Eight Year Experience with Type I Endoleaks at a Tertiary Care Center
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1 Eight Year Experience with Type I Endoleaks at a Tertiary Care Center Adam Tanious MD, Megan Carroll MD, Mathew Wooster MD, Andrew Jung BA, Marcello Giarelli MSN, Martin Back MD, Bruce Zwiebel MD, Peter Nelson MD, Murray Shames MD Florida Vascular Society Annual Meeting 4/28/2016
2 Conflicts of Interest Dr. Shames Speaker: Gore, Medtronic Educational program support: Cook, Gore, Medtronic Research Study Investigator: Gore, Medtronic Dr. Nelson None Dr. Back Cook consulting and physician training Gore consulting and physician training Medtronic physician training
3 Background Though not the most common, type I endoleaks are one of the most morbid sequelae of EVAR Patients with Type I endoleaks are more likely to require secondary interventions, open conversions, and experience post-evar ruptures than any other group of endoleak patients 1,2 1. Buth J, Harris PL, van Marrewijk C, Fransen G. The significance and management of different types of endoleaks. Seminars in Vascular Surgery. 2003;16(2): doi: /s (03) Szmidt J, Galazka Z, Rowinski O, et al. Late aneurysm rupture after endovascular abdominal aneurysm repair. Interact Cardiovasc Thorac Surg. 2007;6(4): doi: /icvts
4 Background Options for treatment include: Angioplasty, Proximal Extension, Stents, Embolization, Open Surgical Conversion 3 Our group previously presented results of a protocoldriven strategy for treatment of proximal fixation loss < 25mm Below Renal Arteries > 25mm Below Renal Arteries Proximal and Distal Fixation Loss or Structural Failure Adequate Suprarenal Aorta with Ia Recalcitrant Ia < 50% Graft-Wall apposition 3. Tan T-W, Eslami M, Rybin D, Doros G, Zhang WW, Farber A. Outcomes of patients with type I endoleak at completion of endovascular abdominal aneurysm repair. J Vasc Surg. March 2016:1-8. doi: /j.jvs Carroll et al. Loss of Proximal Fixation After EVAR: Durability Assessment of a Selected Algorithm for Endograft Salvage. SCVS 2014
5 Objective Present the trends in treatment of Type I endoleaks over an 8 year period at a tertiary referral center
6 Methods Retrospective review of prospectively collected endoleak database 121 Patients with type I endoleaks identified May 2007 May 2015 Start date of prospective endoleak database Procedural (diagnostic and therapeutic), as well as hospital course, and follow-up data captured and analyzed.
7 Feature Demographics Rate/Average N 121 Treatment Rate 118 (98%) Age 79yrs (+/- 7.3) Time to Presentation 5.3yrs (+/- 3.1) Follow-up Time 1.7yrs (+/- 1.7) Male 124 (92%) Symptomatic 33 (27%) Presenting AAA Size 7.1cm (+/- 1.7) Expanding Aneurysm Sac 110 (90%) Total Endoleak Sources 1.5 (+/- 0.6)
8 Feature Demographics Rate/Average N 121 Treatment Rate 118 (98%) Age 79yrs (+/- 7.3) Time to Presentation 5.3yrs (+/- 3.1) Follow-up Time 1.7yrs (+/- 1.7) Male 124 (92%) Symptomatic 33 (27%) Presenting AAA Size 7.1cm (+/- 1.7) Expanding Aneurysm Sac 110 (90%) Total Endoleak Sources 1.5 (+/- 0.6)
9 Feature Demographics Rate/Average N 121 Treatment Rate 118 (98%) Age 79yrs (+/- 7.3) Time to Presentation 5.3yrs (+/- 3.1) Follow-up Time 1.7yrs (+/- 1.7) Male 124 (92%) Symptomatic 33 (27%) Presenting AAA Size 7.1cm (+/- 1.7) Expanding Aneurysm Sac 110 (90%) Total Endoleak Sources 1.5 (+/- 0.6)
10 Feature Demographics Rate/Average N 121 Treatment Rate 118 (98%) Age 79yrs (+/- 7.3) Time to Presentation 5.3yrs (+/- 3.1) Follow-up Time 1.7yrs (+/- 1.7) Male 124 (92%) Symptomatic 33 (27%) Presenting AAA Size 7.1cm (+/- 1.7) Expanding Aneurysm Sac 110 (90%) Total Endoleak Sources 1.5 (+/- 0.6)
11 Feature Demographics Rate/Average N 121 Treatment Rate 118 (98%) Age 79yrs (+/- 7.3) Time to Presentation 5.3yrs (+/- 3.1) Follow-up Time 1.7yrs (+/- 1.7) Male 124 (92%) Symptomatic 33 (27%) Presenting AAA Size 7.1cm (+/- 1.7) Expanding Aneurysm Sac 110 (90%) Total Endoleak Sources 1.5 (+/- 0.6)
