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ObjectiveCurrent data supporting the effect of anticoagulation drug use on aneurysm sealing and the durability of endovascular abdominal aneurysm repair (EVAR) are conflicting. This study assessed the safety of chronic anticoagulation therapy after EVAR.MethodsRecords of 1409 consecutive patients having elective EVAR during 1997–2011 who were prospectively followed were reviewed. Survival, reintervention, conversion, and endoleak rates were analyzed in patients with and without chronic anticoagulants. Cox proportional hazards models were used to estimate the effect of anticoagulation therapy on outcomes.ResultsOne-hundred and three (7.3%) patients were on chronic anticoagulation drugs (80 on vitamin K antagonists) at the time of EVAR. An additional 46 patients started on anticoagulants after repair were identified. Patients on chronic anticoagulation therapy at repair (mean age 73.6 years; 91 males) had more frequent cardiac disease (74.8% vs. 44.2%; p

BackgroundOperator training is a key factor for the safety of carotid stenting (CAS). Whether institutional practice is associated with improved individual operator outcomes is debated.ObjectiveTo evaluate the effect of the institutional experience on outcomes of new trainees with CAS, a retrospective analysis of a prospectively held database was performed.MethodsThe overall study period, 2004–2012, was divided into two sequential time frames: 2004–April 2006 (leaders-team phase) and May 2006–2012 (expanded team phase). In the first frame, a single leader-operators team that first approached CAS and passed the original institutional learning curve, performed all the procedures; in the following expanded-team phase, five new trainees joined. Institutional CAS training for new trainees was based on a team-working approach including selection of patients, devices and techniques and collegial meetings with critical review and discussion of all procedural steps and imaging.ResultsA total of 431 CAS procedures were performed in the leaders-team phase and 1026 in the sequential expanded-team phase. Periprocedural complication rates in the two time frames were similar: stroke/death (3.0% vs. 2.1%; P = 0.35), stroke (2.8% vs. 2.1%; P = 0.45) major stroke (0.9% vs. 0.6%, P = 0.49), death (0.2% vs. 0%; P = 0.29) during the leaders-team and expanded-team phase, respectively. However, rates of CAS failure requiring surgical conversions (3.7% vs. 0.8%; P

Objectives Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. Materials and methods Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90–99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. Results In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90–99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. Conclusions In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

Objective/Background Absence of an adequate iliac seal rarely represents an absolute contraindication to endovascular abdominal aortic aneurysm repair. Iliac branch devices (IBD) are increasingly used in patients with extensive aorto-iliac aneurysmal disease, but few data are available on the long-term results of these procedures. Methods Between 2006 and 2016, 157 consecutive IBD procedures performed at a single centre were entered into a prospective database. Indications included unilateral or bilateral common iliac artery aneurysms combined or not with abdominal aortic aneurysms. Long-term results were reported according to the Kaplan–Meier method. Results During the study period 149 patients were treated with an iliac branched endograft. Isolated IBD was implanted in 17.8% of the cases; technical success rate was 97.5%. Peri-operative procedure failure occurred in seven patients, four during surgery and three within 30 days of the procedure. Presence of ipsilateral hypogastric aneurysm ( p = .031; Exp [B] = 6.72) and intervention performed during the initial study period ( p = .006; Exp [B] = 10.40) were predictive of early failure on multivariate analysis. After a mean follow-up of 44.2 months actuarial freedom from IBD related re-intervention was 97.4%, 95.6%, 94.0%, and 91.8% at 1, 3, 5, and 9 years, respectively. Hypogastric artery patency was 94.7%, 92.6%, and 90.4% at 1, 3, and 10 years, respectively. Presence of a hypogastric aneurysm was an independent predictor of target artery occlusion during follow-up on multivariate analysis ( p = .007; Exp [B] = 5.93). Conclusion Iliac branched endografting can now be performed with a high technical success rate; long-term freedom from re-intervention is comparable with patients treated with standard aortic endografting. IBD should be considered a first-option treatment in patients with adequate vascular anatomy unsuitable for standard endovascular aortic repair.

