status (ASA PS) > 3, known history of thrombophilia or functional platelet dysfunction. Perioperative laboratory tests will be performed according to institutional guidelines. These include a complete blood count, conventional coagulation tests, and kidney and liver function tests. In addition, the following parameters will be determined: von Willebrand factor, factors VIII and XI, D-dimers, fibrinogen, Adamts-13, anti-Xa, platelet activation (multiplate), and high-sensitivity troponin. Blood samples will be taken pre-operatively before induction of anesthesia (01), on postoperative day 1 (02), and on postoperative day 3–4 (03). During hospitalization, myocardial injury after non-cardiac surgery (MINS), major adverse cardiovascular events after non-cardiac surgery (MACE), acute kidney injury (AKI), post-implantation syndrome (PIS), and death from any cause will be recorded. In addition, our patients will be reviewed at 30 days, 3, 6, and 12 months for MACE, implant failure, or death from any cause. All enrolled patients will be treated by the same medical team at UHL according to the indications. According to our power analysis, for a cohort of patients with three consecutive measurements, 58 patients should be included in the study. To compensate for possible dropouts, the sample size was increased to 65 patients. Conclusions: The results of the present study could help physicians to better understand the effects of complex EVAR of para-renal and thoraco-abdominal aortic aneurysms on blood coagulation and platelet activation. Full article

Objectives: To report the results of pre-emptive embolization of collateral branches of the abdominal aorta in patients undergoing standard bifurcated EVAR versus those undergoing standard EVAR without embolization. Methods: This study is a single-center, retrospective, observational cohort analysis of consecutive patients who underwent elective standard endovascular aneurysm repair (EVAR) between 1 October 2013, and 31 December 2022, with a minimum follow-up period of 2 years. The patients were divided into two groups: group A, which did not receive embolization, and group B, which underwent pre-emptive embolization of aortic collateral branches. The primary outcomes for this study include overall survival, freedom from aorta-related mortality (ARM), and freedom from reinterventions related to type 2 endoleak (T2E). In cases of multiple reinterventions, only the first one was considered for this analysis. The secondary outcome focused on assessing freedom from aneurysm sac enlargement. Results: We analyzed a total of 265 endovascular aneurysm repairs (EVARs): 183 (69.1%) were classified into group A, and 82 (30.9%) into group B. The median follow-up duration was 48 months [interquartile range (IQR), 28–65.5], which was not significantly different between the two groups [45 months (26–63) in group A vs. 52.5 months (29.5–72.5) in group B, p = 0.098]. The estimated cumulative survival rates were 87% (0.2) at 2 years (95% confidence interval [CI]: 82.6–92.9) and 67% (0.3) at 5 years (95% CI: 60.3–73.1), with no significant difference between the groups (p = 0.263). The aorta-related mortality rate was 1.1% (n = 3); all instances occurred following open conversion due to graft infection (n = 2) and in one case of secondary aortic rupture (n = 1). In total, 34 cases (12.8%) indicated a secondary intervention related to type 2 endoleak (T2E). The freedom from T2E-related reintervention rate was 99% (0.01) at 2 years (95% CI: 99.4–99.8) and 88% (0.3) at 5 years (95% CI: 81.4–92.5), with no differences between the groups (p = 0.282). Cox regression analysis revealed that age over 80 years is an independent negative predictor of survival, with a hazard ratio (HR) of 3.5 (95% confidence interval [CI]: 2.27–5.50; p < 0.001). Additionally, T2E-related reintervention was identified as a negative predictor, with an HR of 2.4 (95% CI: 1.05–5.54; p = 0.037). In this study, conversion to open repair was necessary for 14 patients (5.3%), with three conversions occurring due to rupture; however, T2E was not a determining factor in any of these conversions. At the last available follow-up computed tomography angiography (CT-A), the median aneurysm diameter was significantly lower in group B, measuring 44 mm (range 37.7–50), compared to group A, measuring 48 mm (range 39–57.5) (p < 0.001). Both groups showed a significant change from baseline measurements (p = 0.001). Conclusions: Pre-emptive embolization of the aortic collateral branches does not lead to improved aorta-related outcomes after EVAR. Full article

