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Safety and Effectiveness of a “Percutaneous-First” Approach to Endovascular Aortic Aneurysm Repair
JOURNAL OF VASCULAR SURGERY Volume 62, Number 3
Abstracts 817
Results: TEVAR patients with FLE experienced a significantly lower 30-day mortality (2.5% vs 15.2%; P < .001) and better 5-year survival (9.6% vs 21.2%; P < .01) compared with TEVAR patients without FLE. Spinal cord ischemic complications occurred in one of the TEVAR without FLE patients (1.5%) and in none of the TEVAR with FLE patients (0%). The incidence of nonfatal complications was comparable in both cohorts. After TEVAR and FLE, nine patients (22.5%) underwent subsequent FLE for persistent false lumen flow. One patient with aortoiliac dissection developed complications of transient cauda equina syndrome that was successfully treated with infrarenal aortoiliac septotomy. All FLE patients were noted to have a significant reduction in false lumen-to-systemic pressure indices, and there were no thoracic or abdominal aortic ruptures, conversions to open surgical repair, or deaths. Conclusions: FLE during TEVAR for complicated acute and chronic TAD is associated with a lower 30-day mortality and improved long-term survival. Nearly one-fourth of patients require secondary FLE procedures. These initial findings would suggest that the adjunctive FLE technique should be considered when managing complicated aortic dissections.
Fig. Compliance. imaging over 6 months. A Kaplan-Meier analysis was used to compare compliance rates in EVAR patients with hostile neck (HN) vs favorable neck (FN) anatomy according to the instructions for use (IFU). A multivariate analysis was also done to correlate compliance and comorbidities. Results: Forty-three percent were compliant (7% had no follow-up imaging) and 57% were NC. The mean follow-up for compliant patients was 25.4 months (range, 0-119 months) vs 31.4 months for NC patients (range, 0-140 months). The mean number of imaging was 3.5 for compliant vs 2.6 for NC (P < .0001). Sixty-four percent were NC for HN patients vs 50% for FN patients (P ¼ .0007). The rates of compliance at 1, 2, 3, 4, and 5 years for all patients were 78%, 63%, 55%, 45%, and 32%; 84%, 68%, 61%, 54%, and 40% for FN patients; and 73%, 57%, 48%, 37%, and 25% for HN patients (P ¼ .009, Fig). The NC rate for patients with late endoleak/sac expansion was 58% vs 54% for patients with no endoleak (P ¼ .51). The NC rate for patients with late reintervention was 70% vs 54% for patients with no reintervention (P ¼ .1254). Multivariate analysis showed that patients with comorbidities (peripheral arterial disease and carotid disease; odds ratio, 2; P ¼ .0318) and HN patients (odds ratio, 1.8; P ¼ .0007) were risk factors for NC. Age was not a factor in compliance. Conclusions: Overall, compliance of PEIS was low, particularly in HN EVAR patients, and caution should be used in using EVAR in certain patients. Author Disclosures: A. F. AbuRahma: None; M. Yacoub: None; S. M. Hass: None; S. Abu-Halimah: None; J. AbuRahma: None; A. Y. Mousa: None; L. S. Dean: None; R. Viradia: None; M. Srivastava: None; P. A. Stone: None. False Lumen Embolization During TEVAR for Complicated Aortic Dissections Is Associated With a Lower 30-Day Mortality and Improved Long-Term Survival Manish Mehta1, Philip S. K. Paty1, Humayun Bhaghtwar2, Kamran Jafree2, Jason Comeau2, Gary Sisken3, Benjamin Chang2, Paul Feustel4. 1Vascular Health Partners, CCP, Glens Falls, NY; 2The Vacular Group, The Institute for Vascular Health and Disease, Albany, NY; 3Community Care Physicians, Albany, NY, Albany Medical College, Albany, NY; 4Albany Medical College, Albany, NY Objectives: This study evaluated the implications of false lumen embolization (FLE) to induce thrombosis during thoracic endovascular aneurysm repair (TEVAR) for complicated acute and chronic thoracic aortic dissections (TAD). Methods: Since 2004, 104 patients with complicated acute and chronic TAD underwent TEVAR with FLE (40 [37.7%]) or without FLE (66 [62.3%]) during the initial procedure. The embolic agents included Amplatz plugs and coils. Data were prospectively collected and analyzed for 30-day and long-term mortality, spinal cord ischemic complications, other nonfatal complications, and the need for secondary interventions.
