warfarin and Aortic-Aneurysm--Abdominal

To evaluate whether postoperative long-term oral anticoagulation affects the durability of endovascular aneurysm repair (EVAR) and whether it is associated with an increased incidence of endoleak and subsequent need for reintervention.. A literature search was performed to identify studies of abdominal aortic aneurysm patients undergoing EVAR including an arm receiving warfarin postoperatively and reporting the frequency of any endoleaks and/or persistent type II endoleaks and reinterventions. The search identified 81 articles, of which 5 observational cohort studies ultimately met the inclusion criteria.. Postoperative anticoagulation was required in 219 (14.6%) of the 1499 patients in the selected studies. The pooled effects analysis found that EVAR patients receiving long-term warfarin postoperatively had significantly more endoleaks of any type (OR 1.77, 95% CI 1.26 to 2.48, p=0.001) as well as persistent type II endoleaks (OR 1.58, 95% CI 1.05 to 2.37, p=0.03) compared with patients not on anticoagulation; however, there was no statistically significant difference in the reintervention rate between the groups.. Long-term anticoagulation in EVAR patients was associated with a statistically significant increase in any endoleak and persisting type II endoleaks, although it was not linked to an increased risk of reintervention. Close monitoring for EVAR patients who require long-term oral anticoagulation is advised.

Topics: Administration, Oral; Anticoagulants; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Chi-Square Distribution; Endoleak; Endovascular Procedures; Humans; Odds Ratio; Retreatment; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Warfarin

Within the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm.. Retrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm.. There were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants.. These data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm.

Topics: Anticoagulants; Aortic Aneurysm; Aortic Aneurysm, Abdominal; Aspirin; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Humans; Retrospective Studies; Risk Factors; Treatment Outcome; Warfarin

The impact of anticoagulation on late endoleaks after endovascular aneurysm repair (EVAR) is unclear despite multiple investigators studying the relationship. The purpose of this study was to determine if long-term anticoagulation impacted the development of late endoleaks and if specific anticoagulants were more likely to exacerbate the development of endoleaks.. Using the Society for Vascular Surgery Vascular Quality Initiative database, patients undergoing EVAR between 2003 and 2019 for abdominal aortic aneurysms were evaluated. Patients were divided into two groups: those without a late endoleak and those with a late endoleak. Bivariate analysis was performed to assess preoperative, intraoperative, postoperative, and long-term follow-up variables. A multivariable analysis was done to determine associations of independent variables with late endoleaks. Patients were further subcategorized based on anticoagulation status before and after EVAR, specific type of anticoagulation, and the presence of an index endoleaks (diagnosed at the time of EVAR) to determine the subsequent frequency of late endoleaks.. A total of 29,783 patients were analyzed with 2169 (7.3%) having a late endoleak identified. Several risk factors were related to late endoleaks, including anticoagulation before and after EVAR (odds ratio [OR], 4.23; 95% confidence interval [CI], 2.57-6.96; P < .001), anticoagulation after EVAR (OR, 1.88; 95% CI, 1.43-2.49; P < .001), and index endoleak (OR, 1.45; 95% CI, 1.26-1.66; P < .001). The frequency of late endoleaks in patients anticoagulated before and after EVAR and after EVAR as compared with those never anticoagulated was 16.89% and 14.40% vs 6.95%, respectively (both P > .001). No difference in late endoleaks were noted for patients treated with warfarin and novel oral anticoagulants. The most common type of index and late endoleak identified was type II, but patients with type I, type II, and type IV index endoleaks were more commonly found to have type I, type II, and type IV late endoleaks, respectively. The frequency of late endoleaks in patients with both an index endoleak and anticoagulation after EVAR was 20.42% as compared with patients with only anticoagulation after EVAR (14.63%; P = .0015) and with patients with index endoleaks not anticoagulated (10.06%; P < .00001).. Late endoleaks were more common in patients treated with anticoagulation after EVAR. No difference in late endoleak frequency was detected between anticoagulation with warfarin and novel oral anticoagulants. Patients on anticoagulation and those with an index endoleak were at a higher risk of having a late endoleak.

