Outcomes and Morphologic Changes After Endovascular Repair for Abdominal Aortic Aneurysms With a Severely Angulated Neck

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Introduction:We retrospectively analyzed outcomes of patients who had undergone endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) more than 3 years previously in a single institution. We compared outcomes between patients who underwent EVAR within and outside of the devices' instructions for use (IFU) and examined mid-term morphological changes in AAA. Methods: A total of 275 patients who underwent EVAR for AAA were selected. IFU parameters included aneurysmal neck length, angulation and presence of massive atheroma. Patients were divided into 2 groups: the Within IFU group (W-IFU: n = 193) and the Outside of IFU group (O-IFU: n = 82). Results: Patients in the O-IFU group were older and had a larger AAA diameter. Other comorbid factors were similar between the 2 groups. There was no difference in overall survival rates and reintervention rates between the 2 groups. The most common cause for reintervention was AAA enlargement 3 years after EVAR. Irrespective of the IFU, mid-term morphological changes, including neck angulation, neck diameter, sac re-expansion, and Palmaz stent displacement, were found. Conclusion: Outcomes of EVAR were considered acceptable in the O-IFU group. Careful follow-up is necessary considering the morphological changes in AAAs after EVAR.

Section: Methodsmentioning

confidence: 99%

Feasibility of Endovascular Abdominal Aortic Aneurysm Repair Outside of the Instructions for Use and Morphological Changes at 3 Years after the Procedure

Hoshina

Hashimoto

Kato

et al. 2014

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“…4) Regarding other devices, the Endurant device (Medtronic, Santa Rosa, CA, US) study showed no migration of the stent-graft even in 45 cases with a mean SAN of 81°. 7) The Aorfix device (Lombard, Oxfordshire, United Kingdom) is approved for an angulated proximal neck of 90° in the instructions for use, and the Aorfix study (PYTHAGO-RAS) demonstrated that proximal neck dilation >10% at 5 mm above the proximal renal artery and 1 mm below the distal renal artery was a risk for stent-graft migration.…”

Section: Resultsmentioning

confidence: 98%

“…[1][2][3] Although migration of the Zenith device at the distal site after EVAR is known to be caused by morphologic changes due to an angulated distal neck, 4) migration at proximal sites during or after EVAR is uncommon.…”

Section: Introductionmentioning

confidence: 99%

Migration of the Zenith Flex Device during Endovascular Aortic Repair of an Infrarenal Aortic Aneurysm with a Severely Angulated Neck

Ogawa

Nishimaki

Chiba

et al. 2016

A woman in her 80s with an infrarenal aortic aneurysm was scheduled for endovascular aortic repair (EVAR). The aneurysm had a severely angulated neck (SAN), and the Zenith Flex device was selected. Completion angiography showed migration of the main body resulting in right renal artery stenosis. A Palmaz genesis was placed across the renal orifice. The patient had no renal dysfunction and was discharged 7 days after EVAR. If Zenith Flex devices are used for a SAN, it is necessary to consider not only the position of the renal artery but also the appropriate position of the stent-graft. Keywords:Zenith flex, migration, severely angulated neck discussed, paying attention to the relationship between the characteristics of the Zenith Flex device and the SAN. Case ReportA woman in her 80s with a medical history of hypertension and an infrarenal aortic aneurysm was scheduled for EVAR. Contrast-enhanced computed tomography (CECT) showed a fusiform aortic aneurysm with a maximum short diameter of 68 mm. Proximal neck (PN) diameter was 20 mm, PN angulation was 110°, and PN length was 35 mm (Fig. 1). A Zenith Flex device was selected because of the SAN.Under general anesthesia, the main body (TEFB 26-96-ZT) was deployed just below the right renal artery via the right femoral artery (Fig. 2a). Then, the ipsilateral leg (TELE 12-73 ZT) and the contralateral leg (TELE 18-73 ZT) were placed into the bilateral common iliac arteries, respectively. Completion angiography showed right renal artery stenosis, thought to be due to migration of the stent-graft (Fig. 2b). A 6F guiding sheath (Parent Plus, Medikit Co., Tokyo, Japan) was inserted via the left brachial artery. The right renal artery was cannulated, and a 6 mm × 18 mm Palmaz genesis (Cordis) was placed across the renal orifice without residual stenosis.The patient had no renal dysfunction and was discharged 7 days after EVAR. DiscussionAn important technical issue was identified in this case. The Zenith Flex device can migrate at proximal sites in an aneurysm with a SAN. To the best of our knowledge, this has not been previously reported.Though a hostile neck including a SAN is known to be associated with a high risk of migration, 5) a EUROSTAR study showed no relationship between migration of the stent-graft and the presence of a SAN. 6) Moreover, a recent report also showed no migration at the proximal

