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1.  Endovascular Repair of Abdominal Aortic Aneurysm 
The Medical Advisory Secretariat conducted a systematic review of the evidence on the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysm in comparison to open surgical repair. An abdominal aortic aneurysm [AAA] is the enlargement and weakening of the aorta (major blood artery) that may rupture and result in stroke and death. Endovascular abdominal aortic aneurysm repair [EVAR] is a procedure for repairing abdominal aortic aneurysms from within the blood vessel without open surgery. In this procedure, an aneurysm is excluded from blood circulation by an endograft (a device) delivered to the site of the aneurysm via a catheter inserted into an artery in the groin. The Medical Advisory Secretariat conducted a review of the evidence on the effectiveness and cost-effectiveness of this technology. The review included 44 eligible articles out of 489 citations identified through a systematic literature search. Most of the research evidence is based on non-randomized comparative studies and case series. In the short-term, EVAR appears to be safe and comparable to open surgical repair in terms of survival. It is associated with less severe hemodynamic changes, less blood transfusion and shorter stay in the intensive care and hospital. However, there is concern about a high incidence of endoleak, requiring secondary interventions, and in some cases, conversion to open surgical repair. Current evidence does not support the use of EVAR in all patients. EVAR might benefit individuals who are not fit for surgical repair of abdominal aortic aneurysm and whose risk of rupture of the aneurysm outweighs the risk of death from EVAR. The long-term effectiveness and cost-effectiveness of EVAR cannot be determined at this time. Further evaluation of this technology is required.
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysms (EVAR) in comparison to open surgical repair (OSR).
Clinical Need
An abdominal aortic aneurysm (AAA) is a localized, abnormal dilatation of the aorta greater than 3 cm or 50% of the aortic diameter at the diaphragm. (1) A true AAA involves all 3 layers of the vessel wall. If left untreated, the continuing extension and thinning of the vessel wall may eventually result in rupture of the AAA. The risk of death from ruptured AAA is 80% to 90%. (61) Heller et al. (44) analyzed information from a national hospital database in the United States. They found no significant change in the incidence rate of elective AAA repair or ruptured AAA presented to the nation’s hospitals. The investigators concluded that technologic and treatment advances over the past 19 years have not affected the outcomes of patients with AAAs, and the ability to identify and to treat patients with AAAs has not improved.
Classification of Abdominal Aortic Aneurysms
At least 90% of the AAAs are affected by atherosclerosis, and most of these aneurysms are below the level of the renal arteries.(1)
An abdominal aortic aneurysm may be symptomatic or asymptomatic. An AAA may be classified according to their sizes:(7)
Small aneurysms: less than 5 cm in diameter.
Medium aneurysms: 5-7cm.
Large aneurysms: more than 7 cm in diameter.
Small aneurysms account for approximately 50% of all clinically recognized aneurysms.(7)
Aortic aneurysms may be classified according to their gross appearance as follows (1):
Fusiform aneurysms affect the entire circumference of a vessel, resulting in a diffusely dilated lesion
Saccular aneurysms involve only a portion of the circumference, resulting in an outpouching (protrusion) in the vessel wall.
Prevalence of Abdominal Aortic Aneurysms
In community surveys, the prevalence of AAA is reported to be between 1% and 5.4%. (61) The prevalence is related to age and vascular risk factors. It is more common in men and in those with a positive family history.
In Canada, Abdominal aortic aneurysms are the 10th leading cause of death in men 65 years of age or older. (60) Naylor (60) reported that the rate of AAA repair in Ontario has increased from 38 per 100,000 population in 1981/1982 to 54 per 100,000 population in 1991/1992. For the period of 1989/90 to 1991/92, the rate of AAA repair in Ontarians age 45 years and over was 53 per 100,000. (60) In the United States, about 200,000 new cases are diagnosed each year, and 50,000 to 60,000 surgical AAA repairs are performed. (2) Ruptured AAAs are responsible for about 15,000 deaths in the United States annually. One in 10 men older than 80 years has some aneurysmal change in his aorta. (2)
Symptoms of Abdominal Aortic Aneurysms
AAAs usually do not produce symptoms. However, as they expand, they may become painful. Compression or erosion of adjacent tissue by aneurysms also may cause symptoms. The formation of mural thrombi, a type of blood clots, within the aneurysm may predispose people to peripheral embolization, where blood vessels become blocked. Occasionally, an aneurysm may leak into the vessel wall and the periadventitial area, causing pain and local tenderness. More often, acute rupture occurs without any prior warning, causing acute pain and hypotension. This complication is always life-threatening and requires an emergency operation.
Diagnosis of Abdominal Aortic Aneurysms
An AAA is usually detected on routine examination as a palpable, pulsatile, and non-tender mass. (1)
Abdominal radiography may show the calcified outline of the aneurysms; however, about 25% of aneurysms are not calcified and cannot be visualized by plain x-ray. (1) An abdominal ultrasound provides more accurate detection, can delineate the traverse and longitudinal dimensions of the aneurysm, and is useful for serial documentation of aneurysm size. Computed tomography and magnetic resonance have also been used for follow-up of aortic aneurysms. These technologies, particularly contrast-enhanced computer tomography, provide higher resolution than ultrasound.
Abdominal aortography remains the gold standard to evaluate patients with aneurysms for surgery. This technique helps document the extent of the aneurysms, especially their upper and lower limits. It also helps show the extent of associated athereosclerotic vascular disease. However, the procedure carries a small risk of complications, such as bleeding, allergic reactions, and atheroembolism. (1)
Prognosis of Abdominal Aortic Aneurysms
The risk of rupture of an untreated AAA is a continuous function of aneurysm size as represented by the maximal diameter of the AAA. The annual rupture rate is near zero for aneurysms less than 4 cm in diameter. The risk is about 1% per year for aneurysms 4 to 4.9 cm, 11% per year for aneurysms 5 to 5.9 cm, and 25% per year or more for aneurysms greater than 6 cm. (7)
The 1-year mortality rate of patients with AAAs who do not undergo surgical treatment is about 25% if the aneurysms are 4 to 6 cm in diameter. This increases to 50% for aneurysms exceeding 6 cm. Other major causes of mortality for people with AAAs include coronary heart disease and stroke.
Treatment of Abdominal Aortic Aneurysms
Treatment of an aneurysm is indicated under any one of the following conditions:
The AAA is greater than 6 cm in diameter.
The patient is symptomatic.
The AAA is rapidly expanding irrespective of the absolute diameter.
Open surgical repair of AAA is still the gold standard. It is a major operation involving the excision of dilated area and placement of a sutured woven graft. The surgery may be performed under emergent situation following the rupture of an AAA, or it may be performed electively.
Elective OSR is generally considered appropriate for healthy patients with aneurysms 5 to 6 cm in diameter. (7) Coronary artery disease is the major underlying illness contributing to morbidity and mortality in OSR. Other medical comorbidities, such as chronic renal failure, chronic lung disease, and liver cirrhosis with portal hypertension, may double or triple the usual risk of OSR.
Serial noninvasive follow-up of small aneurysms (less than 5 cm) is an alternative to immediate surgery.
Endovascular repair of AAA is the third treatment option and is the topic of this review.
PMCID: PMC3387737  PMID: 23074438
2.  Fenestrated Endovascular Grafts for the Repair of Juxtarenal Aortic Aneurysms 
Executive Summary
Endovascular repair of abdominal aortic aneurysm (AAA) allows the exclusion of the dilated aneurismal segment of the aorta from the systematic circulation. The procedure requires, however, that the endograft extends to the healthy parts of the aorta above and below the aneurysm, yet the neck of a juxtarenal aortic aneurysm (JRA) is too short for a standard endovascular repair. Fenestrated endovascular aortic repair (f—EVAR) provides a solution to overcome this problem by enabling the continuation of blood flow to the renal and visceral arteries through holes or ‘fenestrations’ in the graft. These fenestrations are designed to match the ostial diameter of the renal and visceral arteries.
There are three varieties fenestration, small, large, and scallop, and their location needs to be customized to fit the anatomy of the patient. If the device is not properly designed, if the alignment is inaccurate, or if the catheterization of the visceral arteries is not possible, the procedure may fail. In such cases, conversion to open surgery may become the only option as fenestrated endografts are not retrievable.
It is recommended that a stent be placed within each small fenestration to the target artery to prevent shuttering of the artery or occlusion. Many authors have noted an increased risk of vessel occlusion in unstented fenestrations and scallops.
Once placed in a patient, life-long follow-up at regular intervals is necessary to ensure the graft remains in its intended location, and that the components have adequate overlap. Should the need arise, routine follow-up allows the performance of timely and appropriate intervention through detection of events that could impact the long-term outcomes.
Alternative Technology
The technique of fenestrated endovascular grafting is still in evolution and few studies have been with published mid-term outcome data. As the technique become more common in vascular surgery practices, it will be important to determine if it can provide better outcomes than open surgical repair (OSR).
In an OSR approach, aortic clamping above one or both renal arteries, or above the visceral arteries, is required. The higher the level of aortic clamping, the greater the risk of cardiac stress and renal or visceral ischemia. During suprarenal or supraceliac aortic clamping, strain-induced myocardial ischemia may also occur due to concomitant rise in cardiac afterload and a decrease in cardiac output. Reports indicate that 6% of patients undergoing surgical repair develop myocardial infarction. The ideal level of clamp location remains controversial with conflicting views having been reported.