Background Iliac branch device (IBD) technique has been introduced as an appealing and effective solution to avoid complications occurring during repair of aorto-iliac aneurysm with extensive iliac involvement. Nevertheless, no large series with long-term follow-up of IBD are available. The aim of this study was to analyse safety and long-term efficacy of IBD in a consecutive series of patients. Methods Between 2006 and 2011, 100 consecutive patients were enrolled in a prospective database on IBD. Indications included unilateral or bilateral common iliac artery aneurysms combined or not with abdominal aneurysms. Patients were routinely followed up with computed tomography. Data were reported according to the Kaplan–Meier method. Results There were 96 males, mean age 74.1 years. Preoperative median common iliac aneurysm diameter was 40 mm (interquartile range (IQR): 35–44 mm). Sixty-seven patients had abdominal aortic aneurysm >35 mm (IQR: 40–57 mm) associated with iliac aneurysm. Eleven patients presented hypogastric aneurysm. Twelve patients underwent isolated iliac repair with IBD and 88 patients received associated endovascular aortic repair. Periprocedural technical success rate was 95%, with no mortality. Two patients experienced external iliac occlusion in the first month. At a median follow-up of 21 months (range 1–60) aneurysm growth >3 mm was detected in four iliac (4%) arteries. Iliac endoleak (one type III and two distal type I) developed in three patients and buttock claudication in four patients. Estimated patency rate of internal iliac branch was 91.4% at 1 and 5 years. Freedom from any reintervention rate was 90% at 1 year and 81.4% at 5 years. No late ruptures occurred. Conclusions Long-term results show that IBD use can ensure persistent iliac aneurysm exclusion at 5 years, with low risk of reintervention. This technique can be considered as a first endovascular option in patients with extensive iliac aneurysm disease and favourable anatomy.

BackgroundRandomised trials have failed to demonstrate benefit from early surgical repair of small abdominal aortic aneurysm (AAA) compared with surveillance. This study aimed to compare results after endovascular aortic aneurysm repair (EVAR) or surveillance in AAA 1 cm /year, symptoms) was achieved. The main end point was all-cause mortality. Recruitment is closed; results at a median follow-up of 32.4 months are here reported.ResultsBetween 2004 and 2008, 360 patients (early EVAR = 182; surveillance = 178) were enrolled. One perioperative death after EVAR and two late ruptures (both in the surveillance group) occurred. At 54 months, there was no significant difference in the main end-point rate [hazard ratio (HR) 0.76; 95% confidence interval (CI) 0.30–1.93; p = 0.6] with Kaplan–Meier estimates of all-cause mortality of 14.5% in the EVAR and 10.1% in the surveillance group. Aneurysm-related mortality, aneurysm rupture and major morbidity rates were similar. Kaplan–Meier estimates of aneurysms growth ≥5 mm at 36 months were 8.4% in the EVAR group and 67.5% in the surveillance group (HR 10.49; 95% CI 6.88–15.96; p

Objective/Background A consistent number of elderly patients with ruptured abdominal aortic aneurysms (rAAAs) are deemed unfit for repair and excluded from any treatment. The objective of this study was to examine the impact on survival of endovascular repair and open surgery with restricted turndown in acute AAA repair. Methods A prospective database for patients treated for rAAA was established. None of the patients admitted alive with rAAA were denied treatment. Multivariate regression models, the predictive risk assessment Glasgow Aneurysm Score (GAS), and subgroup analyses in older patients were applied to identify indicators of excessive 30 day mortality risk that could affect the decision for turndown. Results From 2006 to 2015, 113 consecutive patients (93 males; mean age 77.2 years) with rAAAs were treated (69 open surgery; 44 EVAR). Overall peri-operative (30 day) mortality was 38.9% (44/113): 40.6% (28/69), and 36.4% (16/44) after open surgery and EVAR, respectively ( p = .70). Multivariate logistic regression identified old age as an indicator of increased peri-operative mortality (odd ratio [OR] 1.2, 95% confidence interval [CI] 1.1–1.3; p = .001), as well as free aneurysm rupture (OR 5.0, 95% CI 1.3–19.9; p = .02). GAS was higher in patients who died (97.75 vs. 86.62), but the score failed to identify increased peri-operative mortality risk in adjusted analyses (OR 1.0; p = .06). Almost two thirds of the patients ( n = 71) were older than 75 at the time of aneurysm rupture (48.6% octogenarians) and EVAR was more commonly applied than open surgery (86.4% vs. 47.8%; p 75 year old patients was 46.5% compared with 26.2% in younger patients ( p = .05), with rates increased after open surgery (54.5% vs. 27.8%, p = .03) but not after EVAR (39.5% vs. 16.7%; p = .39). According to Kaplan–Meier estimates, mean survival was 39.7 ± 4.8 months. Patients older than 75 years of age survived for a mean of 23.0 ± 4.47 months after rupture. Conclusion In this study aggressive treatment with a very restricted or no turndown strategy for any rAAA, also applied to older patients, allowed for an additional mean 40 months of survival after aneurysm rupture. In the contemporary endovascular era the decision to deny repair arbitrarily to older patients with rAAAs must be revisited.

