Search

Objective: After alerts on EndoVascular Aneurysm Seal (EVAS) failure were raised, the European Society for Vascular Surgery (ESVS) Abdominal Aortic Aneurysm (AAA) Clinical Practice Guidelines Writing Committee (WC) initiated a task force with the aim to provide guidance on surveillance and management of patients with implanted EVAS devices.Methods: Based on a scoping review of risk for late serious aortic-related adverse events in patients treated with EVAS for AAA, the ESVS AAA Guidelines WC agreed on recommendations graded according to the European Society of Cardiology (ESC) grading system.Results: EVAS has a very high incidence of late endograft migration resulting in proximal type 1 endoleak with risk of rupture, requiring open conversion with device explantation. The reported mortality rate for elective explantation varies between 0% and 14%, while acute conversion for rupture has a very dismal prognosis with a 67 -75% mortality rate.Conclusion: It is recommended that all patients in whom a Nellix device has been implanted should be identified, properly informed, and enrolled in enhanced surveillance. If device failure is detected, early elective device explantation should be considered in surgically fit patients. The authors, on behalf of the ESVS AAA Guidelines Writing Committee and the ESVS Guidelines Steering Committee.

OBJECTIVE A structured and transparent approach is instrumental in translating research evidence to health recommendations and evidence informed clinical decisions. The aim was to conduct an overview and analysis of principles and methodologies for health guideline development. METHODS A literature review on methodologies, strategies, and fundamental steps in the process of guideline development was performed. The clinical practice guideline development process and methodology adopted by the European Society for Vascular Surgery are also presented. RESULTS Sophisticated methodologies for health guideline development are being applied increasingly by national and international organisations. Their overarching principle is a systematic, structured, transparent, and iterative process that is aimed at making well informed healthcare choices. Critical steps in guideline development include the assessment of the certainty of the body of evidence; evidence to decision frameworks; and guideline reporting. The goal of strength of evidence assessments is to provide well reasoned judgements about the guideline developers' confidence in study findings, and several evidence hierarchy schemes and evidence rating systems have been described for this purpose. Evidence to decision frameworks help guideline developers and users conceptualise and interpret the construct of the quality of the body of evidence. The most widely used evidence to decision frameworks are those developed by the GRADE Working Group and the WHO-INTEGRATE, and are structured into three distinct components: background; assessment; and conclusions. Health guideline reporting tools are employed to ensure methodological rigour and transparency in guideline development. Such reporting instruments include the AGREE II and RIGHT, with the former being used for guideline development and appraisal, as well as reporting. CONCLUSION This guide will help guideline developers/expert panels enhance their methodology, and patients/clinicians/policymakers interpret guideline recommendations and put them in context. This document may be a useful methodological summary for health guideline development by other societies and organisations.

OBJECTIVE: To evaluate the dynamics of the iliac attachment zone after EVAR, and the association with clinical events. METHODS: A tertiary institution's prospective EVAR database was searched to identify common iliac arteries at risk. Internally validated measurements were made, using centre lumen line reconstructions. Iliac dilatation and endograft limb retraction were the main endpoints. Associations between dilatation, retraction, oversizing, and distal seal length were investigated. Association with clinical events (sealing or occlusion) was also explored. RESULTS: Of 452 primary EVAR patients treated from 2004 to 2012, 341 were included (mean age 72 years, 12% female, 597 common iliac arteries). Median follow-up was 4.7 years. At 30 days, the mean iliac diameter increased from 14 mm to 15 mm (p < .001). Over follow-up, it increased to 18 mm (p < .001). Iliac dilatation ≥20% occurred in 295 cases (49.4%) and exceeded the implanted endograft diameter in 170 (28.7%). Limb retraction ≥5 mm was identified in 54 patients (9.1%) and was associated with iliac seal complications (p < 0.001). Iliac endograft extension diameter ≥24 mm (OR 3.3, 95% CI 1.7-6.4) and iliac artery dilatation beyond the endograft (OR 2.1, 95% CI 1.2-3.8) were independent risk factors. Overall, there were 34 (5.7%) iliac seal complications. Retraction of the iliac endograft (OR 1.17 per mm, 95% CI 1.10-1.24) and baseline AAA diameter (1.04 per mm, 95% CI 1.01-1.07) were independent risk factors for seal related complications. Greater initial post-operative iliac seal length was protective (OR 0.94 per mm, 95% CI 0.90-0.97). CONCLUSIONS: Iliac dilatation and endograft retraction are common findings during follow-up, potentially leading to adverse clinical events. Optimisation of the iliac seal zone providing a long distal seal length and added attention to patients with large aneurysms or receiving ≥24 mm diameter iliac extensions are recommended. Also, long-term surveillance including CTA is advised to reveal and correct loss of seal at the iliac attachments before adverse clinical events occur. info:eu-repo/semantics/publishedVersion