A search of electronic databases (OVID MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, The Cochrane Library, and the International Agency for Health Technology Assessment [INAHTA] database was undertaken to identify evidence published from January 1, 2004 to December 19, 2008. The search was limited to English-language articles and human studies. The automatic search alerts were received and reviewed up to March 23, 2009.
The literature search and automatic search update identified 320 citations, of which 13 met inclusion/exclusion criteria. One comparative study presented at an international seminar, five single-arm studies on f—EVAR, and 7 studies on OSR (one prospective and six retrospective) were considered for this analysis.
To grade the strength of the body of evidence, the grading system formulated by the GRADE working group and adopted by MAS, was applied. The GRADE system classifies evidence quality as high (Grade A), moderate (Grade B), or low (Grade C) according to four key elements: study design, study quality, consistency across studies, and directness.
A summary of the characteristics of the f—EVAR and OSR studies found through the literature search is shown in Table ES-1.
Patient Characteristics: f–EVAR Studies versus OSR Studies
JRA, Juxtarenal aortic aneurysm; SRA, Suprarenal aortic aneurysm; TAA, Thoracic aortic aneurysm
Mortality Outcomes
The pooled estimate for 30-day mortality was 1.8% among the f—EVAR studies and 3.1% among the OSR studies that reported data for the repair of JRA separately. The pooled estimate for late mortality was 12.8% among the f—EVAR studies and 23.7% among the OSR studies that reported data for JRA separately.
Visceral Artery Events Reported in f—EVAR Studies
Renal Events during f-EVAR
A total of three main renal arteries and two accessory renal arteries became occluded during the procedure. These were all due to technical issues, except one accessory renal artery in which the artery was intentionally covered. One patient required open surgery following the procedure.
Renal Events During the follow-up
A total of 12 renal arteries (12 patients) were found to be occluded during follow-up. In two patients, the same side accessory renal artery was also occluded. Four (1.5%) patients lost one kidney and five (2.3%) patients underwent dialysis, three (1.4%) of which became permanent.
A total of 16 cases of renal artery stenosis (16 patients) occurred during follow-up. Eight of these were treated and eight were observed. Segmental renal infarcts were found in six patients but renal function was not impaired.
Mesenteric Events during f-EVAR
Three mesenteric events occurred during the f—EVAR procedures resulting in two deaths. One patient developed bowel ischemia due to embolization of the superior mesenteric artery (SMA); this patient died 13 days after the procedure from multiorgan failure. One patient died eights days after the procedure from mesenteric ischemia and bowel perforation. The third SMA event occurred during surgery with subsequent occlusion in early follow-up.
Mesenteric Events during Follow-up
During follow-up, five (1.8%) SMA occlusions/partial occlusions and one SMA stenosis were noted. Three of the five patients with SMA occlusion/partial occlusion remained asymptomatic and no further intervention was necessary. One patient underwent SMA bypass surgery and in two patients, the problem solved by SMA stenting. A summary of the outcomes reported in the f—EVAR and OSR studies is shown in Table ES-2.
Summary of Outcomes: Fenestrated Endovascular Graft Versus Open Surgical Repair for Treatment of Juxtarenal Aortic Aneurysm
Short- and medium-term results (up to 2 years) of f—EVAR for the repair of JRA showed that outcomes in f—EVAR series compare favourably with the figures for the OSR series; however, uncertainty remains regarding the long-term results. The following observations are based on low quality evidence.
F—EVAR has lower 30-day mortality than OSR (1.8% vs. 3.1%) and a lower late-mortality over the period of time that patients have been followed (12.8% vs. 23.7%).
There is a potential for the loss of target vessels during or after f—EVAR procedures. Loss of a target vessel may lead to loss of its respective end organ. The risk associated with this technique is mainly due to branch vessel ischemia or occlusion (primarily among the renal arteries and SMA). Ischemia or occlusion of these arteries can occur during surgery due to technical failure and/or embolization or it may occur during follow-up due to graft complications such as graft migration, component separation, or arterial thrombosis. The risk of kidney loss in this series of f—EVAR studies was 1.5% and the risk of mesenteric ischemia was 3.3%. In the OSR studies, the risk of developing renal insufficiency was 14.4% and the risk of mesenteric ischemia was 2.9%.
F—EVAR has a lower rate of postoperative cardiac and pulmonary complications.
Endoleak occurs in 22.5% of patients undergoing f—EVAR (all types) and about 8% of these require treatment. Most of the interventions performed to treat such endoleaks conducted using a minimally invasive approach.
Due to the complexity of the technique, patients must be appropriately selected for f—EVAR, the procedure performed by highly experienced operators, and in centers with advanced, high-resolution imaging systems to minimize the risk of complications.
Graft fenestrations have to be custom designed for each patient to fit and match the anatomy of their visceral arteries. Planning and sizing thus requires scrutiny of the target vessels with a high degree precision. This is important not only to prevent end organ ischemia and infarction, but to avoid prolonging procedures and subsequent adverse outcomes.
Assuming the average cost range of FEVAR procedure is $24,395-$30,070 as per hospital data and assuming the maximum number of annual cases in Ontario is 116, the average estimated cost impact range to the province for FEVAR procedures is $2.83M-$3.49M annually.
PMCID: PMC3377528  PMID: 23074534
3.  Endovascular Repair of Descending Thoracic Aortic Aneurysm 
Executive Summary
To conduct an assessment on endovascular repair of descending thoracic aortic aneurysm (TAA).
Clinical Need
Aneurysm is the most common condition of the thoracic aorta requiring surgery. Aortic aneurysm is defined as a localized dilatation of the aorta. Most aneurysms of the thoracic aorta are asymptomatic and incidentally discovered. However, TAA tends to enlarge progressively and compress surrounding structures causing symptoms such as chest or back pain, dysphagia (difficulty swallowing), dyspnea (shortness of breath), cough, stridor (a harsh, high-pitched breath sound), and hoarseness. Significant aortic regurgitation causes symptoms of congestive heart failure. Embolization of the thrombus to the distal arterial circulation may occur and cause related symptoms. The aneurysm may eventually rupture and create a life-threatening condition.
The overall incidence rate of TAA is about 10 per 100,000 person-years. The descending aorta is involved in about 30% to 40% of these cases.
The prognosis of large untreated TAAs is poor, with a 3-year survival rate as low as 25%. Intervention is strongly recommended for any symptomatic TAA or any TAA that exceeds twice the diameter of a normal aorta or is 6 cm or larger. Open surgical treatment of TAA involves left thoracotomy and aortic graft replacement. Surgical treatment has been found to improve survival when compared with medical therapy. However, despite dramatic advances in surgical techniques for performing such complex operations, operative mortality from centres of excellence are between 8% and 20% for elective cases, and up to 50% in patients requiring emergency operations. In addition, survivors of open surgical repair of TAAs may suffer from severe complications. Postoperative or postprocedural complications of descending TAA repair include paraplegia, myocardial infarction, stroke, respiratory failure, renal failure, and intestinal ischemia.
The Technology
Endovascular aortic aneurysm repair (EVAR) using a stent graft, a procedure called endovascular stent-graft (ESG) placement, is a new alternative to the traditional surgical approach. It is less invasive, and initial results from several studies suggest that it may reduce mortality and morbidity associated with the repair of descending TAAs.
The goal in endovascular repair is to exclude the aneurysm from the systemic circulation and prevent it from rupturing, which is life-threatening. The endovascular placement of a stent graft eliminates the systemic pressure acting on the weakened wall of the aneurysm that may lead to the rupture. However, ESG placement has some specific complications, including endovascular leak (endoleak), graft migration, stent fracture, and mechanical damage to the access artery and aortic wall.
The Talent stent graft (manufactured by Medtronic Inc., Minneapolis, MN) is licensed in Canada for the treatment of patients with TAA (Class 4; licence 36552). The design of this device has evolved since its clinical introduction. The current version has a more flexible delivery catheter than did the original system. The prosthesis is composed of nitinol stents between thin layers of polyester graft material. Each stent is secured with oversewn sutures to prevent migration.
Review Strategy
To compare the effectiveness and cost-effectiveness of ESG placement in the treatment of TAAs with a conventional surgical approach
To summarize the safety profile and effectiveness of ESG placement in the treatment of descending TAAs
Measures of Effectiveness
Primary Outcome
Mortality rates (30-day and longer term)
Secondary Outcomes
Technical success rate of introducing a stent graft and exclusion of the aneurysm sac from systemic circulation
Rate of reintervention (through surgical or endovascular approach)
Measures of Safety
Complications were categorized into 2 classes:
Those specific to the ESG procedure, including rates of aneurysm rupture, endoleak, graft migration, stent fracture, and kinking; and
Those due to the intervention, either surgical or endovascular. These include paraplegia, stroke, cardiovascular events, respiratory failure, real insufficiency, and intestinal ischemia.
Inclusion Criteria
Studies comparing the clinical outcomes of ESG treatment with surgical approaches
Studies reporting on the safety and effectiveness of the ESG procedure for the treatment of descending TAAs
Exclusion Criteria
Studies investigating the clinical effectiveness of ESG placement for other conditions such as aortic dissection, aortic ulcer, and traumatic injuries of the thoracic aorta
Studies investigating the aneurysms of the ascending and the arch of the aorta
Studies using custom-made grafts
Literature Search
The Medical Advisory Secretariat searched The International Network of Agencies for Health Technology Assessment and the Cochrane Database of Systematic Reviews for health technology assessments. It also searched MEDLINE, EMBASE, Medline In-Process & Other Non-Indexed Citations, and Cochrane CENTRAL from January 1, 2000 to July 11, 2005 for studies on ESG procedures. The search was limited to English-language articles and human studies.