Topics: Administration, Oral; Anticoagulants; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Canada; Databases, Factual; Endoleak; Endovascular Procedures; Factor Xa Inhibitors; Female; Humans; Incidence; Male; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States; Warfarin

This study aims to determine whether warfarin therapy influences the occurrence of endoleaks or aneurysm sac enlargement after endovascular aortic repair (EVAR).. A total of 367 patients who underwent EVAR for abdominal aortic aneurysm between 2007 and 2013 were recruited for this study. Satisfactory follow-up data including completed computed tomography scan follow-up for more than 2 years were available for 209 patients, and the mean follow-up time was 37 ± 12 months. Twenty-nine (16%) patients were on warfarin therapy (warfarin group), whereas 180 (84%) patients were not on warfarin therapy (control group).. Two- and four-year freedom rates for persistent type II endoleaks were significantly lower in patients of the warfarin group compared with the control group (85 and 49% vs 93 and 91%, respectively; P = 0.0001). Similarly, 2- and 4-year freedom rates for sac enlargement (>5 mm) were significantly lower in patients of the warfarin group compared with the control group (83 and 61% vs 92 and 82%, respectively; P = 0.0036). Using Cox regression analysis, the warfarin therapy was identified to be an independent positive predictor of sac enlargement after EVAR [hazard ratio (HR): 2.4; 95% confidence interval (CI): 1.08-5.40; P = 0.032], together with persistent type II endoleak. Warfarin therapy was also an independent predictor for persistent type II endoleak (HR: 3.7; 95% CI: 1.81-7.41; P < 0.0001) together with the number of patent lumbar arteries.. Results suggested that warfarin therapy was significantly associated with an increased risk for persistent II endoleak and sac enlargement after EVAR.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Female; Humans; Male; Middle Aged; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Anticoagulants; Aortic Aneurysm, Abdominal; Aortic Rupture; Blood Coagulation Factors; Humans; Male; Middle Aged; Necrosis; Perioperative Care; Skin; Warfarin

A 78-year-old man presented with abdominal pain, high International Normalised Ratio and rapidly falling haemoglobin. He had a background of Marfan syndrome and was on warfarin following mechanical aortic valve replacement. Abdominal CT imaging showed haemoperitoneum with a leaking aneurysm of the left gastric artery measuring 10 mm in diameter. The decision whether to reverse his anticoagulation provided a difficult clinical scenario given the risk of thrombosis associated with the mechanical aortic valve. The patient went on to have a successful percutaneous embolisation of the aneurysm using a metallic coil and Onyx. Left gastric artery aneurysms are rare and have a reported mortality of up to 70%. This is the first case of gastric artery aneurysm described in a patient with Marfan syndrome.

Topics: Abdominal Pain; Aged; Anticoagulants; Aortic Aneurysm, Abdominal; Aortic Dissection; Blood Vessel Prosthesis Implantation; Celiac Artery; Embolization, Therapeutic; Heart Valve Prosthesis; Humans; Male; Marfan Syndrome; Risk; Warfarin

Current data supporting the effect of anticoagulation drug use on aneurysm sealing and the durability of endovascular abdominal aneurysm repair (EVAR) are conflicting. This study assessed the safety of chronic anticoagulation therapy after EVAR.. Records of 1409 consecutive patients having elective EVAR during 1997-2011 who were prospectively followed were reviewed. Survival, reintervention, conversion, and endoleak rates were analyzed in patients with and without chronic anticoagulants. Cox proportional hazards models were used to estimate the effect of anticoagulation therapy on outcomes.. One-hundred and three (7.3%) patients were on chronic anticoagulation drugs (80 on vitamin K antagonists) at the time of EVAR. An additional 46 patients started on anticoagulants after repair were identified. Patients on chronic anticoagulation therapy at repair (mean age 73.6 years; 91 males) had more frequent cardiac disease (74.8% vs. 44.2%; p < 00001), but no other differences in demographic and major baseline comorbidities with respect to the others. At baseline, mean abdominal aortic aneurysm (AAA) diameter was 56.43 mm vs. 54.65 mm (p = .076) and aortic neck length 26.54 mm vs. 25.21 mm (p = .26) in patients with and without anticoagulants, respectively. At 5 years, freedom from endoleak rates were 55.5% vs. 69.9% (p < .0001), and freedom from reintervention/conversion rates were 69.4% vs. 82.4% (p < .0001) in patients with (including those with delayed drug use) and without chronic anticoagulants, respectively. Controlling for covariates with the Cox regression method, at a mean follow-up of 64.3 ± 45.2 months after EVAR, use of anticoagulation drugs was independently associated with an increased risk of endoleak (odds ratio, OR 1.6; 95% confidence interval, CI: 1.23-2.07; p < .0001) and reintervention or late conversion rates (OR 1.8; 95% CI: 1.31-2.48; p < .0001).. The safety of anticoagulation therapy after EVAR is debatable. Chronic anticoagulation drug use risks exposure to a poor long-term outcome. A critical and balanced decision-making approach should be applied to patients with AAA and cardiac disease who may require prolonged anticoagulation treatment.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Aneurysm, Abdominal; Endoleak; Endovascular Procedures; Female; Humans; Kaplan-Meier Estimate; Male; Postoperative Complications; Postoperative Period; Proportional Hazards Models; Retrospective Studies; Warfarin

