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Infrarenal EVAR for Penetrating Aortic Ulcer: A Comparative Study with Abdominal Aortic Aneurysm

      Highlights

      • In infrarenal aorta, penetrating aortic ulcers are more symptomatic than fusiform aneurysms.
      • Narrow aortic bifurcation, extensive calcification are typical of penetrating aortic ulcers.
      • Outcomes of EVAR for penetrating aortic ulcer is comparable with aneurysm ones.

      Background

      Endovascular aortic repair (EVAR), currently the preferred treatment for abdominal aortic aneurysm (AAA), has been described also for penetrating aortic ulcers (PAU) of the infrarenal aorta. However, data on its performance in this particular setting are still sparse in the literature. Aim of this study is to compare patient clinical characteristics, aorto-iliac features, and post-operative outcomes between infrarenal PAU and AAA treated by standard EVAR.

      Methods

      In this retrospective observational case-control multicenter study, the patients treated for infrarenal PAU (G1) with EVAR in 2 high-volume European centers from January 2014 to December 2019 were prospectively entered into a dedicated database and retrospectively analyzed. A 4-fold control group (G2) of infrarenal AAA patients, homogeneous for age and gender, was also considered. Preoperative clinical characteristics, aorto-iliac features (rupture, aortic maximum diameter, proximal neck diameter and length, aortic bifurcation diameter, distance between the lowest renal artery and the aortic bifurcation [RA-AoBi], severe aortic calcification), technical success, 30-day (morbidity, reintervention, complications, mortality) and follow-up outcomes (freedom from reintervention [FFR] and survival) were compared in the 2 groups (chi square/Fisher exact test, t-student test, Mann-Whitney test, logistic regression and Kaplan-Meier analysis).

      Results

      Seventy-three patients (age 78 ± 7 years; male 84.9%) were included in G1 and 299 (age 78.4 ± 6.6 years; male 89.3%) in G2. At the time of diagnosis, G1 patients were more often symptomatic compared with G2 (odds ratio OR 10.21, 95% confidence interval CI 4.17–24.99, P < 0.001). At preoperative computed tomography angiography, G1 patients had more ruptures (OR 8.11, 95% CI 3.50–18.78, P < 0.001), smaller maximum diameter (OR 1.05, 95% CI 1.03–1.08, P < 0.001), longer and narrower proximal neck (OR 0.97, 95% CI 0.95–0.99, P = 0.020 and OR 1.47, 95% CI 1.32–1.64, P < 0.001, respectively) narrower aortic bifurcation (OR 1.34, 95% CI 1.24–1.45, P < 0.001), lower RA-AoBi (OR 1.09, 95% CI 1.07–1.12, P < 0.001), and more severe aortic calcification (OR 57, 95% CI 16–198, P = 0.001). Technical success (G1 98.6% vs G2 95.7% P = 0.320), 30-day morbidity (G1 2.7% vs G2 8.7% P = 0.133), reintervention (G1 2.7% vs G2 2.3% P = 0.691), complications (G1 6.8% vs G2 8% P = 0.737) and mortality (G1 1.4% vs 2% P = 0.720) were comparable in the 2 groups. The mean follow-up was 17.7 ± 16.4 months in G1 and 18.8 ± 15.1 in G2 (P = 0.576). Late FFR and survival were comparable in the 2 groups (1-year FFR: G1 94.8% vs G2 97.5%, P = 0.995; 1-year survival: G1 91.7% vs G2 92.3%, P = 0.960).

      Conclusions

      Infrarenal PAU are more often symptomatic with a higher rupture rate compared to infrarenal AAA. Despite some negative anatomical characteristics (narrower aortic bifurcation, lower RA-AoBi, extensive calcification), the results of EVAR are extremely satisfactory in this setting, suggesting that endovascular exclusion could be considered a valid treatment for infrarenal PAU.
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      References

