Current Endovascular Treatment of Abdominal Aortic Aneurysms
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See the article online for full details of the relationships. Buck declares no competing interests. National Center for Biotechnology Information , U. Author manuscript; available in PMC Feb 1. Buck , Joost A. Schermerhorn , and Frans L. The publisher's final edited version of this article is available at Nat Rev Cardiol.
Endovascular treatment of abdominal aortic aneurysms. - PubMed - NCBI
See other articles in PMC that cite the published article. Abstract Patients with abdominal aortic aneurysms AAAs are usually treated with endovascular aneurysm repair EVAR , which has become the standard of care in many hospitals for patients with suitable anatomy. Ultrasonography The most-commonly used technique for screening and surveillance of patients with AAA is ultrasonography Figure 1a,b. Open in a separate window. CTA Whereas conventional angiography has largely fallen out of favour as a first-line imaging modality in the management of AAA, spiral CTA, with its less-invasive approach, has been demonstrated to be the best imaging technique for both preoperative patient assessment and postoperative aortic stent graft surveillance.
Procedural improvements over time The studies discussed above were conducted over the past 10 years and include the largest, most-cutting-edge trials performed to date. New devices and future developments As EVAR became widely accepted as a safe technique, some physicians began experimenting with off-label use of stent grafts to treat patients deemed unfit for open surgery, but who were also not candidates for standard EVAR.
New devices approved by the FDA Endostapling In response to concerns about EVAR treatment failure secondary to endoleak and stent graft migration, endostaplers Figure 2 have been developed to improve durability of the graft by fixation of the graft at its landing zones, and ultimately decrease the need for reintervention.
Off-the-shelf fenestrated stent grafts Currently, fenestrated and branched stent grafts must be customized for individual patients, a process that requires meticulous preoperative planning. Multilayer stent For management of complex aneurysms involving aortic branches, a new multilayer self-expanding stent technology Figure 7 has been developed. A sac-anchoring endoprosthesis Unlike open AAA repair, EVAR leaves the aneurysm sac itself untreated, which allows the possibility of persistent blood flow type 2 endoleak and stent migration.
Other changes to stent graft design Developments in stent grafts have facilitated their deployment through smaller access sites than was previously possible, and with improved sealing and fixation in an ever-increasing cohort of patients. Conclusions Over the past 20 years, endovascular technology has propelled EVAR from an obscure technology with limited applicability to being the standard of care in an increasing number of AAA indications.
Endovascular aneurysm repair EVAR , rather than open repair, is currently the treatment of choice for most patients with an anatomically suitable infrarenal abdominal aortic aneurysm AAA. Clinical evidence-based research shows a lower perioperative morbidity and mortality, and similar long-term survival, for EVAR compared with open repair of suitable infrarenal AAAs.
The indications for endovascular management of AAA are expanding to include increasingly complex and anatomically challenging aneurysms. Challenging anatomy might require the use of fenestrated and branched stent grafts, chimney grafts, or the sandwich technique. Future directions for stent grafts include fenestrated and branched off-the-shelf stent grafts, multilayer stents, endoanchor systems, and sac-anchoring endoprostheses.
Stent graft technology for infrarenal AAA continues to evolve, with profile downsizing, optimization of sealing and fixation, and the use of fabrics with reduced porosity.
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Acknowledgements The authors thank Thomas Curran M. Footnotes Competing interests J. Buck researched data for the article. All authors substantially contributed to discussion of content and reviewed and edited the manuscript before submission. Contributor Information Dominique B. A self-fixing synthetic blood vessel endoprosthesis [Russian] Vestn. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.
Percutaneous endovascular aortic aneurysm repair: Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm. Nowygrod R, et al.
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Trends, complications, and mortality in peripheral vascular surgery. Schermerhorn ML, et al. Changes in abdominal aortic aneurysm rupture and short-term mortality, — Risk factors for asymptomatic abdominal aortic aneurysm: Lederle FA, et al. The aneurysm detection and management study screening program: Small abdominal aortic aneurysms. Lo RC, et al. Gender differences in abdominal aortic aneurysm presentation, repair, and mortality in the Vascular Study Group of New England.
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Dynamics of the aorta before and after endovascular aneurysm repair: Neschis DG, et al. The role of magnetic resonance angiography for endoprosthetic design.
