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Endovascular aneurysm repair in high-risk patients
T A Chuter1, L M Reilly, R M Faruqi
1Divisions of Vascular Surgery, University of California-San Francisco, CA 94143, USA.
Insights
Endovascular aneurysm repair (EVAR) is a safe and effective treatment for high-risk patients with aortic aneurysms. This study shows EVAR offers a preferred alternative to open surgery, with good technical and clinical success rates.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Medical Devices
Background:
- Abdominal aortic aneurysms (AAAs) pose significant risks, especially in high-risk surgical candidates.
- Endovascular Aneurysm Repair (EVAR) has emerged as a less invasive alternative.
- Evaluating EVAR's role in high-risk populations is crucial for treatment selection.
Purpose of the Study:
- To assess the safety and efficacy of endovascular aneurysm repair (EVAR) in patients deemed high-risk for open surgical repair.
- To determine the feasibility and outcomes of EVAR using custom-made and commercial stent grafts in this challenging patient group.
Main Methods:
- A prospective study involving 116 high-risk patients undergoing elective endovascular repair of infrarenal aortic aneurysms.
- Utilized custom-made and commercial stent grafts.
- Follow-up included serial contrast-enhanced computed tomography (CT) scans and re-evaluation for endoleaks, with prompt endovascular treatment for persistent leaks.
Main Results:
- EVAR was feasible in 67% of high-risk patients (mean age 75 years, ASA grade III-IV).
- The 30-day mortality and major morbidity rates significantly decreased from the first to the second half of the patient cohort (3.4% to 0% and 20.7% to 3.4%, respectively).
- Technical success at 2 weeks was 86.2%, with a high clinical success rate of 96.6% and continuing success of 87.9%.
Conclusions:
- Endovascular aneurysm repair (EVAR) is a safe and effective treatment option for high-risk patients.
- EVAR may be the preferred treatment modality for selected high-risk individuals unsuitable for open repair.
- Continuous improvement in outcomes suggests learning curve benefits and optimized EVAR strategies.
Purpose:
The purpose of this study was to evaluate the role of endovascular aneurysm repair in high-risk patients.
Methods:
The elective endovascular repair of infrarenal aortic aneurysm was performed in 116 high-risk patients with either custom-made or commercial stent grafts. The routine follow-up examination included contrast-enhanced computed tomography (CT) before discharge, at 3, 6, and 12 months, and annually thereafter. Patients with endoleak on the initial CT underwent re-evaluation at 2 weeks. Those patients with positive CT results at 2 weeks underwent endovascular treatment.
Results:
Endovascular repair was considered feasible in 67% of the patients. The mean age was 75 years, and the mean aneurysm diameter was 6.3 cm. The American Society of Anesthesiologists grade was II in 3.4%, III in 65.5%, IV in 30.1%, and V in 0.9%. There were no conversions to open repair. Custom-made aortomonoiliac stent grafts were implanted in 77.6% of the cases, custom-made aortoaotic stent grafts in 11.2%, and commercial bifurcated stent grafts in 11.2%. The 30-day rates of mortality, major morbidity, and minor morbidity were 3.4%, 20.7%, and 12%, respectively, in the first 58 patients and 0%, 3.4%, and 3.4%, respectively, in the last 58. The late complications included five cases of stent graft kinking, two cases of femorofemoral graft occlusion, and three cases of proximal stent migration, one of which led to aneurysm rupture. At 2 weeks after repair, endoleak was present in 10.3% of the cases. All the type I (direct perigraft) endoleaks underwent successful endovascular treatment, whereas only one type II (collateral) endoleak responded to treatment. The technical success rate at 2 weeks was 86.2%, and the clinical success rate was 96.6%. The continuing success rate was 87.9%. Seventeen patients died late, unrelated deaths.
Conclusion:
Endovascular aneurysm repair is safe and effective in patients at high risk, for whom it may be the preferred method of treatment.