One health technology assessment from the United Kingdom was identified. This systematic review included all pathologies of the thoracic aorta; therefore, it did not match the inclusion criteria. The search yielded 435 citations; of these, 9 studies met inclusion criteria.
Summary of Findings
The results of a comparative study found that in-hospital mortality was not significantly different between ESG placement and surgery patients (2 [4.8%] for ESG vs. 6 [11.3%] for surgery).
Pooled data from case series with a mean follow-up ranging from 12 to 38 months showed a 30-day mortality and late mortality rate of 3.9% and 5.5%, respectively. These rates are lower than are those reported in the literature for surgical repair of TAA.
Case series showed that the most common cause of early death in patients undergoing endovascular repair is aortic rupture, and the most common causes of late death are cardiac events and aortoesophageal or aortobronchial fistula.
Technical Success Rate
Technical success rates reported by case series are 55% to 100% (100% and 94.4% in 2 studies with all elective cases, 89% in a study with 5% emergent cases, and 55% in a study with 42% emergent cases).
Surgical Reintervention
In the comparative study, 3 (7.1%) patients in the ESG group and 14 (26.5%) patients in the surgery group required surgical reintervention. In the ESG group, the reasons for surgical intervention were postoperative bleeding at the access site, paraplegia, and type 1 endoleak. In the surgical group, the reasons for surgery were duodenal perforation, persistent thoracic duct leakage, false aneurysm, and 11 cases of postoperative bleeding.
Pooled data from case series show that 9 (2.6%) patients required surgical intervention. The reasons for surgical intervention were endoleak (3 cases), aneurysm enlargement and suspected infection (1 case), aortic dissection (1 case), pseudoaneurysm of common femoral artery (1 case), evacuation of hematoma (1 case), graft migration (1 case), and injury to the access site (1 case).
Endovascular Revision
In the comparative study, 3 (7.1%) patients required endovascular revision due to persistent endoleak.
Pooled data from case series show that 19 (5.3%) patients required endovascular revision due to persistent endoleak.
Graft Migration
Two case series reported graft migration. In one study, 3 proximal and 4 component migrations were noted at 2-year follow-up (total of 5%). Another study reported 1 (3.7%) case of graft migration. Overall, the incidence of graft migration was 2.6%.
Aortic Rupture
In the comparative study, aortic rupture due to bare stent occurred in 1 case (2%). The pooled incidence of aortic rupture or dissection reported by case series was 1.4%.
Postprocedural Complications
In the comparative study, there were no statistically significant differences between the ESG and surgery groups in postprocedural complications, except for pneumonia. The rate of pneumonia was 9% for those who received an ESG and 28% for those who had surgery (P = .02). There were no cases of paraplegia in either group. The rate of other complications for ESG and surgery including stroke, cardiac, respiratory, and intestinal ischemia were all 5.1% for ESG placement and 10% for surgery. The rate for mild renal failure was 16% in the ESG group and 30% in the surgery group. The rate for severe renal failure was 11% for ESG placement and 10% for surgery.
Pooled data from case series show the following postprocedural complication rates in the ESG placement group: paraplegia (2.2%), stroke (3.9%), cardiac (2.9%), respiratory (8.7%), renal failure (2.8%), and intestinal ischemia (1%).
Time-Related Outcomes
The results of the comparative study show statistically significant differences between the ESG and surgery group for mean operative time (ESG, 2.7 hours; surgery, 5 hours), mean duration of intensive care unit stay (ESG, 11 days; surgery, 14 days), and mean length of hospital stay (ESG, 10 days; surgery, 30 days).
The mean duration of intensive care unit stay and hospital stay derived from case series is 1.6 and 7.8 days, respectively.
Ontario-Based Economic Analysis
In Ontario, the annual treatment figures for fiscal year 2004 include 17 cases of descending TAA repair procedures (source: Provincial Health Planning Database). Fourteen of these have been identified as “not ruptured” with a mean hospital length of stay of 9.23 days, and 3 cases have been identified as “ruptured,” with a mean hospital length of stay of 28 days. However, because one Canadian Classification of Health Interventions code was used for both procedures, it is not possible to determine how many were repaired with an EVAR procedure or with an open surgical procedure.
Hospitalization Costs
The current fiscal year forecast of in-hospital direct treatment costs for all in-province procedures of repair of descending TAAs is about $560,000 (Cdn). The forecast in-hospital total cost per year for in-province procedures is about $720,000 (Cdn). These costs include the device cost when the procedure is EVAR (source: Ontario Case Costing Initiative).
Professional (Ontario Health Insurance Plan) Costs
Professional costs per treated patient were calculated and include 2 preoperative thoracic surgery or EVAR consultations.
The professional costs of an EVAR include the fees paid to the surgeons, anesthetist, and surgical assistant (source: fee service codes). The procedure was calculated to take about 150 minutes.
The professional costs of an open surgical repair include the fees of the surgeon, anesthetist, and surgical assistant. Open surgical repair was estimated to take about 300 minutes.
Services provided by professionals in intensive care units were also taken into consideration, as were the costs of 2 postoperative consultations that the patients receive on average once they are discharged from the hospital. Therefore, total Ontario Health Insurance Plan costs per treated patient treated with EVAR are on average $2,956 (ruptured or not ruptured), as opposed to $5,824 for open surgical repair and $6,157 for open surgical repair when the aneurysm is ruptured.
Endovascular stent graft placement is a less invasive procedure for repair of TAA than is open surgical repair.
There is no high-quality evidence with long-term follow-up data to support the use of EVAR as the first choice of treatment for patients with TAA that are suitable candidates for surgical intervention.
However, short- and medium-term outcomes of ESG placement reported by several studies are satisfactory and comparable to surgical intervention; therefore, for patients at high risk of surgery, it is a practical option to consider. Short- and medium-term results show that the benefit of ESG placement over the surgical approach is a lower 30-day mortality and paraplegia rate; and shorter operative time, ICU stay, and hospital stay.
PMCID: PMC3382300  PMID: 23074469
4.  National outcomes for the treatment of ruptured abdominal aortic aneurysm 
Endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA) has been shown to acutely decrease procedural mortality compared to open aortic repair (OAR). However, little is known about the effect of choice of procedure; EVAR vs OAR, or the impact of physician and institution volume on long-term survival and outcome.
Patients hospitalized with rAAA who underwent either OAR or EVAR, were derived from the Medicare inpatient dataset (1995-2004) using ICD9 codes. We evaluated long-term survival after OAR and EVAR in the entire fee-for-service Medicare population, and then in patients matched by propensity score to create two similar cohorts for comparison with Kaplan-Meier analysis. Annual surgeon and hospital volumes of EVAR (elective and ruptured), OAR (elective and ruptured), and rAAA (EVAR and OAR) were divided into quintiles to determine if increasing volumes correlate with decreasing mortality. Predictors of survival were determined by Cox modeling.
A total of 43,033 Medicare beneficiaries had rAAA repair: 41,969 had OAR and 1,064 had EVAR. The proportions of patients with diabetes, hypertension, cardiovascular, cerebrovascular, renal disease, hyperlipidemia, and cancer were statistically higher in the EVAR than in the OAR group, whereas lower extremity vascular disease was higher in the OAR group. The initial evaluation of EVAR vs OAR, prior to propensity matching, showed no statistical advantage in EVAR-survival after 90 days. The survival analysis of patients matched by propensity score showed a benefit of EVAR over OAR that persisted throughout the 4 years of follow-up P = .0042). (Perioperative and long-term survival after rAAA repair correlated with increasing annual surgeon and hospital volume in OAR and EVAR and also with rAAA experience. EVAR repair had a protective effect (HR = 0.857, P = .0061) on long-term survival controlling for comorbidities, demographics, and hospital and surgeon volume.
When EVAR and OAR patients are compared using a reliable statistical technique such as propensity analysis, the perioperative survival advantage of rAAA repaired endovascularly is maintained over the long term. Institutional experience with rAAA is critical for survival after either OAR or EVAR.
PMCID: PMC2622721  PMID: 18971032
5.  Decrease in total aneurysm related deaths in the era of endovascular aneurysm repair 
With the expansion of elective abdominal aortic aneurysm (AAA) repair after the introduction of endovascular aneurysm repair (EVAR), there is a concern that even with a lower operative mortality there could be increasing number of aneurysm related deaths. To evaluate this, we looked at national trends in AAA repair volume as well as mortality after intact and ruptured AAA repair encompassing the introduction of EVAR.
Patients with intact or ruptured AAA undergoing open repair or EVAR and all those with a diagnosis of ruptured AAA were identified within the 1993–2005 Nationwide Inpatient Sample database using ICD-9 diagnosis and procedure codes. The number of repairs, number of rupture diagnoses without repair, number of deaths, and associated mortality rates were measured for each year of the database. Outcomes (mean annual volumes) were compared from the pre-EVAR era (1993–1998) to the post-EVAR era (2001–2005).
