551
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Heider P, Wolf O, Reeps C, Hanke M, Zimmermann A, Berger H, Eckstein HH. Aneurysmen und Dissektionen der thorakalen und abdominellen Aorta. Chirurg 2007; 78:600, 602-6, 608-10. [PMID: 17594068 DOI: 10.1007/s00104-007-1370-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
One to four per cent of all deaths in patients over 65 are caused by aneurysmatic diseases of the abdominal or thoracic aorta. For elective surgery in abdominal aneurysms, open surgery and endovascular treatment both demonstrate brilliant overall results. In the thoracic aorta, new endovascular procedures have led to considerable reductions of postoperative morbidity and mortality. Nevertheless, in view of the endovascular procedure's high cost and the still unclear long-term behaviour of the stent device, a second opinion from a specialised centre is an absolute necessity.
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Affiliation(s)
- P Heider
- Abteilung für Gefässchirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Strasse 22, 81675, München, Deutschland.
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552
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Riambau V, Guerrero F, Montañá X, Gilabert R. [Abdominal aortic aneurysm and renovascular disease]. Rev Esp Cardiol 2007; 60:639-54. [PMID: 17580053 DOI: 10.1157/13107121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Recent technological advances in the diagnosis and therapy of abdominal aortic aneurysm and renovascular disease are continuing to bring about changes in the way patients suffering from these conditions are treated. The prevalence of both these conditions is increasing. This is due to greater life-expectancy in patients with arteriosclerosis, a pathogenetic factor underlying both conditions. The application of diagnostic imaging techniques to non-vascular conditions has led to the early diagnosis of abdominal aortic aneurysm. Clinical suspicion of reno-vascular disease can be confirmed easily using high-resolution diagnostic imaging modalities such as CT angiography and magnetic resonance angiography. Endovascular intervention is successfully replacing conventional surgical repair techniques, with the result that it may be possible to improve outcome in both conditions using effective and minimally invasive approaches. Future technological developments will enable these endovascular techniques to be applied in the large majority of patients with abdominal aortic aneurysm or renovascular disease.
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Affiliation(s)
- Vicente Riambau
- Cirugía vascular, Instituto del Tórax, Hospital Clínic, Barcelona, Spain
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553
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Abstract
It is now 16 years since the endovascular treatment of abdominal aortic aneurysm (AAA) was first described. It is probably true to say that, with current device technology, > 50% of all patients with an infrarenal aneurysm can be treated with an endograft. Endografting has become an important tool in the treatment of AAA. There are many reasons for this success. Rapid technical development followed the initial "homemade" devices, allowing easy accurate insertion. In early cohort series it was always the case that the operative mortality of endografting in AAA was lower than surgical treatment. In addition, postoperative management was easier and hospital stay was shorter after an endograft. No evidence indicated that quality of life improved after the perioperative period, however, and it was unclear whether the reduction in intensive hospital care requirement justified the considerable extra costs for an endovascular device. Despite these shortcomings, early widespread public awareness pushed endograft treatment forward. Patients started to ask for this new treatment option. But long-term outcome data then, and to some extent today, are still lacking.
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Affiliation(s)
- Jim A Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
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554
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Brown LC, Greenhalgh RM, Howell S, Powell JT, Thompson SG. Patient fitness and survival after abdominal aortic aneurysm repair in patients from the UK EVAR trials. Br J Surg 2007; 94:709-16. [PMID: 17514695 DOI: 10.1002/bjs.5776] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The aim was to use a validated fitness score to determine whether fitter patients with a large abdominal aortic aneurysm (AAA) benefited from having open rather than endovascular repair.
Methods
The Customized Probability Index (CPI) was applied to patients in the Endovascular Aneurysm Repair (EVAR) I and II trials. Interaction tests between CPI and randomized group assessed the effect of fitness and type of AAA repair on elective 30-day mortality and 4-year survival.
Results
The mean(s.d.) CPI scores were 3·6(9·3) for 1252 EVAR I patients and 10·0(11·3) for 404 EVAR II patients (range − 25 to + 43) (P < 0·001). The fitness of EVAR I patients was classified as good (579 patients, mean CPI − 4·2), moderate (331 patients, mean CPI 5·7) or poor (338 patients, mean CPI 15·1). Only in the good fitness group did 30-day mortality convincingly favour endovascular repair (odds ratio 0·24, P = 0·030), but overall the test of interaction was not significant (P = 0·363). For 4-year all-cause and aneurysm-related mortality, there was no benefit for either treatment across all fitness scores (P = 0·281 and P = 0·371 respectively).
Conclusion
The benefit of endovascular repair was most convincing in the fittest patients. There was no evidence that the fittest patients benefited more from open surgery.
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Affiliation(s)
- L C Brown
- Vascular Surgery Research Group, Imperial College, London, UK.
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555
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Powell JT, Brown LC, Forbes JF, Fowkes FGR, Greenhalgh RM, Ruckley CV, Thompson SG. Final 12-year follow-up of Surgery versus Surveillance in the UK Small Aneurysm Trial. Br J Surg 2007; 94:702-8. [PMID: 17514693 DOI: 10.1002/bjs.5778] [Citation(s) in RCA: 211] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
The aim was to determine whether early open surgical repair would benefit patients with small abdominal aortic aneurysm compared with surveillance on long-term follow-up.
