UNIVERSITY OF PADUA DEPARTMENT OF VASCULAR AND ENDOVASCULAR SURGERY Director: Prof. F. GREGO Predictors of endoleak type II risk, in the era of prevention with aneurysm sac filling during EVAR Prof. Franco Grego
UNIVERSITY OF PADUA DEPARTMENT OF VASCULAR AND ENDOVASCULAR SURGERY Director: Prof. F. GREGO NO DISCLOSURE
Background Endoleak type II (EII), is a frequent complication (10-40%) of EVAR Most of EIIs are benign and spontaneously resolve, but some EIIs are associated to sac growth and risk of rupture EII endovascular treatment is associated to technical failure in 40% of cases In this scenario, EII prevention appears as a reasonable approach
How to prevent EII? BRANCHES EMBOLIZATION SAC EMBOLIZATION EVAS
When? DURING EVAR Exposure to a single procedure Time-consuming compared to standard EVAR Technical feasibility BEFORE EVAR Exposure to the risks of 2 different procedures Contrast and radiation exposure Infection risk Costs
Who? All patients Routinely aneurysm sac embolization has been demonstrated to be effective in reducing the rate of EII s and EII-related reinterventions However, a selection is needed in order to optimize outcomes and costs
Who? high risk patients Traditionally, EII-preventing procedures have been performed in patients considered at HIGH RISK for EII, on the basis of risk factors for EII: Patent IMA >3 mm Number and diameter of lumbar arteries Thrombus Aneurysm sac diameter/volume LIMITS: Volume (cm 3 ) Glue (cc) Coil 125 5 3 125-175 10 3 175-225 10 4 225 10 5 Prevention only in a small subset of EVAR patients Case-by-case selection of patients Does not prevent unpredictable endoleaks
Who? Example of a high risk patient PRE-OPERATIVE CT SCAN POST-OPERATIVE CT SCAN POST-EMBOLIZATION OF EII
Who? Exclusion of patients at low risk OBJECTIVES Reproducible, easy method of selection Prevention of EII s Prevention of EIIrelated reinterventions (malignant endoleaks) Prevention of unpredictable EII s
Methods Included 189 Jan 2008-Dec 2015 EVAR Excluded EXCLUSION CRITERIA Branched/fenestrated/chimney grafts Aorto-uni-iliac Tubular endografts urgent/emergent repair Embo-EVAR (previous studies) EVAS ANATOMIC INCLUSION CRITERIA At least one of the following: At Low risk LRG 66 (34.9%) At Risk RG 123 (65.1%) SG1: IMA>3 mm SG2: 3 couples of lumbar arteries SG3: 2 couples of lumbars + accessory renal artery/sacral artery/ima<3mm SG4: more than SG1, 2, and 3 www.chirurgiavascolarepadova.it
0 20 40 60 80 100 Results Freedom from Endoleak II Freedom from Endoleak-reintervention P<.001* P<.001* P<.001*P=.002* P=.048* P=.54 100% 80.6% N. At risk R: 114 110 95 89 75 64 55 53 LR: 61 55 53 50 44 39 27 22 R Group LR Group P=.001* 0 6 12 18 24 30 36 42 48 Months Sensitivity 90% Specificity 40% Sensitivity 100% Specificity 38% www.chirurgiavascolarepadova.it
Results Multivariate Analysis Variable OR 95% CI Coefficient P Predictors of EII IMA > 3 mm 1.32 0.45-3.86 0.28.60 > 3 lumbars 1.16 0.40-3.42 0.15.78 Thrombus volume < 35% 2.16 1.01-5.09 0.77.09 Groups -RG 9.91 2.92-33.72 2.29 <.001 a -SG4 0.41 1.16-1.14-0.73.10 Predictors of reintervention IMA > 3 mm 2.87 0.84-9.81 1.05.10 > 3 lumbars 1.73 0.40-7.46 0.55.45 Thrombus volume < 35% 2.96 1.01-8.76 0.55.08 Aneurysm volume > 200 cm 3 0.44 0.04-4.19-0.81.47 Groups -RG 9.11 1.06-78.44 2.21.04 a -SG4 0.31 0.08-1.20-1.10.10 IMA, inferior mesenteric artery; RG, risk group; SG4, subgroup 4 a Statistically significant
Results Multivariate Analysis ( Only Risk Group) Variable OR 95% CI Coefficient P Predictors of EII IMA > 3 mm 1.67 0.54-4.79 0.47.39 > 3 lumbars 0.76 0.41-1.41-0.26.39 Sac volume 1.01 0.99-1.02 0.01.19 Thrombus volume < 35% 5.21 1.75-15.47 1.65.003 a Predictors of reintervention IMA > 3 mm 2.08 0.61-7.15 0.73.24 Sac volume 1.01 1.00-1.02 0.01.09 Thrombus volume < 35% 8.33 2.20-31.51 2.12.002 a SG4 0.61 0.19-2.02-0.48.42 IMA, inferior mesenteric artery; SG4, subgoup 4 a Statistically significant
Conclusions The identification of a group of patients AT LOW RISK for EII is feasible on the basis of simple CT characteristics. This group is very unlikely to develop EII or EII-complications. On the other hand, the criteria to define patients AT RISK for EII are effective and reliable, and the association to thrombus volume <35% increases the risk 5-8 fold EII-preventive procedures or a careful follow-up protocol should be performed in this subpopulation of EVAR patients
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