        • Vilacosta I.
        • San Román J.A.
        Acute aortic syndrome.
        Heart. 2001; 85: 365-368
        • Gifford S.M.
        • Duncan A.A.
        • Greiten L.E.
        • et al.
        The natural history and outcomes for thoracic and abdominal penetrating aortic ulcers.
        J Vasc Surg. 2016; 63: 1182-1188
        • Flohr T.R.
        • Hagspiel K.D.
        • Jain A.
        • et al.
        The history of incidentally discovered penetrating aortic ulcers of the abdominal aorta.
        Ann Vasc Surg. 2016; 31: 8-17
        • Wanhainen A.
        • Verzini F.
        • Van Herzeele I.
        • et al.
        Editor's choice - European society for vascular surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms.
        Eur J Vasc Endovasc Surg. 2019; 57: 8-93
        • Greenhalgh R.M.
        • Brown L.C.
        • Kwong G.P.
        EVAR trial participants. Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial.
        Lancet. 2004; 364: 843-848
        • Hyhlik-Dürr A.
        • Geisbüsch P.
        • Kotelis D.
        • et al.
        Endovascular repair of infrarenal penetrating aortic ulcers: a single-center experience in 20 patients.
        J Endovasc Ther. 2010; 17: 510-514
        • Nathan D.P.
        • Boonn W.
        • Lai E.
        • et al.
        Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease.
        J Vasc Surg. 2012; 55: 10-15
        • Georgiadis G.S.
        • Trellopoulos G.
        • Antoniou G.A.
        • et al.
        Endovascular therapy for penetrating ulcers of the infrarenal aorta.
        ANZ J Surg. 2013; 83: 758-763
        • Mak P.
        • Campbell R.
        • Irwin M.
        • et al.
        The ASA physical status classification: interobserver consistency. American Society of Anesthesiologists.
        Anaesth Intensive Care. 2002; 30: 633640
        • Chaikof E.L.
        • Blankensteijn J.D.
        • Harris P.L.
        • et al.
        Reporting standards for endovascular aortic aneurysm repair.
        J Vasc Surg. 2002; 35: 1048-1060
        • Grimes D.A.
        • Schulz K.F.
        Compared to what? Finding controls for case-control studies.
        Lancet. 2005; 365: 1429-1433
        • Czerny M.
        • Schmidli J.
        • Adler S.
        • et al.
        Editor's choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European association for cardio-thoracic surgery (EACTS) & the European society for vascular surgery (ESVS).
        Eur J Vasc Endovasc Surg. 2019; 57: 165-198
        • Oderich G.S.
        • Tallarita T.
        Classification systems relevant to complex endovascular aortic repair.
        in: Oderich G.S. Endovascular Aortic Repair. 1st ed. Springer International Publishing AG, Cham, Switzerland2017: 72-93
        • Calero A.
        • Illig K.A.
        Overview of aortic aneurysm management in the endovascular era.
        Semin Vasc Surg. 2016; 29: 3-17
        • Chaikof E.L.
        • Dalman R.L.
        • Eskandari M.K.
        • et al.
        The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.
        J Vasc Surg. 2018; 67: 2-77.e2
        • Patel H.J.
        • Sood V.
        • Williams D.M.
        • et al.
        Late outcomes with repair of penetrating thoracic aortic ulcers: the merits of an endovascular approach.
        Ann Thorac Surg. 2012; 94 (discussion: 522-3): 516-522
        • Oderich G.S.
        • Kärkkäinen J.M.
        • Reed N.R.
        • et al.
        Penetrating aortic ulcer and intramural hematoma.
        Cardiovasc Intervent Radiol. 2019; 42: 321-334
        • Rokosh R.S.
        • Shah N.
        • Safran B.
        • et al.
        Natural history, clinical significance, and the role of vascular referral in the management of penetrating ulcers of the abdominal aorta.
        Ann Vasc Surg. 2020; 67: 338-345
        • Georgiadis G.S.
        • Antoniou G.A.
        • Georgakarakos E.I.
        • et al.
        Surgical or endovascular therapy of abdominal penetrating aortic ulcers and their natural history: a systematic review.
        J Vasc Interv Radiol. 2013; 24: 1437-1449.e3
        • Salim S.
        • Locci R.
        • Martin G.
        • et al.
        Short- and long-term outcomes in isolated penetrating aortic ulcer disease.
        J Vasc Surg. 2020; 72: 84-91
        • Gabel J.A.
        • Tomihama R.T.
        • Abou-Zamzam Jr., A.M.
        • et al.
        Early surgical referral for penetrating aortic ulcer leads to improved outcome and overall survival.
        Ann Vasc Surg. 2019; 57: 29-34
        • Engelberger S.
        • Prouse G.
        • Riva F.
        • et al.
        Outcome of tubular aortoaortic endografts in infrarenal aneurysmal disease and penetrating abdominal aortic ulcers-a long-term follow-up.
        Ann Vasc Surg. 2020; 62: 206-212
        • Saratzis N.
        • Melas N.
        • Saratzis A.
        • et al.
        Midterm results of a modified technique for implanting tube grafts during endovascular abdominal aortic aneurysm repair.
        J Endovasc Ther. 2008; 15: 433-440
        • Kruszyna Ł.
        • Dzieciuchowicz Ł.
        • Strauss E.
        • et al.
        Midterm results of the treatment of penetrating abdominal aortic or iliac artery ulcer with the BeGraft balloon-expandable covered stent-A single-center experience.
        Ann Vasc Surg. 2020; 69: 382-390