Methods
The 1090 patients who were enrolled into the UK Small Aneurysm Trial between 1991 and 1995 were followed up for aneurysm repair and mortality until November 2005.
Results
By November 2005, 714 patients (65·5 per cent) had died, 929 (85·2 per cent) had undergone aneurysm repair, 150 (13·8 per cent) had died without aneurysm repair and 11 (1·0 per cent) remained alive without aneurysm repair. After 12 years, mortality in the surgery and surveillance groups was 63·9 and 67·3 per cent respectively, unadjusted hazard ratio 0·90 (P = 0·139). Three-quarters of the surveillance group eventually had aneurysm repair, with a 30-day elective mortality of 6·3 per cent (versus 5·0 per cent in the early surgery group, P = 0·366). Estimates suggested that the cost of treatment was 17 per cent higher in the early surgery group, with a mean difference of £1326. The death rate in these patients was about twice that in the population matched for age and sex.
Conclusion
There was no long-term survival benefit of early elective open repair of small abdominal aortic aneurysms. Even after successful aneurysm repair, the mortality among these patients was higher than in the general population.
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Affiliation(s)
- J T Powell
- Vascular Surgery Research Group, Imperial College, Charing Cross Hospital, London, UK.
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556
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Peterson BG, Matsumura JS, Brewster DC, Makaroun MS. Five-year report of a multicenter controlled clinical trial of open versus endovascular treatment of abdominal aortic aneurysms. J Vasc Surg 2007; 45:885-90. [PMID: 17398057 DOI: 10.1016/j.jvs.2007.01.044] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Accepted: 01/08/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Compare long-term results of endovascular treatment and standard open repair of abdominal aortic aneurysms in a multicenter, concurrent-controlled trial. METHODS 334 subjects were treated with standard open repair (control, n = 99) or the original EXCLUDER Bifurcated Endoprosthesis (test, n = 235). Five-year clinical evaluations and corelab radiographic results are analyzed. RESULTS Overall and aneurysm-related survival are similar. There have been ten open conversions, most frequently for enlarging sacs without endoleak. Two patients died after conversion. Including reinterventions and complications of reinterventions as adverse events, there is significant, persistent long-term reduction in major adverse events. At 5 years, corelab reported 0% limb narrowing, 0% trunk migration, 0% component (contralateral leg, aortic extender, and iliac extender) migration, 0% fracture, endoleak in 3% (2 type II/68), and aneurysm growth (>5 mm compared to baseline) in 38% (30/78) of the test group. There are no aneurysm ruptures in either test or control group. CONCLUSIONS After 5 years follow-up, endovascular repair is a safer and effective treatment compared with open surgical repair for abdominal aortic aneurysms. Major adverse events are less frequent with the endograft despite the need for late reinterventions. Aneurysm expansion is observed in nearly two-fifths of patients but is not associated with endoleak or aneurysm rupture. Multicenter clinical trials are evaluating a newer version of this device designed to avoid this high rate of sac expansion.
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557
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Schouten O, Dunkelgrun M, Feringa HHH, Kok NFM, Vidakovic R, Bax JJ, Poldermans D. Myocardial Damage in High-risk Patients Undergoing Elective Endovascular or Open Infrarenal Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2007; 33:544-9. [PMID: 17196849 DOI: 10.1016/j.ejvs.2006.11.028] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Accepted: 11/07/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. METHODS Consecutive patients with >or=3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. RESULTS All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair. CONCLUSION In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.
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Affiliation(s)
- O Schouten
- Department of Vascular Surgery, Erasmus MC, Rotterdam, The Netherlands
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558
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Falkensammer J, Oldenburg WA, Biebl M, Hugl B, Hakaim AG, Crook JE, Berland TL, Paz-Fumagalli R. Abdominal aortic aneurysm neck remodeling after open aneurysm repair. J Vasc Surg 2007; 45:900-5. [PMID: 17466786 DOI: 10.1016/j.jvs.2007.01.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 01/03/2007] [Indexed: 11/22/2022]
Abstract
PURPOSE Proximal endovascular aortic graft fixation and maintenance of hemostatic seal depends on the long-term stability of the aortic neck. Previous investigations of aortic neck dilation mostly focused on the infrarenal aortic diameter. Fenestrated and branched stent grafts facilitate suprarenal graft fixation and may thereby improve the long-term integrity of the aortic attachment site. For these devices, the natural history of the suprarenal aortic segment is also of interest. We investigated the natural history of the supra- and infrarenal aortic segment after open abdominal aortic aneurysm (AAA) repair. METHODS For this retrospective analysis, we reviewed the preoperative and the initial postoperative as well as the most recent CT series that were obtained from 52 patients undergoing conventional repair of an infrarenal abdominal aortic aneurysm between January 1998 and December 2002. Measurements were performed using electronic calipers on a "split screen", allowing direct comparison of subsequent CT series at corresponding levels along the vessel. Main outcome measures were changes in postoperative measures of the supra- and infrarenal aortic diameters. RESULTS The first postoperative exam was at a mean (+/-SD) of 7.0 +/- 3.5 months, and the final exams were at 44.4 +/- 21 months. Over this time period, the estimated rate of change in suprarenal diameter was 0.18 mm/ y with 95% confidence interval (CI) from 0.08 to 0.27. The estimated rate of change for the infrarenal diameter was 0.16 (95% CI: 0.05 to 0.27). A clinically relevant diameter increase of >or=3 mm was observed in seven patients (13%). There was evidence of larger diameter increases associated with larger AAA diameters (P = .003 and <.001 for suprarenal and infrarenal diameters), an inverted funnel shape (P = .002 and <.001), and marginal evidence of association with a history of inguinal hernia (P = .043 and .066). CONCLUSIONS Although there is statistically significant evidence of increases in the supra- and infrarenal aortic diameters after conventional AAA repair, mean annual increases tended to be small and clinically relevant increases of 3 mm or more were observed in only a small proportion of cases.