Since introduction, EVAR increased steadily and accounted for 56% of repairs, yet only 27% of the deaths for intact repairs in 2005. The mean annual number of intact repairs increased from 36,122 in the pre-EVAR era to 38,901 in the post-EVAR era while the mean annual number of deaths related to intact AAA repair decreased from 1,693 pre-EVAR to 1,207 post-EVAR (P < .0001). Mortality for all intact AAA repair decreased from 4.0% to 3.1% (P < .0001) pre and post-EVAR but open repair mortality was unchanged (open repair 4.7% to 4.5%, P= .31; EVAR 1.3%). During the same time periods, mean annual number of ruptured repairs decreased from 2,804 to 1,846 and deaths from ruptured AAA repairs decreased from 2,804 to 1,846 (P < .0001). Mortality for ruptured AAA repair decreased from 44.3% to 39.9% (P < .0001) pre and post-EVAR (open repair 44.3% to 39.9%, P< .001; EVAR 32.4%). The overall mean annual number of ruptured AAA diagnoses (9,979 to 7,773, P < .0001) and overall mean annual deaths from a ruptured AAA decreased post-EVAR (5,338 to 3,901, P < .0001).
Since the introduction of EVAR, there has been a significant decrease in the annual number of deaths from both intact and ruptured AAA. This coincided with an increase in intact AAA repair after the introduction of EVAR and a decrease in ruptured AAA diagnosis and repair volume.
PMCID: PMC2709247  PMID: 19135843
6.  Informed consent for abdominal aortic aneurysm repair: Assessing variations in surgeon opinion through a national survey 
Informed consent discussions for elective abdominal aortic aneurysm (AAA) repair should reflect appropriate risks of the open or endovascular repair (EVAR), but few guidelines exist describing what surgeons should discuss. This study examines expert opinion regarding what constitutes informed consent.
We conducted an anonymous, web-based, national survey of vascular surgeons. Associations between surgeon characteristics and opinions regarding informed consent were measured using bivariate statistics; multivariable logistic regression was performed to estimate effects adjusted for covariates.
Academic and private practice surgeons were surveyed.
United States members of the International Society for Vascular Surgery membership. Main Outcome Measure. Surgeons' self-reported opinions regarding the content of informed consent for AAA repair.
A total of 199 surgeons completed the survey (response rate 51%). More than 90% of respondents reported that it was essential to discuss mortality risk for both procedures. However, only 60% and 30% of respondents reported that it was essential to discuss the risk of myocardial infarction and stroke, respectively. Opinions varied by procedure regarding the risks of impotence (32% vs 62%; EVAR vs open repair), reintervention (78% vs 17%), and rupture during long-term follow-up (57% vs 17%). Younger and private practice surgeons were more likely to discuss complications compared with older surgeons and those in academic practice. Surgeons who perform predominantly EVAR were more likely to quote higher mortality rates for open repair (odds ration [OR] = 3.1, 95% confidence interval [CI] = 1.4-6.4) and lower reintervention rates for EVAR (OR = 0.3, 95% CI = 0.1-0.7) compared with other surgeons.
This is the first study of the practice of informed consent for AAA repair. The only risk that the vast majority of surgeons agreed should be included in informed consent for AAA repair was mortality. Significant variation exists regarding whether other complications should be discussed and what complication rates should be quoted. surgeon characteristics may influence how risks are presented to patients. Further efforts are needed to develop guidelines to ensure consistent communication of appropriate risk during informed consent for AAA repair.
PMCID: PMC2659171  PMID: 18241751
7.  Early and delayed rupture after endovascular abdominal aortic aneurysm repair in a 10-year multicenter registry 
Journal of vascular surgery  2014;60(5):1146-1152.
Rupture after abdominal endovascular aortic aneurysm repair (EVAR) is a function of graft maintenance of the seal and fixation. We describe our 10-year experience with rupture after EVAR.
From 2000 to 2010, 1736 patients with abdominal aortic aneurysm (AAA) from 17 medical centers underwent EVAR in a large, regional integrated health care system. Preoperative demographic and clinical data of interest were collected and stored in our registry. We retrospectively identified patients with postoperative rupture, characterized as “early” and “delayed” rupture (≤30 days and >30 days after the initial EVAR, respectively), and identified predictors associated with delayed rupture.
The overall follow-up rate was 92%, and the median follow-up was 2.7 years (interquartile range, 1.2–4.4 years) in these 1736 EVAR patients. We identified 20 patients with ruptures; 70% were male, the mean age was 79 years, and mean AAA size at the initial EVAR was 6.3 cm. Six patients underwent initial EVAR for rupture (n = 2) or symptomatic presentation (n = 4). Of the 20 post-EVAR ruptures, 25% (five of 20) were early, all occurring within 2 days after the initial EVAR. Of these five patients, four had intraoperative adverse events leading directly to rupture, with one type I and one type III endoleak. Of the five early ruptures, four patients underwent endovascular repair and one received repair with open surgery, resulting in two perioperative deaths. Among the remaining 15 patients, the median time from initial EVAR to rupture was 31.1 months (interquartile range, 13.8–57.3 months). Most of these delayed ruptures (10 of 15) were preceded by AAA sac increases, including three patients with known endoleaks who underwent reintervention. At the time of delayed rupture, nine of 15 patients had new endoleaks. Among all 20 patients, six patients did not undergo repair (all delayed patients) and died, nine underwent repeated EVAR, and five had open repair. For patients who underwent repair for delayed rupture, mortality at 30 days and 1 year were 44.4% and 66.7%, respectively. Multivariable Cox regression analysis identified age 80 to 89 (hazard ratio, 3.3; 95% confidence interval, 1.1–9.4; P =.03), and symptomatic or ruptured initial indication for EVAR (hazard ratio, 7.4; 95% confidence interval, 2.2–24.8; P < .01) as significant predictors of delayed rupture.
Rupture after EVAR is a rare but devastating event, and mortality after repair exceeds 60% at 1 year. Most delayed cases showed late AAA expansion, thereby implicating late loss of seal and increased endoleaks as the cause of rupture in these patients and mandating vigilant surveillance.
PMCID: PMC4331642  PMID: 24957409
8.  The Impact of Body Mass Index on Perioperative Outcomes of Open and Endovascular Abdominal Aortic Aneurysm Repair from the National Surgical Quality Improvement Program 2005–2007 
Obesity and morbid obesity have been shown to increase wound infections and occasionally mortality after many surgical procedures. Little is known about the relative impact of body mass index on these outcomes after open (OAR) and endovascular abdominal aortic aneurysm repair (EVAR).
The 2005–2007 National Surgical Quality Improvement Program (NSQIP), a multi-institutional risk-adjusted database, was retrospectively queried to compare perioperative mortality (in-hospital or 30-day) and postoperative wound infections after OAR and EVAR. Patient demographics, comorbidities, and operative details were analyzed. Body mass index (BMI) was calculated from height and weight variables and definitions of obesity and morbid obesity were defined as BMI > 30kg/m2 and BMI > 40kg/m2 respectively. Student's T-test, Wilcoxon Rank Sum, Chi-square, and multivariate logistic regression were used to compare outcomes.
There were 2,097 OAR and 3,358 EVAR. Compared to EVAR, OAR patients were younger, more likely to be female (26% vs. 17%, P < .001), and less obese (27% vs. 32%, P < .001). Mortality was 3.7% vs. 1.2% after OAR vs. EVAR respectively (RR 3.1, P < .001) and overall morbidity was 28% vs. 12% (RR 2.3, P < .001). Morbidly obese patients had a higher mortality for both OAR (7.3%) and EVAR (2.4%) than obese patients (3.9% OAR; 1.5% EVAR) or non-obese patients (3.7% OAR; 1.1% EVAR). Obese patients had a higher rate of wound infection vs. non-obese after open repair (6.3% vs. 2.4%, P < .001) and EVAR (3.3% vs. 1.5%, P < .001). Morbid obesity predicted mortality after OAR but not EVAR and obesity was an independent predictor of wound infection after OAR and EVAR.
Morbid obesity confers a worse outcome for mortality after AAA repair. Obesity is also a risk factor for infectious complications after OAR and EVAR. Obese patients and particularly morbidly obese patients should be treated with EVAR when anatomically feasible.
PMCID: PMC3005989  PMID: 20843627
9.  Technical tips and procedural steps in endovascular aortic aneurysm repair with concomitant recanalization of iliac artery occlusions 
SpringerPlus  2013;2:605.
The goal of this paper is to describe our technical strategy and procedural steps for endovascular aneurysm repair (EVAR) when performed with concomitant recanalization of the iliac artery occlusion.
Materials and methods
Three octogenarians having abdominal aortic aneurysm (AAA)/common iliac artery aneurysms (CIAA) with unilateral external iliac artery (EIA) occlusion underwent EVAR with recanalization of the occluded iliac arteries. Crossing the iliac artery occlusions was attempted in a retrograde approach using a 0.035 inch-hydrophilic guidewire. After passage of a guidewire, predilation was performed using 6mm balloon. Then a 12-Fr sheath was advanced via the occluded EIA for contralateral iliac limb delivery. Internal iliac artery embolization was subsequently performed as needed. A self-expanding stent was then placed in the occluded EIA after EVAR.
Recanalization of the EIA occlusion, followed by stentgraft delivery through the occlusion and EVAR, was successfully performed in all three patients. Penetration of the occluded EIA was successfully achieved only by retrograde approach in two patients, and by bidirectional approach in the other patient. No perioperative complication or death occurred. Postoperative CT showed no type I or III endoleaks in the aneurysms and patent iliac arteries in all patients.
Total endovascular repairs were successfully performed for three patients with AAA and concomitant unilateral EIA occlusions. The proposed steps described in this report might reduce the complication rate and enhance the technical success rate associated with this procedure.
