title: Endovascular treatment of abdominal aortic aneurysms with the Powerlink Endograft System: influence of placement on the bifurcation and use of a proximal extension on early and late outcomes.
abstract: OBJECTIVE
  We evaluated the influence of placement of the bifurcated Powerlink endograft (Endologix Inc, Irvine, Calif) on the aortic bifurcation, with the addition of a proximal extension, in the endovascular treatment (EVAR) of selected patients with atherosclerotic abdominal aortic aneurysms (AAAs).
  
  
  METHODS
  From September 1999 to June 2007, 205 patients were treated with the bifurcated Powerlink endograft for atherosclerotic AAA at two Italian centers with shared protocols. Patients were retrospectively divided in two groups according to treatment with the bifurcated graft only (n = 126), or its placement on the bifurcation with the addition of a proximal extension (n = 79) at the initial procedure. Study end points included postoperative complications, secondary procedures, immediate and late conversion, migration, endoleak, death, and aneurysmal sac behavior.
  
  
  RESULTS
  Overall technical success was 98.5%. Additional procedures were performed in 18%, and postoperative complications occurred in 11.2% (systemic, 8.3%; local, 2.9%). Median follow-up was 42.4 months (range, 6-94 months). Secondary procedures were recorded in 11.2%, migration in 3.9%, type I proximal endoleak in 7.8%, and late conversions in 2.4%. Placement on the bifurcation and the addition of an extension were associated with a higher incidence of postoperative complications (7.1% vs 17.7%, P = .020). A reduced incidence of endoleak (19% vs 8.9%, P = .048), secondary procedures (14.3% vs 6.3%, P = .04), and migration (6.3% vs 0%, P = .024) were observed in the group with a proximal extension. Analysis of single variables reveals that migration was significantly influenced by placement of the graft on the bifurcation (47% vs 0%, P < .001). Both placement on the bifurcation and the addition of an extension positively influenced the type I proximal endoleak rate (3.8% vs 35.3% P < .001) and the need for a secondary intervention (6.3% vs 35.3% P < .001) Two aneurysm ruptures and five cases of late conversion occurred in the group treated with a bifurcated graft only (4%, P = .52, P = .159). Analysis of aneurysm sac behavior was not statistically significant: enlargement, 4.1% vs 1.3% (P = .158); reduction, 34.1% vs 40.5% (P = .542).
  
  
  CONCLUSIONS
  The placement of the bifurcated Powerlink endograft on the aortic bifurcation with a proximal extension for complete sealing seems to improve late outcomes, particularly secondary procedures, migration, and endoleak development. Larger prospective studies with longer follow-up are necessary to confirm these promising results.
authors.affiliation: Department of Vascular Surgery, Nuovo Ospedale di S. Agostino-Estense, Modena, Italy.
authors.forename: Gioacchino
authors.initials: G
authors.lastname: Coppi
authors.forename: Roberto
authors.initials: R
authors.lastname: Silingardi
authors.forename: Sebastiano
authors.initials: S
authors.lastname: Tasselli
authors.forename: Stefano
authors.initials: S
authors.lastname: Gennai
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Saitta
authors.forename: Gian Franco
authors.initials: GF
authors.lastname: Veraldi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000601:surgery*; D001018:Aortic Diseases / Q000150:complications / Q000601:surgery; D050197:Atherosclerosis / Q000150:complications / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013997:Time Factors; D016896:Treatment Outcome