Background

Type II endoleaks (ELII) are the most common complication following endovascular aneurysm repair (EVAR). Persistent ELII require continual surveillance and have been shown to increase the risk of Type I and III endoleaks, sac growth, need for intervention, conversion to open or even rupture, directly or indirectly. These are often difficult to treat following EVAR, and there are limited data regarding the effectiveness of prophylactic treatment of ELII. The aim of this study is to report the midterm outcomes of prophylactic perigraft arterial sac embolization (pPASE) performed in patients undergoing EVAR.

Methods

This is a comparison of 2 elective cohorts of those undergoing EVAR using the Ovation stent graft with and without prophylactic branch vessel and sac embolization. Patients who underwent pPASE at our institution had their data collected in a prospective, institutional review board-approved database. These were compared against the core lab-adjudicated data from the Ovation Investigational Device Exemption trial. Prophylactic PASE was performed at the time of EVAR with thrombin, contrast, and Gelfoam if the lumbar or mesenteric arteries were patent. Endpoints included freedom from ELII, reintervention, sac growth, all-cause mortality, and aneurysm-related mortality.

Results

Thirty-six patients (13.1%) underwent pPASE, while 238 patients (86.9%) had standard EVAR. Median follow-up was 56 months (33-60 months). The 4-year freedom from ELII estimates were 84% for the pPASE versus 50.7% for the standard EVAR group (P = 0.0002). All aneurysms in the pPASE group remained stable in size or demonstrated regression, whereas aneurysm sac expansion was seen in 10.9% of the standard EVAR group, P = 0.03. At 4 years, mean AAA diameter decreased by 11 mm (95% CI 8-15) in the pPASE group versus 5 mm (95% CI 4-6) for the standard EVAR group, P = 0.0005. There were no differences in the 4-year freedom from all-cause mortality and aneurysm-related mortality. However, the difference in reintervention for ELII trended toward significance (0.0% vs. 10.7%, P = 0.1). On multivariable analysis, pPASE was associated with a 76% reduction in ELII [(95% CI): 0.24 (0.08-0.65), P = 0.005].

Conclusions

These results suggest that pPASE in those undergoing EVAR is safe and effective in the prevention of ELII and significantly improves sac regression over standard EVAR while minimizing the need for reintervention.

BACKGROUND: Aortic aneurysms are normally treated by an endovascular approach. Due to the lack of devices and increasing experience, there is a growing number of complex aneurysms undergoing repair by physician modified endografts (PMEGs). Previously, our practice was to target visceral vessels exclusively through upper extremity access. We have since then shifted to an all transfemoral approach when possible. This study aims to show the operative benefits of transfemoral only approaches. METHODS: Patients who underwent a PMEG at a tertiary center between 2015 and 2020 were included. Patients were stratified into 2 groups based on branched vessel approach-transfemoral only versus axillary or composite (axillary and femoral). Forty-one patients had a pararenal or type IV thoracoabdominal aortic aneurysm (TAAA) and 15 patients had more complex TAAA. Primary outcomes were operative time, radiation exposure, fluoroscopy time, contrast, and blood loss. Secondary outcomes were 30-day mortality and major adverse events. Linear regression models were used to evaluate the association between approach type and the main outcomes. RESULTS: Fifty-six patients were included with 48% (n = 27) in the transfemoral group and 52% (n = 29) in the axillary/composite group. Baseline characteristics were similar between the groups. Intraoperative outcomes revealed significant increase in the average operative time (418 vs. 246 min, P < 0.001), in radiation exposure (2,755 vs. 1,740 mGy, P = 0.03), in fluoroscopy time (108 vs. 74 min, P = 0.01) and in blood loss (579 vs. 202 cc, P = 0.002) in the axillary/composite group compared to the transfemoral group. There was no significant difference in 30-day mortality or major adverse events including stroke. CONCLUSIONS: This study shows a transfemoral approach to complex endovascular aortic aneurysm repair as opposed to axillary/composite approach has decreased operative time, radiation exposure, and fluoroscopy time and no significant differences in 30-day mortality or major adverse events. When treating complex aneurysms, improving efficiency is important to minimize morbidity to patients and operators.

