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European Journal of Vascular and... Sep 2020Occupational exposure is a growing concern among the endovascular specialist community. Several types of imaging equipment are available, such as mobile C arms or hybrid...
OBJECTIVE
Occupational exposure is a growing concern among the endovascular specialist community. Several types of imaging equipment are available, such as mobile C arms or hybrid rooms, and some have been shown to deliver higher levels of radiation. A literature review was conducted to identify studies reporting dose data during standard (EVAR) and complex abdominal aortic endovascular repair (fenestrated/branched EVAR [F/BEVAR]).
METHODS
A search of the MEDLINE and the Cochrane databases was performed by two independent investigators using the medical subject heading terms "aortic aneurysms", "radiation", and "humans" over a search period of 10 years. Studies with full text available in English and reporting radiation data independently from the imaging equipment type were included. Experimental studies were excluded.
RESULTS
The lowest dose-area product levels during EVAR and F/BEVAR were identified in hybrid rooms, while the highest were with fixed systems. When adherence to the as low as reasonably achievable principles was stipulated by the authors, dose reports tended to be among the lowest. Several studies, especially of F/BEVAR, report concerning levels of radiation for both patients and staff.
CONCLUSION
Modern imaging equipment type, team involvement with radiation management, and the support of recent imaging technologies such as fusion help to reduce the dose delivered during standard and complex EVAR. Investment in modern imaging technology should be considered in every centre providing endovascular management of aortic aneurysms.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Endovascular Procedures; Humans; Occupational Exposure; Occupational Health; Operating Rooms; Radiation Dosage; Radiation Exposure; Radiation Protection; Radiography, Interventional; Risk Assessment; Risk Factors; Scattering, Radiation
PubMed: 32682690
DOI: 10.1016/j.ejvs.2020.05.036 -
Quantitative Imaging in Medicine and... Jun 2020Abnormally invasive placenta (AIP) is a potentially severe condition. To date, arterial embolization in women with postpartum hemorrhage due to AIP is the treatment... (Review)
Review
Abnormally invasive placenta (AIP) is a potentially severe condition. To date, arterial embolization in women with postpartum hemorrhage due to AIP is the treatment option for which highest degrees of evidence are available. However, other techniques have been tested, including prophylactic catheter placement, balloon occlusion of the iliac arteries and abdominal aorta balloon occlusion. In this systematic review, we provide an overview of the currently reported interventional radiology procedures that are used for the treatment of postpartum hemorrhage due to AIP and suggest recommendations based on current evidences. Owing to a high rate of adverse events, prophylactic occlusion of internal iliac arteries should be used with caution and applied when the endpoint is hysterectomy. On the opposite, when a conservative management is considered to preserve future fertility, uterine artery embolization should be the preferred option as it is associated with a hysterectomy rate of 15.5% compared to 76.5% with prophylactic balloon occlusion of the internal iliac arteries and does not result in fetal irradiation. Limited data are available regarding the application of systematic prophylactic embolization and no comparative studies with arterial embolization are available.
PubMed: 32550143
DOI: 10.21037/qims-20-548 -
Folia Morphologica 2021The aim of this study is to present the level of aortic bifurcation in a sample of Greek origin (case series) and to perform an up-to-date systematic review in the...
BACKGROUND
The aim of this study is to present the level of aortic bifurcation in a sample of Greek origin (case series) and to perform an up-to-date systematic review in the existing literature.
MATERIALS AND METHODS
Seventy-six formalin-fixed adult cadavers were dissected and studied in order to research the level of aortic bifurcation. Additionally, PubMed and Google Scholar databases were searched for eligible articles concerning the level of aortic bifurcation for the period up to February 2020.
RESULTS
The mean level of aortic bifurcation according to our case series was the lower third of the L4 vertebral body (21/76, 27.6%). The level of aortic bifurcation ranged between the lower third of the L3 vertebral body and the lower third of the L5 body. No statistically significant correlation was found between the two sexes. The systematic review of the literature revealed 31 articles which were considered eligible and a total number of 3537 specimens were retracted. According to the recorded findings the most common mean level of aortic bifurcation was the body of L4 vertebra (1495/3537 cases, 42.2%), while the range of aortic bifurcation was described to occur from upper third of L3 vertebrae to the upper third of the S1 vertebrae in the 52.8% of the cases (1866/3537).
