- Email: [email protected]
Re: ‘Long-term Outcomes and Sac Volume Shrinkage after Endovascular Popliteal Artery Aneurysm Repair (EVPAR)’
Correspondence
Response to ‘Re. Spontaneous Delayed Sealing in Selected Patients with a Primary Type-Ia Endoleak After Endovascular Aneurysm Repair’ We have become dependent on imaging to define the need for and timing of interventions after EVAR. Imaging, however, is not without limitations and patients at persistent risk of rupture may frequently be misidentified. Intermittent or position dependent type-I endoleaks are a good example of the situation where absence of endoleak on CTA may not be a perfect surrogate of success.1 In another publication, it was found that effective sealing in heavily thrombotic necks is possible as neck remodelling results in thrombus dissolution and complete graft-wall apposition in the mid-term. This occurred without any additional risk of rupture.2 However in the present study, the authors believe that thrombosis was not the reason why the primary endoleaks sealed spontaneously. The appropriate interpretation is different. Much has changed in the technology, planning and execution of EVAR since the consensus publication of 2002.3 In the case of appropriate evaluation of neck suitability, correct sizing and implantation, and consequently optimal sealing of the proximal endograft, immediate type-Ia endoleaks are most likely transitory. A watchful waiting period may be preferable to an aggressive strategy directed at immediate repair. In contrast to what is suggested, the authors defend the position that an unnecessary obsession with intra-operative correction of the picture may well result in the loss of a life. REFERENCES 1 May J, Harris JP. Intermittent, posture-dependent, and late endoleaks after endovascular aortic aneurysm repair. Semin Vasc Surg 2012;25(3):167e73. 2 Bastos Gonçalves F, Verhagen HJ, Chinsakchai K, van Keulen JW, Voûte MT, Zandvoort HJ, et al. The influence of neck thrombus on clinical outcome and aneurysm morphology after endovascular aneurysm repair. J Vasc Surg 2012;56(1):36e44. 3 Veith FFJ, Baum RA, Ohki T, Amor M, Adiseshiah M, Blankensteijn JD, et al. Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference. J Vasc Surg 2002;35:1029e35.
F. Bastos Gonçalves* Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands Department of Angiology and Vascular Surgery, Hospital de Santa Marta, CHLC, Lisbon, Portugal J.A. van Herwaarden, F.L. Moll Department of Vascular Surgery, Utrecht University Medical Centre, Utrecht, The Netherlands H.J.M. Verhagen Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands *Corresponding author. F. Bastos Gonçalves, Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
105
Email-address: [email protected] (F. Bastos Gonçalves) Available online 22 November 2014 Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2014.10.011 DOI of original article: http://dx.doi.org/10.1016/ j.ejvs.2014.09.015
Re: ‘Long-term Outcomes and Sac Volume Shrinkage after Endovascular Popliteal Artery Aneurysm Repair (EVPAR)’ I read the article by Piazza et al.1 with interest, as it seems clear that endovascular exclusion of popliteal artery aneurysms (PAAs) is here to stay. There are a few issues to be considered, though. Firstly, the suggested 20-mm threshold may be obsolescent given that papers recommend a wait-and-watch policy up to a 30-mm threshold, other considerations being thrombus burden, distal embolization, inflow, and outflow vessel angulation.2 Secondly, the authors indeed highlight the fact that less than three-vessel runoff is acceptable, an important issue that some surgeons think is a contraindication, and this is a welcome point. They indicate that they never deploy below the knee joint: the radiological knee joint and the actual line of knee flexion are two completely different areas. If their endografts all landed down to the radiological joint then the graft is still across the line