Author Disclosures: M. Mehta: Honoraria; W. L. Gore, TriVascular Inc, Aptus Endosystems, Endologix, and Medtronic Inc, speaking agreement; other financial benefit, W. L. Gore, Medtronic, Bolton Medical, Silkroad Medical, Abbott Vascular, National Institutes of Health, Aptus Endosystems, TriVascular, Terumo, Boston Scientific, principal investigator clinical trials; P. S. K. Paty: Other financial benefit, W. L. Gore, Medtronic, Bolton Medical, Silkroad Medical, Abbott Vascular, National Institutes of Health, Aptus Endosystems, TriVascular, Terumo, and Boston Scientific, sub-investigator clinical trials; H. Bhaghtwar: None; K. Jafree: None; J. Comeau: None; G. Sisken: None; B. Chang: None; P. Feustel: None. Safety and Effectiveness of a “Percutaneous-First” Approach to Endovascular Aortic Aneurysm Repair Chris Agrusa, MD, Andrew Meltzer, MD, Darren Schneider, MD, Peter Connolly, MD. New York Presbyterian, New York, NY Objectives: Percutaneous endovascular aneurysm repair (PEVAR) has been increasingly used in the endovascular treatment of abdominal aortic aneurysms. The purpose of this study was to assess the safety and effectiveness of a “percutaneous-first” approach to femoral access for EVAR. Methods: From 2012 to 2014, PEVAR was the preferred approach to femoral access for EVAR at our institution. Retrospective review of institutional vascular quality initiative data was used to compare outcomes with PEVAR to a contemporary institutional series of EVAR via open femoral exposure. Matched cohort comparison was used to assess perioperative outcomes, procedural details, including anesthesia modality, surgical time, length of stay (LOS), and access-related complications between groups. Results: A total of 105 consecutive patients underwent attempted PEVAR and were compared with 98 patients undergoing surgical femoral exposure. Demographics and comorbidities were similar between cohorts. PEVAR was associated with an increased use of local anesthesia (67.6% vs 12.2%; P < .001). PEVAR was associated with shorter postoperative LOS (mean, 1.59 vs 3.08 days; P ¼ .044), shorter procedure times (139 vs 222 minutes; P < .001), and significantly less blood loss (176 vs 481 mL; P < .001). There were 11 access site complications (10%) in the PEVAR group, with five (4.8%) requiring conversion to open femoral exposure, compared with three patients (3.1%) with access-related complications after open femoral exposure (P < .001). There were no significant differences in wound infection, intensive care unit LOS, or access site morphology on postoperative computed tomography scan. Conclusions: A PEVAR-first approach proved feasible in the overwhelming majority of patients. Conversion to open transfemoral exposure was rare. PEVAR facilitated endovascular abdominal aortic aneurysm repair under local anesthesia in the majority of patients and resulted in decreased procedural morbidity and resource utilization. Author Disclosures: C. Agrusa: None; A. Meltzer: None; D. Schneider: None; P. Connolly: None. Patient Factors and Hospital Open Experience Predominate Outcomes After AAA Repair Caitlin W. Hicks, MD, MS, Joseph K. Canner, MHS, Isibor Arhuidese, MD, MPH, Umair Qazi, MD, MPH, Tammam Obeid, MD, James H. Black III, MD, Mahmoud B. Malas, MD, MHS. Johns Hopkins Hospital, Baltimore, Md Objectives: Patient-level factors affecting outcomes after open (OAR) and endovascular (EVAR) abdominal aortic aneurysm (AAA) repair are well described. We aim to describe hospital-level factors affecting mortality after AAA repair.