CONCLUSIONS
The mean level of AA corresponds to the body of L4 and presents a great range (form L3U to S1U). Knowledge of the mean level of aortic bifurcation and its probable ranges is of great significance for interventional radiologists and especially vascular surgeons that deal with aneurism proximal to the aortic bifurcation.
Topics: Adult; Aorta, Abdominal; Cadaver; Greece; Humans; Lumbar Vertebrae; Sacrum
PubMed: 32488853
DOI: 10.5603/FM.a2020.0064 -
Journal of Vascular Surgery Sep 2020The efficacy and safety of placement of a proximal covered stent graft combined with a distal bare stent are controversial because of the lack of evidence. This... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The efficacy and safety of placement of a proximal covered stent graft combined with a distal bare stent are controversial because of the lack of evidence. This systematic review and meta-analysis compared the outcomes of combined proximal covered stent grafting with distal bare stenting (BS group) and proximal covered stent grafting without distal bare stenting (non-BS group).
METHODS
The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases and key references were searched up to January 26, 2019. Predefined outcomes of interest were mortality, morbidity, and postoperative assessment of aortic remodeling. We pooled risk ratios (RRs) of the outcomes of interest using fixed effects model or random effects model.
RESULTS
Overall, eight observational studies involving 914 patients were included. There were no significant differences in overall aorta-related mortality (RR, 0.54; confidence interval [CI], 0.24-1.24; P = .15), complete thoracic false lumen (FL) thrombosis rate (RR, 1.23; CI, 0.83-1.81; P = .30), or complete abdominal FL thrombosis rate (RR, 1.96; CI, 0.68-5.69; P = .21) between the BS group and the non-BS group. The BS group had a lower rate of partial thoracic FL thrombosis (RR, 0.40; CI, 0.25-0.65; P = .0002), a lower stent graft-induced new entry rate (RR, 0.08; CI, 0.02-0.41; P = .003), and a lower reintervention rate (RR, 0.42; CI, 0.26-0.69; P = .0005).
CONCLUSIONS
Combined proximal covered stent grafting with distal adjunctive bare stenting had the potential to reduce the partial thoracic FL thrombosis rate and the rates of stent graft-induced new entry and reintervention but was not associated with lower aorta-related mortality or the complete FL thrombosis rate. Further research with a stricter methodology is needed.
Topics: Aortic Dissection; Aortic Aneurysm; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Female; Humans; Male; Middle Aged; Observational Studies as Topic; Risk Assessment; Risk Factors; Stents; Treatment Outcome
PubMed: 32304727
DOI: 10.1016/j.jvs.2020.02.052 -
Cureus Feb 2020Isolated renal artery dissection (IRAD) is a rare and often unrecognized clinical entity, with a paucity of data on its epidemiology and management. We extracted 129... (Review)
Review
Isolated renal artery dissection (IRAD) is a rare and often unrecognized clinical entity, with a paucity of data on its epidemiology and management. We extracted 129 cases of IRAD from the medical literature between 1972 and 2016. IRAD as a result of an extended dissection from the aorta and splanchnic or mesenteric arteries was excluded. The mean age of presentation was 42.7±12.9 years, with a male predominance (79%). Abdominal pain (75.9%) was the most common presenting symptom. Etiology was more likely to be spontaneous (76%) than traumatic (12%), iatrogenic (9%), or drug-induced (1.5%). The most common risk factors were hypertension (28.7%), fibromuscular dysplasia (8.5%), and Ehlers-Danlos syndrome (5.4%). Unilateral renal artery dissection (right 45.5%, left 40.5%) was more frequent than bilateral (14%). More than half (56.6%) of the cohort were managed medically (blood pressure control and /or anticoagulation). Of those who underwent intervention, endovascular stenting or embolization (35%) was utilized more frequently than nephrectomy or bypass (21%). Computed tomography (CT) and magnetic resonance angiography (MRA) have the highest diagnostic sensitivity (91% and 93%, respectively) as compared to ultrasonography (27%). A high degree of clinical suspicion is required to diagnose IRAD. CT and MRI have a higher diagnostic sensitivity. As compared to invasive management, conservative management has comparable outcomes.