Purpose Vascular intervention studies generally consider patency and limb salvage as primary outcomes. However, quality of life is increasingly considered an important patient-oriented outcome measurement of vascular interventions. Existing literature was analyzed to determine the effect of different treatments on quality of life for patients suffering from either claudication or critical limb ischemia. Basic methods A review of the literature was undertaken in the Medline library. A search was performed on quality of life in peripheral arterial disease. Results were stratified according to treatment groups. Principal findings Twenty-one articles described quality of life in approximately 4600 patients suffering from peripheral arterial disease. Invasive treatment generally results in better quality of life scores (at a maximum of 2 years of follow-up), compared with non-invasive treatment. In patients with critical limb ischemia, successful revascularization improves quality of life scores. Only one study reported long-term results. Conclusions Increase in quality of life scores can be found for any intervention performed for peripheral arterial disease. However, there is scarce information on long-term quality of life after vascular intervention.

WHAT THIS PAPER ADDS In this study the influence of low socioeconomic status (SES) on severity of disease at presentation and survival following vascular surgery was assessed. The present data underline the importance of socioeconomic deprivation as a risk factor for delayed presentation and the prognosis of vascular surgical patients independent of healthcare disparities. Therefore, increasing focus on low SES as a risk factor may improve outcome of socioeconomically deprived patients undergoing vascular surgery. Objective/Background: The association between socioeconomic status (SES), presentation, and outcome after vascular surgery is largely unknown. This study aimed to determine the influence of SES on post-operative survival and severity of disease at presentation among vascular surgery patients in the Dutch setting of equal access to and provision of care. Methods: Patients undergoing surgical treatment for peripheral artery disease (PAD), abdominal aortic aneurysm (AAA), or carotid artery stenosis between January 2003 and December 2011 were retrospectively included. The association between SES, quantified by household income, disease severity at presentation, and survival was studied using logistic and Cox regression analysis adjusted for demographics, and medical and behavioral risk factors. Results: A total of 1,178 patients were included. Low income was associated with worse post-operative survival in the PAD cohort (n ¼ 324, hazard ratio 1.05, 95% confidence interval [CI] 1.00e1.10, per 5,000 Euro decrease) and the AAA cohort (n ¼ 440, quadratic relation, p ¼ .01). AAA patients in the lowest income quartile were more likely to present with a ruptured aneurysm (odds ratio [OR] 2.12, 95% CI 1.08e4.17). Lowest income quartile PAD patients presented more frequently with symptoms of critical limb ischemia, although no significant association could be established (OR 2.02, 95% CI 0.96e4.26). Conclusions: The increased health hazards observed in this study are caused by patient related factors rather than differences in medical care, considering the equality of care provided by the study setting. Although the exact mechanism driving the association between SES and worse outcome remains elusive, consideration of SES as a risk factor in pre-operative decision making and focus on treatment of known SES related behavioral and psychosocial risk factors may improve the outcome of patients with vascular disease.

Objective: To assess the incidence and risk factors for proximal aneurysm neck related complications with a late generation device for endovascular abdominal aneurysm repair (EVAR). Methods: Data were retrieved from a prospective registry (Endurant Stent Graft Natural Selection Global Postmarket Registry) involving 79 institutions worldwide. The risk factors tested were age, gender, surgical risk profile, proximal neck length (30 mm), supra- and infrarenal angulation (>60 degrees and 75 degrees), mural thrombus/calcification (>50%) and taper (>10%), and AAA diameter (>65 mm). Two neck related composite endpoints were used, for intra-operative (type-1a endoleak, conversion, deployment/retrieval complication or unintentional renal coverage) and post-operative (type-1a endoleak or migration) adverse events. Independent risk factors were identified using multivariable backwards modeling. Results: The study included 1263 patients (mean age 73, 10.3% female) from March 2009 to May 2011. Twenty three (1.8%) intra-operative adverse events occurred. Neck length 50% (OR 4.8, 95% CI 1.7-13.5) were risk factors for intra-operative events. The planned 1 year follow up visit was reached for the entire cohort, and the 2 year visit for 431 patients. During this time, 99 (7.8%) events occurred. Female gender (HR 1.9, 95% Cl 1.1-3.2), aneurysm diameter >65 mm (HR 2.8, 95% CI 1.9-4.2), and neck length