Background

Hostile proximal aortic neck anatomy has been associated with an increased risk of perioperative mortality after endovascular aneurysm repair (EVAR). However, all available mortality risk prediction models after EVAR lack neck anatomic associations. The aim of this study is to develop a preoperative prediction model for perioperative mortality after EVAR incorporating important anatomic factors.

Methods

Data were obtained from the Vascular Quality Initiative database on all patients who underwent elective EVAR between January 2015 and December 2018. A stepwise multivariable logistic regression analysis was implemented to identify independent predictors and develop a risk calculator for perioperative mortality after EVAR. Internal validation was done using bootstrap of 1,000 reps.

Results

A total of 25,133 patients were included, of whom 1.1% (N = 271) died within 30 days or before discharge. Significant preoperative predictors of perioperative mortality were age (odds ratio [OR], 1.053; 95% confidence interval [CI], 1.050-1.056; P < 0.001), female sex (OR, 1.46; 95% CI, 1.38-1.54; P < 0.001), chronic kidney disease (OR, 1.65; 95% CI, 1.57-1.73; P < 0.001), chronic obstructive pulmonary disease (OR, 1.86; 95% CI, 1.77-1.94; P < 0.001), congestive heart failure (OR, 2.02; 95% CI, 1.91-2.13, P < 0.001), aneurysm diameter ≥ 6.5 cm (OR, 2.35; 95% CI, 2.24-2.47, P < 0.001), proximal neck length < 10 mm (OR, 1.96; 95% CI, 1.81-2.12; P < 0.001), proximal neck diameter ≥ 30 mm (OR, 1.41; 95% CI, 1.32-1.5; P < 0.001), infrarenal neck angulation ≥ 60° (OR, 1.27; 95% CI, 1.18-1.26; P < 0.001), and suprarenal neck angulation ≥ 60° (OR, 1.26; 95% CI, 1.16-1.37; P < 0.001). Significant protective factors included aspirin use (OR, 0.89; 95% CI, 0.85-0.93; P < 0.001) and statin intake (OR, 0.77; 95% CI, 0.73-0.81; P < 0.001). These predictors were incorporated to build an interactive risk calculator of perioperative mortality after EVAR (C-statistic = 0.749).

Conclusions

This study provides a prediction model for mortality following EVAR that incorporates aortic neck features. The risk calculator can be used to weigh risk/benefit ratio when counseling patients preoperatively. Prospective use of this risk calculator may show its benefit in long-term prediction of adverse outcomes.

Background

Studies have suggested that there is increased risk of thromboembolism (TE) associated with coronavirus disease 2019 (COVID-19). However, overall arterial and venous TE rates of COVID-19 and effect of TE on COVID-19 mortality is unknown.

Methods

We did a systematic review and meta-analysis of studies evaluating TE in COVID-19. We searched PubMed, Cochrane, and Embase for studies published up to June 12, 2020. Random effects models were used to produce summary TE rates and odds ratios (OR) of mortality in COVID-19 patients with TE compared to those without TE. Heterogeneity was quantified with I ² .

Findings

Of 425 studies identified, 42 studies enrolling 8271 patients were included in the meta-analysis. Overall venous TE rate was 21% (95% CI:17-26%): ICU, 31% (95% CI: 23-39%). Overall deep vein thrombosis rate was 20% (95% CI: 13-28%): ICU, 28% (95% CI: 16-41%); postmortem, 35% (95% CI:15-57%). Overall pulmonary embolism rate was 13% (95% CI: 11-16%): ICU, 19% (95% CI:14-25%); postmortem, 22% (95% CI:16-28%). Overall arterial TE rate was 2% (95% CI: 1-4%): ICU, 5% (95%CI: 3-7%). Pooled mortality rate among patients with TE was 23% (95%CI:14-32%) and 13% (95% CI:6-22%) among patients without TE. The pooled odds of mortality were 74% higher among patients who developed TE compared to those who did not (OR, 1.74; 95%CI, 1.01-2.98; P = 0.04).

Interpretation

TE rates of COVID-19 are high and associated with higher risk of death. Robust evidence from ongoing clinical trials is needed to determine the impact of thromboprophylaxis on TE and mortality risk of COVID-19.

Funding

None.