PubMed: 32076589
DOI: 10.7759/cureus.6960 -
European Journal of Vascular and... May 2020To investigate the effect of hostile aortic anatomy on the outcomes of endovascular and open repair for ruptured abdominal aortic aneurysm (AAA). (Comparative Study)
Comparative Study Meta-Analysis
Systematic Review and Meta-Analysis of Outcomes of Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysm in Patients with Hostile vs. Friendly Aortic Anatomy.
OBJECTIVE
To investigate the effect of hostile aortic anatomy on the outcomes of endovascular and open repair for ruptured abdominal aortic aneurysm (AAA).
METHODS
Electronic bibliographic sources (MEDLINE, EMBASE, CENTRAL) were searched using a combination of thesaurus and free text terms to identify studies comparing treatment outcomes of ruptured AAA in patients with hostile vs. friendly aortic anatomy. A systematic review was conducted that conformed to the PRISMA guidelines using a registered protocol (CRD42019127307). The primary outcomes were peri-operative mortality, freedom from aneurysm related mortality, and overall survival. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) and 95% confidence interval (CI). A time to event data meta-analysis was conducted using the inverse variance method and the results were reported as summary hazard ratio (HR) and associated 95% CI. Subgroup analysis for type of treatment (endovascular aneurysm repair [EVAR] or open repair) was undertaken. Random effects models of meta-analysis were developed.
RESULTS
Ten observational studies were included reporting a total of 1284 patients (748 with hostile anatomy and 536 with friendly anatomy). Patients with hostile anatomy had a higher peri-operative mortality than patients with friendly anatomy (OR 1.73, 95% CI 1.13-2.66; p = .01). Subgroup analysis showed a significant difference in peri-operative mortality in favour of friendly anatomy in patients treated by EVAR (OR 1.76, 95% CI 1.01-3.08; p = .05), but not in those treated by open repair (OR 1.37, 95% CI 0.83-2.27; p = .22). Patients with hostile anatomy treated by EVAR had a significantly higher hazard of death in follow up than patients with friendly aortic anatomy (HR 2.01, 95% CI 1.18-3.44, p = .01), whereas for open surgical repair, the survival was similar in patients with hostile and those with friendly aortic anatomy (HR 0.90, 95% CI 0.61-1.32, p = .58).
CONCLUSION
Hostile aortic anatomy is associated with increased mortality in patients with ruptured AAA treated by EVAR.
Topics: Aorta; Aortic Aneurysm, Abdominal; Aortic Rupture; Endovascular Procedures; Humans; Treatment Outcome
PubMed: 31948911
DOI: 10.1016/j.ejvs.2019.12.024 -
European Journal of Vascular and... Apr 2020To present the pooled quantitative evidence of basic profiles, initial treatment strategies, and clinical outcomes in patients with isolated abdominal aortic dissection... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To present the pooled quantitative evidence of basic profiles, initial treatment strategies, and clinical outcomes in patients with isolated abdominal aortic dissection (IAAD).
METHODS
A comprehensive systematic review and meta-analysis was performed of all available studies reporting IAAD, retrieved from the MEDLINE, Embase, and Cochrane Databases. The logistic normal random effect model was fitted using the generalised linear mixed model with random intercepts to calculate the pooled proportion estimates.
RESULTS
Seventeen studies with 482 patients were included in this meta-analysis. Male smokers with hyperlipidaemia and hypertension were the most prominent basic profile. IAADs were predominantly spontaneous and infrarenal, and roughly half were acute and symptomatic. Approximately 67% [95% confidence interval (CI) 42-86%] of patients were managed initially conservatively. In the overall population, the 30 day all cause mortality was 3% (95% CI 1-5%) and the long term mortality during follow up was 8% (95% CI 5-14%). Re-intervention during follow up occurred in 8% (95% CI 5-15%) of patients. In the subgroup analysis, patients with conservative treatment had a 30 day mortality of 1% (95% CI 0-8%), a long term mortality of 5% (95% CI 1-29%), and a re-intervention rate of 18% (95% CI 10-29%). Patients with open surgery had a 30 day mortality of 9% (95% CI 0-82%), a long term mortality of 12% (95% CI 4-31%), and a re-intervention rate of 9% (95% CI 1-44%). Patients with endovascular repair had a 30 day mortality of 2% (95% CI 0-10%), a long term mortality of 5% (95% CI 2-13%), a re-intervention rate of 6% (95% CI 3-13%), and a persistent endoleak rate of 4% (95% CI 2-10%).