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Affiliation(s)
- Juergen Falkensammer
- Section of Vascular Surgery, Mayo Clinic Jacksonville, Jacksonville, FL 32224, USA
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559
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Diehm N, Hobo R, Baumgartner I, Do DD, Keo HH, Kalka C, Dick F, Buth J, Schmidli J. Influence of Pulmonary Status and Diabetes Mellitus on Aortic Neck Dilatation Following Endovascular Repair of Abdominal Aortic Aneurysms:A EUROSTAR Report. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[122:iopsad]2.0.co;2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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560
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Baril DT, Jacobs TS, Marin ML. Surgery Insight: advances in endovascular repair of abdominal aortic aneurysms. ACTA ACUST UNITED AC 2007; 4:206-13. [PMID: 17380166 DOI: 10.1038/ncpcardio0849] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Despite improvements in diagnostic and therapeutic methods and an increased awareness of their clinical significance, abdominal aortic aneurysms (AAAs) continue to be a major source of morbidity and mortality. Endovascular repair of AAAs, initially described in 1990, offers a less-invasive alternative to conventional open repair. The technology and devices used for endovascular repair of AAAs have progressed rapidly and the approach has proven to be safe and effective in short to midterm investigations. Furthermore, several large trials have demonstrated that elective endovascular repair is associated with lower perioperative morbidity and mortality than open repair. The long-term benefits of endovascular repair relative to open repair, however, continue to be studied. In addition to elective repair, the use of endovascular repair for ruptured AAAs has been increasing, and has been shown to be associated with reduced perioperative morbidity and mortality. Advances in endovascular repair of AAAs, including the development of branched and fenestrated grafts and the use of implantable devices to measure aneurysm-sac pressures following stent-graft deployment, have further broadened the application of the technique and have enhanced postoperative monitoring. Despite these advances, endovascular repair of AAAs remains a relatively novel technique, and further long-term data need to be collected.
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561
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Norwood MGA, Lloyd GM, Bown MJ, Fishwick G, London NJ, Sayers RD. Endovascular abdominal aortic aneurysm repair. Postgrad Med J 2007; 83:21-7. [PMID: 17267674 PMCID: PMC2599974 DOI: 10.1136/pgmj.2006.051177] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The operative mortality following conventional abdominal aortic aneurysm (AAA) repair has not fallen significantly over the past two decades. Since its inception in 1991, endovascular aneurysm repair (EVAR) has provided an alternative to open AAA repair and perhaps an opportunity to improve operative mortality. Two recent large randomised trials have demonstrated the short and medium term benefit of EVAR over open AAA repair, although data on the long term efficacy of the technique are still lacking. This review aimed at providing an overview of EVAR and a discussion of the potential benefits and current limitations of the technique.
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Affiliation(s)
- M G A Norwood
- Department of Vascular Surgery, The Leicester Royal Infirmary, Leicester, UK.
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562
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Haveman JW, Karliczek A, Verhoeven ELG, Tielliu IFJ, de Vos R, Zwaveling JH, van den Dungen JJAM, Zeebregts CJ, Nijsten MWN. Results of streamlined regional ambulance transport and subsequent treatment of acute abdominal aortic aneurysms. Emerg Med J 2007; 23:807-10. [PMID: 16988317 PMCID: PMC2579610 DOI: 10.1136/emj.2006.037879] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe the triage of patients operated for non-ruptured and ruptured abdominal aortic aneurysms (AAAs) before the endovascular era. DESIGN Retrospective single-centre cohort study. METHODS All patients treated for an acute AAA between 1998 and 2001 and admitted to our hospital were evaluated in the emergency department for urgent AAA surgery. All time intervals, from the telephone call from the patient to the ambulance department, to the arrival of the patient in the operating theatre, were analysed. Intraoperative, hospital and 1-year survival were determined. RESULTS 160 patients with an acute AAA were transported to our hospital. Mean (SD) age was 71 (8) years, and 138 (86%) were men. 34 (21%) of these patients had symptomatic, non-ruptured AAA (sAAA) and 126 patients had ruptured AAA (rAAA). All patients with sAAA and 98% of patients with rAAA were operated upon. For the patients with rAAA, median time from telephone call to arrival at the hospital was 43 min (interquartile range 33-53 min) and median time from arrival at the hospital to arrival at the operating room was 25 min (interquartile range 11-50 min). Intraoperative mortality was 0% for sAAA and 11% for rAAA (p = 0.042), and hospital mortality was 12% and 33%, respectively (p = 0.014). CONCLUSIONS A multidisciplinary unified strategy resulted in a rapid throughput of patients with acute AAA. Rapid transport, diagnosis and surgery resulted in favourable hospital mortality. Despite the fact that nearly all the patients were operated upon, survival was favourable compared with published data.
