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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Article Info
Publication History
Published online: July 31, 2022
Accepted:
June 30,
2022
Received:
April 19,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
