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Five Years Results of Aortic Arch Debranching
JOURNAL OF VASCULAR SURGERY Volume 57, Number 5S
Abstracts 23S
Results: There were 390 patients (75%) with JRA/ PRAs considered potential candidates for the two devices. Proximal seal (>15 mm) could be achieved in all patients using p-BranchÔ and in 61% of the patients using VentanaÔ stent-graft (P < .0001). The ability to incorporate visceral arteries (Fig) was greater using VentanaÔ (90%) compared to p-BranchÔ (61%; P < .0001) design. Less than a third of patients met strict IFU criteria for using VentanaÔ (25%) or p-BranchÔ (32%; P < .05) devices. Using liberal IFU criteria, 42% of patients were candidates for VentanaÔ and 49% for p-BranchÔ (P < .03). Overall 63% of the patients with JRA/PRAs were candidates for endovascular repair using one of the two devices. Conclusions: p-BranchÔ design has greater anatomical feasibility and achieves proximal seal in all patients with JRA/PRAs, but is not able to incorporate visceral arteries in 40% of patients. VentanaÔ design allows incorporation of the visceral arteries in 90% of patients, but fails to provide sufficient seal in 40%. Nearly 40% of JRA/PRAs do not meet anatomical criteria for endovascular repair using one the two devices, justifying need for additional designs.
showed a relative increase of active-MMP-2 (62kD) in media from AAA-SMC. AAA-SMC demonstrated 2 fold greater expression of MMP-2 mRNA (P < .05) and 7.3 fold greater MMP-9 expression (P < .01) than NAA-SMC. Culture with activated U937 monocytes led to a synergistic increase in elastolytic activity by AAA-SMC (41%; P < .001). This effect was not apparent in NAA or CEA co-cultures (P ¼ .99). Coculture with U937 led to a large increase in MMP-9 mRNA in both AAA and NAA-SMC (P < .001). MMP-2 mRNA expression was not affected. Western blots of conditioned media showed increased MMP-9 (92 kD) protein secretion by AAA-SMC/U937 cultures which was approximately 4fold greater than NAA-SMC/U937 (P < .001). AAASMC/U937 co-cultures also exhibited a large increase in active-MMP2 (62 kD) in conditioned media, an effect which was much less apparent in NAA/U937 media (P < .01). Conclusions: AAA-SMC exhibit a unique gene expression pattern and have a pro-elastolytic phenotype that is augmented by macrophages. This may occur via a failure of post-transcriptional control of MMP-9 protein synthesis, leading to increased production and activation of elastolytic MMPs.
Author Disclosures: T. C. Bower: Nothing to disclose; S. Cha: Nothing to disclose; A. A. Duncan: Nothing to disclose; M. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; M. Kalra: Nothing to disclose; T. Macedo: Nothing to disclose; B. Mendes: Nothing to disclose; G. S. Oderich: Cook Medical Inc, Consulting fees or other remuneration (payment) WL Gore, Consulting fees or other remuneration (payment)
Author Disclosures: N. D. Airhart: Nothing to disclose; B. Arif: Nothing to disclose; B. Brownstein: Nothing to disclose; P. Cobb: Nothing to disclose; J. A. Curci: Nothing to disclose; T. Ennis: Nothing to disclose; W. Schierding: Nothing to disclose; R. Thompson: Nothing to disclose.
S2: SVS Plenary Session II SS6.
