The objective of this study was to identify sex-related differences in outcomes following branched and/or fenestrated endovascular aortic repair (B/FEVAR) for thoracoabdominal (TAAA) and juxtarenal ...(JRAA) aortic aneurysms.
Chart review completed on 242 B/FEVAR patients (57 female; 23.5%) between 2007 and 2020 at a single center. Median follow-up time was 3.3 years (interquartile range IQR, 1.6-5.3 years).
No statistically significant differences in age (females, 75.9 ± 5.4 years vs males, 74.7 ± 7.2 years; P = .162) or aneurysm size (64.9 ± 6.8 vs 65.8 ± 9.4 mm; P = .41) at presentation were observed between sexes. Females presented with fewer JRAAs (45.6% vs 73%; P < .001) and received more Crawford extent II (26.3% vs 10.8%; P =.004) TAAA coverage. Increased incidence of moderate/severe target vessel stenosis (29.8% vs 14%; P = .022) was observed in female patients. Intraoperatively, females had higher procedure times (530 IQR, 425-625 vs 420 IQR, 350-510 minutes; P < .001), fluoroscopy times (124.1 ± 49 vs 107.3 ± 43.5 minutes; P = .017), and contrast usage (200 IQR, 150-270 vs 175 IQR, 130-225 mL; P = .005). Unplanned intraoperative maneuvers (45.6% vs 28.1%; P = .043), graft delivery issues (24.6% vs 4.9%; P < .001), and additional intraoperative complications (61.4% vs 35.7%; P < .001) were also increased in females. Postoperatively, females had a longer intensive care unit (3 IQR, 1-5 vs 1 IQR, 1-3 days; P = .002) and hospital stay (8 IQR, 5-13 vs 5 IQR, 3-9 days; P < .001) and experienced increased rates of spinal cord ischemia (15.8% vs 3.8%; P = .001) and bowel ischemia (10.5% vs 2.7%; P = .013). In-hospital mortality (12.3% vs 2.7%; P = .004) was higher in female patients but midterm (6-year) survival was 60.2% for all patients (95% confidence interval, 53.0%-68.5%) and was similar between sexes (hazard ratio, 0.95; P = .83), which were the primary endpoints. No sex differences in midterm follow-up reintervention, endoleak, and rupture rates were observed.
Females experienced significantly higher B/FEVAR intraoperative times, complications, and in-hospital morbidity and mortality compared with males but similar midterm outcomes. Anatomic and atherosclerotic differences may have contributed to the observed in-hospital differences.
Purpose
The aim of this study was to evaluate diagnostic performance of non-contrast-enhanced 2D quiescent-interval single-shot (QISS) and 3D turbo spin-echo (TSE)-based subtraction magnetic ...resonance angiography (MRA) in the assessment of peripheral arteries in patients with critical limb ischemia (CLI).
Materials and methods
Nineteen consecutive patients (74 % male, 72.8 ± 9.9 years) with CLI underwent 2D QISS and 3D TSE-based subtraction MRA at 1.5 T. Axial-overlapping QISS MRA (3 mm/2 mm; 1 × 1 mm
2
) covered from the toes to the aortic bifurcation while coronal 3D TSE-based subtraction MRA (1.3 × 1.2 × 1.3 mm
3
) was restricted to the calf only. MRA data sets (two readers) were evaluated for stenosis (≥50 %) and image quality. Results were compared with digital subtraction angiography (DSA).
Results
Two hundred and sixty-seven (267) segments were available for MRA-DSA comparison, with a prevalence of stenosis ≥50 % of 41.9 %. QISS MRA was rated as good to excellent in 79.5–96.0 % of segments without any nondiagnostic segments; 89.8–96.1 % of segments in 3D TSE-based subtraction MRA were rated as nondiagnostic or poor. QISS MRA sensitivities and specificities (segmental) were 92 % and 95 %, respectively, for reader one and 81–97 % for reader two. Due to poor image quality of 3D TSE-based subtraction MRA, diagnostic performance measures were not calculated.
Conclusion
QISS MRA demonstrates excellent diagnostic performance and higher robustness than 3D TSE-based subtraction MRA in the challenging patient population with CLI.
Key Points
•
QISS MRA allows reliable diagnosis of peripheral artery stenosis in critical limb ischemia.
•
Robustness of TSE-based subtraction MRA is limited in critical limb ischemia.
•
QISS MRA allows robust therapy planning in PAD patients with resting leg pain.
To report outcomes after portal vein embolization (PVE) and right hepatectomy in patients receiving embolization with N-butyl cyanoacrylate (NBCA) glue + central AMPLATZER Vascular Plug (AVP; glue ...group) or polyvinyl alcohol (PVA) particles ± coils (PVA group).
Between March 2008 and August 2013, all patients having PVE with NBCA + AVP or PVA ± coils before right hepatectomy were retrospectively reviewed; 85 patients underwent PVE with NBCA + AVP (n = 45) or PVA ± coils (n = 40). The groups were compared using Mann-Whitney U and χ
tests.
