catheterised and perfused. The in-hospital mortality rate was 9% (3/33).
Transient spinal cord ischaemia was diagnosed in 4/33 (12%) patients, and
permanent paraplegia in one (3%). The median follow-up period was
11 months (range 1–33 months). Endoleaks were identified in 5/33 (15%)
patients: type II in four patients and a type III endoleak in one patient which
required the only secondary intervention. During follow-up, two patients
died: one from stroke and the other from myocardial infarction 9 and
29 months respectively after the procedure.
Conclusion: This preliminary study, which includes our learning
curve, confirms the feasibility and safety of the endovascular repair of TAAA
in high-risk patients. Meticulous follow-up to assess sac behaviour and
visceral perfusion is critical in order to ensure optimal results of these
complex endovascular repairs requiring numerous mating components.
The Proximal Fixation Strength of Modern EVAR Grafts in a Short
Aneurysm Neck. An In Vitro Study
Bosman W.M.P.F., Steenhoven T.J.v.d., Suárez D.R., Hinnen J.W., Valstar
E.R., Hamming J.F. Eur J Vasc Endovasc Surg 2010;30:in press
Objectives: The study aims to measure the strength of the proximal
fixation of endografts in short and long necks.
Design: Three types of endografts were compared: Gore Excluder®,
Vascutek Anaconda®and Medtronic Endurant®.
Materials and methods: The proximal part of the stent grafts was
inserted in bovine arteries and the graft was then attached to a tensile testing
machine. The force to obtain dislodgement (DF) from the aorta was
recorded for each graft at proximal seal lengths of 10 and 15 mm.
Results: The median DF (interquartile range, IQR) for the Excluder,
the Anaconda and the Endurant with a seal length of 15 mm was: 11.8
(10.5–12.0) N, 20.8 (18.0–30.1) N and 10.7 (10.4–11.3) N. With the
shorter proximal seal of 10 mm, DF was, respectively: 6.0 (4.5–6.6) N, 17.0
(11.2–36.6) N and 6.4 (6.1–12.0) N.
Conclusions: The proximal fixation of the Anaconda is superior to the
Excluder and the Endurant at short necks of 10 and 15 mm in an experi-
mental set-up. There is a statistically significant decrease of proximal fixation
from 15 to 10 mm.
The Influence of Different Types of Stent Grafts on Aneurysm Neck
Dynamics after Endovascular Aneurysm Repair
van Keulen J.W., Vincken K.L., van Prehn J., Tolenaar J.L., Bartels L.W.,
Viergever M.A., Moll F.L., van Herwaarden J.A. Eur J Vasc Endovasc Surg
Objective: Dynamic imaging provides insight into aortic shape
changes throughout the cardiac cycle. These changes may be important for
proximal aortic stent graft fixation, sealing and durability. The objective of
this study is to analyse the influence of different types of stent grafts on
dynamic changes of the aneurysm neck.
Methods: Pre- and postoperative electrocardiography (ECG)-gated
computed tomographic angiography (CTA) scans were obtained in 30
abdominal aortic aneurysm (AAA) patients, 10 each from three different
types of stent grafts (10 Talent, Endurant, and Excluder). Each dynamic
CTA dataset consisted of eight reconstructed images over the cardiac cycle.
Aortic area and radius changes during the cardiac cycle were determined at
two levels: (A) 3 cm above and (B) 1 cm below the lowermost renal artery.
Radius changes were measured over 360 axes, and plotted in a polar plot. An
ellipse was fitted over the plots to determine radius changes over the major
and minor axis for assessment of the asymmetric aspect and most prominent
direction of distension.
Results: Baseline characteristics did not differ significantly between the
three groups. Preoperatively, the aortic area increased significantly
(p ? 0.001) over the cardiac cycle in all patients at both levels: (A) mean
increase 8.3 ? 4.1% (2.0–17.3%); (B) mean increase 5.9 ? 4.2% (1.9–
12.4%). The postoperative aortic area increase over the cardiac cycle did not
differ significantly from preoperative increases: (A) mean increase
9.9 ? 2.2% (4.4–20.0%); (B) mean increase 7.7 ? 2.4% (3.8–12.4%). The
difference between radius change over the major and minor axis was signif-
icant both pre- and postoperatively for all three stent grafts, indicating
asymmetric distension. Suprarenal, the distension showed a tendency to
right-anterior and infrarenal to left-anterior. The distension and direction of
the aortic expansion was preserved after stent grafting. There were no
differences between the three types of stent grafts regarding their impact on
the aortic distension or direction of this distension.