SS5. SVS Foundation Resident Research Prize Paper Smooth Muscle Cells from Abdominal Aortic Aneurysms Are Unique and Can Independently and Synergistically Degrade Insoluble Elastin Nathan D. Airhart, Bernard Brownstein, William Schierding, Perren Cobb, Batool Arif, Terri Ennis, Robert Thompson, John A. Curci. Surgery, Washington University School of Medicine, St Louis, Mo Objectives: The purpose of this study was to further elucidate the role of the vascular smooth muscle cell (SMC) in abdominal aortic aneurysm (AAA) disease. Our hypothesis is that AAA-SMC are unique and actively participate in the process of degrading the aortic matrix. Methods: Using microarray, we compared wholegenome expression profiles of SMC from AAA, normal abdominal aorta (NAA) and carotid endarterectomy (CEA). We quantified elastolytic activity by culturing SMC in [3H] elastin-coated plates and measuring solubilized tritium in the media after 7 days. MMP-2 and MMP-9 production was assessed using real-time PCR, zymography and western blotting. Results: Unique gene expression patterns were observed for each SMC type. Under basal conditions, AAA-SMC had much greater elastolytic activity than NAA (+68%; P < .001) and CEA-SMC (+45%; P < .001). Zymography
Five Years Results of Aortic Arch Debranching Paola De Rango2, Ciro Ferrer1, Carlo Coscarella1, Gioele Simonte2, Enrico Cieri2, Luca Farchioni2, Fabio Verzini2, Gianbattista Parlani2, Piergiorgio Cao1. 1Vascular Surgery, Hospital S Camillo Forlanini, Rome, Italy; 2 Vascular and Endovascular Surgery; University of Perugia, Hospital S.M.Misericordia, Perugia, Italy Objectives: To evaluate early and five years results of partial or total arch debranching. Methods: In 2001-2012, 100 consecutive patients underwent elective hybrid arch repair with debranching and stentgraft (TEVAR). Outcomes were stratified for extension of arch involvement. Primary outcomes were perioperative (30-day) and five years mortality. Results: Mean patients age was 70.1years and 88 were males. 16 arches were repaired for dissection. Twenty patients required total debranching for diseases extended to Zone-0. In 55, debranching and TEVAR procedures were staged. At 30-day, death, stroke and paraplegia occurred in 6, 4 and 3 patients respectively. In 80, requiring partial debranching, the same outcome rates were 2.5%, 3.8% and 2.5%, respectively. In patients with dissections, there was no death, paraplegia or stroke. Extension to ascending aorta requiring total arch debranching was the only multivariate independent predictor for mortality (odds ratio, 11.4; 95% Confidence Interval 1.91-68.4; P ¼ .008), but not for stroke or paraplegia. One retrograde dissection with successful repair, occurred after total debranching. Kaplan-Meier
JOURNAL OF VASCULAR SURGERY May Supplement 2013
24S Abstracts
estimates of survival at 1, 3 and 5-years were 85.8%, 81.4% and 69.7%. Two reinterventions for endoleak were required and no migration or late aneurysm related mortality was recorded. Conclusions: The incidence of stroke is acceptable after both total and partial arch debranching. Total debranching is an important predictor for mortality. Retrograde dissection may be infrequent complication with careful arch approach. After the perioperative interval, debranching is a safe and durable procedure up to 5 years. Author Disclosures: P. Cao: Nothing to disclose; E. Cieri: Nothing to disclose; C. Coscarella: Nothing to disclose; P. De Rango: Nothing to disclose; L. Farchioni: Nothing to disclose; C. Ferrer: Nothing to disclose; G. Parlani: Nothing to disclose; G. Simonte: Nothing to disclose; F. Verzini: Nothing to disclose. SS7. Eligiblity for Endovascular Repair of Short Neck Abdominal Aortic Aneurysms Tina M. Morrison1, Clark A. Meyer1, Mark F. Fillinger2, Ron M. Fairman3, Marc H. Glickman4, Richard P. Cambria5, Mark A. Farber6, Thomas C. Naslund7, Peter S. Fail8, James R. Elmore9, Rodney A. White10, Carlo A. Dall’Olmo11, David M. Williams12. 1Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md; 2Dartmouth Hitchcock Medical Center, Lebanon, NH; 3University of Pennsylvania Medical Center, Philadelphia, Pa; 4Sentara Norfolk General Hospital, Norfolk, Va; 5Massachusetts General Hospital, Boston, Mass; 6University of North Carolina Medical Center, Chapel Hill, NC; 7Vanderbilt Medical Center, Nashville, Tenn; 8Cardiovascular Institute of the South, Houma, La; 9 Geisinger Medical Center, Danville, Pa; 10Harbor UCLA Medical Center; Los Angeles, Calif; 11Michigan Vascular Center, Flint, Mich; 12University of Michigan Medical Center, Ann Arbor, Mich Objectives: Using the CHAP database of nearly 10,000 patients nationwide, we examined eligibility for EVAR in patients with a short neck AAA (snAAA), where the neck length < 10 mm, and identified the anatomic parameters driving endograft (EVG) ineligibility. Methods: Preoperative CT scans from eleven US clinical sites were prospectively entered into a database from 7/96 to 11/12. A blinded third-party, M2S, recorded standardized measurements from the 3D reconstructions. Two currently marketed EVG in the US are labeled to treat snAAA, with neck angulation #45 deg and neck lengths
$4 mm (Cook Fenestrated) and >7 mm (Trivascular Ovation). The EVAR criteria were analyzed in 2245 men (M) and 1079 women (W) with snAAA. Results: Of the 9848 AAAs, 3324 have snAAA (34%). Even if iliac and access criteria are excluded, EVAR eligibility for snAAA is at most 45%. In snAAA >5 cm diameter, neck angulation is 48 deg for women and 37 deg for men (P < .01). Women are more likely to have neck length < 4 mm and neck angulation > 45 deg (risk ratio is 90). Only 6% of patients are eligible for both EVG. Larger AAAs are not less likely to be eligible for fenestrated EVAR (Table; P ¼ NS). Conclusions: One-third of AAAs have a short neck, and less than half of these are eligible for current EVG, even with a fenestrated option. Neck angulation and length continue to challenge EVAR eligibility, especially for women. Eligibility for EVAR does not lessen as aneurysms enlarge, so there is no indication for early repair. Author Disclosures: R. P. Cambria: Nothing to disclose; C. A. Dall’Olmo: Nothing to disclose; J. R. Elmore: Nothing to disclose; P. S. Fail: Nothing to disclose; R. M. Fairmain: Nothing to disclose; M. A. Farber: Nothing to disclose; M. F. Fillinger: Nothing to disclose; M. H. Glickman: Nothing to disclose; C. A. Meyer: Nothing to disclose; T. M. Morrison: Nothing to disclose; T. C. Naslund: Paid consultant (Data Monitoring Committee) CVRx, Paid consultant (Clinical Events Committee) WL Gore, Paid educator Cook Medical; R. A. White: Nothing to disclose; D. M. Williams: Nothing to disclose.
VS2. Video Presentation Percutaneous Endovascular Repair of Aortoiliac Aneurysm Using Iliac Branch Device Mateus P. Correa, Gustavo S. Oderich. Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn Background: Exclusion of one or both internal iliac arteries (IIA) during endovascular aortic aneurysm repair (EVAR) has been associated with a predictable rate of pelvic ischemic complications. We present the preoperative planning and technique of implantation of Iliac Branch Device (IBD, Cook Inc., Brisbane, Australia) in a patient with bilateral common iliac artery (CIA) aneurysms using total percutaneous approach. Technical Description: Computed tomography angiography (CTA) was used to determine measurements