Background: Endovascular aortic aneurysm repair (EVAR) is a commonly used treatment for abdominal aortic aneurysms (AAAs), but anatomical complexities limit its application in certain cases. Objective: This study evaluates the mid-term outcomes, referring to a follow-up period with a mean of 29.9 ± 24.1 months (approximately 1–5 years), of a novel double-barrel technique that employs overlapping tubular stent grafts to address these challenges. Methods: A retrospective analysis was conducted on seven patients treated with this technique from May 2014 to February 2023. Patients had narrow and short proximal necks, inadequate landing zones, or required re-do procedures. Results: The double-barrel technique achieved technical success in 85.7% of cases with zero mortality. Patients had an average hospital stay of 11.9 ± 10.0 days and attended follow-up for a mean of 29.9 ± 24.1 months. Minimal complications and no significant adverse events were reported. Conclusions: These findings suggest that the double-barrel technique is a cost-effective and viable alternative for anatomically complex cases where standard EVAR is unsuitable. While promising mid-term outcomes were observed, further studies with larger cohorts are necessary to confirm its long-term effectiveness and broader applicability. Full article

Background: Abdominal aortic aneurysms (AAAs) are life-threatening conditions that require timely intervention to prevent rupture. Endovascular aneurysm repair (EVAR) is preferred due to faster recovery and lower perioperative risk; however, intraoperative failure and long-term complications highlight the continued significance of open surgical repair (OSR) and the need for improved risk assessment. Methods: This retrospective study analyzed data from 210 patients who underwent EVAR (n = 163) or OSR (n = 47) at a single center. Clinical characteristics, complications, reintervention rates, and 30-day mortality were recorded. EVAR-to-OSR conversion and mortality predictors in AAA treatments were identified. Results: The overall mortality rate was 9.5% (20/210 patients), with 12 patients (7.3%) in the EVAR group and 8 patients (17%) in the OSR group (p = 0.085). Five patients required early and six required late conversion to open surgery. In follow-ups beyond 30 days, the reintervention rate for EVAR was higher (HR: 1.2, 95% CI: 0.4–3.6; p = 0.754). According to the multivariable analysis, rupture (p = 0.045), female sex (p = 0.018), body weight (p = 0.003), and aortic size index (p = 0.019) were significant predictors of mortality, whereas OSR was not (p = 0.212). Conclusions: Treatment optimization requires a balanced approach, integrating both EVAR and OSR based on patient-specific factors. Maintaining expertise in both techniques is essential to ensure the best possible outcomes, and OSR should remain a viable option when clinically indicated. Full article

Background: Endovascular aneurysm repair (EVAR) is the preferred treatment for abdominal aortic aneurysms (AAAs). This study evaluated the differences between the anticipated and actual achieved proximal sealing zones for standard EVAR endografts and their potential implications in a real-world AAA population. Methods: Data from 275 consecutive EVAR patients treated with the Endurant endograft (Medtronic, Minneapolis, MN, USA) between 2009 and 2022 were retrospectively analyzed. The proximal sealing zone was calculated preoperatively (target anticipated sealing zone, TASZ) and postoperatively (real achieved sealing zone, RASZ) from computed tomography angiography (CTA) images. These metrics were evaluated by assuming that they had a truncated cone shape, calculating the cone’s lateral surface by measuring the proximal and distal centerline areas and the distance between the planes. The primary outcome was the occurrence of type 1A endoleak at the longest available follow-up. Results: RASZ was significantly smaller and shorter than TASZ (p = 0.001), with an average area reduction of 24.5 mm² and a median length reduction of 3 mm. Area and cranial length loss were present even when correcting for graft positioning imperfections. In the Cox proportional hazard regression model, TASZ and RASZ lengths were both independently associated with a lower risk of type 1A endoleak (HR: 0.88, 95% CI 0.80–0.96 and HR: 0.92, 95% CI 0.86–0.99, respectively). A Kaplan–Meier analysis confirmed that patients with RASZ > 5.5 mm had a survival free from endoleak higher than patients with RASZ ≤ 5.5 mm. Conclusions: In this real-world AAA population, the achieved proximal sealing zone was significantly shorter and smaller than planned, regardless of optimal endograft placement. The early calculation of RASZ, i.e., the PSZ achieved via CTA, is critical for risk stratification and follow-up. Full article