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Affiliation(s)
- J W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen Hanzeplein 1, PO Box 30.001, 9700 RB Groningen, The Netherlands.
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563
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Diehm N, Kickuth R, Gahl B, Do DD, Schmidli J, Rattunde H, Baumgartner I, Dick F. Intraobserver and interobserver variability of 64-row computed tomography abdominal aortic aneurysm neck measurements. J Vasc Surg 2007; 45:263-8. [PMID: 17264000 DOI: 10.1016/j.jvs.2006.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2006] [Accepted: 10/04/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND Integrity of the abdominal aortic aneurysm (AAA) neck is crucial for the long-term success of endovascular AAA repair (EVAR). However, suitable tools for reliable assessment of changes in small aortic volumes are lacking. The purpose of this study was to assess the intraobserver and interobserver variability of software-enhanced 64-row computed tomographic angiography (CTA) AAA neck volume measurements in patients after EVAR. METHODS A total of 25 consecutive patients successfully treated by EVAR underwent 64-row follow-up CTA in 1.5-mm collimation. Manual CTA measurements were performed twice by three blinded and independent readers in random order with at least a 4-week interval between readings. Maximum and minimum transverse aortic neck diameters were measured twice on two different levels within the proximal neck. Volumetry of the proximal aortic neck was performed by using dedicated software. Variability was calculated as 1.96 SD of the mean arithmetic difference according to Bland and Altman. Two-sided and paired t tests were used to compare measurements. P values <.05 were considered to indicate statistical significance. RESULTS Intraobserver agreement was excellent for dedicated aneurysmal neck volumetry, with mean differences of less than 1 mL (P > .05), whereas it was poor for transverse aortic neck diameter measurements (P < .05). However, interobserver variability was statistically significant for both neck volumetry (P < .005) and neck diameter measurements (P < .015). CONCLUSIONS The reliability of dedicated AAA neck volumetry by using 64-row CTA is excellent for serial measurements by individual readers, but not between different readers. Therefore, studies should be performed with aortic neck volumetry by a single experienced reader.
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Affiliation(s)
- Nicolas Diehm
- Division of Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, University Hospital of Bern, Bern, Switzerland
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564
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Fillinger MF. Invited commentary. J Vasc Surg 2007. [DOI: 10.1016/j.jvs.2006.12.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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565
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Moore R, Nutley M, Cina CS, Motamedi M, Faris P, Abuznadah W. Improved survival after introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms. J Vasc Surg 2007; 45:443-50. [PMID: 17257800 DOI: 10.1016/j.jvs.2006.11.047] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2006] [Accepted: 11/18/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND The study was conducted to demonstrate improved survival (30-day mortality) after the introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms (rAAA). Numerous authors have successfully demonstrated reduced mortality in patients with rAAA using endovascular techniques. Comparison of endovascular aneurysm repair (EVAR) with open repair for rAAA may be misleading, however, because EVAR cannot be performed on all patients, and selection bias may explain the superior performance of any given surgical or endovascular strategy. We developed a model to predict mortality in patients before the introduction of EVAR (preprotocol population), applied this model to predict 30-day mortality among prospective patients (postprotocol population), and compared observed vs expected results. METHODS We assessed 126 patients with rAAA. Primary outcome was 30-day mortality. Potential confounding variables were age, sex, presurgical lowest recorded systolic blood pressure (SBP), and glomerular filtration rate (GFR). A logistic regression model incorporating significant confounders was used to evaluate changes in 30-day mortality for all patients with rAAA after introduction of the EVAR protocol. Separate logistic regressions were done to compare 30-day mortality for preprotocol vs patients receiving EVAR and preprotocol vs patients receiving postprotocol open repair. Cumulative sum (CUSUM) analysis was used to assess shifts in the performance of the rAAA program over time. RESULTS Significant confounders were SBP, absence of SBP, and GFR. Logistic regression found evidence of lower mortality after the protocol was introduced, 17.9% vs 30.0% (odds ratio [OR], 0.385; 95% confidence interval [CI], 0.141 to 0.981; P = .046). Comparison of all open repairs (preprotocol and postprotocol) and EVAR demonstrated decreased risk for EVAR of 5.0% vs 28.3% (OR, 0.109; 95% CI, 0.013 to 0.906; P = .0084). Unstable patients (SBP <or=80) showed a trend towards improved survival with EVAR relative to open repair (14.3% vs 56.0%, P = .061). Comparison of preprotocol surgery with open repair after the introduction of the protocol found no evidence of a difference between mortality rates for the open procedures-30.0% (preprotocol) vs 25.0% (postprotocol; OR, 0.688; 95% CI, 0.335 to 1.415, P = .3031)-demonstrating that the improved performance observed with CUSUM analysis was related to the introduction of the EVAR protocol. CONCLUSION Our predictive model using "weighted" CUSUM analysis (a measure of performance over time) demonstrated that a predefined strategy of management of rAAA that includes EVAR is associated with improved (P < .05) mortality. Unstable patients with rAAA may be particularly benefited by EVAR and should not be excluded from repair. Appropriate patients with rAAA who are undergoing treatment in experienced vascular centers should be offered EVAR as the treatment of choice.
