Prof. Franco Grego - MAC Conference 2016past.mac-conference.com/xconfig/upload/files/$03-Fr_F....

www.chirurgiavascolarepadova.it

Prof. Franco Grego

UNIVERSITY OF PADUADEPARTMENT OF VASCULAR AND ENDOVASCULAR SURGERY

Director: Prof. F. GREGO

Predictors of endoleak type II risk, in the era of prevention

with aneurysm sac fillingduring EVAR


NO DISCLOSURE

UNIVERSITY OF PADUADEPARTMENT OF VASCULAR AND ENDOVASCULAR SURGERY

Director: Prof. F. GREGO


Background

• Endoleak type II (EII), is a frequent complication (10-40%) of EVAR

• Most of EIIs are benign and spontaneously resolve, but some EIIs are associated to sac growth and risk of rupture

• EII endovascular treatment is associated to technical failure in 40% of cases

• In this scenario, EII prevention appears as a reasonable approach


How to prevent EII?

BRANCHES EMBOLIZATION SAC EMBOLIZATION

EVAS


When?

DURING EVAR• Exposure to a single procedure• Time-consuming compared to

standard EVAR• Technical feasibility

BEFORE EVAR• Exposure to the risks of 2

different procedures• Contrast and radiation exposure• Infection risk• Costs


Who?All patients

Routinely aneurysm sac embolization has been demonstrated to be effective in reducing the rate of EII’s and EII-related reinterventions

However, a selection is needed in order to optimize outcomes and costs


Who?high risk patients

• Traditionally, EII-preventing procedures have been performed in patients considered at HIGH RISK for EII, on thebasis of risk factors for EII:– Patent IMA >3 mm– Number and diameter of lumbar arteries– Thrombus– Aneurysm sac diameter/volume

• LIMITS:

– Prevention only in a small subset of EVAR patients– Case-by-case selection of patients– Does not prevent “unpredictable endoleaks”

Volume (cm3) Glue (cc) Coil

≤ 125 5 3

125 - 175 10 3

175 - 225 10 4

≥ 225 10 5


Who?Example of a high risk patient

PRE-OPERATIVE CT SCAN POST-OPERATIVE CT SCAN POST-EMBOLIZATION OF EII


Who?Exclusion of patients at low risk

OBJECTIVES

• Reproducible, easy method of selection

• Prevention of EII’s

• Prevention of EII-related reinterventions(malignant endoleaks)

• Prevention of “unpredictable EII’s”


Methods

ANATOMIC INCLUSION CRITERIAAt least one of the following:

• SG1: IMA>3 mm

• SG2: 3 couples of lumbar arteries

• SG3: 2 couples of lumbars + accessory renal

artery/sacral artery/IMA<3mm

• SG4: more than SG1, 2, and 3

Jan 2008-Dec 2015

EVAR

ExcludedIncluded

189

At Low risk

LRG

66 (34.9%)

At Risk

RG

123 (65.1%)

EXCLUSION CRITERIA• Branched/fenestrated/chimney

grafts• Aorto-uni-iliac• Tubular endografts• urgent/emergent repair• Embo-EVAR (previous studies)• EVAS


Results

P<.001* P<.001* P<.001*P=.002* P=.048*

02

04

06

080

10

0

Months

0 6 12 18 24 30 36 42 48

R GroupLR Group

80.6%

100%

N. At risk

R:

LR: 55 3950 22

110 6489 5395 75 55

61

114

53 44 27

P=.001*

P=.54

Sensitivity 90%Specificity 40%

Sensitivity 100%Specificity 38%

Freedom from Endoleak II Freedom from Endoleak-reintervention


Results

Variable OR 95% CI Coefficient P

Predictors of EII

IMA > 3 mm 1.32 0.45-3.86 0.28 .60

> 3 lumbars 1.16 0.40-3.42 0.15 .78

Thrombus volume < 35% 2.16 1.01-5.09 0.77 .09

Groups

-RG 9.91 2.92-33.72 2.29 <.001a

-SG4 0.41 1.16-1.14 -0.73 .10

Predictors of reintervention

IMA > 3 mm 2.87 0.84-9.81 1.05 .10

> 3 lumbars 1.73 0.40-7.46 0.55 .45

Thrombus volume < 35% 2.96 1.01-8.76 0.55 .08

Aneurysm volume > 200 cm3

0.44 0.04-4.19 -0.81 .47

Groups -RG 9.11 1.06-78.44 2.21 .04

a

-SG4 0.31 0.08-1.20 -1.10 .10

IMA, inferior mesenteric artery; RG, risk group; SG4, subgroup 4 aStatistically significant

Multivariate Analysis


Results

Variable OR 95% CI Coefficient P

Predictors of EII

IMA > 3 mm 1.67 0.54-4.79 0.47 .39

> 3 lumbars 0.76 0.41-1.41 -0.26 .39

Sac volume 1.01 0.99-1.02 0.01 .19 Thrombus volume < 35% 5.21 1.75-15.47 1.65 .003

a

Predictors of reintervention

IMA > 3 mm 2.08 0.61-7.15 0.73 .24

Sac volume 1.01 1.00-1.02 0.01 .09 Thrombus volume < 35% 8.33 2.20-31.51 2.12 .002

a

SG4 0.61 0.19-2.02 -0.48 .42

IMA, inferior mesenteric artery; SG4, subgoup 4 aStatistically significant

Multivariate Analysis( Only Risk Group)


Conclusions

• The identification of a group of patients AT LOW RISK forEII is feasible on the basis of simple CT characteristics. Thisgroup is very unlikely to develop EII or EII-complications.

• On the other hand, the criteria to define patients AT RISKfor EII are effective and reliable, and the association tothrombus volume <35% increases the risk 5-8 fold

• EII-preventive procedures or a careful follow-up protocolshould be performed in this subpopulation of EVARpatients


THANKS FOR YOUR ATTENTION

I SINCERELY HOPE TO SEE ALL OF YOU IN PADUA AT THE VIP CONGRESS 2018

Prof. Franco Grego - MAC Conference 2016past.mac-conference.com/xconfig/upload/files/$03-Fr_F....

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