Table. Eligibility for two marketed EVGs excluding iliac and access criteria; median (10th-90th percentile) values of anatomic parameters snAAA < 5 cm
Cook fenestrated, % Trivascular ovation, % Neck length, mm Neck angulation, deg Neck diameter, mm
snAAA $ 5 cm
snAAA > 5.5 cm
snAAA > 6.5 cm
M (512)
W (324)
M (1733)
W (755)
M (1152)
W (437)
M (465)
W (154)
44 24 6 (3-9) 31 (16-55) 24 (26-35)
44 10 5 (2-9) 38 (18-63) 23 (18-34)
42 16 6 (2-9) 37 (18-61) 25 (20-97)
45 7 5 (2-9) 48 (25-74) 24 (19-37)
45 14 6 (2 9) 39 (19 64) 25 (21 38)
45 6 5 (2-9) 51 (28-77) 24 (19-39)
45 18 5 (2 9) 43 (20 67) 26 (21 41)
43 3 4 (1-8) 57 (32-81) 24 (19-42)
Abstracts 23S
Results: There were 390 patients (75%) with JRA/ PRAs considered potential candidates for the two devices. Proximal seal (>15 mm) could be achieved in all patients using p-BranchÔ and in 61% of the patients using VentanaÔ stent-graft (P < .0001). The ability to incorporate visceral arteries (Fig) was greater using VentanaÔ (90%) compared to p-BranchÔ (61%; P < .0001) design. Less than a third of patients met strict IFU criteria for using VentanaÔ (25%) or p-BranchÔ (32%; P < .05) devices. Using liberal IFU criteria, 42% of patients were candidates for VentanaÔ and 49% for p-BranchÔ (P < .03). Overall 63% of the patients with JRA/PRAs were candidates for endovascular repair using one of the two devices. Conclusions: p-BranchÔ design has greater anatomical feasibility and achieves proximal seal in all patients with JRA/PRAs, but is not able to incorporate visceral arteries in 40% of patients. VentanaÔ design allows incorporation of the visceral arteries in 90% of patients, but fails to provide sufficient seal in 40%. Nearly 40% of JRA/PRAs do not meet anatomical criteria for endovascular repair using one the two devices, justifying need for additional designs.
showed a relative increase of active-MMP-2 (62kD) in media from AAA-SMC. AAA-SMC demonstrated 2 fold greater expression of MMP-2 mRNA (P < .05) and 7.3 fold greater MMP-9 expression (P < .01) than NAA-SMC. Culture with activated U937 monocytes led to a synergistic increase in elastolytic activity by AAA-SMC (41%; P < .001). This effect was not apparent in NAA or CEA co-cultures (P ¼ .99). Coculture with U937 led to a large increase in MMP-9 mRNA in both AAA and NAA-SMC (P < .001). MMP-2 mRNA expression was not affected. Western blots of conditioned media showed increased MMP-9 (92 kD) protein secretion by AAA-SMC/U937 cultures which was approximately 4fold greater than NAA-SMC/U937 (P < .001). AAASMC/U937 co-cultures also exhibited a large increase in active-MMP2 (62 kD) in conditioned media, an effect which was much less apparent in NAA/U937 media (P < .01). Conclusions: AAA-SMC exhibit a unique gene expression pattern and have a pro-elastolytic phenotype that is augmented by macrophages. This may occur via a failure of post-transcriptional control of MMP-9 protein synthesis, leading to increased production and activation of elastolytic MMPs.
Author Disclosures: T. C. Bower: Nothing to disclose; S. Cha: Nothing to disclose; A. A. Duncan: Nothing to disclose; M. Fleming: Nothing to disclose; P. Gloviczki: Nothing to disclose; M. Kalra: Nothing to disclose; T. Macedo: Nothing to disclose; B. Mendes: Nothing to disclose; G. S. Oderich: Cook Medical Inc, Consulting fees or other remuneration (payment) WL Gore, Consulting fees or other remuneration (payment)
Author Disclosures: N. D. Airhart: Nothing to disclose; B. Arif: Nothing to disclose; B. Brownstein: Nothing to disclose; P. Cobb: Nothing to disclose; J. A. Curci: Nothing to disclose; T. Ennis: Nothing to disclose; W. Schierding: Nothing to disclose; R. Thompson: Nothing to disclose.
S2: SVS Plenary Session II SS6.