of knee flexion, which is actually the inter-epicondylar line.3 We readily land the distal end of endografts into the below-knee popliteal arterial segment (“P3”) leaving enough for salvage bypass. As they are treating small PAAs then they likely gain the luxury of a distal neck, probably above the knee joint/flexion line (“P2”). They say nothing about their endovascular strategy for a large PAA that still has a good P3 segment to land in. However, complete deployment above the knee may lend itself to EVPAR even in younger, more active patients, something to consider in the future. Thirdly, while they effectively summarize that their first line is open surgical repair (OSR), issues like age and lifestyle are not commented on older, sedentary patients in whom our first approach would be EVPAR as a default, including synchronous bilateral approaches.4 At our centre, we have had experience with both flowmodulator stents5 and heparin-bonded endoprostheses (Viabahn, WL Gore & Associates, Inc., Medical Products Division, Flagstaff, AZ, USA) in the femoropopliteal segment in about 30 patients in the last 4 years, with results in the later group as promising as the authors suggest. Surveillance ought to be continued for at least 5 years if not indefinitely, given specific device issues in that they lack barb fixation (as opposed to AAA endografts) and are subject to the extreme stresses that are a default of the
106
Correspondence
femoropopliteal arterial segment. We have certainly noted Viabahn fracture at 3 years (effectively resulting in type IIIb endoleakage) in a 77-year-old who took up vigorous cycling post procedure. The issue of longer endograft lengths being a negative predictor of patency, remains open to question, as larger endografts are used in EVPAR in general, likely offsetting this aspect; the concerns from the occlusive scenario suggesting patency is length-related do not apply.6 The Viabahn is quite kink-resistant even at 90-degree knee flexion, but we certainly advise patients to avoid prolonged periods of hyperflexion, for example kneeling for a long time. Delayed PAA rupture as is known with OSR, is also not reported.7 The key messages from the paper of course are that EVPAR is technically successful from both deployment and patency aspects, and the shrinkage aspects demonstrated are indeed promising. However, it would still seem that the authors are being rather overselective in terms of how far they extend the endografts from an anatomical standpoint, and in whom they extend EVPAR to. REFERENCES 1 Piazza M, Menegolo M, Ferrari A, Bonvini S, Ricotta JJ, Frigatti P, et al. Long-term outcomes and sac volume shrinkage after endovascular popliteal artery aneurysm repair (EVPAR). Eur J Vasc Endovasc Surg 2014;48(2):161e8. 2 Galland RB, Magee TR. Popliteal aneurysms: distortion and size related to symptoms. Eur J Vasc Endovasc Surg 2005;30:534e8. 3 Smidt GL. Biomechanical analysis of knee flexion and extension. J Biomech 1973;6:79e80. 4 Chaudhuri A. Synchronous endobypass of bilateral superficial femoral artery aneurysms (after bilateral popliteal aneurysm bypass surgery) using heparin-bonded stent-grafts. Eur J Vasc Endovasc Surg Extra 2013;26(6):e58e60. 5 Thakar T, Chaudhuri A. Early experiences with the Multilayer Aneurysm Repair System in endovascular treatment of trans/ infrageniculate popliteal artery aneurysms: a mixed bag. J Endovasc Ther 2013;20:381e8. 6 Kuhan G, Abisi S, Braithwaite BD, MacSweeney STR, Whitaker SC, Habib SB. Early results with the use of heparinbonded stent graft to rescue failed angioplasty of chronic femoropopliteal occlusive lesions: TASC D lesions have a poor outcome. Cardiovasc Intervent Radiol 2012;35:1023e8. 7 Mehta M, Champagne B, Darling 3rd RC, Roddy SP, Kreienberg PB, Ozsvath KJ, et al. Outcome of popliteal artery aneurysms after exclusion and bypass: significance of residual patent branches mimicking type II endoleaks. J Vasc Surg 2004;40(5):886e90.