Age is a main risk factor for stroke and perioperative risk. This study aims to analyze the effect of age by symptomatic status in young patients receiving carotid revascularization.Consecutive carotid revascularization procedures performed during the period 2001-2009 were reviewed. Patients were analyzed by age using the 70-year threshold as suggested by trials. Primary end point was perioperative stroke or death rate. Secondary end points included survival and late stroke incidence at 6 years.A total of 2,196 procedures (1,080 by carotid artery stenting [CAS] and 1,116 by carotid endarterectomy [CEA]) were analyzed. Symptomatic patients (n = 684) showed higher perioperative stroke or death risks (24 of 684 [3.5%] versus 29 of 1,512 [1.9%], odds ratio [OR] 1.8; 95% confidence interval [CI] 1.07-3.22; P = 0.034) and lower 6-year survival (74% vs. 82%, P0.0001) or freedom from late stroke (93% vs. 97%, P = 0.001) when compared with asymptomatic patients with similar differences detected within CEA or CAS procedure. Overall 949 procedures were in patients with 70 years or less at the time of intervention (500 CEA and 449 CAS); 282 were in patients symptomatic for minor stroke or transient ischemic attack within 6 months before revascularization. For young symptomatic patients, primary end point rates were2.5% after both CEA and CAS procedure. Perioperative stroke or death rates were 2.4% in symptomatic versus 1.5% in asymptomatic (4 of 170 vs. 5 of 330; OR 1.57; 95% CI 0.42-5.91; P = 0.50) within the CEA group and 1.8% in symptomatic versus 1.2% in asymptomatic (2 of 112 vs. 4 of 337; OR 1.51; 95% CI 0.27-8.38; P = 0.64) within the CAS group. At 6 years, symptomatic young patients showed survival (89.5% vs. 89%, P = 0.76) and freedom from late stroke (97% vs. 98%, P = 0.56) rates comparable to those found in asymptomatic patients, with similar incidences after CAS or CEA procedure.Outcomes after carotid revascularization are related to patients' age. At younger ages (70 years), after carotid revascularization, symptomatic patients show low perioperative risks of stroke or death, comparable with those in asymptomatic patients. The same, 2.5% or lower, threshold for perioperative stroke or death risk related to asymptomatic carotid procedures must be applied today to symptomatic patients when younger than age of 70 years.

Hypothesis: There may be sex differences in presentation and outcomes of abdominal aortic aneurysms (AAA) with increased mortality rates in women. Aim of this study was to assess mortality risk after repair of ruptured AAA (rAAA) in women in the endovascular repair (EVAR) era. Methods: All patients treated in 2006-2014 for rAAA were reviewed. Characteristics at presentation and outcomes were compared between women and men. Multivariable logistic regression and Cox proportional hazards modeling were performed to identify the effect of sex adjusted for other predictors on mortality. Results: One-hundred and four patients were identified: 16.3% (17/104) were women. Forty-one procedures (39.4%) were by EVAR, with comparable rates in women (47.1%) and men (37.9%;P=0.59). On admission women and men shared similar comorbidities and presentation (shock rates 43.8% vs. 45.9%; P=1; free rupture rates 58.8% vs. 67.8%; P=0.58 ) and comparable mean aneurysm diameter (76.2mm vs.77.7mm;P=0.8) but women were older (mean age 86.2+5.8 vs. 75.5 +10.3 years; P Conclusions: Despite AAA repair is often delayed in women and applied at older age, women might not show increased perioperative mortality risks from rAAA treatment after the introduction of EVAR. Larger data are required to confirm this hypothesis.