12 Type I Endoleaks per Year
13 Type I Endoleaks by Device
14 Operative/Post-Operative Variables Feature Rate Most Common Original EVAR Device Medtronic AneuRx (60) Guidant Ancure (18) Gore Excluder (12) Type IA Endoleak 104 (78%) Type IB Endoleak 42 (31%) Type II Endoleak 52 (39%)
15 Operative/Post-Operative Variables Feature Rate Most Common Original EVAR Device Medtronic AneuRx (60) Guidant Ancure (18) Gore Excluder (12) Type IA Endoleak 104 (78%) Type IB Endoleak 42 (31%) Type II Endoleak 52 (39%)
16 Operative/Post-Operative Variables Feature Rate Most Common Original EVAR Device Medtronic AneuRx (60) Guidant Ancure (18) Gore Excluder (12) Type IA Endoleak 104 (78%) Type IB Endoleak 42 (31%) Type II Endoleak 52 (39%)
17 Operative/Post-Operative Variables Feature Rate Most Common Original EVAR Device Medtronic AneuRx (60) Guidant Ancure (18) Gore Excluder (12) Type IA Endoleak 104 (78%) Type IB Endoleak 42 (31%) Type II Endoleak 52 (39%)
18 Operative/Post-Operative Variables Feature Rate Endovascular Treatment (72%) Open Surgery (28%) LOS Proximal and/or Iliac Cuff 43 Endostaple 8 Relining 20 Parallel Stent 19 Open Plication 12 Open Explant 21 Overall 8 Days (+/- 8) Endovascular 6.1 Days (+/- 6) Open 14 Days (+/- 10.4)
19 Operative/Post-Operative Variables Feature Rate Endovascular Treatment (72%) Open Surgery (28%) LOS Proximal and/or Iliac Cuff 43 Endostaple 8 Relining 20 Parallel Stent 19 Open Plication 12 Open Explant 21 Overall 8 Days (+/- 8) Endovascular 6.1 Days (+/- 6) Open 14 Days (+/- 10.4)
20 Operative/Post-Operative Variables Feature Rate Endovascular Treatment (72%) Open Surgery (28%) LOS Proximal and/or Iliac Cuff 43 Endostaple 8 Relining 20 Parallel Stent 19 Open Plication 12 Open Explant 21 Overall 8 Days (+/- 8) Endovascular 6.1 Days (+/- 6) Open 14 Days (+/- 10.4)
21 Operative/Post-Operative Variables Feature Rate Endovascular Treatment (72%) Open Surgery (28%) Proximal and/or Iliac Cuff 43 Endostaple 8 Relining 20 Parallel Stent 19 Open Plication 12 Open Explant 21 LOS p <.0001 Overall 8 Days (+/- 8) Endovascular 6.1 Days (+/- 6) Open 14 Days (+/- 10.4)
22 Follow-up Variables Feature Rate p-value Primary Technical Success Clinical Success Post-Operative Sac Growth Endovascular = 92 (90%) Open = 29 (90%) 1.0 Endovascular = 80 (94%) Open = 24 (72%).62 Endovascular = 19 (22%) Open = 1 (6%).06
23 Complications Type Open Endovascular p-value Renal 8 (25%) 1 (1%) <.0001 Pulmonary 4 (13%) 3 (3%).056 Cardiac 0 5 (5%).34 Gastrointestinal 3 (9%) 1 (1%).04 Wound/Access 4 (13%) 5 (5%).22 Genitourinary 1 (3%) 4 (4%) 1.00 Neurologic 1 (3%) 0.24 Infected Graft 4 (13%) 2 (2%).03 Overall 21 (68%) 33 (33%).0007
24 Complications Type Open Endovascular p-value Renal 8 (25%) 1 (1%) <.0001 Pulmonary 4 (13%) 3 (3%).056 Cardiac 0 5 (5%).34 Gastrointestinal 3 (9%) 1 (1%).04 Wound/Access 4 (13%) 5 (5%).22 Genitourinary 1 (3%) 4 (4%) 1.00 Neurologic 1 (3%) 0.24 Infected Graft 4 (13%) 2 (2%).03 Overall 21 (68%) 33 (33%).0007
25 Complications Feature Rate p-value Endoleak Overall 22 (19%) Type I 12 (10%) Type II 8 (7) Type III 2 (2%) Overall 3 (2%) Thirty-Day Open 3 (9%) Mortality Endovascular 0.01 Overall Mortality Overall 17 (13%) Open 8 (25%) Endovascular 9 (9%).03
26 Complications Feature Rate p-value Endoleak Overall 22 (19%) Type I 12 (10%) Type II 8 (7) Type III 2 (2%) Overall 3 (2%) Thirty-Day Open 3 (9%) Mortality Endovascular 0.01 Overall Mortality Overall 17 (13%) Open 8 (25%) Endovascular 9 (9%).03
27 Logistic Regression Analysis Outcome Variable Open Surgery Predictive Variable Presentation < 5 Years from Original EVAR OR 4.1 Complication Endovascular Surgery Death Endovascular Surgery 0.295
28 Conclusions Type I Endoleaks present a complex problem Both open and endovascular surgery remain valid treatment options Open surgery is associated with increased odds of complication and death compared to endovascular approaches
29
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