Technical success of embolization was 100%. Degree of hypertrophy (16.2% ± 7.8 vs 12.3% ± 7.62, P = .009) and kinetic growth rate (3.5%/wk ± 2.0 vs 2.6%/wk ± 1.9, P = .016) were greater in the glue group versus the PVA group. Contrast volume (66.1 mL ± 44.8 vs 189.87 mL ± 62.6, P < .001) and fluoroscopy time (11.2 min ± 7.8 vs 23.49 min ± 11.7, P < .001) were significantly less during the PVE procedure in the glue group. Surgical outcomes were comparable between groups, including the number of patients unable to go onto surgery (P = 1.0), surgical complications (P = .30), length of hospital stay (P = .68), and intensive care unit admissions (P = .71). There was 1 major complication (hepatic abscess) in each group after PVE.
PVE performed with NBCA + AVP compared with PVA ± coils resulted in greater degree of hypertrophy of the future liver remnant, less fluoroscopic time and contrast volume, and similar complication rates.
Purpose
Non-operative management of aortic graft infection is usually only considered in a palliative context. We describe the safety, efficacy, and clinical outcomes of percutaneous drainage of ...aortic graft infections (AGI) following either open or endovascular repair of aneurysmal disease.
Methods
Twelve consecutive patients (11 males, 1 female, mean age 72.7 ± 10.3 years, age range 52-88 years) between January 2010-July 2020 who underwent percutaneous drain insertion in either an infected aortic sac or periaortic abscess cavity following endovascular or open surgical graft repair were identified. Patient and procedural characteristics as well as clinical outcomes were determined.
Results
Of the 12 patients who underwent percutaneous drain insertion, five (41.7%) had undergone open abdominal aneurysm repair, one (8.3%) open thoracoabdominal aneurysmal repair, and six (50%) endovascular abdominal aneurysm repairs. Drain size ranged from 10-20 French. All were inserted under ultrasound (US), computed tomography (CT), and/or fluoroscopic guidance. Median duration of drain placement was 55.2 days (range 3-174). Five patients (41.7%) had the drain in place as a stabilizing bridge until or after definitive surgical explantation and aortic reconstruction. Seven patients (58.3%) were managed with drain placement and antibiotic therapy without surgical intervention. Six (50%) were alive at the most recent time of follow-up (median, 732 days, range 166-1650 days). Three patients (25%) died during follow-up with causes including erosion of aortic reconstruction into sigmoid colon, unrelated chronic obstructive pulmonary disease exacerbation, and severe clostridium difficile colitis and pseudomonal pneumonia (median 1244 days, range 992-1597 days). Three (25%) patients were lost to follow-up. No drain-related complications were noted.
Conclusion
Percutaneous drainage of AGI following endovascular or open aneurysm repair is a safe and viable management option either as a temporizing measure as a bridge to surgical graft explantation or as a non-surgical therapy for long term management.
Radiological assessment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) is critical to decide whether patients should be treated with pulmonary endarterectomy (PEA). Although ...computed tomography pulmonary angiography (CTPA) is increasingly used for decision making in CTEPH, the value of CTPA to predict surgical findings and outcome has never been explored.
We retrospectively reviewed 100 consecutive patients with high-quality CTPA undergoing PEA for CTEPH between May 2015 and December 2017. The most proximal level of disease in the pulmonary artery on CTPA was classified by two blinded radiologists as level 1 (main pulmonary artery), 2a (lobar pulmonary artery), 2b (origin of basal segmental pulmonary artery), 3 (segmental pulmonary artery) or 4 (predominantly subsegmental pulmonary artery).
CTPA demonstrated level 1 in 20%, level 2a in 43%, level 2b in 11%, level 3 in 23% and level 4 in 3%. A majority of males presented with level 1 (55%) and level 2 (57%), and a majority of females (83%) with level 3 (p=0.01). Levels 3 and 4 were associated with longer duration of circulatory arrest (p=0.03) and higher frequency of Jamieson type III disease at surgery (p<0.0001). Requirement for targeted pulmonary hypertension therapy after PEA was 28% at 3 years in level 2b/3/4 compared with 6% in level 2a and 13% in level 1 (p=0.002). Level 2b/3/4 was an independent predictor for targeted pulmonary hypertension therapy after PEA (hazard ratio 4.23, 95% CI 1.24-14.39; p=0.02).
High-quality CTPA provides accurate evaluation of CTEPH patients. The level of disease on CTPA can help guide peri-operative planning and post-operative monitoring.
To investigate the patient and magnetic resonance (MR) imaging characteristics associated with clinical failure after uterine artery embolization (UAE).
Seventy-eight consecutive patients who ...underwent UAE were examined. Contrast-enhanced MR imaging was performed before and 4 months after the procedure, and clinical follow-up was performed at 15 months. Patients were divided into success and failure groups strictly on the basis of their clinical outcomes. Clinical follow-up included evaluation of fibroid symptoms and the need for further treatment after UAE. Findings at pre- and postprocedural MR imaging were compared, and data collected included changes in uterine and fibroid volumes, fibroid location, and fibroid perfusion.