PMCID: PMC3837076  PMID: 24294549
Abdominal aortic aneurysm; Endovascular aneurysm repair; Iliac artery occlusion; Peripheral arterial disease; Stent placement
10.  Designation as “Unfit for Open Repair” Is Associated With Poor Outcomes After Endovascular Aortic Aneurysm Repair 
Endovascular aortic aneurysm repair (EVAR) is often offered to patients with abdominal aortic aneurysms (AAAs) considered preoperatively to be unfit for open AAA repair (oAAA). This study describes the short- and long-term outcomes of patients undergoing EVAR with AAAs <6.5 cm who are considered unfit for oAAA.
Methods and Results
We analyzed elective EVARs for AAAs <6.5 cm diameter in the Vascular Study Group of New England (2003–2011). Patients were designated as fit or unfit for oAAA by the treating surgeon. End points included in-hospital major adverse events and long-term mortality. We identified patient characteristics associated with being unfit for open repair and predictors of survival using multivariable analyses. Of 1653 EVARs, 309 (18.7%) patients were deemed unfit for oAAA. These patients were more likely to have advanced age, cardiac disease, chronic obstructive pulmonary disease, and larger aneurysms at the time of repair (54 versus 56 mm, P=0.001). Patients unfit for oAAA had higher rates of cardiac (7.8% versus 3.1%, P<0.01) and pulmonary (3.6 versus 1.6, P<0.01) complications and worse survival rates at 5 years (61% versus 80%; log rank P<0.01) compared with those deemed fit for oAAA. Finally, patients designated as unfit for oAAA had worse survival, even adjusting for patient characteristics and aneurysm size (hazard ratio, 1.6; 95% confidence interval, 1.2–2.2; P<0.01).
In patients with AAAs <6.5 cm, designation by the operating surgeon as unfit for oAAA provides insight into both short- and long-term efficacy of EVAR. Patients unable to tolerate oAAA may not benefit from EVAR unless their risk of AAA rupture is very high.
PMCID: PMC4279216  PMID: 24046399
aneurysm; complications; mortality
11.  Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age 
Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA.
We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital.
Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01–1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70–79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008).
The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.
PMCID: PMC4206251  PMID: 25342890
ruptured abdominal aneurysm repair; clinical decision-making; emergency endovascular aneurysm repair; open repair
12.  Complex Regional Pain Syndrome Type II Secondary to Endovascular Aneurysm Repair 
Complex regional pain syndrome (CRPS) is a chronic pain disorder characterized by severe pain and vasomotor and pseudomotor changes. Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms is a recent advance in vascular surgery that has allowed repair of AAA while offering reduced intensive care unit and hospital lengths of stay, reduced blood loss, fewer major complications, and more rapid recovery. Pseudoaneurysms are a rare complication of an EVAR procedure that may result in a wide range of complications. The present report examines CRPS type II as a novel consequence of pseudoaneurysm formation from brachial artery access in the EVAR procedure. To our knowledge, this is the first reported case of CRPS type II presentation as sequelae of an EVAR procedure.
PMCID: PMC4305616  PMID: 25650247
13.  Secondary aortoduodenal fistula following endovascular repair of inflammatory abdominal aortic aneurysm due to Streptococcus anginosus infection: A case report and literature review☆ 
Aortoenteric fistula is a rare but very serious complication of both surgical and endovascular abdominal aortic reconstruction. Since the advent of endovascular abdominal aortic aneurysm repair (EVAR), 20 cases of aortoduodenal fistula associated with aortic stent grafts have been reported.1 However, only a handful has been reported following inflammatory abdominal aortic aneurysm repair. It most commonly presents with bleeding, usually from the upper gastro-intestinal tract. With recent advances in the screening, diagnosis and management of abdominal aortic aneurysms either surgically or through an endovascular approach, the diagnosis of an aortoduodenal fistula in patients with gastro-intestinal bleeding must be suspected and excluded.
We describe a case of secondary aortoduodenal fistula that occurred two and a half years following endovascular stent graft repair of an inflammatory abdominal aortic aneurysm. We also outline the emergency correction plan and the attempts at repair.
This case defies the general concept that patients with inflammatory abdominal aortic aneurysms are relatively immune to rupture. Although the presence of a peri-aneurysm thick inflammatory membrane decreases the possibility of rupture, these patients are more susceptible to other related complications such as aorto-enteric and aorto-caval fistulas.2 This case also demonstrates the peculiar presence of Streptococcus anginosus as the pathological organism leading to graft infection and subsequent fistula, as opposed to enterococci which are often found in endograft infection.
Aorto-enteric fistulas are associated with a grave prognosis. Early diagnosis is crucial and extra vigilance should be taken in cases of inflammatory AAA.
PMCID: PMC4189064  PMID: 25201477
14.  Open Surgery for Abdominal Aortic Aneurysm in the Era of Endovascular Repair: Comparison with Long Term Results of Endovascular Repair Using Zenith Stentgraft 
Annals of Vascular Diseases  2013;6(2):189-194.
Objective: Our study focuses on the long term result of open surgery and endovascular abdominal aortic aneurysm repair (EVAR) using the Zenith stentgraft.
Patients and Methods: A total of 237 patients underwent elective abdominal aortic aneurysm (AAA) repair between April 1999 and December 2006. Nineteen patients underwent EVAR, whereas 218 patients underwent open surgery. The mean follow-up time for EVAR group was 73.8 ± 49 months (range; 25–150 months), and 69.7 ± 46 months (range; 1–156 months) for open surgery group.
Results: One open surgery patient (1/218, 0.46%) died of aspiration pneumonia, whereas all the EVAR patients survived the operation. Remote complications requiring reintervention occurred in 8 patients (8/174, 4.6%) in open surgery group. Six EVAR patients (6/19, 31.6%) developed late aneurysm expansion, among whom four patients (4/19, 21.1%) required reinterventions after 3 or more years postoperatively. The need for reintervention persisted even at 11 years after initial EVAR. There was no significant intergroup difference in late mortality.
Conclusions: There was no statistically significant intergroup difference in early and long term mortality. Complications requiring reinterventions, however, were more frequent in EVAR than in open surgery, especially in the late period. Long term follow-up is mandatory for comparison of the clinical results between open surgery and EVAR.
PMCID: PMC3692989  PMID: 23825500
aorta; aneurysm; surgery; stentgraft
15.  An Unusual Complication of EVAR, Spontaneous Rectus Sheath Hematoma: A Case Report 
Annals of Vascular Diseases  2009;2(2):122-125.
Objective: To report a successful conservative management in a case of spontaneous rectus sheath hematoma (SRSH) after Endovascular Aneurysmal Repair (EVAR) of infrarenal Abdominal Aortic Aneurysm (AAA).
Case Presentation: An 84-year-old woman with a 6 cm in diameter infrarenal AAA underwent EVAR at our hospital. During the procedure, intravenous heparin was administered to keep the activated clotting time around 300 seconds. One hour after the procedure, the patient complained of pain on her right side abdomen. Physical examination revealed a tender mass in the right lower abdominal wall. Laboratory studies showed a fall in hemoglobin from 12.7 g/dl to 9.3 g/dl. Ultrasound (US) examination demonstrated an 8 × 5 cm hematoma within the right rectus muscle. Follow-up US examination revealed that the hematoma had enlarged and a computed tomography (CT) examination of the lower abdomen was performed. CT scan showed a smooth-shaped mass within the layers of the anterolateral abdominal wall leading to enlargement of the right rectus abdominis muscle without signs of active bleeding. A conservative management was considered.
Result: The clinical course was uneventful with a stable hemodynamic state. The patient was discharged 12 days later and was doing well at the 2 week follow-up.
Conclusion: Spontaneous rectus sheath hematoma is an unusual complication of a patient on anticoagulant therapy during EVAR. A prompt radiological investigation may prevent unnecessary surgical procedures in this unusual complication.
PMCID: PMC3611845  PMID: 23555371
abdominal wall; hemorrhage; anticoagulation therapy; endovascular
16.  Causes and Implications of Readmission after Abdominal Aortic Aneurysm Repair 
Annals of surgery  2012;256(4):595-605.
To determine the frequency, causes, predictors, and consequences of 30-day readmission after abdominal aortic aneurysm (AAA) repair.
Summary Background Data
CMS will soon reduce total Medicare reimbursements for hospitals with higher-than-predicted 30-day readmission rates after vascular surgical procedures including AAA repair. However, causes and factors leading to readmission in this population have never before been systematically analyzed.
We analyzed elective AAA repairs over a two-year period from the CMS Chronic Conditions Warehouse, a 5% national sample of Medicare beneficiaries.
2481 patients underwent AAA repair – 1502 endovascular (EVAR) and 979 open. 30-day readmission rates were equivalent for EVAR (13.3%) and open repair (12.8%). While wound complication was the most common reason for readmission after both procedures, the relative frequency of other causes differed – e.g., bowel obstruction was common following open repair and graft complication after EVAR. In multivariate analyses, preoperative comorbidities had a modest effect on readmission; however, postoperative factors including serious complications leading to prolonged length of stay and discharge destination other than home had a profound influence on the probability of readmission. The one-year mortality in readmitted patients was 23.4% versus 4.5% in those not readmitted (p<0.001).
Early readmission is common after AAA repair. Adjusting for comorbidities, postoperative events predict readmission, suggesting that proactively preventing, detecting, and managing postoperative complications may provide an approach to decreasing readmissions, with the potential to reduce cost and possibly enhance long-term survival.
PMCID: PMC3444679  PMID: 22964736
17.  Abdominal aortic aneurysm repair: long-term follow-up of endovascular versus open repair 
Archives of Medical Science : AMS  2014;10(2):273-282.