Objectives To determine the influence of a positive family history for aneurysms on clinical success and mortality after endovascular aneurysm repair (EVAR). Methods From 2009 to 2011, 1262 patients with abdominal aortic aneurysms (AAA) treated by EVAR were enrolled in a prospective, industry sponsored clinical registry ENGAGE. Patients were classified into familial and sporadic AAA patients according to baseline clinical reports. Clinical characteristics, aneurysm morphology, and follow-up were registered. The primary endpoint was clinical success after EVAR, a composite of technical success and freedom from the following complications: AAA increase >5 mm, type I and III endoleak, rupture, conversion, secondary procedures, migration, and occlusion. Secondary endpoints were the individual components of clinical success, 30 day mortality, and aneurysm related and all cause mortality. Results Of the 1262 AAA patients (89.5% male and mean age 73.1 years), 86 patients (6.8%) reported a positive family history and were classified as familial AAA. Duration of follow-up was 4.4 ± 1.7 years. Patients with familial AAA were more often female (18.6% vs. 9.9%, p = .012). No difference was observed in aneurysm morphology. There was no significant difference in clinical success between patients with familial and sporadic AAA (72.1% vs. 79.3%, p= .116). Familial AAA patients had a higher 30 day mortality after EVAR (4.7% vs. 1.0%, adjusted HR 5.7, 1.8–17.9, p = .003) as well as aneurysm related mortality (5.8% vs. 1.3%, adjusted HR 5.4, 1.9–14.9, p = .001), while no difference was observed in all cause mortality (19.8% vs. 24.3%, adjusted HR 0.8, 0.5–1.4, p = .501). Conclusions The current study shows a higher 30 day mortality after EVAR in familial AAA patients. Future studies should determine the role of family history in AAA treatment, suitability for endovascular or open repair, and on adaptation of post-operative surveillance. For the time being, patients with familial forms of AAA should be considered at higher risk for EVAR and warrant extra vigilance.

Objective: The decision whether or not to proceed with surgical intervention of a patient with a ruptured abdominal aortic aneurysm (rAAA) is very difficult in daily practice. The primary objective of the present study was to develop and to externally validate a new prediction model: the Dutch Aneurysm Score (DAS).Methods: With a prospective cohort of 10 hospitals (n = 508) the DAS was developed using a multivariate logistic regression model. Two retrospective cohorts with rAAA patients from two hospitals (n = 373) were used for external validation. The primary outcome was the combined 30 day and in-hospital death rate. Discrimination (AUC), calibration plots, and the ability to identify high risk patients were compared with the more commonly used Glasgow Aneurysm Score (GAS).Results: After multivariate logistic regression, four pre-operative variables were identified: age, lowest in hospital systolic blood pressure, cardiopulmonary resuscitation, and haemoglobin level. The area under the receiver operating curve (AUC) for the DAS was 0.77 (95% CI 0.72-0.82) compared with the GAS with an AUC of 0.72 (95% CI 0.67-0.77). The DAS showed a death rate in patients with a predicted death rate >80% of 83%.Conclusions: The present study shows that the DAS has a higher discriminative performance (AUC) compared with the GAS. All clinical variables used for the DAS are easy to obtain. Identification of low risk patients with the DAS can potentially reduce turndown rates. The DAS can reliably be used by clinicians to make a more informed decision in dialogue with the patient and their family whether or not to proceed with surgical intervention. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Introduction Primary infection of a bare metal stent is a rare condition, associated with significant morbidity and mortality. Definitive treatment includes stent removal and arterial reconstruction. Report This study details a common iliac stent infection after re-intervention for iliac stent occlusion, complicated by pseudoaneurysm formation and septic embolisation. Potential risk factors for stent infection were identified. An open surgical resection of the affected artery along with all stent material was performed, followed by reconstruction with autologous interposition superficial femoral vein. There were no complications and no recurrent infection at 6 months follow-up. Conclusion Although rare, bare metal stent infection may occur, and a high index of suspicion is required. Stent surgical removal and arterial in situ reconstruction with autologous femoral vein proved to be a definitive procedure with no mid-term morbidity., Highlights • Iliac bare metal stent infection is a rare complication associated with morbidity. • Pseudoaneurysm formation and septic embolization are presentation signs. • Stent resection and in situ reconstruction with femoral vein is a definitive treatment. • Re-intervention and use of local antimitotic drugs could be potential risk factors.