Abstracts 817
Results: TEVAR patients with FLE experienced a significantly lower 30-day mortality (2.5% vs 15.2%; P < .001) and better 5-year survival (9.6% vs 21.2%; P < .01) compared with TEVAR patients without FLE. Spinal cord ischemic complications occurred in one of the TEVAR without FLE patients (1.5%) and in none of the TEVAR with FLE patients (0%). The incidence of nonfatal complications was comparable in both cohorts. After TEVAR and FLE, nine patients (22.5%) underwent subsequent FLE for persistent false lumen flow. One patient with aortoiliac dissection developed complications of transient cauda equina syndrome that was successfully treated with infrarenal aortoiliac septotomy. All FLE patients were noted to have a significant reduction in false lumen-to-systemic pressure indices, and there were no thoracic or abdominal aortic ruptures, conversions to open surgical repair, or deaths. Conclusions: FLE during TEVAR for complicated acute and chronic TAD is associated with a lower 30-day mortality and improved long-term survival. Nearly one-fourth of patients require secondary FLE procedures. These initial findings would suggest that the adjunctive FLE technique should be considered when managing complicated aortic dissections.
Fig. Compliance. imaging over 6 months. A Kaplan-Meier analysis was used to compare compliance rates in EVAR patients with hostile neck (HN) vs favorable neck (FN) anatomy according to the instructions for use (IFU). A multivariate analysis was also done to correlate compliance and comorbidities. Results: Forty-three percent were compliant (7% had no follow-up imaging) and 57% were NC. The mean follow-up for compliant patients was 25.4 months (range, 0-119 months) vs 31.4 months for NC patients (range, 0-140 months). The mean number of imaging was 3.5 for compliant vs 2.6 for NC (P < .0001). Sixty-four percent were NC for HN patients vs 50% for FN patients (P ¼ .0007). The rates of compliance at 1, 2, 3, 4, and 5 years for all patients were 78%, 63%, 55%, 45%, and 32%; 84%, 68%, 61%, 54%, and 40% for FN patients; and 73%, 57%, 48%, 37%, and 25% for HN patients (P ¼ .009, Fig). The NC rate for patients with late endoleak/sac expansion was 58% vs 54% for patients with no endoleak (P ¼ .51). The NC rate for patients with late reintervention was 70% vs 54% for patients with no reintervention (P ¼ .1254). Multivariate analysis showed that patients with comorbidities (peripheral arterial disease and carotid disease; odds ratio, 2; P ¼ .0318) and HN patients (odds ratio, 1.8; P ¼ .0007) were risk factors for NC. Age was not a factor in compliance. Conclusions: Overall, compliance of PEIS was low, particularly in HN EVAR patients, and caution should be used in using EVAR in certain patients. Author Disclosures: A. F. AbuRahma: None; M. Yacoub: None; S. M. Hass: None; S. Abu-Halimah: None; J. AbuRahma: None; A. Y. Mousa: None; L. S. Dean: None; R. Viradia: None; M. Srivastava: None; P. A. Stone: None. False Lumen Embolization During TEVAR for Complicated Aortic Dissections Is Associated With a Lower 30-Day Mortality and Improved Long-Term Survival Manish Mehta1, Philip S. K. Paty1, Humayun Bhaghtwar2, Kamran Jafree2, Jason Comeau2, Gary Sisken3, Benjamin Chang2, Paul Feustel4. 1Vascular Health Partners, CCP, Glens Falls, NY; 2The Vacular Group, The Institute for Vascular Health and Disease, Albany, NY; 3Community Care Physicians, Albany, NY, Albany Medical College, Albany, NY; 4Albany Medical College, Albany, NY Objectives: This study evaluated the implications of false lumen embolization (FLE) to induce thrombosis during thoracic endovascular aneurysm repair (TEVAR) for complicated acute and chronic thoracic aortic dissections (TAD). Methods: Since 2004, 104 patients with complicated acute and chronic TAD underwent TEVAR with FLE (40 [37.7%]) or without FLE (66 [62.3%]) during the initial procedure. The embolic agents included Amplatz plugs and coils. Data were prospectively collected and analyzed for 30-day and long-term mortality, spinal cord ischemic complications, other nonfatal complications, and the need for secondary interventions.