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Affiliation(s)
- Randy Moore
- Division of Vascular Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
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566
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Golledge J, Parr A, Boult M, Maddern G, Fitridge R. The outcome of endovascular repair of small abdominal aortic aneurysms. Ann Surg 2007; 245:326-33. [PMID: 17245188 PMCID: PMC1876984 DOI: 10.1097/01.sla.0000253965.95368.52] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the outcome of endovascular repair (EVAR) of small abdominal aortic aneurysms (AAA, <or=5.5 mm maximum diameter) in Australia. SUMMARY BACKGROUND DATA Randomized trials have suggested that small AAAs should not be treated by open surgery. EVAR is associated with less perioperative mortality than open surgery for large AAAs. We assessed the outcome of EVAR of small AAAs as part of a national audit. METHODS ASERNIP-S carried out a prospective audit of EVAR performed between November 1999 and May 2001 in Australia. A total of 478 of the 961 patients entered underwent treatment of a small AAA. Data were collected regarding preoperative characteristics, procedural outcome, and intermediate success. Median follow-up was 3.2 years. Data were analyzed using Kaplan-Meier and Cox proportional hazard analyses. RESULTS The 30-day mortality and technical success rates were 1.1% and 98%, respectively. Postoperative complications occurred in 29%. Survival was 84% and 52% at 3 and 5 years, respectively. Primary, assisted primary, and secondary clinical success rates were 72%, 79%, and 82%, respectively, at 3 years. Reintervention rate was 11% at 3 years; however, 15% of patients continued to have significant aortic sac enlargement. Survival was reduced in patients considered unfit for general anesthesia (odds ratio = 2.6; 95% confidence interval, 1.4-4.8, P = 0.002) or those who had elevated preoperative serum creatinine (odds ratio = 2.0; 95% confidence interval, 1.3-3.0, P = 0.001). CONCLUSIONS EVAR can be carried with good perioperative outcome in patients with small AAA; however, intermediate success is hampered by the need for reintervention and continued aortic sac enlargement. At present, widespread treatment of small AAAs by EVAR would appear inappropriate.
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Affiliation(s)
- Jonathan Golledge
- Vascular Biology Unit, James Cook University, Townsville, Queensland, Australia.
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567
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Schermerhorn M. Should usual criteria for intervention in abdominal aortic aneurysms be "downsized," considering reported risk reduction with endovascular repair? Ann N Y Acad Sci 2007; 1085:47-58. [PMID: 17182922 DOI: 10.1196/annals.1383.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Two randomized trials have demonstrated the safety of waiting until abdominal aortic aneurysm (AAA) diameter reaches 5.5 cm for repair in most patients. Other recent randomized trials have demonstrated lower perioperative mortality and morbidity with endovascular aneurysm repair (EVAR) compared to open surgery. Therefore, it is logical to assume that endovascular repair may change the appropriate threshold for intervention. However, endovascular repair is not as durable as open surgery and is associated with ongoing risks of rupture and reintervention. Decision analysis based on data available in 1998 showed that endovascular repair should not change the threshold for intervention. Since that time retrospective data have emerged to suggest that outcomes with endovascular repair are improved in smaller AAAs, although this may simply represent selection bias and the natural history of small AAAs. Randomized trials are appropriate to determine whether improved endovascular outcomes in small AAAs reduce late rupture and reintervention enough to justify early intervention in patients with appropriate anatomy. In the absence of data from these trials, the threshold for intervention should not be changed.
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Affiliation(s)
- Marc Schermerhorn
- Beth Israel Deaconess Medical Center, 110 Francis St. 5B, Boston, MA 02215, USA.