Background Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance. Methods Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6–18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks. Results Some 597 EVARs (71·1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47·6 per cent), moderate shrinkage (5–9 mm) in 142 (23·8 per cent) and major shrinkage (at least 10 mm) in 171 patients (28·6 per cent). Four years after the index imaging, the rate of freedom from complications was 84·3 (95 per cent confidence interval 78·7 to 89·8), 88·1 (80·6 to 95·5) and 94·4 (90·1 to 98·7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3·11; P < 0·001). Moderate compared with major shrinkage (HR 2·10; P = 0·022), early postoperative complications (HR 3·34; P < 0·001) and increasing abdominal aortic aneurysm baseline diameter (HR 1·02; P = 0·001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage. Conclusion Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance.

Objectives: The efficacy and need for secondary interventions for type II endoleaks following endovascular abdominal aortic aneurysm repair (EVAR) remain controversial. This systematic review aimed at investigating the clinical outcomes of different type II endoleak treatments in patients with a persistent type II endoleak after EVAR. Data sources: Embase, Medline via Ovid, Web of Science Core Collection, the Cochrane CENTRAL, and Google Scholar. Review methods: This systematic review was performed in accordance with the PRISMA Statement. Outcomes of interest were technical and clinical success, change in sac diameter, complications, need for additional interventions, abdominal aortic aneurysm (AAA) rupture, and (AAA related) mortality. Meta-analyses were performed with random effects models. Results: A total of 59 studies were included, with a cumulative cohort of 1073 patients with persistent type II endoleak. Peri-operative complications following treatment of type II endoleaks occurred in 3.8% of patients (95% CI 2.7–5.2%), and AAA related mortality was 1.8% (95% CI 1.1–2.7%). Overall technical success was 87.9% (95% CI 83.1–92.1%), while clinical success was 68.4% (95% CI 61.2–75.1%). Among studies detailing sac dynamics, decrease or stable sac, with or without resolution, was achieved in 78.4% (95% CI 70.2–85.6%). Changes in sac diameter following type II endoleak treatment were documented in 157 patients to at least 24 months. Within this group an actual decrease in sac diameter was reported in only 27 of 40 patients. Conclusion: There is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR. Although generally safe, the lack of evidence supporting the efficacy of type II endoleak treatment leads to difficulty in assessing its merits.

Response to ‘Re. Spontaneous Delayed Sealing in SelectedPatients with a Primary Type-Ia Endoleak AfterEndovascular Aneurysm Repair’We have become dependent on imaging to define the needfor and timing of interventions after EVAR. Imaging, how-ever, is not without limitations and patients at persistentriskof rupture may frequently be misidentified. Intermittentor position dependent type-I endoleaks are a good exampleof the situation where absence of endoleak on CTA may notbe a perfect surrogate of success.