Author Disclosures: M. Mehta: Honoraria; W. L. Gore, TriVascular Inc, Aptus Endosystems, Endologix, and Medtronic Inc, speaking agreement; other financial benefit, W. L. Gore, Medtronic, Bolton Medical, Silkroad Medical, Abbott Vascular, National Institutes of Health, Aptus Endosystems, TriVascular, Terumo, Boston Scientific, principal investigator clinical trials; P. S. K. Paty: Other financial benefit, W. L. Gore, Medtronic, Bolton Medical, Silkroad Medical, Abbott Vascular, National Institutes of Health, Aptus Endosystems, TriVascular, Terumo, and Boston Scientific, sub-investigator clinical trials; H. Bhaghtwar: None; K. Jafree: None; J. Comeau: None; G. Sisken: None; B. Chang: None; P. Feustel: None. Safety and Effectiveness of a “Percutaneous-First” Approach to Endovascular Aortic Aneurysm Repair Chris Agrusa, MD, Andrew Meltzer, MD, Darren Schneider, MD, Peter Connolly, MD. New York Presbyterian, New York, NY Objectives: Percutaneous endovascular aneurysm repair (PEVAR) has been increasingly used in the endovascular treatment of abdominal aortic aneurysms. The purpose of this study was to assess the safety and effectiveness of a “percutaneous-first” approach to femoral access for EVAR. Methods: From 2012 to 2014, PEVAR was the preferred approach to femoral access for EVAR at our institution. Retrospective review of institutional vascular quality initiative data was used to compare outcomes with PEVAR to a contemporary institutional series of EVAR via open femoral exposure. Matched cohort comparison was used to assess perioperative outcomes, procedural details, including anesthesia modality, surgical time, length of stay (LOS), and access-related complications between groups. Results: A total of 105 consecutive patients underwent attempted PEVAR and were compared with 98 patients undergoing surgical femoral exposure. Demographics and comorbidities were similar between cohorts. PEVAR was associated with an increased use of local anesthesia (67.6% vs 12.2%; P < .001). PEVAR was associated with shorter postoperative LOS (mean, 1.59 vs 3.08 days; P ¼ .044), shorter procedure times (139 vs 222 minutes; P < .001), and significantly less blood loss (176 vs 481 mL; P < .001). There were 11 access site complications (10%) in the PEVAR group, with five (4.8%) requiring conversion to open femoral exposure, compared with three patients (3.1%) with access-related complications after open femoral exposure (P < .001). There were no significant differences in wound infection, intensive care unit LOS, or access site morphology on postoperative computed tomography scan. Conclusions: A PEVAR-first approach proved feasible in the overwhelming majority of patients. Conversion to open transfemoral exposure was rare. PEVAR facilitated endovascular abdominal aortic aneurysm repair under local anesthesia in the majority of patients and resulted in decreased procedural morbidity and resource utilization. Author Disclosures: C. Agrusa: None; A. Meltzer: None; D. Schneider: None; P. Connolly: None. Patient Factors and Hospital Open Experience Predominate Outcomes After AAA Repair Caitlin W. Hicks, MD, MS, Joseph K. Canner, MHS, Isibor Arhuidese, MD, MPH, Umair Qazi, MD, MPH, Tammam Obeid, MD, James H. Black III, MD, Mahmoud B. Malas, MD, MHS. Johns Hopkins Hospital, Baltimore, Md Objectives: Patient-level factors affecting outcomes after open (OAR) and endovascular (EVAR) abdominal aortic aneurysm (AAA) repair are well described. We aim to describe hospital-level factors affecting mortality after AAA repair.