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Upchurch GR, Criado E, editors. Habets J, et al. Magnetic resonance imaging is more sensitive than computed tomography angiography for the detection of endoleaks after endovascular abdominal aortic aneurysm repair: Time-resolved contrast-enhanced 3D MR angiography. Cohen EI, et al. Time-resolved MR angiography for the classification of endoleaks after endovascular aneurysm repair. Time-resolved magnetic resonance angiography as a noninvasive method to characterize endoleaks: Marrocco CJ, et al.
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Greenhalgh RM, et al. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm EVAR trial 1 , day operative mortality results: Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm EVAR trial 1: Endovascular versus open repair of abdominal aortic aneurysm. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm EVAR trial 2: Brown LC, et al. Endovascular repair of aortic aneurysm in patients physically ineligible for open repair.
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Schanzer A, et al. Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair. US Food and Drug Administration. Cao P, et al. Donas KP, Torsello G. Midterm results of the Anson Refix endostapling fixation system for aortic stent-grafts. Avci M, et al. The use of endoanchors in repair EVAR cases to improve proximal endograft fixation. The juxtarenal abdominal aortic aneurysm. A more common problem than previously realized?
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Endovascular treatment for ruptured abdominal aortic aneurysm
Bicknell CD, et al. Treatment of complex aneurysmal disease with fenestrated and branched stent grafts. A prospective analysis of fenestrated endovascular grafting: Durability of branches in branched and fenestrated endografts. Amiot S, et al. Verhoeven EL, et al. Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: Pararenal aortic aneurysm repair using fenestrated endografts. Cross J, et al. Indications for fenestrated endovascular aneurysm repair.
Ohrlander T, et al. Endovascular aortic aneurysm repair with chimney and snorkel grafts: Chimney grafts and bare stents: Tolenaar JL, et al. The chimney graft, a systematic review. Technical considerations and results of chimney grafts for the treatment of juxtarenal aneurysms.
Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms. A novel technique of aortomonoiliac AAA repair in patients with a single patent iliac artery: Urgent endovascular treatment of thoraco-abdominal aneurysms using a sandwich technique and chimney grafts—a technical description. No robust conclusion can be made on outcomes at six months or one year.
More studies are needed to better understand whether or not one of the aneurysm repair techniques, endovascular or open surgical, is superior based on patient outcomes. We found from the data available moderate-quality evidence suggesting there is no difference in day mortality between eEVAR and open repair. Not enough information was provided for complications for us to make a well-informed conclusion, although it is possible that eEVAR is associated with a reduction in bowel ischaemia. We downgraded the quality of the evidence as some studies contained too few participants, not all studies reported on all complication outcomes, and the number of complications occurring between studies varied substantially.
The conclusions of this review are currently limited by the paucity of data. Long-term data were lacking for both survival and late complications. More high-quality randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.
An abdominal aortic aneurysm AAA pathological enlargement of the aorta is a condition that can occur as a person ages.
It is most commonly seen in men older than 65 years of age. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, which is fatal unless timely repair can be achieved. Endovascular aneurysm repair EVAR , a minimally invasive technique, has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. More recently emergency endovascular aneurysm repair eEVAR has been used successfully to treat ruptured abdominal aortic aneurysm RAAA , proving that it is feasible in select patients; however, it is unclear if eEVAR will lead to significant improvements in outcomes for these patients or if indeed it can replace conventional open repair as the preferred treatment for this lethal condition.
This is an update of the review first published in To assess the advantages and disadvantages of emergency endovascular aneurysm repair eEVAR in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm RAAA. This will be determined by comparing the effects of eEVAR and conventional open surgical repair on short-term mortality , major complication rates, aneurysm exclusion specifically endoleaks in the eEVAR treatment group , and late complications.
We also checked reference lists of relevant publications. Randomised controlled trials in which participants with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair. Two review authors independently assessed studies identified for potential inclusion for eligibility. Two review authors also independently completed data extraction and quality assessment.
Disagreements were resolved through discussion. We included four randomised controlled trials in this review. Overall risk of bias was low, but we considered one study that performed randomisation in blocks by week and performed no allocation concealment and no blinding to be at high risk of selection bias. Another study did not adequately report random sequence generation, putting it at risk of selection bias , and two studies were underpowered. There was no clear evidence to support a difference between the two interventions for day or in-hospital mortality OR 0.
There were a total of 44 endoleak events in participants from three studies low-quality evidence.