Fifty-eight patients were placed into the success group and 20 into the failure group. There were no differences between the baseline characteristics of the two groups. The reduction in uterine and dominant fibroid volumes was greater in the success group compared with the failure group; however, the difference was not statistically significant (success group: 295/845 34.9% vs 80/282.5 28.3%, respectively, P=.18; failure group: 317/733 43.2% vs 114/337.6 33.9%, P=.32). The reduction in total fibroid volume was greater in the success group than the failure group (189.6/393.5 48.2% vs 148.7/439.9 33.8%, respectively; P=.02) despite the fact that the percentage of fibroids completely infarcted was similar between the two groups (136/172 79% vs 41/50 82%, P=.77). Pedunculated subserosal fibroids were more common in the failure group than in the success group (P<.03) and did not reduce in volume as significantly (53.8% vs 14.7%, respectively; P=.02).
In general, the reduction in total fibroid volume after embolization is smaller in patients with poor clinical improvement. In addition, these patients have a higher number of pedunculated subserosal fibroids, and these fibroids tend to reduce in volume to a lesser extent.
To evaluate the safety and efficacy of a self-expanding bare-metal nitinol stent (Astron; BIOTRONIK AG, Bülach, Switzerland) for the treatment of atherosclerotic lesions in the common and external ...iliac arteries. This study tested the hypothesis that the major adverse event (MAE) rate at 12 months was less than or equal to a performance goal of 15%.
In a prospective study that began in November 2011, 161 patients with symptomatic iliac lesions were treated with an Astron stent in the United States, Canada, and Austria. The primary endpoint was a composite rate of procedure- and stent-related MAEs at 12 months that included 30-day mortality, clinically indicated target lesion revascularization (TLR), and index limb amputation.
The MAE rate at 12 months was 2.1% (3/146; 95% CI: 0.4% to 5.9%; p < 0.001). The acute procedural success and 30-day clinical success outcomes were both 95% (153/161). The primary patency rate at 12 months was 89.8% (115/128). The comparison of baseline and 12-month Ankle Brachial Index (ABI) measurements showed a mean increase of 0.23 ± 0.19 (p < 0.001). The Walking Impairment Questionnaire (WIQ) PAD specific score, walking distance score, walking speed score and stair climbing score paired each showed a significant increase from baseline to 12 months (p<0.001).
The Astron stent system was shown to be safe and effective in the treatment of patients with atherosclerotic disease. The observed MAE rate met the pre-specified performance goal of 15%. The stent demonstrated a high 12-month primary patency rate and showed improvement in quality of life measures.
Accurate endoleak classification is essential following fenestrated endovascular aneurysm repair (f-EVAR). Both endoleak type and exact source of endoleak have implications upon the urgency and ...complexity of future management strategies. Herein we report on a patient with a documented endoleak post-f-EVAR, in which the source of blood flow into the aneurysm sac could not be determined using conventional computed tomographic angiography. Consequently, dynamic volumetric computed tomographic angiography (DV-CTA) was employed, which clearly illustrated the site of origin of the endoleak. DV-CTA enables accurate endoleak characterization following f-EVAR, with excellent conspicuity of the source of blood flow into the aneurysm sac.
To describe early experience with the use of iliac branch grafts (IBGs) in aortoiliac aneurysm repair.
From July 2007 to August 2009 (25 months), 14 patients (13 men, one woman) with a mean age of ...70.1 years (range, 59.3-80.0 y) were treated with IBGs. Indications were abdominal aneurysm with common iliac artery (CIA) involvement (n = 11), juxtarenal aortic aneurysm with CIA involvement (n = 1), and bilateral CIA and internal iliac artery (IIA) aneurysms (n = 1). Postoperative endoleaks and patency rate were determined with computed tomography within 1 month of implantation and 1 year thereafter, with concurrent clinical evaluation for pelvic ischemia. Mean follow-up period was 18.7 months (range, 6-35 mo).
Technical success rate, as defined by successful implantation of IBG with no intraprocedural type I or type III endoleak, was 86% (12 of 14). A total of 14 IBGs were successfully deployed in 12 patients. Two cases of technical failure were related to excessive iliac tortuosity. The mean hospitalization duration was 6.5 days (range, 3-14 d), with zero mortality at 30 days. There were two cases of type II endoleak treated conservatively and a single case of IBG-related type III endoleak that required repeat intervention. The rest of the stent-implanted aortic and iliac aneurysms remained stable in size, with no aneurysm rupture or death recorded. All stent-implanted iliac branches remained patent on follow-up. None of the patients who received IBGs had new symptoms of pelvic ischemia.
Iliac branch graft placement is a feasible technique with excellent short-term results in the treatment of aortoiliac aneurysms.
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