Objective: To determine if mid-term outcome following endovascular aneurysm repair (EVAR) with the Endurant Stent Graft (Medtronic, Santa Rosa, CA, USA) is influenced by severe proximal neck angulation. Methods: A retrospective case-control study was performed using data from a prospective multicenter database. All measurements were obtained using dedicated reconstruction software and center-lumen line reconstruction. Patients with neck length >15 mm, infrarenal angle (beta) >75 degrees, and/or suprarenal angle (alpha) >60 degrees, or neck length >10 mm with beta >60 degrees, and/or alpha >45 degrees were compared with a matched control group. Primary endpoint was primary clinical success. Secondary endpoints were freedom from rupture, type 1A endoleak, stent fractures, freedom from neck-related reinterventions, and aneurysm-related adverse events. Morphological neck variation over time was also assessed. Results: Forty-five patients were included in the study group and were compared with a matched control group with 65 patients. Median follow-up time was 49.5 months (range 30.5-58.4). The 4-year primary clinical success estimates were 83% and 80% for the angulated and nonangulated groups (p = .42). Proximal neck angulation did not affect primary clinical success in a multivariate model (hazard ratio 1.56, 95% confidence interval 0.55-4.41). Groups did not differ significantly in regard to freedom from rupture (p = .79), freedom from type 1A endoleak (p = .79), freedom from neck-related adverse events (p = .68), and neck-related reinterventions (p = .68). Neck angle reduction was more pronounced in patients with severe proximal neck angulation (mean Delta alpha -15.6 degrees, mean Delta beta -30.6 degrees) than in the control group (mean Delta alpha -0.39 degrees, mean Delta beta -5.9 degrees) (p < .001). Conclusion: Mid-term outcomes following [VAR with the Endurant Stent Graft were not influenced by severe proximal neck angulation in our population. Despite the conformability of the device, moderate aortic neck remodeling was identified in the group of patients with angulated neck anatomy on the first computed tomography scan after implantation with no important further remodeling afterwards. No device integrity failures were encountered. (c) 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Fenestrated endovascular aneurysm repair (fEVAR) is a wellestablished alternative to open repair for patients with juxtarenal or short-neck AAAs. While computed tomography angiography (CTA) is considered the gold standard for surveillance, it bears the risk of contrast nephropathy and exposure to ionizing radiation, and is associated with high cost and resource allocation. Recommendations for standard EVAR have progressively changed to accept Duplex ultrasound (DUS)-based strategies, at least for patients at lower risk of complications. Currently, there are no specific recommendations from scientific societies regarding fEVAR surveillance, but expert opinion suggests close surveillance is necessary to insure lasting results. Gargiulo et al. addressed the issue of surveillance after fEVAR in a retrospective study comparing CTA and fourdimensional contrast-enhanced ultrasound (4D-CEUS). The authors suggest that 4D-CEUS is as accurate as CTA for detecting diameter and volume changes, endoleaks, and revascularized visceral vessel patency.While the conclusions are interesting, these data must be analyzed with caution. In fact, endoleak detection may be sub-optimal, as one in three endoleaks were not detected with CEUS. A sample of 22 patients is clearly underpowered to obtain conclusions that may influence clinical practice. It may be possible that, due to the relative rarity of fEVAR, one may never obtain enough power for robust conclusions. Also, the added value of 4D (compared to “standard” CEUS) appears only pertinent for volumetric measurements. While this is a valuable research tool, it is not regularly used in clinical practice and may have very limited influence on the course of treatment. As such, the present study does not add significantly to the larger study by Perini et al., where CEUS was compared favorably to CTA. Lastly, DUS and CEUS have important limitations that limit its applicability. These are largely related to access to

Objective/background: Endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) has faced resistance owing to the marginal evidence of benefit over open surgical repair (OSR). This study aims to determine the impact of treatment modality on early mortality after rAAA, and to assess differences in postoperative complications and long-term survival. Methods: Patients treated between January 2000 and June 2013 were identified. The primary endpoint was early mortality. Secondary endpoints were postoperative complications and long-term survival. Independent risk factors for early mortality were calculated using multivariate logistic regression. Survival estimates were obtained by means of Kaplan-Meier curves. Results: Two hundred and twenty-one patients were treated (age 72 +/- 8 years, 90% male), 83 (38%) by EVAR and 138 (62%) by OSR. There were no differences between groups at the time of admission. Early mortality was significantly lower for EVAR compared with OSR (odds ratio [OR]: 0.45, 95% confidence interval [Cl]: 0.21-0.97). Similarly, EVAR was associated with a threefold risk reduction in major complications (OR: 0.33, 95%Cl: 0.15-0.71). Hemoglobin level