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568
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Hobo R, Kievit J, Leurs LJ, Buth J. Influence of Severe Infrarenal Aortic Neck Angulation on Complications at the Proximal Neck Following Endovascular AAA Repair: A EUROSTAR Study. J Endovasc Ther 2007; 14:1-11. [PMID: 17291144 DOI: 10.1583/06-1914.1] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To examine the influence of severe infrarenal neck angulation (SNA) on complications after endovascular repair of abdominal aortic aneurysm (AAA). METHODS From October 1996 to January 2006, 5183 patients who underwent endovascular aneurysm repair using a Talent, Zenith, or Excluder stent-graft were enrolled into the EUROSTAR registry. Incidence of proximal type I endoleak, stent-graft migration, proximal neck dilatation, aneurysm rupture, secondary interventions, and all-cause and aneurysm-related mortality were compared between patients with and without severe infrarenal neck angulation (>60 degrees angle between the infrarenal aortic neck and the longitudinal axis of the aneurysm). RESULTS In the short term (before discharge), proximal type I endoleak (OR 2.32, 95% CI 1.60 to 3.37, p<0.0001) and stent-graft migration (OR 2.17, 95% CI 1.20 to 3.91, p=0.0105) were observed more frequently in patients with SNA. Over the long term, higher incidences of proximal neck dilatation > or =4 mm (HR 1.26, 95% CI 1.11 to 1.43, p=0.0004), proximal type I endoleak (HR 1.80, 95% CI 1.25 to 2.58, p=0.0016), and need for secondary interventions (HR 1.29, 95% CI 1.00 to 1.67, p=0.0488) were seen in patients with SNA. All-cause mortality, aneurysm-related mortality, and rupture of the aneurysm were similar in patients with and without severe neck angulation. In the subgroup of patients with an Excluder endograft, proximal endoleak at the completion angiogram (OR 4.49, 95% CI 1.31 to 15.32, p=0.0166) and long-term proximal neck dilatation (HR 1.67, 95% CI 1.20 to 2.33, p=0.0026) were more frequently observed in patients with SNA. In the Zenith subgroup, proximal endoleak at the completion angiogram (OR 2.62, 95% CI 1.49 to 4.63, p=0.0009) and proximal stent-graft migration before discharge (OR 2.34, 95% CI 1.06 to 5.19, p=0.0353) were more common in patients with SNA. In the Talent subgroup, long-term proximal endoleak (HR 2.09, 95% CI 1.27 to 3.44, p=0.0036), proximal neck dilatation (HR 1.29, 95% CI 1.05 to 1.60, p=0.0168), and secondary interventions (HR 1.54, 95% CI 1.05 to 2.24, p=0.0259) were more frequently observed in patients with SNA. CONCLUSION Severe infrarenal aortic neck angulation was clearly associated with proximal type I endoleak, while the relationship with stent-graft migration was not clear. Excluder, Zenith, and Talent stent-grafts perform well in patients with severe neck angulation, with only a few differences among devices.
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Affiliation(s)
- Roel Hobo
- EUROSTAR Data Registry Centre, Catharina Hospital, Eindhoven, The Netherlands.
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569
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Chahwan S, Comerota AJ, Pigott JP, Scheuermann BW, Burrow J, Wojnarowski D. Elective treatment of abdominal aortic aneurysm with endovascular or open repair: The first decade. J Vasc Surg 2007; 45:258-62; discussion 262. [PMID: 17263998 DOI: 10.1016/j.jvs.2006.09.046] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Accepted: 09/16/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The development of endovascular aneurysm repair (EVAR) as an alternative to open repair of abdominal aortic aneurysms (AAA) has led to an increasing number of patients being treated by this less-invasive technique. It was anticipated that EVAR would reduce the operative mortality and morbidity compared with open repair. This study examined the initial 10-year experience in one center when both techniques were available to determine if there were advantages to one technique or the other, putting the results into the perspective of routine clinical care of patients with infrarenal AAA. METHODS From June 1996 to May 2005, 677 patients underwent elective repair of their infrarenal AAA, of which 417 were treated with open repair and 260 by EVAR. Demographic and aneurysm-specific data, comorbidities, operative morbidity, mortality, and late outcome were analyzed. RESULTS Open repair patients were 2 years younger (71 vs 74 years, P < .001), had larger aneurysms (6.01 +/- 1.38 cm vs 5.45 +/- 0.99 cm, P < .001), greater familial predisposition, a higher incidence of current smokers, and a higher incidence of chronic obstructive pulmonary disease than the EVAR group. There were no differences in renal function, hypertension, coronary artery disease, or heart failure between the two groups. Overall operative mortality was 3.1%; operative mortality per group was 3.5% for open and 2.7% for EVAR (P = .627). Procedure-related outcomes showed significant differences in operative blood loss and length of hospital stay in favor of EVAR, and 95% of the EVAR patients were discharged home vs 83% in the open repair group (P < .001). A Kaplan-Meier log-rank analysis showed no difference in early or long-term survival between open repair and EVAR (P = .20), but did show a difference in mid-term (3-year) survival favoring open repair (P < .002). Survival analysis by age (<70 and > or =70 years) showed no difference between treatment groups. CONCLUSIONS Open repair and EVAR are both performed safely in patients treated for elective infrarenal AAA. EVAR has the perioperative advantages of reduced blood loss, reduced length of intensive care unit and hospital stay, and increased number of patients discharged to home. The mid-term survival advantage of open repair has been observed in other reports and deserves further study.
