title: Perianeurysmal fibrosis: a relative contra-indication to endovascular repair.
abstract: OBJECTIVE
  Perianeurysmal fibrosis (PAF) with involvement of neighbouring viscera can render open repair of inflammatory aneurysms technically difficult and therefore hazardous. For this reason, endovascular repair (EVAR) has been advocated as the preferred approach for this condition. EVAR is known to induce a systemic inflammatory response in patients but the nature of the local response remains unknown. If significant, such a response could exacerbate rather than ameliorate PAF. The aim of the study was to examine the incidence, course and consequences of perianeurysmal fibrosis detected by computerised tomography (CT) before and after EVAR.
  
  
  METHODS
  The clinical records of patients treated by EVAR and followed for at least 6 months were reviewed. Pre and post-operative CT images were independently graded for PAF by three radiologists according to a standard protocol.
  
  
  RESULTS
  PAF was documented preoperatively in six out of a total of 61 patients. In two of these PAF worsened after EVAR resulting in ureteric obstruction and hydronephrosis requiring ureteric stents. In the remaining 4 patients PAF did not reduce postoperatively. PAF of low grade developed postoperatively in 10 out of 55 patients (18%) in whom there was no evidence of PAF on preoperative imaging. Median follow-up was 18 months (range 6-36 months). The development of periaortic fibrosis de novopostoperatively was statistically significant (McNemar's test p=0.002).
  
  
  CONCLUSIONS
  EVAR does not seem to reverse PAF if this is present preoperatively and it induces this condition in approximately one sixth of patients without evidence of preoperative PAF. The potential for this adverse inflammatory local response should be taken into account when considering EVAR for treatment of aneurysms with perianeurysmal fibrosis and must be weighed against the perceived benefits of this approach.
authors.affiliation: Vascular Surgery, Regional Vascular Unit, Liverpool University Hospital, UK.
authors.forename: S R
authors.initials: SR
authors.lastname: Vallabhaneni
authors.forename: R G
authors.initials: RG
authors.lastname: McWilliams
authors.forename: A
authors.initials: A
authors.lastname: Anbarasu
authors.forename: P C
authors.initials: PC
authors.lastname: Rowlands
authors.forename: J A
authors.initials: JA
authors.lastname: Brennan
authors.forename: D A
authors.initials: DA
authors.lastname: Gould
authors.forename: P L
authors.initials: PL
authors.lastname: Harris
authors.forename: G L
authors.initials: GL
authors.lastname: Gilling-Smith
mesh_terms: D000368:Aged; D017130:Angioplasty; D001012:Aorta, Abdominal / Q000000981:diagnostic imaging / Q000473:pathology; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation; D005260:Female; D005355:Fibrosis; D006801:Humans; D007249:Inflammation; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D015607:Stents; D014057:Tomography, X-Ray Computed; D014513:Ureter / Q000473:pathology