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Citations
... Safety profiles of the eight FDAapproved endovascular stent grafts are well established. [4][5][6][7] JOURNAL OF VASCULAR SURGERY Surveillance monitoring for EVARs remain a critical part of AAA care to maintain freedom from rupture. One recognized method of EVAR failure is development of a T-III endoleak, which can return aortic sac pressures to systemic levels. ...
... There was no significant difference between the low and high angle groups with respect to type I/III endoleaks at 1 year (0 vs. 1.9%, p ¼ 1.0) and graft migration (0 vs. 1.9%, p ¼ 1.0). 32 A similar experience has been reported from Europe 33 in a small nonrandomized prospective trial. In 30 patients with highly angulated necks (median neck angulation 81.2 degrees) treated with the Aorfix device, there were no proximal type I endoleaks reported at 30 days and one proximal type I endoleak (3.3%) reported at 1 year. ...
Advances in endovascular technology, and access to this technology, have significantly changed the field of vascular surgery. Nowhere is this more apparent than in the treatment of abdominal aortic aneurysms (AAAs), in which endovascular aneurysm repair (EVAR) has replaced the traditional open surgical approach in patients with suitable anatomy. However, approximately one-third of patients presenting with AAAs are deemed ineligible for standard EVAR because of anatomic constraints, the majority of which involve the proximal aneurysmal neck. To overcome these challenges, a bevy of endovascular approaches have been developed to either enhance stent graft fixation at the proximal neck or extend the proximal landing zone to allow adequate apposition to the aortic wall and thus aneurysm exclusion. This article is composed of two sections that together address new endovascular approaches for treating aortic aneurysms with difficult proximal neck anatomy. The first section will explore advancements in the traditional EVAR approach for hostile neck anatomy that maximize the use of the native proximal landing zone; the second section will discuss a technique that was developed to extend the native proximal landing zone and maintain perfusion to vital aortic branches using common, off-the-shelf components: the snorkel technique. While the techniques presented differ in terms of approach, the available clinical data, albeit limited, support the notion that they may both have roles in the treatment algorithm for patients with challenging proximal neck anatomy.
Objective:
Type III (T-III) endoleaks following endovascular aneurysm repair (EVAR) remain a major concern. Our center experienced a recent concentration of T-III endoleaks requiring elective and emergency treatment and prompted our review of all EVAR implants over a 40-month period from April 2011 until August 2014. This report represents a single center experience with T-III endoleak management with analysis of factors leading to the T-III-related failure of EVAR.
Methods:
A retrospective review of all the operative reports, medical records, and computed tomography scans were reviewed from practice surveillance. Using Society for Vascular Surgery aneurysm reporting standards, we analyzed the morphology of the aneurysms before and after EVAR implant using computed tomography. Index procedure and frequency of reinterventions required to maintain aneurysm freedom from rupture were compared across all devices using SAS v 9.4 (SAS Institute, Inc, Cary, NC). Major adverse events (MAEs) requiring secondary interventions for aneurysm treatment beyond primary implant were analyzed for methods of failure. Aneurysm morphology of patients requiring EVAR was compared across all endograft devices used for repair. For purposes of MAE analysis, patients receiving Endologix (ELX) endograft were combined into group 1; Gore, Cook, and Medtronic endograft patients were placed into group 2.
Results:
Overall, technical success and discharge survival were achieved in 97.3% and 98% of patients regardless of device usage. There was no significant device related difference identified between patient survival or freedom from intervention. MAEs involving aneurysm treatment were over seven-fold more frequent with ELX (group 1) vs non-ELX (group 2) endografts (P < .01). Group 1 patients with aneurysm diameters larger than 65 mm were associated with a highly significant value for development of a T-III endoleak (odds ratio, 11.16; 95% confidence interval, 2.17, 57.27; P = .0038).
Conclusions:
While EVAR technical success and survival were similar across all devices, ELX devices exhibited an unusually high incidence of T-III endoleaks when implanted in abdominal aortic aneurysms with a diameter of more than 65 mm. Frequent reinterventions were required for Endologix devices for prevention of aneurysm rupture due to T-III endoleaks.