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570
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Leurs LJ, Buth J, Harris PL, Blankensteijn JD. Impact of Study Design on Outcome after Endovascular Abdominal Aortic Aneurysm Repair. A Comparison between the Randomized Controlled DREAM-trial and the Observational EUROSTAR-registry. Eur J Vasc Endovasc Surg 2007; 33:172-6. [PMID: 17097901 DOI: 10.1016/j.ejvs.2006.09.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 09/04/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with abdominal aortic aneurysm (AAA) can be treated by transfemoral endovascular intervention and by conventional open surgery. Level-one evidence of the safety and efficacy of one treatment mode over the other is only provided by a randomised controlled trial (RCT). Results reported by voluntary registries are considered less valid than data from RCTs. On the other hand the outcome of a RCT may not be generalisable to the common practice because of vigorous selection of patients and institutions. PURPOSE The outcomes reported by the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial were compared with the results of the EURopean collaborators on Stent-graft techniques for AAA Repair (EUROSTAR) registry. METHODS To obtain comparable study groups with regard to risk factors equal proportions of ASA I, II and III patients as observed in the endovascular arm of the DREAMtrial were selected at random from the EUROSTAR-registry. All patients had an aneurysm of at least 50mm. Only patients, who had been enrolled into the registry from 1999, were selected to avoid the influence of first generation endografts which are not longer in use. Patient characteristics and outcomes of endovascular AAA repair (EVAR) of EUROSTAR and DREAM-trial participants were compared. Differences in early findings between study groups were assessed by Chi-Square tests for discrete variables and by Wilcoxon rank sum tests for continuous variables. Follow-up variables were analysed by Kaplan-Meier and Cox proportional hazard models. RESULTS Data of 177 patients of the DREAM trial with randomization to EVAR and 856 patients selected in the EUROSTAR-registry were compared. Baseline characteristics were comparable between the EUROSTAR-cohort and EVAR-arm of the DREAM-trial. The 36-month survival-rate was 87.6% for EVAR-arm in the DREAM-trial similar to the 86.8% found in this EUROSTAR-study population. The freedom of secondary procedures reached after 3 years 85.7%, and 86.9% in the DREAM and EUROSTAR-cohort, respectively. CONCLUSION We found comparable characteristics and outcomes between patients of comparable risk class of the EUROSTAR-registry and the EVAR-cohort of the DREAM-trial. This demonstrates the following: first, the EUROSTAR-data provide reliable information, and further comparisons of registry data with patients treated by conventional AAA surgery may be justified. Secondly, the various outcomes of the randomised DREAM trial appear generalisable, as it agrees with observations in a broad common practice derived database.
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Affiliation(s)
- L J Leurs
- EUROSTAR Data Registry Center, Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
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571
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Alfonso F, Segovia J, Heras M, Bermejo J. Patología arterial no coronaria: ¿de interés para el cardiólogo? Rev Esp Cardiol 2007. [DOI: 10.1157/13099464] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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572
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Franks SC, Sutton AJ, Bown MJ, Sayers RD. Systematic Review and Meta-analysis of 12 Years of Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2007; 33:154-71. [PMID: 17166748 DOI: 10.1016/j.ejvs.2006.10.017] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Accepted: 10/03/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Endovascular repair (ER) of abdominal aortic aneurysm (AAA) is a new technique, and reported rates of endoleak, conversion to open repair, rupture and mortality vary widely. The aim of this study was to estimate these rates from the published data, and examine how this has changed as more patients have undergone ER. METHODS A systematic review and meta-analysis of publications identified through searches of the electronic databases EMBASE and Medline. All publications quoting endoleak, conversion to open repair, rupture and mortality rates for a series of patients undergoing ER were included. RESULTS 163 studies pertaining to 28,862 patients undergoing ER were identified as relevant for the review and meta-analysis. The pooled estimate for operative mortality was 3.3% (95% confidence interval 2.9 to 3.6%). The pooled estimate for type 1 endoleaks was 10.5% (95% confidence interval 9.0 to 12.1%), with an annual rate of 8.4% (95% confidence interval 5.7% to 12.2%). The pooled estimate of type 2,3 and 4 endoleaks was 13.7% (95% confidence interval 12.3 to 15.3%), with an annual rate of 10.2% (95% confidence interval 7.4% to 14.1%). The pooled estimate for primary conversion to open repair was 3.8% (95% confidence interval 3.2 to 4.4%), and for secondary conversion to open repair 3.4% (95% confidence interval 2.8 to 4.2%). The pooled estimate for post-operative rupture was 1.3% (95% confidence interval 1.1 to 1.7%), with an annual rupture rate of 0.6% (95% confidence interval 0.5% to 0.8%). Multivariate meta-regression analysis showed that rates of operative mortality, post-operative rupture and total number of endoleaks all fell significantly (p<0.05) over time. CONCLUSIONS This study demonstrates a low mortality and a gradual reduction in vascular morbidity and mortality associated with endovascular repair since it was first introduced.
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Affiliation(s)
- S C Franks
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
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573
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Abstract
Abdominal aortic aneurysm (AAA) is a condition whereby the terminal aorta permanently dilates to dangerous proportions, risking rupture. The biomechanics of AAA has been studied with great interest since aneurysm rupture is a mechanical failure of the degenerated aortic wall and is a significant cause of death in developed countries. In this review article, the importance of considering the biomechanics of AAA is discussed, and then the history and the state-of-the-art of this field is reviewed--including investigations into the biomechanical behavior of AAA tissues, modeling AAA wall stress and factors which influence it, and the potential clinical utility of these estimates in predicting AAA rupture.
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Affiliation(s)
- David A Vorp
- Department of Surgery, Division of Vascular Surgery, Department of Bioengineering, McGowan Institute for Regenerative Medicine, Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, PA, USA.
