Commentary: New-Generation Devices and Adjunctive Procedures Are the Key Elements to Expanding the Indications for Endovascular Aneurysm Repair

Troisi, Nicola; Torsello, Giovanni

doi:10.1177/1526602815575484

Cited by 7 publications

(3 citation statements)

References 30 publications

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“…7 The off-label use of standard EVAR is currently used for patients who are not eligible for OR, with acceptable short-and mid-term outcomes. 8,9 Long-term durability of EVAR depends on the maintenance of a successful seal between the stent graft and the aortic neck as well as the iliac arteries. Some aortic neck characteristics contribute in the definition of ''hostile neck,'' namely, length shorter than 15 mm, large diameter, tapered/reverse tapered anatomy, mural thrombus, moderate/severe circumferential calcification, and angulation, in addition to maximum aneurysm diameter.…”

Section: Introductionmentioning

confidence: 99%

Expert Opinion on Hostile Neck Definition in Endovascular Treatment of Abdominal Aortic Aneurysms (a Delphi Consensus)

Marone

Freyrie

Ruotolo

et al. 2020

Annals of Vascular Surgery

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Section: Introductionmentioning

confidence: 99%

Expert Opinion on Hostile Neck Definition in Endovascular Treatment of Abdominal Aortic Aneurysms (a Delphi Consensus)

Marone

Freyrie

Ruotolo

et al. 2020

Annals of Vascular Surgery

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“…Indeed, unfavorable anatomy, documented in 40–60% of treated AAAs, seems to be the factor most related to negative outcomes [ 5 , 6 , 7 ]. Despite this, in “real-world” clinical practice, up to 44% of EVAR cases are performed using stent grafts outside their instruction for use (IFU) due to the presence of a ”hostile” aortic neck anatomy, with acceptable short- and mid-term outcomes [ 8 , 9 , 10 ]. In order to overcome this problem, several different technical solutions, such as parallel grafts and fenestrated or branched devices, have been developed as an alternative to standard EVAR grafts in patients with a “challenging neck”.…”

Section: Introductionmentioning

confidence: 99%

Is Evar Feasible in Challenging Aortic Neck Anatomies? A Technical Review and Ethical Discussion

Sirignano

Ceruti

Aloisi

et al. 2022

JCM

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Background: Endovascular aneurysm repair (EVAR) has become an accepted alternative to open repair (OR) for the treatment of abdominal aortic aneurysm (AAA) despite “hostile” anatomies that may reduce its effectiveness. Guidelines suggest refraining from EVAR in such circumstances, but in clinical practice, up to 44% of EVAR procedures are performed using stent grafts outside their instruction for use (IFU), with acceptable outcomes. Starting from this “inconsistency” between clinical practice and guidelines, the aim of this contribution is to report the technical results of the use of EVAR in challenging anatomies as well as the ethical aspects to identify the criteria by which the “best interest” of the patient can be set. Materials and Methods: A literature review on currently available evidence on standard EVAR using commercially available endografts in patients with hostile aortic neck anatomies was conducted. Medline using the PubMed interface and The Cochrane Library databases were searched from 1 January 2000 to 6 May 2021, considering the following outcomes: technical success; need for additional procedures; conversion to OR; reintervention; migration; the presence of type I endoleaks; AAA-related mortality rate. Results: A total of 52 publications were selected by the investigators for a detailed review. All studies were either prospective or retrospective observational studies reporting the immediate, 30-day, and/or follow-up outcomes of standard EVAR procedures in patients with challenging neck anatomies. No randomized trials were identified. Fourteen different endo-grafts systems were used in the selected studies. A total of 45 studies reported a technical success rate ranging from 93 to 100%, and 42 the need for additional procedures (mean value of 9.04%). Results at 30 days: the incidence rate of type Ia endoleak was reported by 37 studies with a mean value of 2.65%; 31 studies reported a null migration rate and 32 a null conversion rate to OR; in 31 of the 35 studies that reported AAA-related mortality, the incidence was null. Mid-term follow-up: the incidence rate of type Ia endoleak was reported by 48 studies with a mean value of 6.65%; 30 studies reported a null migration rate, 33 a null conversion rate to OR, and 28 of the 45 studies reported that the AAA-related mortality incidence was null. Conclusions: Based on the present analysis, EVAR appears to be a safe and effective procedure—and therefore recommendable—even in the presence of hostile anatomies, in patients deemed unfit for OR. However, in order to identify and pursue the patient’s best interest, particular attention must be paid to the management of the patient’s informed consent process, which—in addition to being an essential ethical-legal requirement to legitimize the medical act—ensures that clinical data can be integrated with the patient’s personal preferences and background, beyond the therapeutic potential of the proposed procedures and what is generically stated in the guidelines.

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“…AAA accounts for ~15,000 deaths in the USA per year (2). In addition, 30-40% of patients with ruptured AAA die without surgery (3)(4)(5). The operative mortality rate of AAA is 40-50% (3-6), however, the overall mortality of AAA rupture is 80-90%.…”

Section: Introductionmentioning

confidence: 99%

Limb graft occlusion following endovascular aortic repair: Incidence, causes, treatment and prevention in a study cohort

Wang

Zhai

et al. 2017

Experimental and Therapeutic Medicine

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Abstract. The present study investigated the incidence, causes, treatment and prevention of limb graft occlusion following endovascular aortic repair (EVAR). A total of 66 cases of abdominal aortic aneurysm receiving EVAR at our department from January 2005 to December 2013 were enrolled. After EVAR, patients received routine antiplatelet therapy of 75 mg PLAVIX for 6 months and then 100 mg Aspirin for another 6 months by oral administration. According to previous clinical experiences, antiplatelet therapy is able to effectively reduce the incidence of iliac occlusion after EVAR. A total of 61 bifurcated grafts and 5 aortauniilac grafts (127 limbs in total) were used. Physical examination, ankle-brachial-index and computer tomographic angiography were performed at 10 days, at 3, 6 and 12 months and annually thereafter. It was found that 7 limbs in 7 patients (10.6% of patients, 5.5% of limbs) were occluded between 20 days and 12 months (average, 7.8±5.3 months) after EVAR. Acute and severe ischemia was found in 2 cases, claudication was in found 3 cases, asthenia in both legs was found in 1 case and 1 case was asymptomatic. Femoral-femoral bypass, femoral-femoral bypass and stenting, aorto-iliac/femoral bypass, thrombectomy and conservative treatment were performed in 1 patient each and thrombectomy together with stenting was performed in 2 cases. Limb graft occlusion was not rare after EVAR. Treatment of this complication included surgery and endovascular therapy such as bypass, thrombectomy and thrombolysis. In conclusion, aggressive pre-emptive treatment including angioplasty and stenting prevented occlusion in certain cases.

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Commentary: New-Generation Devices and Adjunctive Procedures Are the Key Elements to Expanding the Indications for Endovascular Aneurysm Repair

Cited by 7 publications

References 30 publications

Expert Opinion on Hostile Neck Definition in Endovascular Treatment of Abdominal Aortic Aneurysms (a Delphi Consensus)

Expert Opinion on Hostile Neck Definition in Endovascular Treatment of Abdominal Aortic Aneurysms (a Delphi Consensus)

Is Evar Feasible in Challenging Aortic Neck Anatomies? A Technical Review and Ethical Discussion

Limb graft occlusion following endovascular aortic repair: Incidence, causes, treatment and prevention in a study cohort

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