Objectives Sac growth after endovascular aneurysm repair (EVAR) is an important finding, which may influence prognosis. In case of a type II endoleak or endotension, clipping of side branches and subsequent sac fenestration has been presented as a therapeutic alternative. The long-term clinical efficacy of this procedure is unknown. Methods The study included eight patients who underwent laparoscopic aortic collateral clipping and sac fenestration for enlarging aneurysms following EVAR. Secondary interventions and clinical outcome were retrieved from hospital records. Sac behaviour was evaluated measuring volumes on periodical computed tomography angiography (CTA) imaging using dedicated software. Results Follow-up had a median length of 6.6 (range 0.6–8.6) years. During this time, only three patients successfully achieved durable aneurysm shrinkage ( n = 2) or stability ( n = 1). The remaining patients suffered persistent ( n = 2) or recurrent sac growth ( n = 3), all regarded as failure of fenestration. A total of six additional interventions were performed, comprising open conversion ( n = 2), relining ( n = 1) and implantation of iliac extensions ( n = 3). All additional interventions were successful at arresting further sac growth during the remainder of follow-up. Conclusions Despite being a less invasive alternative to conversion and open repair, the long-term outcome of sac fenestration is unpredictable and additional major procedures were often necessary to arrest sac growth.

The authors of this manuscript present a case where an endoleak was detected in a growing aneurysm sac, after endovascular aneurysm repair. This was presumed to be a type-II EL, and it was not until reconstructions with open source post-processing software were made that they discovered device failure as the origin of the endoleak. This case report clearly underlines the added value of reconstruction software, as it altered the diagnosis from a type II endoleak e the optimal management of which is still debatable e to a type III endoleak, which constitutes a serious and threatening complication requiring expeditious intervention. Although the value of using post-processing software to improve insight in the anatomy and to provide more accurate diameter and length measurements is undisputable, advocating the wide use of OsiriX open-source version has some important pitfalls not highlighted by the authors. First of all, this has not been approved for primary clinical use to our knowledge. This may pose serious ethical and medicolegal issues. Fortunately, there are several commercially available FDA approved alternatives, including OsiriX MD. 1 Second, before adopting reconstruction software in clinical practice, education in post-processing is paramount, as deficient use of these tools may result in misleading information and generate errors in patient management. Apart from the arguments in favor of reconstruction software, the clinical case that was presented also provided some food for thought. The final diagnosis was graft failure as a result of graft material discontinuity in the main body, although no cause of this could be traced. This finding is worrying, especially since the implantationwas only sixteen months before. Mandatory reporting of graft failures should be part of standard care to improve overall quality. Last but not least, this case emphasizes that finding a type II endoleak in a patient with a growing aneurysm should never preclude the search for an alternative, more serious cause for growth. It is of utmost importance to make sure that growth is not caused by a type I a/b or III endoleak. Assuring a generous proximal and distal seal is key in this. Furthermore, contrast-enhanced magnetic resonance using a blood pool agent can help identifying the cause of growth as well, as it has demonstrated that many growing aneurysms without detectable endoleaks on CTA may actually have occult endoleaks.2 Only if one is convinced that no other cause than type II endoleak is present, conservative treatment may be advisable.

After endovascular aneurysm repair (EVAR), an enlarging aneurysm is a concern as it suggests continued pressure and persistent risk of rupture. Improved visualization of endoleaks is therefore desirable, offering, as an alternative to open conversion, therapeutic targets to reverse the tendency for growth. In previous work by Habets et al., blood pool agents have been successfully used for identification of occult endoleaks. 1 The present study by the same group nicely illustrates the use of a weak albumin binding contrast magnetic resonance imaging (MRI) technique that may improve the capacity to detect and better visualize type II endoleaks. 2 As the study focused on patients with growing aneurysms, inherently creating a selection bias, the true incidence of “occult” endoleaks in patients with stable or shrinking aneurysms remains unknown. The absence of formal validation against a gold standard also hinders determination of the sensitivity and predictive value of this new technique. However, these limitations do not invalidate the findings. What remains to be determined is the implication of the endoleaks newly detected on magnetic resonance angiography. It appears undisputed that a newly found type I or III endoleak warrants repair, and therefore identifying them is most valuable. However, in only 11 of 29 patients did the MRI actually detect an endoleak not identified on standard computed tomography angiography surveillance, and the majority were interpreted as type II. In a meta-analysis by Sidloff et al., only 0.04% of patients suffered from rupture allegedly attributed to a type II endoleak. 3 Also, it has recently been suggested that patients with a type II endoleak detected by standard methods may even have improved survival and equivalent aneurysm related mortality. 4 The actual effect of invasive therapy is unclear e intervention directed at the occlusion of type II endoleaks in the 11 patients with previously undetected endoleaks was either unsuccessful or the duration of follow up was too short to render conclusive results. As MRI was not performed post-intervention, the actual failure rate may be even higher. Most importantly, no ruptures were identified. Finally, one more observation should be stressed: in 10% of patients, the cause for continued expansion was not determined, reflecting the lack of knowledge on the mechanisms of post-implant growth. In conclusion, novel methods to improve visualization of endoleaks may be useful in some cases, but the added value and implications should be thoroughly assessed before generalization. Further research focusing on validation of the diagnostic tool and on the outcome of treatment of “newly revealed” endoleaks is necessary.