A. Chaudhuri Bedfordshire e Milton Keynes Vascular Centre, Bedford Hospital, Kempston Road, Bedford MK42 9DJ, UK Email-address: [email protected] Available online 6 December 2014 Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejvs.2014.10.024 DOI of original article: http://dx.doi.org/10.1016/ j.ejvs.2014.11.003
Re: ‘Re. Long-term Outcomes and Sac Volume Shrinkage After Endovascular Popliteal Artery Aneurysm Repair’ We would like to thank the author of the letter for his comments regarding our manuscript. We agree that the threshold for popliteal artery aneurysm (PAA) treatment from 2 cm in maximum diameter may still be controversial, but not an obsolescent issue; in 2011, a specific Trans-Atlantic debate on the appropriate management of small asymptomatic PAA (<3 cm.),1 still found authors in favor of repair. Recently Vrijenhoek et al.2 pointed to the important clinical consequences of small PAA. Other than that, we want to clarify that our study is not conducted on small PAA; as described in the text, the mean PAA diameter is 3.3 0.78 (range 2.0e5.7) with 85% of cases 3 cm (only 7 out of 46 cases between 2 and 3 cm). Regarding distal runoff, we have developed our policy over 15 years.3 Even if the primary choice is to have threevessel runoff, in a few selected cases at high surgical risk (n ¼ 2, 4%), we pushed the indication to one native tibial vessel with no disease and valid runoff at the foot. This last aspect is, in our opinion, as important as the number of patent tibial vessels. However, in cases with poor runoff, the gold standard is open surgery. We never stated throughout the text that we “never deploy below the knee joint”; all our endografts were in the below-knee popliteal artery (Table 3 in the original article). We said that “landing distally at the level of the knee joint was always avoided”; thus meaning that our distal landing zone was never in the point of knee flexion and that the endograft distal landing zone always extended beyond that point in the below-knee popliteal artery. Concerning patient selection, we avoid an endovascular approach in young patients (<50 years) or those with an active lifestyle (sports, gardening, activities requiring prolonged periods of knee hyperflexion); in older and sedentary patients we prefer an open approach if they are not high risk, have good saphenous vein or have poor runoff; if not, we prefer an endovascular approach in association to adequate antiplatelet therapy. The aim of this study was evaluate patency and efficacy of EVPAR on aneurysm sac exclusion over the long term; the satisfactory results obtained by this series are an expression, in our opinion, not of patient overselection, but of a careful evaluation of different issues to be considered in patient selection between open and endovascular repair during daily practice. REFERENCES 1 Cross JE, Galland RB, Hingorani A, Ascher E. Nonoperative versus surgical management of small (less than 3 cm), asymptomatic popliteal artery aneurysms. J Vasc Surg 2011;53(4):1145e8.
Response to ‘Re. Spontaneous Delayed Sealing in Selected Patients with a Primary Type-Ia Endoleak After Endovascular Aneurysm Repair’ We have become dependent on imaging to define the need for and timing of interventions after EVAR. Imaging, however, is not without limitations and patients at persistent risk of rupture may frequently be misidentified. Intermittent or position dependent type-I endoleaks are a good example of the situation where absence of endoleak on CTA may not be a perfect surrogate of success.1 In another publication, it was found that effective sealing in heavily thrombotic necks is possible as neck remodelling results in thrombus dissolution and complete graft-wall apposition in the mid-term. This occurred without any additional risk of rupture.2 However in the present study, the authors believe that thrombosis was not the reason why the primary endoleaks sealed spontaneously. The appropriate interpretation is different. Much has changed in the technology, planning and execution of EVAR since the consensus publication of 2002.3 In the case of appropriate evaluation of neck suitability, correct sizing and implantation, and consequently optimal sealing of the proximal endograft, immediate type-Ia endoleaks are most likely transitory. A watchful waiting period may be preferable to an aggressive strategy directed at immediate repair. In contrast to what is suggested, the authors defend the position that an unnecessary obsession with intra-operative correction of the picture may well result in the loss of a life. REFERENCES 1 May J, Harris JP. Intermittent, posture-dependent, and late endoleaks after endovascular aortic aneurysm repair. Semin Vasc Surg 2012;25(3):167e73. 2 Bastos Gonçalves F, Verhagen HJ, Chinsakchai K, van Keulen JW, Voûte MT, Zandvoort HJ, et al. The influence of neck thrombus on clinical outcome and aneurysm morphology after endovascular aneurysm repair. J Vasc Surg 2012;56(1):36e44. 3 Veith FFJ, Baum RA, Ohki T, Amor M, Adiseshiah M, Blankensteijn JD, et al. Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference. J Vasc Surg 2002;35:1029e35.
