Objectives:To evaluate the role of intraoperative aneurysm sac embolization during EVAR (edEVAR) with coils and glue, in the prevention of Endoleak type II (ET2).Methods: Two groups were compared: 85 patients underwent standard EVAR during 2007 -2008 and 81 patients underwent edEVAR during 2009 -2010. CT scans were elaborated with the Osirix 4.0 software in order to obtain aneurysm sac volume. ET2 rates at the first CT scan follow-up, as mid-term free from ET2 and free from related reintervention were compared. Preoperative patent number of aortic side branches (IMA, lumbars, accessories renal), thrombus and sac volume were evaluated for their association with ET2 in the two groups, using multivariate analysis.Results: Patients characteristics, Society for Vascular Surgery (SVS) comorbidity score (0.85Ϯ0.44 vs 0.82Ϯ0.48; P ϭ .68) and operative time (185.4Ϯ51.8 vs 172.9Ϯ50.8;P ϭ .99) were similar between group A and B. The first CT scan (Ͻor ϭ 2 months) demonstrated significantly higher number of ET2 in group A compared to group B (23.5% vs 9.8%;P ϭ .02). Spontaneous ET2 resolution occurred in 65% of patients in Group A and 79% in group B (P ϭ 1.0), while sac volume increased in 25% vs 10% (P ϭ .63) of cases respectively. At 18 months (range:6 to 24) overall mean difference in sac volume shrinkage (27.2Ϯ12.3 cm3 vs 24.8Ϯ11.6 cm3; P ϭ .19) and free from ET2 (91.8% vs 96.3%; P ϭ 0.33) were similar, while free from reintervention was significantly lower in Group A (94.1% vs 98.8%; P ϭ .05) compared to Group B. Multivariate analysis showed preoperative aneurysm sac volume Ͼ 125 cm3 to be the only independent significant predictor of ET2 (OR, 3.64; 95% CI, 1.54 to 8.58; P ϭ .003).Conclusions: EdEVAR seems to be a valid approach to prevent ET2 and its complications during short and midterm follow-up. Patients with preoperative aneurysm sac volume higher than 125 cm3 should be considered for a more aggressive intraoperative embolization.Objectives: Alvimopan is a peripherally acting mu-opioid antagonist used to shorten the time to return of gastrointestinal function after surgery. Randomized clinical trials have demonstrated a shorter time period to return of bowel function and discharge in open abdominal colonic surgeries, but no data exists on its use in the aortic vascular surgery population.Methods: Alvimopan was administered to patients having open abdominal aortic aneurysm repair or aortofemoral bypass. The administration protocol was one 12 mg dose preoperatively and doses of 12 mg twice a day postoperatively until the first bowel movement or a total of seven days. There were seven patients in the study group and 6 patients in the control group. The primary end points were time to regain bowel function and length of hospital stay.Results: The average age (Study ϭ 69.3 Ϯ 3.8 years vs. Control ϭ 68.5 Ϯ 3.4 years; P ϭ .88), abdominal aortic aneurysm size (Study ϭ 5.9 Ϯ 0.3 cm vs. Control ϭ 5.3 Ϯ 0.5 cm; P ϭ .28), procedure time (Study ϭ 2.1 Ϯ 0.1 hours vs. Control ϭ 2.6 Ϯ 0.3 hours; P ϭ .12), gender and comorbidities...
During a 5-year period, 148 patients underwent FEVAR. Upper extremity access for FEVAR was used in 98 (66.2%) patients. The median number of vessels fenestrated was 3 (interquartile range, 2-4), with a total of 457 vessels stented. Twelve were percutaneous (12.2%) and 86 (87.8%) were open. All patients that required a sheath size >7F underwent high brachial open access, with the exception of 1 patient who underwent percutaneous axillary access with a 12F sheath. The median sheath size was 12F (interquartile range, 10-12), which was advanced into the descending thoracic aorta allowing multiple wire and catheter exchanges. Results: One (1/98; 1.0%) hemorrhagic stroke in the upper extremity access group and one (1/54; 1.9%) ischemic stroke in the femoral-only access group occurred (P ¼ .67). The stroke in the upper extremity access group occurred 5 days after FEVAR and was related to uncontrolled hypertension, whereas the stroke in the femoral group occurred on postoperative day 3. Neither patient had signs or symptoms of a stroke immediately after FEVAR. The right upper extremity was accessed six times without a stroke (0/6; 0%), compared with the left being accessed 92 times with one stroke (1/92; 1.1%) (P ¼ .8). Four (4.1%) patients had complications related to upper extremity access; one (1.0%) required exploration for an expanding hematoma after manual compression for a 7F sheath, one (1.0%) required exploration for hematoma and neurologic symptoms after open access for a 12F sheath; and two (2.0%) patients with small hematomas did not require intervention. Two (2/12; 16.7%) of these complications were in the percutaneous access group, which were significantly more frequent than in the open group (2/86; 2.3%) (P ¼ .02). Conclusions: Upper extremity access appears to be a safe and feasible approach for patients undergoing FEVAR. Open exposure in the upper extremity may be safer than percutaneous access during FEVAR. Unlike chimney and snorkel grafts, upper extremity access during FEVAR is not associated with an increased risk of stroke, despite the need for multiple visceral vessel stenting.
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