Objective Management of anti-platelet therapy during carotid artery stenting (CAS) is mainly based on indirect evidence from coronary stenting experience. There is common agreement on the use of thienopyridine (mainly second-generation) during CAS, but some patients are unsuitable for clopidogrel treatment and data on the benefit of its use in large CAS populations are lacking. The aim of this study was to investigate whether clopidogrel was associated with reduced perioperative morbidity in patients undergoing CAS. Methods Consecutive patients undergoing CAS for primary carotid stenosis from 2004 to 2009 were reviewed. The independent association of clopidogrel and perioperative morbidity was assessed using multivariable analysis. Results A total of 1083 patients were treated (29% females, mean age 71.6 years); 825 (76%) patients were given clopidogrel starting before treatment. Clopidogrel use was associated with a non-significant reduction of perioperative stroke/death (4.3% vs. 2.4%; p = 0.13) and disabling stroke (1.2% vs. 1.0%; p = 1) rates. The non-significant stroke/death difference was similar in symptomatic (5.8% vs. 4.0%, p = 0.37) and asymptomatic (3.7% vs. 1.9%; p = 0.17) patients. After adjusting for demographics, co-morbidities and other therapies with multivariable analysis, clopidogrel use failed to show any significant independent association in decreasing operative risks. The only independent protective factor was use of statins (p = 0.010). The additional use of dual anti-platelet therapy did not add any advantage to the use of clopidogrel alone. Conclusions The suggested benefit of clopidogrel in decreasing the incidence of complications in patients undergoing CAS may be overestimated due to the overlapping effect of other more relevant factors (e.g., pleiotropy and plaque stabilisation from statins). More data and level I evidence are needed to understand which is the best medical management of CAS that will help improve outcomes of the procedure.

AimTo compare the results of endovascular repair (EVAR) in large and small (diameter < 5.5cm) abdominal aortic aneurysms (AAA).MethodsA systematic review was performed to identify studies comparing the outcomes after EVAR of large and small aneurysms. Outcomes considered were: risk of death (perioperative, all cause, aneurysm-related), ruptures, and complications (conversion, reintervention). Weighted pooled estimates of outcomes in patients with small versus large aneurysms were calculated. The inverse variance method was used (random-effect model). Subgroup analyses by a follow-up longer or shorter than 24 months were performed.ResultsFive studies, with published and unpublished data, totallying 7,735 patients, were included. Overall, the weighted pooled estimates were: OR 0.68; 95% CI 0.51–0.90 for operative mortality, OR 0.77; 95% CI 0.69 to 0.86 for all cause mortality, OR 0.58; 95% CI 0.40 to 0.87 for aneurysm-related mortality and OR 0.61; 95% CI 0.47 to 0.79 for rupture in favour of small AAA group. Pooled estimates were not influenced by follow-up length. Conversion and reintervention rates were not significantly lower for small AAA.ConclusionsEVAR in small versus large AAA might be associated with lower operative mortality, aneurysm-related mortality and aneurysm rupture. Better evidence is needed to support these suggestions.

Carotid artery stenting (CAS) is becoming increasingly common for the treatment of carotid stenosis. Accumulating data, but not randomised data, suggest that CAS has promising efficacy in preventing stroke with an acceptable rate of procedure-related complications when compared to carotid endarterectomy (CEA). However, CAS procedures can carry a risk of non-negligible complications such as cerebral embolization, cerebral hemorrhage, severe hypotension and bradycardia. These may occur after the first 24 hours. Lessons may be learned from the timing of occurrence of CAS adverse events. The most severe neurological complications are generally due to embolism and occur intraprocedurally especially during catheter, wire or sheath manipulation in the aortic arch and common carotid. These strokes, obviously, cannot be prevented by using cerebral protection devices and enhance the importance of an appropriate learning curve that includes proper material choice, patient selection, good technique and the skill of "know when to quit".

Objective To evaluate frequency, causes and results of conversion to Open repair (OR) after endovascular repair (EVAR) in a single centre during an 8-year period. Design Six hundred and forty-nine consecutive patients undergoing EVAR were followed up prospectively for endograft-related complications. Outcomes Early conversion was any OR during or within 30 days from the primary EVAR. Late conversion was any OR with removal of the endograft after 30 days since a completed EVAR procedure. Results Median patient follow-up was 38 months (1–93 months). Conversion to OR was performed in 38 patients; nine early and 29 late. Most (7/9) early conversions were due to extensive vessel calcification. Peri-operative mortality was 22% (2/9). Late conversions occurred at a median of 33 months after primary EVAR: 29 were elective and 4 urgent. During the same interval, 79 secondary endovascular interventions were performed, 7 of which failed. The risk of conversion to OR was 9% at 6 years. At multivariate logistic regression analysis, no single factor (short, large or angulated neck, suprarenal fixation, large pre-operative diameter, iliac aneurysms, ASA score risk) was associated with the risk of late failure requiring conversion to OR. Conclusion The risk of death after early conversion should be recognized, to avoid forcing morphological indications for primary EVAR. Occurrence of late conversion after EVAR is not negligible, affecting almost 1 out of 10 patients after 6 years. In the presence of an expanding aneurysm after EVAR, especially after a failed secondary endovascular correction, an aggressive attitude in fit patients allows outcomes at similar to those of primary OR.