F. Bastos Gonçalves* Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands Department of Angiology and Vascular Surgery, Hospital de Santa Marta, CHLC, Lisbon, Portugal J.A. van Herwaarden, F.L. Moll Department of Vascular Surgery, Utrecht University Medical Centre, Utrecht, The Netherlands H.J.M. Verhagen Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands *Corresponding author. F. Bastos Gonçalves, Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
105
Email-address: [email protected] (F. Bastos Gonçalves) Available online 22 November 2014 Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2014.10.011 DOI of original article: http://dx.doi.org/10.1016/ j.ejvs.2014.09.015
Re: ‘Long-term Outcomes and Sac Volume Shrinkage after Endovascular Popliteal Artery Aneurysm Repair (EVPAR)’ I read the article by Piazza et al.1 with interest, as it seems clear that endovascular exclusion of popliteal artery aneurysms (PAAs) is here to stay. There are a few issues to be considered, though. Firstly, the suggested 20-mm threshold may be obsolescent given that papers recommend a wait-and-watch policy up to a 30-mm threshold, other considerations being thrombus burden, distal embolization, inflow, and outflow vessel angulation.2 Secondly, the authors indeed highlight the fact that less than three-vessel runoff is acceptable, an important issue that some surgeons think is a contraindication, and this is a welcome point. They indicate that they never deploy below the knee joint: the radiological knee joint and the actual line of knee flexion are two completely different areas. If their endografts all landed down to the radiological joint then the graft is still across the line of knee flexion, which is actually the inter-epicondylar line.3 We readily land the distal end of endografts into the below-knee popliteal arterial segment (“P3”) leaving enough for salvage bypass. As they are treating small PAAs then they likely gain the luxury of a distal neck, probably above the knee joint/flexion line (“P2”). They say nothing about their endovascular strategy for a large PAA that still has a good P3 segment to land in. However, complete deployment above the knee may lend itself to EVPAR even in younger, more active patients, something to consider in the future. Thirdly, while they effectively summarize that their first line is open surgical repair (OSR), issues like age and lifestyle are not commented on older, sedentary patients in whom our first approach would be EVPAR as a default, including synchronous bilateral approaches.4 At our centre, we have had experience with both flowmodulator stents5 and heparin-bonded endoprostheses (Viabahn, WL Gore & Associates, Inc., Medical Products Division, Flagstaff, AZ, USA) in the femoropopliteal segment in about 30 patients in the last 4 years, with results in the later group as promising as the authors suggest. Surveillance ought to be continued for at least 5 years if not indefinitely, given specific device issues in that they lack barb fixation (as opposed to AAA endografts) and are subject to the extreme stresses that are a default of the
106
Correspondence
femoropopliteal arterial segment. We have certainly noted Viabahn fracture at 3 years (effectively resulting in type IIIb endoleakage) in a 77-year-old who took up vigorous cycling post procedure. The issue of longer endograft lengths being a negative predictor of patency, remains open to question, as larger endografts are used in EVPAR in general, likely offsetting this aspect; the concerns from the occlusive scenario suggesting patency is length-related do not apply.6 The Viabahn is quite kink-resistant even at 90-degree knee flexion, but we certainly advise patients to avoid prolonged periods of hyperflexion, for example kneeling for a long time. Delayed PAA rupture as is known with OSR, is also not reported.7 The key messages from the paper of course are that EVPAR is technically successful from both deployment and patency aspects, and the shrinkage aspects demonstrated are indeed promising. However, it would still seem that the authors are being rather overselective in terms of how far they extend the endografts from an anatomical standpoint, and in whom they extend EVPAR to. REFERENCES 1 Piazza M, Menegolo M, Ferrari A, Bonvini S, Ricotta JJ, Frigatti P, et al. Long-term outcomes and sac volume shrinkage after endovascular popliteal artery aneurysm repair (EVPAR). Eur J Vasc Endovasc Surg 2014;48(2):161e8. 