Low Thrombus Burden Is Associated With An Increased Rate Of Endoleak Following Repair Of Juxtarenal Aneurysm Using Physician Modified Endografts
Chase Nelson, BS, Gerald Anderson, Amit Pujari, MD, Benjamin Starnes, MD, Sara Zettervall, MD.
University of Washington, Seattle, WA, USA.
ObjectiveStudies have suggested that aortic thrombus may be associated with adverse outcomes following endovascular repair of aortic aneurysms, while other reports have suggested a reduced risk of endoleak. However, the effect of thrombus on patient outcomes following physician-modified endograft (PMEG) remains unknown. This study aims to assess volume and morphology of thrombus burden and the effect on patient outcomes following PMEG for the repair of juxtarenal abdominal aortic aneurysm.
MethodsPatients who underwent PMEG from 2009-2021 in a single institution investigational device exemption trial were included. Pre-operative CT data was used to measure thrombus burden in cm3 from the lowest renal artery to the aortic bifurcation using TeraRecon software by two independent reviewers, intraclass correlation (ICC) was then performed. Thrombus morphology was also documented. A cutoff was established using ROC curve analysis to establish significant points of inflection in thrombus burden. Univariate and multivariable analysis was performed to evaluate the impact of thrombus on perioperative outcomes as well as the long-term impact on endoleak and reintervention. Survival was assessed using Kaplan-Meier analysis.
ResultsThrombus burden was assessed in 142 patients. Interrater agreement showed an ICC value of 0.96. Seventy-eight (55%) of patients had less than 45% thrombus burden, and finger-like projections were observed in 20% of morphologic assessments. There were no differences in perioperative outcomes or survival by thrombus burden or morphology (Table 1). There were two patients (2.6%) with spinal cord injury, both had <45% thrombus burden and one was noted to have finger-like projections, however this was not significant. In multivariate analysis, endoleak was increased in patients with low thrombus burden (OR, 2.6 [1.1-6.1]), which appeared to be driven by type II endoleak (OR, 2.6 [1.2-6.0]).
ConclusionsThrombus burden measurements can be reliably measured using reconstructive software. While thrombus burden is not associated with adverse perioperative events, a low thrombus burden is associated with increased rates of type II endoleaks.
Table : Perioperative outcomes and endoleaks in patients by thrombus burden (less than or greater than 45%) and by finger-like projections on morphologic assessment
| Thrombus Burden | Fingerlike Projections | |||||||||||||
| ≥ 45% (n=64) | <45% (n=78) | Yes (n=21) | No (n=86) | |||||||||||
| Outcomes | N | % | N | % | P-Value | N | % | N | % | P-Value | ||||
| Death in <30 days | 3 | 4.7% | 3 | 3.8% | 0.80 | 2 | 9.5% | 2 | 2.3% | 0.12 | ||||
| Stroke | 0 | 0.0% | 2 | 2.6% | 0.20 | 0 | 0.0% | 1 | 1.2% | 0.62 | ||||
| Renal Failure | 3 | 4.7% | 3 | 3.8% | 0.80 | 1 | 4.8% | 3 | 3.5% | 0.78 | ||||
| Respiratory Failure | 5 | 7.8% | 2 | 2.6% | 0.20 | 0 | 0.0% | 3 | 3.5% | 0.39 | ||||
| Spinal Cord Injury | 0 | 0.0% | 2 | 2.6% | 0.20 | 1 | 4.8% | 1 | 1.2% | 0.28 | ||||
| Bowel Ischemia | 1 | 1.6% | 1 | 1.3% | 0.89 | 1 | 4.8% | 1 | 1.2% | 0.28 | ||||
| EBL >1000mL | 1 | 1.6% | 1 | 1.3% | 0.89 | 1 | 4.8% | 0 | 0.0% | 0.04 | ||||
| ICU readmission | 4 | 6.3% | 1 | 1.3% | 0.11 | 0 | 0.0% | 4 | 4.6% | 0.31 | ||||
| Myocardial infarction | 3 | 4.7% | 4 | 5.1% | 0.90 | 1 | 4.8% | 3 | 3.5% | 0.78 | ||||
| Reintervention | 19 | 29% | 25 | 32% | 0.76 | 3 | 14% | 31 | 36% | 0.06 | ||||
| Endoleak | N | % | N | % | P-Value | N | % | N | % | P-Value | ||||
| Any Endoleak | 24 | 37% | 47 | 60% | <0.01 | 8 | 38% | 47 | 55% | 0.48 | ||||
| Type 1a | 0 | 0.0% | 6 | 7.7% | 0.03 | 1 | 4.8% | 3 | 3.5% | 0.74 | ||||
| Type 1b | 2 | 3.1% | 4 | 5.1% | 0.59 | 0 | 0.0% | 3 | 3.5% | 0.40 | ||||
| Type 2 | 20 | 31% | 45 | 57% | <0.01 | 7 | 33% | 41 | 47% | 0.32 | ||||
| Type 3 | 6 | 9.4% | 17 | 21% | 0.06 | 2 | 9.5% | 15 | 17.4% | 0.43 | ||||
| Note section: Fingerlike projections noted on qualitative thrombus analysis. EBL = estimated blood loss; ICU = intensive care unit | ||||||||||||||
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