Objectives to evaluate the role of endovascular repair (ER) of abdominal aortic aneurysm (AAA) repair in American Society for Anaesthesiology [ASA] class IV patients. Patients and Methods between April 1997 and March 2000, 266 consecutive patients underwent ER for AAA. There were 26 patients (10%) with ASA grade IV. The remaining 240 patients, ASA grade between I and III (ASA

Objective To evaluate and compare changes over time in health-related quality of life reported by patients with small (4.1–5.4 cm) abdominal aortic aneurysms (AAAs) undergoing endovascular aortic aneurysm repair (EVAR) or surveillance. Methods Participants were randomly assigned to receive either early EVAR or surveillance within a multicentre, randomised clinical trial on small AAA (Comparison of surveillance vs. Aortic Endografting for Small Aneurysm Repair, CAESAR). Patient-reported health-related quality of life was assessed before randomisation, at 6 months and yearly thereafter using the Short Form 36 (SF-36) Health Survey. Results Between 2004 and 2008, 360 patients (345 males, mean age 68.9 years) were randomised, 182 to early EVAR and 178 to surveillance. There was one perioperative death. Mean follow-up was 31.8 months. No significant difference in survival was found. At baseline, comparable quality of life scores were recorded in both treatment groups: Total SF-36: 73.0 versus 75.5 ( p = 0.18), Physical domain: 71.4 versus 73.3 ( p = 0.33); Mental health domain: 70.9 versus 72.7 ( p = 0.33), in the EVAR arm versus the surveillance arm, respectively. Six months after randomisation, Total SF-36 and Physical and Mental domain scores were all significantly higher with respect to baseline in the EVAR group, while patients of the surveillance group scored lower. The differences between EVAR and surveillance arms in score changes at 6 months were significant and in favour of EVAR: Total score: difference 5.4; p = 0.0017; Physical: difference 3.8; p = 0.02; and Mental: difference 6.0; p = 0.0005. Differences between EVAR and surveillance diminished over time. At the last assessment, patients in both groups had decreased scores with a significant drop with respect to the baseline (−3.9 in EVAR, −6.3 in surveillance). There were no significant differences between the EVAR and surveillance arms: Total score: p = 0.25; Physical: p = 0.47; and Mental: p = 0.38. Conclusions Patients with small AAA under surveillance compared with early EVAR had significant impaired functional health at 6 months after assignment. After a mean of 31.8 months, SF-36 health-related quality of life in patients allocated to early EVAR and surveillance was similar.

Background: it has been suggested that female patients have a less favourable outcome of endoluminal repair of abdominal aortic aneurysms. Yet, data on stratified per gender are lacking. Methods: we reviewed our prospective database of 402 endografts over a 4-year period and the peri- and postoperative course in the 25 (6%) female patients was compared with the 377 (94%) male patients. Median follow-up was 24 months (range 1-56 months). Logistic regression analysis was performed to test the effect of five confounding variables (gender, age, ASA grade IV, EUROSTAR class D or E, AAA diameter) on failure of AAA exclusion. Results: there were no perioperative deaths in the female group and 5 (1.3%) in the male group ( p = 0.8). Major perioperative morbidity occurred in 17% versus 6% (OR 3.7; 95% CI 1.2-10.6; p = 0.026). There were 1 (4%) and 5 (1%) conversions to open repair in the female and male groups, respectively ( p = 0.3). Late failure of AAA exclusion occurred in 5 (21%) and 26 (7%) patients, respectively ( p = 0.03). Of the five variables examined for their influence on failure of AAA exclusion, female gender (hazard ratio 4.42; 95% CI 1.4-13.4; p = 0.009) and AAA diameter (hazard ratio 1.05; 95% CI 1.009-1.09; p = 0.017), were positive independent predictors of late failure of AAA exclusion on multivariate analysis. Conclusion: endoluminal AAA repair in female patients appear associated with a less favorable outcome when compared to their male counterparts. These data may be taken into consideration when enodoluminal AAA repair is suggested to a female patient. Eur J Vasc Endovasc Surg 26 , 69-73 (2003)