The presence of an endoleak after endovascular abdominal aortic aneurysm (AAA) repair (EVAR) may predispose to sac expansion and potential sac rupture. The incidence of endoleak after AAA repair can be as high as 20% to 30%. We investigated whether warfarin anticoagulation was an independent risk factor for endoleak after EVAR for AAA.. All AAA patients who underwent elective EVAR were prospectively followed-up. Data for demographics, clinical comorbidities, outcomes, EVAR devices, and anticoagulation methods were recorded. All patients underwent routine follow-up at 1, 6, and 12 months and annually thereafter. Computed tomography angiography (CTA) with 3-dimensional (3D) volumetric analysis was also completed.. During a 7-year period, 127 consecutive patients with infrarenal AAAs who underwent EVAR were monitored for a mean of 2.14 years. The average age at the time of EVAR was 73.8 years. Warfarin therapy alone was administered to 24 patients, and anticoagulation with antiplatelet therapy alone was administered to 103. During the study period, 38 (29.9%) endoleaks were documented. The overall endoleak rate was 13 of 24 in the warfarin group and 25 of 103 in the antiplatelet group (P = .004). CTA 3D volumetric aneurysm sac analysis showed an increase of 16.09% in the warfarin study group and a reduction of 9.71% in the antiplatelet group (P = .04).. Anticoagulation with warfarin appears to be linked to an increased risk for the development of endoleak after EVAR, specifically type II. Volumetric analysis showed warfarin therapy also contributed to persistent aneurysm sac expansion. These data suggest that patients who require warfarin anticoagulation for other indications should be advised that they might be at an increased risk for the development of endoleaks, subsequent secondary interventions, persistent sac expansion, and possible delayed sac rupture.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Aneurysm, Abdominal; Aortography; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Elective Surgical Procedures; Female; Humans; Male; Prosthesis Design; Prosthesis Failure; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Tomography, Spiral Computed; Treatment Outcome; Warfarin; Wisconsin

Instrumentation of the aorta during cardiac catheterization, resulting in peripheral embolization, is an underdiagnosed clinical entity. Such an atheromatous embolization can present in a subtle way or could be catastrophic. Isolated splenic infarction as a complication of the procedure is extreme rare. We report a 59-year-old man with risk factors for atherosclerotic vascular disease who underwent percutaneous coronary intervention and presented 3 days later with isolated splenic infarction. He was managed conservatively with heparin. Further evaluation revealed a concomitant mural thrombus in an abdominal aortic aneurysm, which could be a contributing factor along with atheroembolization from advanced atherosclerosis. Our case highlights the importance of using a right brachial or radial approach in an individual with significant atherosclerotic vascular disease and with an abdominal aortic aneurysm.