To compare early and long-term outcomes of endovascular abdominal aortic aneurysm repair (EVAR) versus open repair (OPEN). Design: Prospective observational, per protocol, non-randomized, with retrospective analyses.
Material and methods
Between 2000 and 2005, a total of 311 patients having EVAR or OPEN repair of infrarenal abdominal aortic aneurysms were identified and included in this prospective single-center observational study. A propensity score-based optimal-matching algorithm was employed, and 138 patients undergoing EVAR procedures were matched (1: 1) to OPEN repair.
Open repair showed higher hospital mortality (17% vs. 6%, p = 0.004), respiratory failure (p < 0.026), transfusion requirement (p < 0.001), and intensive care unit admission (27% vs. 7%, p < 0.001), and longer hospitalization (p < 0.001). Median follow-up was 70 months (25th to 75th percentile, 24 to 101). Actuarial survival estimates at 1, 5 and 10 years were 93%, 74%, 49% for the OPEN group compared to 89%, 69%, 59% for the EVAR group (p = 0.465). A significant difference between groups was observed in younger patients (< 75 years) only (p < 0.044). Late complication and re-intervention rates were significantly higher in EVAR patients (p < 0.001 and p = 0.002, respectively). Freedom from late complications at 1, 5 and 10 years was 96%, 92%, 86%, and 84%, 70%, 64% for OPEN and EVAR procedures, respectively.
Our experience confirms the excellent results of the EVAR procedures, offering excellent early and long-term results in terms of safety and reduction of mortality. Patients < 75 years seem to benefit from EVAR not only in the immediate postoperative period but even in a long-term perspective.
PMCID: PMC4042047  PMID: 24904660
abdominal aortic aneurysms; long-term results; aneurysm mortality
18.  Laparoscopic pancreaticoduodenectomy after endovascular repair for abdominal aortic aneurysm☆ 
Most gastroenterological surgeries, even pancreatic surgery, can now be performed laparoscopically. However, the management of concomitant abdominal aortic aneurysm (AAA) and intra-abdominal malignancy is controversial. The performance of endovascular repair (EVAR) for AAA has been increasing; however, there is no report of laparoscopic pancreaticoduodenectomy after EVAR.
A pancreatic tumor was detected during follow-up after EVAR for AAA. The enlarging tumor was diagnosed as an intraductal papillary mucinous tumor with a nodule. Laparoscopic pancreaticoduodenectomy was safely performed. After laparoscopic dissection around the pancreas head, an additional incision was made in the upper abdomen, and pancreatic reconstruction was performed through the incision. In spite of grade B pancreatic fistulae, the patient recovered with medical therapy. The pathological diagnosis was intraductal papillary mucinous adenoma with small foci of carcinoma in situ. The patient has been well with neither recurrence of the tumor nor any cardiovascular events for 18 months.
The management of concomitant malignancy and AAA is challenging, especially in patients with a pancreatic tumor. The reasons for the rarity of treatment include prognosis, anatomical vicinity, and postoperative complications. EVAR reduces retroperitoneal adhesions. A laparoscopic approach provides a small operative field and decreases mutual interference with AAA. Moreover, reconstruction is performed through an upper abdominal incision apart from the AAA. Hand-sewing provides more reliable stability of the anastomosis.
The increasing frequency of performance of EVAR for AAA and subsequent computed tomography may help to detect malignancy. Laparoscopic surgery appears to be a valid approach to malignancy after EVAR.
PMCID: PMC3860024  PMID: 24240083
Laparosocopic surgery; Pancreaticoduodenectomy; Abdominal aortic aneurysm; Endovascular repair; Intraductal mucinous neoplasm; Pancreatic cancer
19.  Endovascular aneurysm repair in emergent ruptured abdominal aortic aneurysm with a ‘real’ hostile neck and severely tortuous iliac artery of an elderly patient 
BMC Surgery  2014;14:11.
Endovascular aneurysm repair (EVAR) has been a revolutionary development in the treatment of abdominal aortic aneurysms (AAAs). Meanwhile, unfavorable anatomy of the aneurysm has always been a challenge to vascular surgeons, and the application of EVAR in emergent and elderly patients are still in dispute.
Case presentation
A 79-year-old woman presented as an emergency of abdominal pain with acute hypotension, heart rate elevation and a rapid decrease of hemoglobin. Emergent computed tomographic angiography (CTA) showed a ruptured AAA (rAAA) extending from below the opening of bilateral renal arteries down to the celiac artery and elongated to both common iliac arteries. The hostile neck and severely tortuous iliac artery made the following procedure a great challenge. An emergent endovascular approach was performed in which an excluder aortic main body was deployed below the origin of the bilateral renal arteries covering the ruptured aortic segment. Two iliac legs were placed superior to the opening of the right hypogastric respectively. In order to avoid the type Ib endoleak, we tried to deploy another cuff above the bifurcation of the iliac artery. However, the severely tortuous right iliac artery made this procedure extremely difficult, and a balloon-assisted technique was used in order to keep the stiff wire stable. Another iliac leg was placed above the bifurcation of the left iliac artery. The following angiography showed a severe Ia endoleak in the proximal neck and therefore, a cuff was deployed distal to opening of the left renal artery with off-the-shelf solution. The patient had an uneventful recovery with a resolution of the rAAA. She is well and symptom-free 6 months later.
Endovascular aneurysm repair (EVAR) in emergent elderly rAAA with hostile neck and severe tortuous iliac artery is extremely challenging, and endovascular management with integrated technique is feasible and may achieve a satisfactory early result.
PMCID: PMC4016293  PMID: 24597740
Endovascular aneurysm repair (EVAR); Ruptured abdominal aortic aneurysm (rAAA); Hostile anatomy; Elderly patient
20.  Coil Embolization for Intracranial Aneurysms 
Executive Summary
To determine the effectiveness and cost-effectiveness of coil embolization compared with surgical clipping to treat intracranial aneurysms.
The Technology
Endovascular coil embolization is a percutaneous approach to treat an intracranial aneurysm from within the blood vessel without the need of a craniotomy. In this procedure, a microcatheter is inserted into the femoral artery near the groin and navigated to the site of the aneurysm. Small helical platinum coils are deployed through the microcatheter to fill the aneurysm, and prevent it from further expansion and rupture. Health Canada has approved numerous types of coils and coil delivery systems to treat intracranial aneurysms. The most favoured are controlled detachable coils. Coil embolization may be used with other adjunct endovascular devices such as stents and balloons.
Intracranial Aneurysms
Intracranial aneurysms are the dilation or ballooning of part of a blood vessel in the brain. Intracranial aneurysms range in size from small (<12 mm in diameter) to large (12–25 mm), and to giant (>25 mm). There are 3 main types of aneurysms. Fusiform aneurysms involve the entire circumference of the artery; saccular aneurysms have outpouchings; and dissecting aneurysms have tears in the arterial wall. Berry aneurysms are saccular aneurysms with well-defined necks.
Intracranial aneurysms may occur in any blood vessel of the brain; however, they are most commonly found at the branch points of large arteries that form the circle of Willis at the base of the brain. In 85% to 95% of patients, they are found in the anterior circulation. Aneurysms in the posterior circulation are less frequent, and are more difficult to treat surgically due to inaccessibility.
Most intracranial aneurysms are small and asymptomatic. Large aneurysms may have a mass effect, causing compression on the brain and cranial nerves and neurological deficits. When an intracranial aneurysm ruptures and bleeds, resulting in a subarachnoid hemorrhage (SAH), the mortality rate can be 40% to 50%, with severe morbidity of 10% to 20%. The reported overall risk of rupture is 1.9% per year and is higher for women, cigarette smokers, and cocaine users, and in aneurysms that are symptomatic, greater than 10 mm in diameter, or located in the posterior circulation. If left untreated, there is a considerable risk of repeat hemorrhage in a ruptured aneurysm that results in increased mortality.
In Ontario, intracranial aneurysms occur in about 1% to 4% of the population, and the annual incidence of SAH is about 10 cases per 100,000 people. In 2004-2005, about 660 intracranial aneurysm repairs were performed in Ontario.
Treatment of Intracranial Aneurysms
Treatment of an unruptured aneurysm attempts to prevent the aneurysm from rupturing. The treatment of a ruptured intracranial aneurysm aims to prevent further hemorrhage. There are 3 approaches to treating an intracranial aneurysm.
Small, asymptomatic aneurysms less than 10 mm in diameter may be monitored without any intervention other than treatment for underlying risk factors such as hypertension.
Open surgical clipping, involves craniotomy, brain retraction, and placement of a silver clip across the neck of the aneurysm while a patient is under general anesthesia. This procedure is associated with surgical risks and neurological deficits.
Endovascular coil embolization, introduced in the 1990s, is the health technology under review.
Literature Review
The Medical Advisory Secretariat searched the International Health Technology Assessment (INAHTA) Database and the Cochrane Database of Systematic Reviews to identify relevant systematic reviews. OVID Medline, Medline In-Process and Other Non-Indexed Citations, and Embase were searched for English-language journal articles that reported primary data on the effectiveness or cost-effectiveness of treatments for intracranial aneurysms, obtained in a clinical setting or analyses of primary data maintained in registers or institutional databases. Internet searches of Medscape and manufacturers’ databases were conducted to identify product information and recent reports on trials that were unpublished but that were presented at international conferences. Four systematic reviews, 3 reports on 2 randomized controlled trials comparing coil embolization with surgical clipping of ruptured aneurysms, 30 observational studies, and 3 economic analysis reports were included in this review.