Objective: Direct additional therapy is advised for type-Ia endoleaks detected on completion angiography after endovascular aneurysm repair (EVAR). Additional intraoperative endovascular procedures are, however, often challenging or not possible, and direct open conversion is unattractive. The results of a selective, conservative strategy for patients with primary type-Ia endoleak has been analysed. Methods: This was a retrospective, single-centre study (UMC, Utrecht, NL). From 2004 to 2008, all patients with a primary type-Ia endoleak and suitable anatomy for EVAR, stentgraft oversizing >= 15%, and optimal deployment were included. Complications during follow-up were studied and all sequential CTA scans were reviewed. These were compared with the remaining patients, treated during the same period. Results: Fifteen patients were included.(14 male, median age 77, range 67-85) with a median aneurysm diameter of 60 mm (48-80), an aneurysm neck diameter of 26 mm (21-32), a neck length of 29 mm (11-39), and infrarenal angulation of 49 degrees (31-90). One patient suffered rupture 2 days after EVAR leading to the only AAA-related death. Eight of the 15 type-Ia endoleaks disappeared spontaneously on the first postoperative CIA, obtained within 1 week of EVAR. On the second postoperative CIA, obtained a median of 5 months (1-12) after EVAR, all remaining endoleaks had sealed. One recurrence occurred at 4.85 years. During a median follow-up of 3.3 years, there were five secondary interventions. Compared with controls, there were more secondary (or recurrent) type-1a endoleaks (13% vs. 4%), endograft migrations (13% vs. 3%), sac growths (33% vs. 16%), and secondary interventions (33% vs. 23%). None of these differences however, were statistically significant. Conclusions: All but one of the primary type-Ia endoleaks sealed spontaneously. Until sealing, the risk of rupture persisted, but subsequently only one recurrence of type-Ia endoleak was seen. In selected patients, a conservative approach for primary type-Ia endoleaks may be justified. (C) 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Objective: Angulation of the proximal aneurysm neck has been associated with adverse outcome after EVAR. We aim to investigate the influence of angulation on early results when using the Endurant Stentgraft System. Methods: A retrospective analysis of a prospective multicentre database identified 45 elective patients treated with the Endurant stentgraft with severe angulation of the proximal neck, which were compared to a control group without significant angulation. Endpoints were early technical and clinical success, deployment accuracy and differences in operative details. Results: Mean age was 74 with 86.4% males. Mean infrarenal angle (beta) was 80.8 degrees +/- 16 and mean suprarenal angle (alpha) was 51.4 degrees +/- 21. Patients in the angulated group had larger aneurysms (mean 309 cc vs. 187 cc), shorter necks (mean 27 mm +/- 14 vs. 32.6 mm +/- 13) and 74% (vs. 56%) were ASA III/IV. Technical success was 100%, with one patient requiring an unplanned proximal extension. No differences were found regarding early type-I endoleaks (0% vs. 0%), major postoperative complications (6.7% vs. 6.2%; p = 0.77) or early survival (97.8% vs. 96.9%, p = 0.79). Distance from lowest renal artery to prosthesis was 2.4 mm +/- 2.7 vs. 2.3 mm +/- 4.8, p = 0.9. Operative details were equivalent for both groups. Conclusions: Treatment with the Endurant stentgraft is technically feasible and safe, with satisfactory results in angulated and non-angulated anatomies alike. No sealing length was lost in extremely angulated cases, confirming the device's high conformability. Mid- and long-term data are awaited to verify durability, but early results are promising and challenge current opinion concerning neck angulation. (C) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.