Topics: Angioplasty, Balloon, Coronary; Anticoagulants; Aortic Aneurysm, Abdominal; Aspirin; Atherosclerosis; Cardiac Catheterization; Clopidogrel; Coronary Stenosis; Embolism, Cholesterol; Heparin; Humans; Infarction; Male; Middle Aged; Platelet Aggregation Inhibitors; Risk Factors; Spleen; Thrombosis; Ticlopidine; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

An aortic aneurysm was successfully treated with an endovascular stent graft, with no evidence of endoleak and documented progressive aortic diameter reduction during the first 23 months. At 29 months, the patient had documented enlargement of the aneurysm sac associated with excessive anticoagulation with warfarin. No evidence of endoleak could be demonstrated with any diagnostic modality. Progressive aneurysm sac diameter regression was documented after reversal of excessive anticoagulation to therapeutic levels (international normalized ratio of 2 to 3). Strict monitoring of coagulation profile in patients after endovascular aneurysm repair requiring anticoagulation with warfarin is recommended to avoid this complication, which to our knowledge has not been previously reported.

Topics: Aged; Anticoagulants; Aortic Aneurysm, Abdominal; Aortography; Blood Coagulation; Blood Vessel Prosthesis Implantation; Humans; International Normalized Ratio; Male; Stents; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

To evaluate the effect of oral anticoagulation on durability of endovascular aortic aneurysm repair (EVAR).. Retrospective review was conducted of 182 consecutive EVAR patients (169 men; mean age 75.3 years, range 53-89) between 1999 and 2003. Patients on warfarin anticoagulation (WA, n=21; International Normalized Ratio of 2 to 3) were compared against a control group (CG) with no postoperative anticoagulation (n=161). Death, aneurysm rupture, and reintervention were considered primary endpoints; endoleaks, endograft migration, and aneurysm remodeling were secondary endpoints.. Mean follow-up was 16.3+/-12.6 months. One-year mortality was 6.6% (9.5% WA versus 6.2% CG); overall mortality was 14.3% (p=0.414). No aneurysm rupture occurred. At 1, 2, and 3 years, respectively, cumulative reinterventions (20%/20%/20% WA versus 12%/15%/20% CG; p=0.633) and endoleak rates (25%/25%/25% WA versus 17%/22%/34% CG; p=0.649) were comparable. In both groups, most completion endoleaks resolved (42.9% WA versus 74.4% CG; p=0.474), but few de novo endoleaks did (0% WA versus 12.8% CG; p=0.538). Anticoagulation did not affect mean time to aneurysm sac shrinkage (1.3+/-0.3 WA versus 1.4+/-0.1 years CG; p=0.769).. After EVAR, anticoagulation appears safe and does not significantly alter mortality, risk for rupture, or the incidence of reintervention. Early endoleaks appear more common in anticoagulated patients, but anticoagulation does not preclude spontaneous endoleak resolution nor does it increase late endoleak rates. Irrespective of the anticoagulation status, early but not late endoleaks usually sealed spontaneously. Observing type II endoleaks appears safe in the absence of aneurysm enlargement.

Topics: Administration, Oral; Aged; Aged, 80 and over; Angiography; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Case-Control Studies; Chi-Square Distribution; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Follow-Up Studies; Humans; Male; Middle Aged; Postoperative Care; Postoperative Complications; Probability; Prosthesis Failure; Registries; Retrospective Studies; Risk Assessment; Severity of Illness Index; Survival Rate; Time Factors; Treatment Outcome; Warfarin

This study was performed to define the incidence of acute deep venous thrombosis (DVT) after endovascular treatment of abdominal aortic aneurysms (AAAs). Because aortic endograft placement requires prolonged femoral vessel instrumentation, it may be hypothesized that these patients are at increased risk for development of an acute DVT.. Fifty consecutive patients (42 men, eight women) ranging in age from 48 to 85 years (mean, 72 years) underwent endovascular treatment of an AAA from January 2000 to August 2001. Clinical examination and bilateral lower extremity duplex ultrasonography for DVT were performed on the first postoperative day and at the 1-month follow-up visit. No patient had a prior DVT or identifiable hypercoagulable state. Seven patients (14%) had concurrent malignant disease. Preoperative antiplatelet agents were administered in 26 patients (52%), and nine (18%) were on warfarin sodium therapy before surgery. No new DVT prophylaxis was initiated perioperatively. Epidural anesthesia was used in 60% of the patients, with general endotracheal anesthesia used in the remainder. Risk factors for DVT were evaluated with univariate statistical analysis.. Three patients (6%) had an acute postoperative DVT develop. Two occurred in the femoral veins, and one occurred in the popliteal vein. Of these patients, one had been continued on perioperative anticoagulation therapy, and the remaining two were started on low-molecular weight heparin and warfarin sodium therapy on recognition of the DVT. One patient had an intraoperative injury of the affected common femoral vein, and this individual was the only one to have clinical signs of a DVT. The mean follow-up period was 8 +/- 0.8 months. In this experience, factors that may have placed patients at increased risk for an acute DVT were not identified.. Six percent of patients undergoing endovascular repair of AAAs had postoperative DVT develop. These patients had a number of risk factors for the development of a DVT; however, no specific factor was identified that predisposed to DVT.