Conclusion: The aorta expands significantly and asymmetrically
throughout the cardiac cycle. After implantation of abdominal aortic stent
grafts, the aortic distension and direction of distension remain equally
preserved in all three groups. The three stent graft types studied seem to be
able to adapt to the asymmetric dynamic aortic shape changes.
Diabetes and the Abdominal Aortic Aneurysm
Shantikumar S., Ajjan R., Porter K.E., Scott D.J.A. Eur J Vasc Endovasc
Surg 2010;30:in press
Objective: The aim of this review is to delineate the association
between abdominal aortic aneurysms (AAAs) and diabetes mellitus. Mech-
anisms for the underlying association are then discussed.
Methods: A systematic review of the English-language literature using
PubMed, EMBASE and Cochrane databases was undertaken up to Septem-
ber 2009. Studies reporting appropriate prevalence data were identified and
a meta-analysis performed.
Results: Eleven studies were identified. The prevalence of diabetes
mellitus in studied patients with AAA ranged from 6% to 14%. The preva-
lence of diabetes in control patients without AAA ranged from 17% to 36%.
Pooled analysis suggested a reduced rate of diabetes amongst people with
AAA compared to those without (OR 0.65, 0.60–0.70, p ? 0.001).
development of AAA. Further research is required to demarcate the under-
lying mechanisms for this possible association.
Poor Inter-observer Agreement on the TASC II Classification of
Kukkonen T., Korhonen M., Halmesmäki K., Lehti L., Tiitola M., Aho P.,
Lepäntalo M., Venermo M. Eur J Vasc Endovasc Surg 2010;30:in press
Objectives: This study aims to evaluate the reproducibility of femoro-
popliteal TASC II classification and to analyse the influence of an educa-
tional intervention on inter-observer agreement.
Design: This is a validation study.
Materials: This study included 200 consecutive angiograms of femo-
ropopliteal arterial lesions.
Methods: Seven investigators evaluated the first 100 angiograms,
independently aided by the available TASC guide. Thereafter, the interven-
tion included a discussion of the 25 most problematic cases, initially by a
panel of 22 vascular surgeons, and later by the seven investigators to clarify
grading principles. In the second stage, the 100 remaining cases were
evaluated independently. A multi-rater variation of Brennan and Prediger’s
free-marginal kappa (?free) was used to calculate inter-observer agreement.
Results: There were lesions not fitting any of the TASC classes. Total
agreement among all seven investigators was reached in 7% and 19% of the
cases before and after the intervention, respectively. In the first stage, ?free
was 0.32 between all observers (range between two observers ?free? 0.11–
0.54). The intervention increased the agreement to ?free? 0.49 (range:
0.20–0.56). Agreement between the two observers was 38–69% (mean
49%) before the intervention and 51–73% (mean 61%) thereafter.
Conclusions: TASC II classification for femoropopliteal lesions allows
for decision making and reporting outcomes could therefore be questioned.
Modified Ankle–brachial Index Detects More Patients at Risk in a
Finnish Primary Health Care
Oksala N.K.J., Viljamaa J., Saimanen E., Venermo M., on behalf of the
ATTAC study group Eur J Vasc Endovasc Surg 2010;30:in press
Objectives: Despite peripheral arterial disease (PAD), defined as ankle–
brachial index (ABI) ? 0.9, being an independent predictor of cardiovascular
for PAD (i.e., ABI ? 0.9 or ABI ? 0.95) exist. In addition, a modified ABI
(ABImod) using the lowest ankle pressure improves identification of patients at
risk. The prevalence of PAD in primary care and association of different ABI
calculations with atherosclerotic disease burden is not known.
Design: The research was conducted as a prospective cross-sectional
study. Finnish health centres and 99 general practitioners were selected and
trained for ABI measurement. Consecutive patients were recruited using inclu-
?70 years or calf pain during exercise. A total of 817 patients were recruited.
ment of brachial and ankle pressures.
Results: An ABImod? 0.9 yielded the highest prevalence of PAD
(47.7%), had the best sensitivity and identified the highest number of
PAD, CAD/CVD/PAD and polyvascular disease (PVD) at the cost of
reduced specificity. All ABI calculations were independently associated with
atherosclerotic disease burden. Interestingly, ABI ? 1.4 had the strongest
association with CVD.
Conclusions: PAD is highly prevalent among patients presenting to
primary care. ABImodcalculation detects more number of patients at risk at the
cost of reduced specificity. The association of high ABI with CVD noted in this
study warrants future research for validation.
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JOURNAL OF VASCULAR SURGERY