BackgroundRegression of the aneurysmal sac after endovascular repair of abdominal aortic aneurysm (AAA) is an accepted indicator of aneurysm exclusion. This study evaluated the spontaneous decrease in sac diameter over a 10-year period in patients undergoing endovascular aneurysm repair (EVAR) with different stentgrafts.Methods1,450 patients (mean age 73.1 ± 7.7 years; 1,325 male) undergoing EVAR and with a minimum of 1-year computed tomography (CT) imaging were included. Different implanted stentgrafts (n = 622 [42.9%] Zenith, n = 236 [16.3%] AneuRx, n = 179 [12.3%] Talent, n = 83 [5.7%] Endurant, n = 236 [16.3%] Excluder, n = 36 [2.5%] Fortron, 53 [3.7%] Anaconda, n = 5 [0.3%] others) were employed. “Persisting shrinkage” was measured as ≥5 mm AAA diameter regression spontaneously persisting or increasing until the end of follow-up without reintervention. Persisting shrinkage among devices was compared with survival and Cox regression analyses.ResultsDuring a median follow-up of 45 months (interquartile range, IQR, 21–79) persisting shrinkage was detected in 768 (53%) aneurysms. Kaplan–Meier estimates of persisting shrinkage were 25.8% at 1 year, 63% at 3 years and 72.6% at 10 years. Persisting shrinkage rates were significantly higher for Zenith (p

Objective: to validate the role of duplex scan in endoleak detection in postoperative surveillance of endoluminal abdominal aneurysm repair (EAAR). Patients and methods between April 1997 and March 1999, 103 patients were eligible for duplex and computed tomography (CT) scan after EAAR. Mean follow-up was 8 months (range 1–24 months). The study protocol comprised concurrent examination with colour-duplex and CT scan at 1, 6, and 12 months after EAAR, for a total of 198 concurrent examinations. All duplex scan examinations were performed by two vascular surgeons with the same machine (ATL HDI 3000). Interobserver agreement in endoleak detection (κ=1) and in type of endoleak (κ=0.7) was evaluated in 50 random duplex examinations. Endoleak detection was examined comparatively in duplex and CT scan, the latter being the gold standard. Sensitivity and specificity tests together with negative- and positive-predictive values (NPV and PPV) were calculated. Results duplex scan was not feasible in one patient. On CT scan the endoleak rate was 4% at one month, 3% at 6 months, and 4% at one year. Overall, CT scan detected 12 endoleaks. With respect to endoleak detection, duplex scan revealed a great ability in ruling out false-negative results (sensitivity 91.7%, NPV 99.4%), but overestimated the presence of endoleak (specificity 98.4%, PPV 78.6%). Regarding type of endoleak, the ability of duplex scan to identify the source of endoleak was low (sensitivity 66.7%). Conclusions duplex scan, if validated, appears to be a reliable means for excluding the presence of endoleak after EAAR.

Objective: to determine whether the presence of an iliac aneurysm compromises outcome of endovascular exclusion of AAA and to ascertain the fate of the iliac aneurysmal sac. Patients and methods: between April 1997 and March 2001, data on 336 consecutive patients undergoing endovascular repair for AAA were entered in a prospective database. Suitability for endovascular repair was assessed by preoperative contrast-enhanced computed tomography. A maximum common iliac artery (CIA) diameter ≥20mm was defined as iliac aneurysm. Patients with and without iliac aneurysms were compared to early (immediate conversion or perioperative death) and late failure (increase in aneurysm diameter or persisting graft-related endoleak, or late AAA rupture or conversion). Results: fifty-nine patients (18%) had iliac aneurysms, 19 were bilateral, for a total of 78 aneurysmal iliac arteries (median diameter 23mm; range 20–50mm). A distal seal was achieved by landing in 33 external iliac arteries, in 20 ectatic CIAs, and in 25 normal CIAs. Operating time differed significantly between patients with and without CIA aneurysms (153±71 vs 123±55min, p =0.0001), whereas no statistically significant differences were found with respect to early and late failure (2% vs 3%, p =0.5 and 14% vs 8%, p =0.11, respectively). There were no cases of buttock or colon necrosis. At a median follow-up of 14 months (range 0–46; i.q.r. 7–27 months) common iliac diameter decreased ≥2mm in 49 cases, remained stable in 25, and increased ≥2mm in 3. Conclusion: the presence of iliac aneurysm rendered endoluminal AAA repair more complex but did not affect feasibility and long-term outcome of the procedure. In our experience internal iliac exclusion was never associated with significant morbidity. These data may be useful when considering endovascular repair in high-risk patients with challenging anatomy.

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