Objectives: In order to reduce the abdominal aortic aneurysm (AAA)-related complication rate in endovascular aneurysm repair (EVAR) procedures, manufacturers recommend following the instructions for use (IFU). However, IFU is considered too conservative in many centers. In this context, we present our experience and patient follow-up data with 248 consecutive patients with or without IFU eligibility. Methods: A total of 248 patients who underwent elective EVAR for AAA between 2014 and 2019 were included. In total, 190 patients were in the IFU group and 58 in the non-IFU group. Patients were evaluated for baseline demographic and anatomic data; unexpected periprocedural intervention; and postoperative data such as development of endoleaks during follow-up, need for re-intervention, development of complications, EVAR patency, and mean 5-year survival rate. Results: The patients did not differ in terms of basic demographic data. The basic anatomical data were suitable for the IFU standard. Intraoperative endoleak development was significantly higher in the non-IFU group. In addition, the development of endoleaks at any time, the need for re-intervention, and the development of complications were higher in the non-IFU group at postoperative follow-up. Survival analysis showed no difference in the mean 5-year follow-up. The EVAR patency rate was higher in the IFU group. Conclusions: We believe that the decision for a non-IFU EVAR should be patient-specific and that the results of the subjective medical assessment should definitely be taken into account. However, we should not forget that EVAR patients, especially non-IFU patients, are susceptible to future changes in the aorta and prone to the development of endoleaks and re-interventions. Full article

Objectives: The ALTURA™ stent graft system is designed for the treatment of abdominal aortic and/or aorto-iliac aneurysms. This study evaluates the performance of the ALTURA™ stent graft, focusing on AAA diameter, landing zones, stent graft length, and migration following endovascular aortic repair (EVAR). Methods: This is a retrospective analysis of computed tomography (CT) images focuses on patients with infrarenal abdominal aortic aneurysm (AAA) treated with the ALTURA™ stent graft system (Lombard, Ltd., Didcot, UK) at Pauls Stradins Clinical University Hospital in Riga, Latvia, and University Hospital Düsseldorf in Düsseldorf, Germany. The study population consisted of patients with asymptomatic AAAs who underwent elective treatment between January 2014 and June 2017. Follow-up CT scans were performed at one month, six months, one, two, and three years after implantation. Changes in stent graft length, aneurysm sac diameter, and the proximal and distal sealing zones were evaluated. Results: A retrospective analysis was conducted on computed tomography (CT) images from 40 patients (mean age 70.4 ± 8.5 years, 34 males, 6 females) who were treated with the ALTURA™ stent graft system for infrarenal abdominal aortic aneurysms (mean aneurysm diameter 5.6 ± 1.0 cm). The mean follow-up duration was 24.2 ± 10.6 months, with CT scans completed for all patients at one month and for 80% at one year. The mean total shortening of the stent graft one year after EVAR was 4 ± 3 mm (p < 0.001), 7 ± 5 mm after two years (p < 0.001), and 9 ± 6 mm after three years (p < 0.001). The iliac extensions shortened by 4 ± 3 mm after one year (p < 0.001), 6 ± 4 mm after two years (p < 0.001), and 8 ± 4 mm after three years (p < 0.001). Significant shortening was observed in the iliac extension, while changes in the aortic stent graft were not statistically significant. The reduction in the distal sealing zone and upward migration of the stent graft were 3 ± 3 mm after one year (p < 0.001), 5 ± 5 mm after two years (p < 0.001), and 7 ± 7 mm after three years (p < 0.001). Over the follow-up period, significant stent graft shortening and loss of the distal sealing zone were observed. However, these changes remained within a clinically acceptable range and did not lead to type I endoleak. Aneurysm sac shrinkage greater than 10 mm one year after treatment was observed in 25% of patients (p < 0.001). No aneurysm ruptures or AAA-related deaths were reported. Conclusions: Significant shortening of ALTURA™ stent graft, migration, and sealing zone reduction were observed without clinical impact after three years. However, in patients with short distal sealing zones, these changes could increase the risk of type Ib endoleak. Longer follow-up is needed to assess long-term durability. Full article