Topics: Aged; Anticoagulants; Aortic Aneurysm, Abdominal; Female; Femoral Vein; Humans; Incidence; Male; Popliteal Vein; Risk Factors; Sensitivity and Specificity; Vascular Surgical Procedures; Venous Thrombosis; Warfarin

Successful endovascular aortic aneurysm repair depends on exclusion and spontaneous thrombosis of the aneurysm sac. The need for chronic postoperative anticoagulation therapy could limit the applicability of this technology with delay or prevention of sac thrombosis resulting in endoleak formation and altered remodeling of the aneurysm sac. The purpose of this study was the determination of whether chronic therapeutic anticoagulation therapy with warfarin was associated with an increased incidence rate of early or delayed postoperative endoleaks or altered rates of reduction in aneurysm sac maximum diameter.. Two hundred thirty-two consecutive patients underwent abdominal aortic endografting during a 32-month period. The data were recorded prospectively with a current mean follow-up period of 18 months. The patients with endoleaks identified with 30-day postoperative computed tomographic scan angiograms subsequently underwent selective arteriography to characterize the source. The patients who underwent chronic warfarin therapy that resulted in a therapeutic internationalized normalized ratio comprised the study group. The control group was defined as all the patients with healthy coagulation profiles.. Thirty-six patients (15%) were undergoing warfarin therapy after surgery, and their conditions were chronically maintained with a therapeutic international normalized ratio. Forty-three patients (18%) had endoleaks on 30-day computed tomographic scan angiographic results. There were 39 patients with type II endoleaks and four patients with type I endoleaks. None of the type I endoleaks occurred in patients who were undergoing warfarin therapy, and all endoleaks were repaired with either proximal or distal covered extensions. At 30 days, seven patients (19.4%) undergoing chronic warfarin therapy had type II endoleaks as compared with 36 controls (18.4%; P =.798). Four patients had delayed type II endoleaks develop, two in the control group and two in the warfarin group (P =.3). Ten control individuals (31%) had spontaneous resolution of type II endoleaks develop, whereas spontaneous endoleak thrombosis was not observed in the warfarin group (P =.33). Aneurysm sac remodeling assessed with mean percent reduction in maximum sac diameter at 12 months revealed a statistical difference between the control group (17.5%) and the warfarin group (7.6%; P =.04).. Warfarin treatment is not associated with an increase in the incidence rate of early or delayed postoperative endoleaks. However, the rate of reduction in maximum aneurysm sac diameter after aortic endografting is slower in patients who undergo therapeutic warfarin therapy at 1-year follow-up examination, a statistically significant difference from the control group. In addition, type II endoleaks may be less likely to undergo spontaneous thrombosis in patients who undergo warfarin therapy.

Topics: Anticoagulants; Aortic Aneurysm, Abdominal; Case-Control Studies; Follow-Up Studies; Humans; Incidence; Postoperative Complications; Retrospective Studies; Time Factors; Warfarin

We describe the case of a woman with congenital rubella who presented with backache. Plain abdominal X-ray revealed calcification of a superior mesenteric artery aneurysm. Intra-arterial digital subtraction angiography demonstrated multiple aneurysms of the arteries to the upper and lower limbs and the viscera. We have not found another report in the literature of the association of congenital rubella with multiple aneurysms.

Topics: Adult; Anticoagulants; Aortic Aneurysm, Abdominal; Back Pain; Female; Humans; Radiography; Rubella Syndrome, Congenital; Treatment Outcome; Warfarin

Topics: Aged; Aortic Aneurysm, Abdominal; Arteriosclerosis; Cholesterol; Embolism; Humans; Male; Skin; Toes; Warfarin