2 Galland RB, Magee TR. Popliteal aneurysms: distortion and size related to symptoms. Eur J Vasc Endovasc Surg 2005;30:534e8. 3 Smidt GL. Biomechanical analysis of knee flexion and extension. J Biomech 1973;6:79e80. 4 Chaudhuri A. Synchronous endobypass of bilateral superficial femoral artery aneurysms (after bilateral popliteal aneurysm bypass surgery) using heparin-bonded stent-grafts. Eur J Vasc Endovasc Surg Extra 2013;26(6):e58e60. 5 Thakar T, Chaudhuri A. Early experiences with the Multilayer Aneurysm Repair System in endovascular treatment of trans/ infrageniculate popliteal artery aneurysms: a mixed bag. J Endovasc Ther 2013;20:381e8. 6 Kuhan G, Abisi S, Braithwaite BD, MacSweeney STR, Whitaker SC, Habib SB. Early results with the use of heparinbonded stent graft to rescue failed angioplasty of chronic femoropopliteal occlusive lesions: TASC D lesions have a poor outcome. Cardiovasc Intervent Radiol 2012;35:1023e8. 7 Mehta M, Champagne B, Darling 3rd RC, Roddy SP, Kreienberg PB, Ozsvath KJ, et al. Outcome of popliteal artery aneurysms after exclusion and bypass: significance of residual patent branches mimicking type II endoleaks. J Vasc Surg 2004;40(5):886e90.
A. Chaudhuri Bedfordshire e Milton Keynes Vascular Centre, Bedford Hospital, Kempston Road, Bedford MK42 9DJ, UK Email-address: [email protected] Available online 6 December 2014 Ó 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejvs.2014.10.024 DOI of original article: http://dx.doi.org/10.1016/ j.ejvs.2014.11.003
Re: ‘Re. Long-term Outcomes and Sac Volume Shrinkage After Endovascular Popliteal Artery Aneurysm Repair’ We would like to thank the author of the letter for his comments regarding our manuscript. We agree that the threshold for popliteal artery aneurysm (PAA) treatment from 2 cm in maximum diameter may still be controversial, but not an obsolescent issue; in 2011, a specific Trans-Atlantic debate on the appropriate management of small asymptomatic PAA (<3 cm.),1 still found authors in favor of repair. Recently Vrijenhoek et al.2 pointed to the important clinical consequences of small PAA. Other than that, we want to clarify that our study is not conducted on small PAA; as described in the text, the mean PAA diameter is 3.3 0.78 (range 2.0e5.7) with 85% of cases 3 cm (only 7 out of 46 cases between 2 and 3 cm). Regarding distal runoff, we have developed our policy over 15 years.3 Even if the primary choice is to have threevessel runoff, in a few selected cases at high surgical risk (n ¼ 2, 4%), we pushed the indication to one native tibial vessel with no disease and valid runoff at the foot. This last aspect is, in our opinion, as important as the number of patent tibial vessels. However, in cases with poor runoff, the gold standard is open surgery. We never stated throughout the text that we “never deploy below the knee joint”; all our endografts were in the below-knee popliteal artery (Table 3 in the original article). We said that “landing distally at the level of the knee joint was always avoided”; thus meaning that our distal landing zone was never in the point of knee flexion and that the endograft distal landing zone always extended beyond that point in the below-knee popliteal artery. Concerning patient selection, we avoid an endovascular approach in young patients (<50 years) or those with an active lifestyle (sports, gardening, activities requiring prolonged periods of knee hyperflexion); in older and sedentary patients we prefer an open approach if they are not high risk, have good saphenous vein or have poor runoff; if not, we prefer an endovascular approach in association to adequate antiplatelet therapy. The aim of this study was evaluate patency and efficacy of EVPAR on aneurysm sac exclusion over the long term; the satisfactory results obtained by this series are an expression, in our opinion, not of patient overselection, but of a careful evaluation of different issues to be considered in patient selection between open and endovascular repair during daily practice. REFERENCES 1 Cross JE, Galland RB, Hingorani A, Ascher E. Nonoperative versus surgical management of small (less than 3 cm), asymptomatic popliteal artery aneurysms. J Vasc Surg 2011;53(4):1145e8.