“…Recent study reported that endograft morphology can be changed chronologically after implantation. 10) The late morphological change might be related to the occurrence of endograft occlusion. In addition, PT-INR was not prolonged at the time of admission in spite of anticoagulation therapy.…”

Section: Resultsmentioning

confidence: 99%

“…Sixteen months ago, he had undergone abdominal aortic endograft implantation for infrarenal abdominal aortic aneurysm at a different hospital. Preoperative computed tomography (CT) showed the maximum aneurysm diameter of 62 mm, the neck angulation 10) of 77°, and the terminal aorta diameter of 21 mm (Fig. 1).…”

Section: Case Reportmentioning

confidence: 99%

Total Occlusion of Abdominal Aortic Endograft Successfully Treated with Axillobifemoral Bypass

Shirasugi

Kimura

Yasuda

et al. 2015

We report a case of total occlusion of a Zenith bifurcated stent graft 16 months after implantation. A 72-year-old man was admitted to our hospital complaining of bilateral lower extremity numbness, followed by severe rest pain 4 h after sudden onset of symptoms. Computed tomography showed total occlusion of the endograft at the mid-portion of the main body. He underwent left axillobifemoral bypass using a reinforced polytetrafluoroethylene T-shaped graft, leading to resolution of symptoms 7 h after onset. Axillobifemoral bypass successfully relieved acute lower extremity ischemia caused by total occlusion of the abdominal aortic endograft.Keywords: abdominal aortic endograft, total occlusion, axillobifemoral bypass life-threatening disease associated with high morbidity and mortality. Here we report a case of abdominal aortic endograft total occlusion that was successfully managed with axillobifemoral bypass; in addition, we discuss the treatment strategies for this critical situation. Case ReportA 72-year-old man was admitted to an emergency department of a district hospital, complaining of sudden bilateral lower extremity numbness and severe rest pain. At the age of 62, he had undergone mechanical valve replacement for aortic valve stenosis and permanent pacemaker insertion for sick sinus syndrome at the same hospital. Sixteen months ago, he had undergone abdominal aortic endograft implantation for infrarenal abdominal aortic aneurysm at a different hospital. Preoperative computed tomography (CT) showed the maximum aneurysm diameter of 62 mm, the neck angulation 10) of 77°, and the terminal aorta diameter of 21 mm (Fig. 1). A Zenith endovascular graft (Cook Inc., Bloomington, Indiana) was implanted through the right femoral approach. The procedure was performed successfully and the postoperative course was uneventful. A postoperative CT showed the neck angulation of 56° and the terminal aorta diameter of 21 mm (Fig. 1). The patient was discharged from the hospital with no endoleak. Subsequently, he had been regularly followed-up for anticoagulation therapy at a local hospital. He had not experienced intermittent claudication previously.On further examination at the district hospital, a CT showed an abdominal endograft implanted from below the orifice of the renal arteries to the bilateral common iliac arteries with complete occlusion at the mid-portion of the main body (Fig. 2). The neck angulation was 54°, and the terminal aorta diameter of 21 mm (Fig. 2). Preoperative echocardiography showed that there was no obvious thrombus in the left atrium and the left ventricle, and around the mechanical aortic valve. A diagnosis of acute endograft occlusion was made. The patient was transferred to our hospital 4 h after the onset of symptoms for