CONCLUSION
Appropriate initial treatment strategies can be used to obtain acceptable clinical outcomes in patients with IAAD. Invasive intervention is necessary if patients match certain indications for intervention. Regular imaging surveillance should be provided for all patients, especially those treated conservatively.
Topics: Aortic Dissection; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Humans; Risk Factors
PubMed: 31822385
DOI: 10.1016/j.ejvs.2019.05.013 -
The Cochrane Database of Systematic... Oct 2019Aortic dissection is a separation of the aortic wall, caused by blood flowing through a tear in the inner layer of the aorta. Aortic dissection is an infrequent but... (Meta-Analysis)
Meta-Analysis
Combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair for complicated type B aortic dissections.
BACKGROUND
Aortic dissection is a separation of the aortic wall, caused by blood flowing through a tear in the inner layer of the aorta. Aortic dissection is an infrequent but life-threatening condition. The incidence of aortic dissection is 3 to 6 per 10,000 per year in the Western population, and can be up to 43 per 10,000 per year in the Eastern population. Over 20% of people with an aortic dissection do not reach a hospital alive. After admission, the mortality rates for people with an aortic dissection are between 10% and 20% for those who received endovascular treatment, and between 20% and 30% for those who had open surgery. Thoracic endovascular aortic repair (TEVAR) is the standard endovascular method to treat complicated type B aortic dissection (aortic dissections without involvement of the ascending aorta). Although TEVAR is less invasive than open surgery and has a better long-term aortic remodeling effect than conservative medical treatment, favourable aortic remodelling is usually limited to the thoracic aortic segment. TEVAR cannot be extended into the abdominal aorta because it could cover the ostia of the reno-visceral arteries. Thus, the abdominal aorta is still at risk of progressive aneurysmal degeneration. The PETTICOAT (provisional extension to induce complete attachment) technique, with proximal endograft and distal bare metal stent, was proposed in 2006 to address this issue. The concept of this technique was to implant a distal bare metal stent into the aortic true lumen, distal to the proximal endograft, to stabilize the distal collapsed intimal flap, while allowing blood flow to reno-visceral arteries. Therefore, the PETTICOAT technique was considered to be related to a more extensive aortic remodelling for people with type B aortic dissection, especially in the area of the abdominal aorta. However, it is still unclear whether the PETTICOAT technique is superior to standard TEVAR.
OBJECTIVES
To assess the effects of combined proximal descending aortic endografting plus distal bare metal stenting versus conventional proximal descending aortic stent graft repair for treating complicated type B aortic dissections.
SEARCH METHODS
The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2018. We also undertook reference checking and citation searching to identify additional studies.
SELECTION CRITERIA
We considered all randomised controlled trials which compared the outcome of complicated type B aortic dissection, when treated by combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) versus conventional proximal descending aortic stent graft repair.
DATA COLLECTION AND ANALYSIS
Two independent review authors assessed all references identified by the Cochrane Vascular Information Specialist. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions.
MAIN RESULTS
We found no trials that met the inclusion criteria for this review.
AUTHORS' CONCLUSIONS
We identified no randomised controlled trials and therefore cannot draw any definite conclusion on this topic. Evidence from non-randomised studies appears to be favourable in the short-term, for combined proximal descending aortic endografting plus distal bare metal stenting (PETTICOAT technique) to solve the problem of unfavourable distal aortic remodeling. Randomised controlled trials are warranted to provide solid evidence on this topic. Evidence from cohort studies with large sample sizes would also be helpful in guiding clinical practice.
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Randomized Controlled Trials as Topic; Stents
PubMed: 31684692
DOI: 10.1002/14651858.CD013149.pub2 -
Annals of Vascular Surgery Jan 2020This study aimed to synthesize data from recently published literature to evaluate the safety and efficacy of endovascular treatment (EVT) for infrarenal aortic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
This study aimed to synthesize data from recently published literature to evaluate the safety and efficacy of endovascular treatment (EVT) for infrarenal aortic occlusion (IAO).
METHODS
The PubMed and Embase were searched to identify all studies reporting EVT for IAO from January 1st, 2000 to December 31st, 2017. Information about patients' characteristics, comorbidities, technical success, mortality, complications, and patency was collected and analyzed.