Backgroud: The use of dynamic computed tomography angiography (dCTA) for the detection of endoleaks in patients who underwent endovascular repair of abdominal aortic aneurysms is gaining interest. This study aims to provide an overview of the current applications of dCTA technologies in vascular surgery. Methods: We performed a comprehensive review by searching in the PubMed database and Cochrane Library (last search: 1 November 2024). We included studies considering endoleak investigation after endovascular aneurysm repair (EVAR). We included papers that reported the outcome of applications of dCTA, excluding case reports or very limited case series (≤4). Finally, 14 studies regarding 377 computed tomography angiographies (CTA) were included and evaluated. Results: Persistent perfusion of the aneurysm sac is the most common complication after EVAR. Imaging-based surveillance post-EVAR is essential with the aim of early detection, characterization, and localization of endoleaks to guide therapeutic intervention or follow-up. dCTA detected 36 type I endoleaks versus 16 identified with standard CTA and 138 versus 95 type II endoleaks. Conclusions: The emergence of dCTA offers a promising solution through enhanced temporal resolution, allowing the visualization of real-time flow dynamics within the aneurysmal sac essential to establishing endoleak treatment or post-EVAR follow-up. Full article

Introduction: A type 2 endoleak (EL2) remains the most prevalent complication of endovascular aortic repair (EVAR) for an abdominal aortic aneurysm (AAA). Methods: We conducted a retrospective, single-center analysis, including patients who underwent embolization for an isolated EL2 after EVAR. The study population was stratified into two groups: Group A, consisting of patients whose EL2 resolved after the first embolization procedure, and Group B, consisting of those with refractory EL2 (rEL2). The indication for EL2 treatment was aneurysmal sac growth amounting to >10 mm from the index EVAR. The indications for endograft explantation were the absence of high comorbidities and persisting aneurysmal sac expansion. Those with high comorbidities were subjected to another endovascular procedure or a conservative approach, the latter being preferred. The primary endpoint was EL2 resolution. The secondary endpoints were mid-term outcomes in terms of aneurysmal sac shrinkage, stability and expansion rates, and aneurysm-related complications. Results: Among 57 patients, 19 patients (33.3%) showed signs of EL2 after the first embolization, whereas 38 (66.6%) presented rEL2. Of these, 14 (36.8%) presented significant aneurysmal sac expansion: 8 patients underwent a secondary embolization, while an open conversion was performed in the remaining 6 patients (42.8%), 4 of whom, in an elective setting, showed a complete resolution of EL2, while 2 patients treated in an urgent setting died from a ruptured aneurysm. Among the patients treated with a secondary embolization, only 2 patients presented EL2 resolution, while the other 6 patients (75%) showed rEL2. Out of the 38 patients with rEL2, 24 patients did not undergo further interventions; of these, 11 (45.8%) presented sac expansion, and 16% developed type IA EL. Conclusions: A strict follow-up and possibly a more aggressive treatment should be considered in an elective setting for patients with rEL2. Full article