Safety and Effectiveness
Coil embolization appears to be a safe procedure. Complications associated with coil embolization ranged from 8.6% to 18.6% with a median of about 10.6%. Observational studies showed that coil embolization is associated with lower complication rates than surgical clipping (permanent complication 3-7% versus 10.9%; overall 23% versus 46% respectively, p=0.009). Common complications of coil embolization are thrombo-embolic events (2.5%–14.5%), perforation of aneurysm (2.3%–4.7%), parent artery obstruction (2%–3%), collapsed coils (8%), coil malposition (14.6%), and coil migration (0.5%–3%).
Randomized controlled trials showed that for ruptured intracranial aneurysms with SAH, suitable for both coil embolization and surgical clipping (mostly saccular aneurysms <10 mm in diameter located in the anterior circulation) in people with good clinical condition:Coil embolization resulted in a statistically significant 23.9% relative risk reduction and 7% absolute risk reduction in the composite rate of death and dependency compared to surgical clipping (modified Rankin score 3–6) at 1-year.
The advantage of coil embolization over surgical clipping varies widely with aneurysm location, but endovascular treatment seems beneficial for all sites.
There were less deaths in the first 7 years following coil embolization compared to surgical clipping (10.8% vs 13.7%). This survival benefit seemed to be consistent over time, and was statistically significant (log-rank p= 0.03).
Coil embolization is associated with less frequent MRI-detected superficial brain deficits and ischemic lesions at 1-year.
The 1- year rebleeding rate was 2.4% after coil embolization and 1% for surgical clipping. Confirmed rebleeding from the repaired aneurysm after the first year and up to year eight was low and not significantly different between coil embolization and surgical clipping (7 patients for coil embolization vs 2 patients for surgical clipping, log-rank p=0.22).
Observational studies showed that patients with SAH and good clinical grade had better 6-month outcomes and lower risk of symptomatic cerebral vasospasm after coil embolization compared to surgical clipping.
For unruptured intracranial aneurysms, there were no randomized controlled trials that compared coil embolization to surgical clipping. Large observational studies showed that:
The risk of rupture in unruptured aneurysms less than 10 mm in diameter is about 0.05% per year for patients with no pervious history of SAH from another aneurysm. The risk of rupture increases with history of SAH and as the diameter of the aneurysm reaches 10 mm or more.
Coil embolization reduced the composite rate of in hospital deaths and discharge to long-term or short-term care facilities compared to surgical clipping (Odds Ratio 2.2, 95% CI 1.6–3.1, p<0.001). The improvement in discharge disposition was highest in people older than 65 years.
In-hospital mortality rate following treatment of intracranial aneurysm ranged from 0.5% to 1.7% for coil embolization and from 2.1% to 3.5% for surgical clipping. The overall 1-year mortality rate was 3.1% for coil embolization and 2.3% for surgical clipping. One-year morbidity rate was 6.4% for coil embolization and 9.8% for surgical clipping. It is not clear whether these differences were statistically significant.
Coil embolization is associated with shorter hospital stay compared to surgical clipping.
For both ruptured and unruptured aneurysms, the outcome of coil embolization does not appear to be dependent on age, whereas surgical clipping has been shown to yield worse outcome for patients older than 64 years.
Angiographic Efficiency and Recurrences
The main drawback of coil embolization is its low angiographic efficiency. The percentage of complete aneurysm occlusion after coil embolization (27%–79%, median 55%) remains lower than that achieved with surgical clipping (82%–100%). However, about 90% of coiled aneurysms achieve near total occlusion or better. Incompletely coiled aneurysms have been shown to have higher aneurysm recurrence rates ranging from 7% to 39% for coil embolization compared to 2.9% for surgical clipping. Recurrence is defined as refilling of the neck, sac, or dome of a successfully treated aneurysm as shown on an angiogram. The long-term clinical significance of incomplete occlusion following coil embolization is unknown, but in one case series, 20% of patients had major recurrences, and 50% of these required further treatment.
Long-Term Outcomes
A large international randomized trial reported that the survival benefit from coil embolization was sustained for at least 7 years. The rebleeding rate between year 2 and year 8 following coil embolization was low and not significantly different from that of surgical clipping. However, high quality long-term angiographic evidence is lacking. Accordingly, there is uncertainty about long-term occlusion status, coil durability, and recurrence rates. While surgical clipping is associated with higher immediate procedural risks, its long-term effectiveness has been established.
Indications and Contraindications
Coil embolization offers treatment for people at increased risk for craniotomy, such as those over 65 years of age, with poor clinical status, or with comorbid conditions. The technology also makes it possible to treat surgical high-risk aneurysms.
Not all aneurysms are suitable for coil embolization. Suitability depends on the size, anatomy, and location of the aneurysm. Aneurysms more than 10 mm in diameter or with an aneurysm neck greater than or equal to 4 mm are less likely to achieve total occlusion. They are also more prone to aneurysm recurrences and to complications such as coil compaction or parent vessel occlusion. Aneurysms with a dome to neck ratio of less than 1 have been shown to have lower obliteration rates and poorer outcome following coil embolization. Furthermore, aneurysms in the middle cerebral artery bifurcation are less suitable for coil embolization. For some aneurysms, treatment may require the use of both coil embolization and surgical clipping or adjunctive technologies, such as stents and balloons, to obtain optimal results.
Information from 3 countries indicates that coil embolization is a rapidly diffusing technology. For example, it accounted for about 40% of aneurysm treatments in the United Kingdom.
In Ontario, coil embolization is an insured health service, with the same fee code and fee schedule as open surgical repair requiring craniotomy. Other costs associated with coil embolization are covered under hospitals’ global budgets. Utilization data showed that in 2004-2005, coil embolization accounted for about 38% (251 cases) of all intracranial aneurysm repairs in the province. With the 2005 publication of the positive long-term survival data from the International Subarachnoid Aneursym Trial, the pressure for diffusion will likely increase.
Economic Analysis
Recent economic studies show that treatment of unruptured intracranial aneurysms smaller than 10 mm in diameter in people with no previous history of SAH, either by coil embolization or surgical clipping, would not be effective or cost-effective. However, in patients with aneurysms that are greater than or equal to 10 mm or symptomatic, or in patients with a history of SAH, treatment appears to be cost-effective.
In Ontario, the average device cost of coil embolization per case was estimated to be about $7,500 higher than surgical clipping. Assuming that the total number of intracranial aneurysm repairs in Ontario increases to 750 in the fiscal year of 2007, and assuming that up to 60% (450 cases) of these will be repaired by coil embolization, the difference in device costs for the 450 cases (including a 15% recurrence rate) would be approximately $3.8 million. This figure does not include capital costs (e.g. $3 million for an angiosuite), additional human resources required, or costs of follow-up. The increase in expenditures associated with coil embolization may be offset partially, by shorter operating room times and hospitalization stays for endovascular repair of unruptured aneurysms; however, the impact of these cost savings is probably not likely to be greater than 25% of the total outlay since the majority of cases involve ruptured aneurysms. Furthermore, the recent growth in aneurysm repair has predominantly been in the area of coil embolization presumably for patients for whom surgical clipping would not be advised; therefore, no offset of surgical clipping costs could be applied in such cases. For ruptured aneurysms, downstream cost savings from endovascular repair are likely to be minimal even though the savings for individual cases may be substantial due to lower perioperative complications for endovascular aneurysm repair.
The two Guidance documents issued by the National Institute of Clinical Excellence (UK) in 2005 support the use of coil embolization for both unruptured and ruptured (SAH) intracranial aneurysms, provided that procedures are in place for informed consent, audit, and clinical governance, and that the procedure is performed in specialist units with expertise in the endovascular treatment of intracranial aneurysms.
For people in good clinical condition following subarachnoid hemorrhage from an acute ruptured intracranial aneurysm suitable for either surgical clipping or endovascular repair, coil embolization results in improved independent survival in the first year and improved survival for up to seven years compared to surgical clipping. The rebleeding rate is low and not significantly different between the two procedures after the first year. However, there is uncertainty regarding the long-term occlusion status, durability of the stent graft, and long-term complications.
For people with unruptured aneurysms, level 4 evidence suggests that coil embolization may be associated with comparable or less mortality and morbidity, shorter hospital stay, and less need for discharge to short-term rehabilitation facilities. The greatest benefit was observed in people over 65 years of age. In these patients, the decision regarding treatment needs to be based on the assessment of the risk of rupture against the risk of the procedure, as well as the morphology of the aneurysm.
In people who require treatment for intracranial aneurysm, but for whom surgical clipping is too risky or not feasible, coil embolization provides survival benefits over surgical clipping, even though the outcomes may not be as favourable as in people in good clinical condition and with small aneurysms. The procedure may be considered under the following circumstances provided that the aneurysm is suitable for coil embolization:
Patients in poor/unstable clinical or neurological state
Patients at high risk for surgical repair (e.g. people>age 65 or with comorbidity), or
Aneurysm(s) with poor accessibility or visibility for surgical treatment due to their location (e.g. ophthalmic or basilar tip aneurysms)
Compared to small aneurysms with a narrow neck in the anterior circulation, large aneurysms (> 10 mm in diameter), aneurysms with a wide neck (>4mm in diameter), and aneurysms in the posterior circulation have lower occlusion rates and higher rate of hemorrhage when treated with coil embolization.