RESULTS
9 articles consisting of 220 patients were included in this meta-analysis. Patients often had severe symptoms and many comorbidities. The overall technical success and periprocedural mortality was 95.64% (95% confidence interval [CI], 88.60%-99.42%) and 0.35% (95% CI, 0.00% to 2.33%). In successful cases, ankle-brachial index was raised from 0.42 to 0.91. The complication described in one article is of the whole samples and that of the technical success cases was not represented separately. We made the meta-analysis on the other 8 articles. Periprocedural complications included vascular complications (11.35% [95% CI: 3.50%-19.20%]) mainly pseudoaneurysm, thromboses, hematoma, and dissections; limb complications 8.28% (95% CI: 4.86%-13.77%); and renal complications 1.25% (95% CI: 0.00%-3.65%). In an article, vascular complications of whole samples were 12.24%, limb complication 6.12%, and renal complication 10.20%. Overall primary patency was 93.53% (95% CI: 89.37%-97.68%) at 1 year, 78.96% (95% CI: 72.26%-84.96%) at 3 years, and 75.31% (95% CI: 66.42%-84.20%) at 5 years. Overall secondary patency was 98.25% (95% CI: 95.50%-99.73%) at 1 year, 95.92% (95% CI: 89.25%-99.47%) at 3 years, and 94.02% (95% CI: 88.10%-98.00%) at 5 years.
CONCLUSIONS
EVT for IAO is acceptable with relatively high technical success rate, low mortality, and satisfying short-term patency. Although primary patency was lower than after surgery, secondary patency was roughly similar to that of surgical repair. However, this conclusion is based on retrospective observational studies, and the results could be imprecise due to the limited sample sizes, especially in midterm and long-term patency. More studies with longer follow-up and bigger sample size are needed to further elucidate this.
Topics: Aged; Angioplasty, Balloon; Aorta, Abdominal; Aortic Diseases; Arterial Occlusive Diseases; Female; Humans; Male; Middle Aged; Recurrence; Risk Assessment; Risk Factors; Stents; Time Factors; Treatment Outcome; Vascular Patency
PubMed: 31415817
DOI: 10.1016/j.avsg.2019.05.034 -
European Journal of Vascular and... Sep 2019The aim of this systematic literature review was to compile an updated overview of mycotic aortic aneurysm (MAA) treatment and outcomes.
OBJECTIVES
The aim of this systematic literature review was to compile an updated overview of mycotic aortic aneurysm (MAA) treatment and outcomes.
METHODS
A systematic literature review was performed using the search terms mycotic and infected aortic aneurysms in the MEDLINE and ScienceDirect databases, published between January 2000 and September 2018. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, articles were scrutinised regarding surgical technique, aortic segment involved, pre- and post-operative antibiotic regimens, survival and infection related complications (IRCs), and factors associated with adverse or favourable outcomes.
RESULTS
Twenty-eight studies, with a total of 963 patients, were included. All publications were observational, retrospective studies. Patient and study heterogeneity, along with missing data, precluded meta-analyses. Overall treatment consisted of open surgical repair (OSR; n = 556 [58%]), endovascular aortic repair (EVAR; n = 373 [39%]), and medical treatment alone (n = 34 [3%]). OSR was the dominant surgical technique prior to 2010, shifting to EVAR thereafter. For MAAs located in the abdominal aorta, EVAR was associated with better short term survival than OSR. Antibiotic treatment for more than six months post-operatively was associated with better survival, but there was no consensus on the length of treatment. MAAs were complicated by IRCs in 21%, irrespective of surgical technique, of which 46%-70% were fatal. The most consistently reported factors associated with adverse outcomes were increasing age, rupture, suprarenal abdominal aneurysm location, and non-Salmonella positive culture.
CONCLUSIONS
With few exceptions, the literature mainly consists of small, retrospective single centre studies. Standardised reporting is needed to increase comparability of studies. EVAR appears to be associated with superior short term survival without late disadvantages, compared with OSR. This suggests that EVAR can be an acceptable alternative to OSR. However, MAA treatment should always be tailor made and planned individually, and general recommendations are in vain. IRCs pose a significant threat to patients after MAA repair and require further investigation.
Topics: Aneurysm, Infected; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Disease Management; Endovascular Procedures; Humans
PubMed: 31320247
DOI: 10.1016/j.ejvs.2019.05.004