SS5. SVS Foundation Resident Research Prize Paper Smooth Muscle Cells from Abdominal Aortic Aneurysms Are Unique and Can Independently and Synergistically Degrade Insoluble Elastin Nathan D. Airhart, Bernard Brownstein, William Schierding, Perren Cobb, Batool Arif, Terri Ennis, Robert Thompson, John A. Curci. Surgery, Washington University School of Medicine, St Louis, Mo Objectives: The purpose of this study was to further elucidate the role of the vascular smooth muscle cell (SMC) in abdominal aortic aneurysm (AAA) disease. Our hypothesis is that AAA-SMC are unique and actively participate in the process of degrading the aortic matrix. Methods: Using microarray, we compared wholegenome expression profiles of SMC from AAA, normal abdominal aorta (NAA) and carotid endarterectomy (CEA). We quantified elastolytic activity by culturing SMC in [3H] elastin-coated plates and measuring solubilized tritium in the media after 7 days. MMP-2 and MMP-9 production was assessed using real-time PCR, zymography and western blotting. Results: Unique gene expression patterns were observed for each SMC type. Under basal conditions, AAA-SMC had much greater elastolytic activity than NAA (+68%; P < .001) and CEA-SMC (+45%; P < .001). Zymography
Five Years Results of Aortic Arch Debranching Paola De Rango2, Ciro Ferrer1, Carlo Coscarella1, Gioele Simonte2, Enrico Cieri2, Luca Farchioni2, Fabio Verzini2, Gianbattista Parlani2, Piergiorgio Cao1. 1Vascular Surgery, Hospital S Camillo Forlanini, Rome, Italy; 2 Vascular and Endovascular Surgery; University of Perugia, Hospital S.M.Misericordia, Perugia, Italy Objectives: To evaluate early and five years results of partial or total arch debranching. Methods: In 2001-2012, 100 consecutive patients underwent elective hybrid arch repair with debranching and stentgraft (TEVAR). Outcomes were stratified for extension of arch involvement. Primary outcomes were perioperative (30-day) and five years mortality. Results: Mean patients age was 70.1years and 88 were males. 16 arches were repaired for dissection. Twenty patients required total debranching for diseases extended to Zone-0. In 55, debranching and TEVAR procedures were staged. At 30-day, death, stroke and paraplegia occurred in 6, 4 and 3 patients respectively. In 80, requiring partial debranching, the same outcome rates were 2.5%, 3.8% and 2.5%, respectively. In patients with dissections, there was no death, paraplegia or stroke. Extension to ascending aorta requiring total arch debranching was the only multivariate independent predictor for mortality (odds ratio, 11.4; 95% Confidence Interval 1.91-68.4; P ¼ .008), but not for stroke or paraplegia. One retrograde dissection with successful repair, occurred after total debranching. Kaplan-Meier
JOURNAL OF VASCULAR SURGERY May Supplement 2013
24S Abstracts
estimates of survival at 1, 3 and 5-years were 85.8%, 81.4% and 69.7%. Two reinterventions for endoleak were required and no migration or late aneurysm related mortality was recorded. Conclusions: The incidence of stroke is acceptable after both total and partial arch debranching. Total debranching is an important predictor for mortality. Retrograde dissection may be infrequent complication with careful arch approach. After the perioperative interval, debranching is a safe and durable procedure up to 5 years. Author Disclosures: P. Cao: Nothing to disclose; E. Cieri: Nothing to disclose; C. Coscarella: Nothing to disclose; P. De Rango: Nothing to disclose; L. Farchioni: Nothing to disclose; C. Ferrer: Nothing to disclose; G. Parlani: Nothing to disclose; G. Simonte: Nothing to disclose; F. Verzini: Nothing to disclose. SS7. Eligiblity for Endovascular Repair of Short Neck Abdominal Aortic Aneurysms Tina M. Morrison1, Clark A. Meyer1, Mark F. Fillinger2, Ron M. Fairman3, Marc H. Glickman4, Richard P. Cambria5, Mark A. Farber6, Thomas C. Naslund7, Peter S. Fail8, James R. Elmore9, Rodney A. White10, Carlo A. Dall’Olmo11, David M. Williams12. 1Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Md; 2Dartmouth Hitchcock Medical Center, Lebanon, NH; 3University of Pennsylvania Medical Center, Philadelphia, Pa; 4Sentara Norfolk General Hospital, Norfolk, Va; 5Massachusetts General Hospital, Boston, Mass; 6University of North Carolina Medical Center, Chapel Hill, NC; 7Vanderbilt Medical Center, Nashville, Tenn; 8Cardiovascular Institute of the South, Houma, La; 9 Geisinger Medical Center, Danville, Pa; 10Harbor UCLA Medical Center; Los Angeles, Calif; 11Michigan Vascular Center, Flint, Mich; 12University of Michigan Medical Center, Ann Arbor, Mich Objectives: Using the CHAP database of nearly 10,000 patients nationwide, we examined eligibility for EVAR in patients with a short neck AAA (snAAA), where the neck length < 10 mm, and identified the anatomic parameters driving endograft (EVG) ineligibility. Methods: Preoperative CT scans from eleven US clinical sites were prospectively entered into a database from 7/96 to 11/12. A blinded third-party, M2S, recorded standardized measurements from the 3D reconstructions. Two currently marketed EVG in the US are labeled to treat snAAA, with neck angulation #45 deg and neck lengths
$4 mm (Cook Fenestrated) and >7 mm (Trivascular Ovation). The EVAR criteria were analyzed in 2245 men (M) and 1079 women (W) with snAAA. Results: Of the 9848 AAAs, 3324 have snAAA (34%). Even if iliac and access criteria are excluded, EVAR eligibility for snAAA is at most 45%. In snAAA >5 cm diameter, neck angulation is 48 deg for women and 37 deg for men (P < .01). Women are more likely to have neck length < 4 mm and neck angulation > 45 deg (risk ratio is 90). Only 6% of patients are eligible for both EVG. Larger AAAs are not less likely to be eligible for fenestrated EVAR (Table; P ¼ NS). Conclusions: One-third of AAAs have a short neck, and less than half of these are eligible for current EVG, even with a fenestrated option. Neck angulation and length continue to challenge EVAR eligibility, especially for women. Eligibility for EVAR does not lessen as aneurysms enlarge, so there is no indication for early repair. Author Disclosures: R. P. Cambria: Nothing to disclose; C. A. Dall’Olmo: Nothing to disclose; J. R. Elmore: Nothing to disclose; P. S. Fail: Nothing to disclose; R. M. Fairmain: Nothing to disclose; M. A. Farber: Nothing to disclose; M. F. Fillinger: Nothing to disclose; M. H. Glickman: Nothing to disclose; C. A. Meyer: Nothing to disclose; T. M. Morrison: Nothing to disclose; T. C. Naslund: Paid consultant (Data Monitoring Committee) CVRx, Paid consultant (Clinical Events Committee) WL Gore, Paid educator Cook Medical; R. A. White: Nothing to disclose; D. M. Williams: Nothing to disclose.
VS2. Video Presentation Percutaneous Endovascular Repair of Aortoiliac Aneurysm Using Iliac Branch Device Mateus P. Correa, Gustavo S. Oderich. Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn Background: Exclusion of one or both internal iliac arteries (IIA) during endovascular aortic aneurysm repair (EVAR) has been associated with a predictable rate of pelvic ischemic complications. We present the preoperative planning and technique of implantation of Iliac Branch Device (IBD, Cook Inc., Brisbane, Australia) in a patient with bilateral common iliac artery (CIA) aneurysms using total percutaneous approach. Technical Description: Computed tomography angiography (CTA) was used to determine measurements
Table. Eligibility for two marketed EVGs excluding iliac and access criteria; median (10th-90th percentile) values of anatomic parameters snAAA < 5 cm
Cook fenestrated, % Trivascular ovation, % Neck length, mm Neck angulation, deg Neck diameter, mm
snAAA $ 5 cm
snAAA > 5.5 cm
snAAA > 6.5 cm
M (512)
W (324)
M (1733)
W (755)
M (1152)
W (437)
M (465)
W (154)
44 24 6 (3-9) 31 (16-55) 24 (26-35)
44 10 5 (2-9) 38 (18-63) 23 (18-34)
42 16 6 (2-9) 37 (18-61) 25 (20-97)
45 7 5 (2-9) 48 (25-74) 24 (19-37)
45 14 6 (2 9) 39 (19 64) 25 (21 38)
45 6 5 (2-9) 51 (28-77) 24 (19-39)
45 18 5 (2 9) 43 (20 67) 26 (21 41)
43 3 4 (1-8) 57 (32-81) 24 (19-42)