The extent of aneurysm obliteration after coil embolization remains lower than that achieved with surgical clipping. Aneurysm recurrences after successful coiling may require repeat treatment with endovascular or surgical procedures. Experts caution that long-term angiographic outcomes of coil embolization are unknown at this time. Informed consent for and long-term follow-up after coil embolization are recommended.
The decision to treat an intracranial aneurysm with surgical clipping or coil embolization needs to be made jointly by the neurosurgeon and neuro-intervention specialist, based on the clinical status of the patient, the size and morphology of the aneurysm, and the preference of the patient.
The performance of endovascular coil embolization should take place in centres with expertise in both neurosurgery and endovascular neuro-interventions, with adequate treatment volumes to maintain good outcomes. Distribution of the technology should also take into account that patients with SAH should be treated as soon as possible with minimal disruption.
PMCID: PMC3379525  PMID: 23074479
21.  A Case of Abdominal Aortic Aneurysm with Short Angulated Proximal Neck Treated with the Chimney Graft Technique 
Korean Circulation Journal  2013;43(6):416-421.
Endovascular aneurysm repair (EVAR) using stent grafts has shown to be an effective alternative to surgical repair in treating an abdominal aortic aneurysm (AAA). EVAR is associated with shorter hospital stays, less blood loss, shorter operating times, and lower early morbidity and mortality compared to open surgical repair, although EVAR required a higher reintervention rate during a longer follow-up period. However, short or severely an angulated infrarenal proximal aortic neck is considered unsuitable for EVAR. The chimney graft technique is a modified procedure based on the deployment of a covered or bare-metal stent parallel to the main aortic endograft within the aneurysm, thereby creating a conduit that runs outside the aortic main endograft to preserve flow to the aortic branches. In this case report, we present a 78-year-old patient with an AAA with a short and severely angulated proximal neck who was successfully treated by EVAR using the chimney graft technique.
PMCID: PMC3717426  PMID: 23882292
Aortic aneurysm, abdominal; Endovascular techniques
22.  Endovascular vs open repair for ruptured abdominal aortic aneurysm 
Journal of vascular surgery  2012;56(1):15-20.
Endovascular repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) has become first-line therapy at our institution and is performed under a standardized protocol. We compare perioperative mortality, midterm survival, and morbidity after EVAR and open surgical repair (OSR).
Records were retrospectively reviewed from May 2000 to September 2010 for repair of infrarenal rAAAs. Primary end points included perioperative mortality and midterm survival. Secondary end points included acute limb ischemia, length of stay, ventilator-dependent respiratory failure, myocardial infarction, renal failure, abdominal compartment syndrome, and secondary intervention. Statistical analysis was performed using the t-test,X2 test, the Fisher exact test, and logistic regression calculations. Midterm survival was assessed with Kaplan-Meier analysis and Cox proportional hazard models.
Seventy-four infrarenal rAAAs were repaired, 19 by EVAR and 55 by OSR. Despite increased age and comorbidity in the EVAR patients, perioperative mortality was 15.7% for EVAR, which was significantly lower than the 49% for OSR (odds ratio, 0.19; 95% CI, 0.05-0.74; P = .008). Midterm survival also favored EVAR (hazard ratio, 0.40; 95% CI, 0.21-0.77; P = .028, adjusted for age and sex). Mean follow-up was 20 months, and 1-year survival was 60% for EVAR vs 45% for OSR. Mean length of stay for patients surviving >1 day was 10 days for EVAR and 21 days for OSR (P = .004). Ventilator-dependent respiratory failure was 5% in the EVAR group vs 42% for OSR (odds ratio, 0.08; 95% CI, 0.01-0.62; P = .001).
EVAR of rAAA has a superior perioperative survival advantage and decreased morbidity vs OSR. Although not statistically significant, overall survival favors EVAR. We recommend that EVAR be considered as the first-line treatment of rAAAs and practiced as the standard of care.
PMCID: PMC4032073  PMID: 22626871
23.  Current status of Canadian vascular surgery training: a survey of program directors 
Canadian Journal of Surgery  2005;48(4):311-318.
With the aging of the North American population and therefore the need for more modern vascular surgeons familiar with open operations and less invasive diagnostic and therapeutic regimens, we wished to obtain suggestions and recommendations that would allow our training programs to more adequately fulfil these needs. Our objectives were to assess recent trends in Canadian vascular surgery training with respect to the trainee's operative and nonoperative experience.
We mailed a survey to the directors of the 8 Canadian vascular surgery training programs, to ascertain the yearly operative volumes of their 3 most recent trainees with respect to 6 index operations: carotid endarterectomy (CEA), types I–IV thoracoabdominal aortic aneurysm (TAA) repair, elective open infrarenal aortic aneurysm (eAAA) repair, ruptured abdominal aortic aneurysm (rAAA) repair, endovascular abdominal aortic aneurysm repair (EVAR) and lower extremity arterial bypass (LEB). Additionally, information pertaining to nonvascular surgery rotations and the final practice location and type of practice for each trainee was requested.
Seven (88%) of 8 program directors completed the survey. Between 1999 and 2002, vascular surgery trainees in Canadian training programs were exposed to the following yearly clinical volumes (expressed as mean [and standard deviation]): CEA 55.4 (33.9), TAA 6.2 (3.8), eAAA 63.8 (30.0), rAAA 13.5 (9.4), EVAR 14.9 (9.6) and LEB 74.5 (34.5). The range of yearly clinical volumes were: CEA 21–124, TAA 1–18, eAAA 30–133, rAAA 3–45, EVAR 0–34 and LEB 20–143. Nonvascular surgery rotations included: endovascular therapy, interventional radiology, noninvasive diagnostics and research. Forty-five (80.4%) of 56 recent graduates practise only vascular surgery. Most (73.2%) of our recent trainees have remained in Canada, with 41.1% settling in the province in which they trained.
Canadian vascular surgery training programs provide more than sufficient operative experience for their trainees. Although some programs have been successful at providing training in endovascular therapies, the integration of such experience in our training programs continues to be a challenge.
PMCID: PMC3211535  PMID: 16149367
24.  Endovascular management of the patent inferior mesenteric artery in two cases of uncontrolled type II endoleak after endovascular aneurysm repair 
Endovascular aneurysm repair (EVAR) has well documented advantages over traditional open repair and has been widely adopted as the alternative treatment modality for abdominal aortic aneurysm. However, endoleaks specifically type II can be a significant problem with this technique leading to aortic sac expansion and potential rupture. A large number of type II endoleaks are caused by persistent inferior mesenteric artery (IMA) retrograde bleeding. Various methods to try to manage this complication have been previously described. IMA embolization via the marginal artery of Drummond, however, has not been adequately popularized as an alternative less invasive approach to the treatment of type II endoleak.
Case Report:
Two men, ages 77 and 81, underwent uneventful EVAR for 5.5 and 5.0 cm infrarenal abdominal aortic aneurysms, respectively, using Zenith Cook® bifurcated stent grafts. Computed tomography angiography at 1 and 6 months postoperatively demonstrated small type II endoleaks in both cases which were followed clinically. Subsequent follow-up tomography scan at 12 months revealed persistent type II endoleaks related to retrograde filling from the IMA with significant enlargement of the aneurysm sacs. Both patients underwent successful IMA coil embolization via the marginal artery of Drummond.
Percutaneous IMA embolization using standard endovascular techniques to access the marginal artery of Drummond is an alternative, and in our opinion, preferred technique for controlling type II endoleaks caused by a persistently patent IMA.
PMCID: PMC3234148  PMID: 22171248
Endoleak; marginal artery; drummond; coil embolization
25.  Hybrid Treatment of Multiple Aortic Aneurysms by Combined Conventional Surgery and Endovascular Aortic Repair 
Annals of Vascular Diseases  2008;1(1):40-44.
Purpose: We evaluated the operative results of our treatment for multiple aortic aneurysms by means of a hybrid procedure consisting of a combination of conventional surgical maneuvers and simultaneous or sequential endovascular aortic repair (EVAR).
Materials and Methods: From August 1998 to April 2007, a total of 15 patients, 11 men and 4 women, ranging in age from 62 to 78 years, were treated with hybrid procedures for multiple aortic aneurysms. The pathology of these patients were, atherosclerotic aneurysm in 12 patients, atherosclerotic aneurysm associated with chronic dissection in 2 and type III chronic dissection in 1 patient. The distribution of aneurysmal locations were as follows: 5 patients had aneurysms at the arch and descending aorta, 1 had at the arch and thoracoabdominal aorta, 6 at the descending and abdominal aorta. Two patients with chronic dissection had simultaneous abdominal aortic aneurysms. In all except 1 of the 7 patients who had abdominal aortic aneurysm, we performed abdominal aneurysmectomy and EVAR simultaneously. In 7 patients, EVAR was performed sequentially after graft replacement surgery. In 2 patients, EVAR was the initial procedure followed by conventional surgery. The mean interval between first and second stage procedures was approximately 4 months.
Results: One patients died of methicillin resistant Staphylococcus aureus pneumonia 3 months after the simultaneous procedure, all others were discharged and survive. In particular, no major EVAR linked complication was observed in the follow-up period (range 3 to 91 months, mean 46 months).
Conclusion: The hybrid procedure for the treatment of multiple aortic aneurysmal disease is less invasive compared to conventional staged surgery and the outcome in terms of mortality and morbidity in hospital as well as long-term follow-up are satisfactory.
PMCID: PMC3610219  PMID: 23555337
multiple aortic aneurysms; hybrid procedure; endovascular aortic repair; elephant trunk

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