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Original Investigation | Association of VA Surgeons

Systemic Inflammatory Disease and Its Association With Type II Endoleak and Late Interventions After Endovascular Aneurysm Repair

Sherif Y. Shalaby, MD1,2; Trenton R. Foster, MD1,2; Michael R. Hall, MD1,2; Kirstyn E. Brownson, MD1,2; Penny Vasilas, RN1; Daniel G. Federman, MD3,4; Hamid R. Mojibian, MD5,6; Alan Dardik, MD, PhD1,2
[+] Author Affiliations
1Department of Surgery, VA Connecticut Healthcare System, West Haven
2Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
3Department of Medicine, VA Connecticut Healthcare System, West Haven
4Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
5Department of Radiology, VA Connecticut Healthcare System, West Haven
6Department of Radiology, Yale University School of Medicine, New Haven, Connecticut
JAMA Surg. 2016;151(2):147-153. doi:10.1001/jamasurg.2015.3219.
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Importance  Abdominal aortic aneurysms are associated with chronic inflammation within the aortic wall, and previous studies have suggested that chronic inflammation may be a consequence of a dysregulated and persistent autoimmune response. Persistent aortic remodeling after aneurysm repair could place the patient at risk for endoleak or sac rupture.

Objective  To determine whether patients with systemic inflammatory disease and large aneurysms have persistent aortic remodeling after endovascular aneurysm repair (EVAR).

Design, Setting, and Participants  The records of all patients who underwent EVAR between July 2002 and June 2011 at the Veterans Affairs Connecticut Healthcare System were included in this retrospective review. Patients were considered to have a systemic inflammatory disease when confirmed by a referring specialist. Post-EVAR surveillance was performed by yearly imaging.

Intervention  Endovascular aneurysm repair.

Main Outcomes and Measures  Significant endoleak, defined as endoleak and sac diameter increase of 0.5 cm or greater.

Results  A total of 51 of 79 patients (65%) had a systemic inflammatory disease. These patients had similar comorbid conditions compared with patients without inflammation but significantly greater numbers of major postoperative complications after EVAR (23.5% vs 3.6%; P = .02) and overall postoperative complications after EVAR (27.5% vs 7.1%; P = .03). Patients with a history of systemic inflammatory disease developed more endoleaks (45.1% vs 17.9%; P = .02) and late sac expansion (51.0% vs 21.4%; P = .01) and required more interventions (21.6% vs 3.6%; P = .03) during long-term follow-up. Systemic inflammatory disease was significantly associated with significant endoleak (odds ratio, 5.18; 95% CI, 1.56-17.16; P = .007).

Conclusions and Relevance  Patients with systemic inflammatory disease are at high risk for postoperative complications, type II endoleak, sac expansion, and additional interventions after EVAR. Additional strategies for improving the efficacy of EVAR in these patients may be warranted.

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Figure.
Survival, Endoleaks, and Sac Shrinkage Over Time

A, Cumulative survival after endovascular aneurysm repair in patients with or without systemic inflammatory disease (log rank, P = .99; Gehan-Breslow-Wilcoxon; P = .86). B, Increased type II endoleaks and late sac expansion in patients with systemic inflammatory disease. Endoleaks: P = .03 (log-rank test) and hazard ratio of 3.179 (95% CI, 1.203-6.210). Late sac expansion: P = .02 (log-rank test) and hazard ratio of 6.087 (95% CI, 1.037-9.380). The slightly reduced numbers of patients at year 0 reflect patients with an endoleak at the completion of the operative procedure who were not included. The solid line indicates sac expansion; dashed line, endoleak. C, Decreased sac shrinkage in patients with systemic inflammatory disease. P < .001 (log-rank test) and hazard ratio of 0.106 (95% CI, 0.032-0.350). D, Sac size shrinkage percentage in patients with and without systemic inflammatory disease at 1 and 5 years after endovascular aneurysm repair. Patients without autoinflammatory disease had significant sac size shrinkage after 5-year follow-up compared with first-year follow-up computed tomographic scan. The error bars indicate SEM.

aP < .05 (Bonferroni post hoc analysis; P < .001).

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