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574
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Chao A, Major K, Kumar SR, Patel K, Trujillo I, Hood DB, Rowe VL, Weaver FA. Carbon dioxide digital subtraction angiography-assisted endovascular aortic aneurysm repair in the azotemic patient. J Vasc Surg 2007; 45:451-8; discussion 458-60. [PMID: 17254739 DOI: 10.1016/j.jvs.2006.11.017] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2005] [Accepted: 11/03/2006] [Indexed: 01/12/2023]
Abstract
OBJECTIVE This report analyzes the safety and efficacy of carbon dioxide digital subtraction angiography (CO(2)-DSA) for EVAR in a group of patients with renal insufficiency compared with a concurrent group of patients with normal renal function undergoing EVAR with iodinated contrast angiography (ICA). METHODS Between 2003 and 2005, 100 consecutive patients who underwent EVAR using ICA, CO(2)-DSA, or both were retrospectively reviewed, and preoperative, intraoperative, postoperative, and follow-up variables were collected. Patients were divided into two groups depending on renal function and contrast used. Group I comprised patients with normal renal function in whom ICA was used exclusively, and group II patients had a serum creatinine >or=1.5 mg/dL, and CO(2)-DSA was used preferentially and supplemented with ICA, when necessary. The two groups were compared for the outcomes of successful graft placement, renal function, endoleak type, and frequency, and the need for graft revision. Comparisons were made using chi(2) analysis, Student t test, and the Fisher exact test. RESULTS A total of 84 EVARs were performed in group I and 16 in group II. Patient demographics and risk factors were similar between groups with the exception of serum creatinine, which was significantly increased in group II (1.8 mg/dL vs 1.0 mg/dL P < .0005). All 100 endografts were successfully implanted. Patients in group II had longer fluoroscopy times, longer operative times, and increased radiation exposure, and 13 of 16 patients required supplemental ICA. Mean iodinated contrast use was 27 mL for group II vs 148 mL in group I (P < .0005). Mean postoperative serum creatinine was unchanged from baseline, and 30-day morbidity was similar for both groups. No patient required dialysis. No patients died. Perioperatively, and at 1 and 6 months, the endoleak type and incidence and need for endograft revision was no different between groups. CONCLUSIONS CO(2)-DSA is safe, can be used to guide EVAR, and provides outcomes similar to ICA-guided EVAR. CO2-DSA protects renal function in the azotemic patient by lessening the need for iodinated contrast and associated nephrotoxicity, but with the tradeoff of longer fluoroscopy and operating room times and increased radiation exposure.
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Affiliation(s)
- Alex Chao
- Department Surgery, Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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575
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Visser JJ, Bosch JL, Hunink MGM, van Dijk LC, Hendriks JM, Poldermans D, van Sambeek MRHM. Endovascular repair versus open surgery in patients with ruptured abdominal aortic aneurysms: clinical outcomes with 1-year follow-up. J Vasc Surg 2007; 44:1148-55. [PMID: 17145414 DOI: 10.1016/j.jvs.2006.08.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 08/11/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare the clinical outcomes of treatment after endovascular repair and open surgery in patients with ruptured infrarenal abdominal aortic aneurysms (AAAs), including 1-year follow-up. METHODS All consecutive conscious patients with ruptured infrarenal AAAs who presented to our tertiary care teaching hospital between January 1, 2001, and December 31, 2005, were included in this study (n = 55). Twenty-six patients underwent endovascular repair, and 29 patients underwent open surgery. Patients who were hemodynamically too unstable to undergo a computed tomography angiography scan were excluded. Outcomes evaluated were intraoperative mortality, 30-day mortality, systemic complications, complications necessitating surgical intervention, and mortality and complications during 1-year follow-up. The statistical tests we used were the Student t test, chi2 test, Fisher exact test, and Mann-Whitney U test (two sided; alpha = .05). RESULTS Thirty-day mortality was 8 (31%) of 26 patients who underwent endovascular repair and 9 (31%) of 29 patients who underwent open surgery (P = .98). Systemic complications and complications necessitating surgical intervention during the initial hospital stay were similar in both treatment groups (8/26 [31%] and 5/26 [19%] for endovascular repair, respectively, and 9/29 [31%] and 8/29 [28%] for open surgery, respectively; P > .40). During 1-year follow-up, two patients initially treated with endovascular repair died as a result of non-aneurysm-related causes; no death occurred in the open surgery group. Complications during 1-year follow-up were 1 (5%) of 20 for endovascular repair and 4 (16%) of 25 for open surgery (P = .36). CONCLUSIONS On the basis of our study with a highly selected population, the mortality and complication rates after endovascular repair may be similar compared with those after open surgery in patients treated for ruptured infrarenal AAAs.
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Affiliation(s)
- Jacob J Visser
- Department of Epidemiology and Biostatistics, Erasmus MC, Rotterdam, The Netherlands
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576
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Hobo R, Laheij RJF, Buth J. The influence of aortic cuffs and iliac limb extensions on the outcome of endovascular abdominal aortic aneurysm repair. J Vasc Surg 2007; 45:79-85. [PMID: 17210387 DOI: 10.1016/j.jvs.2006.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 09/01/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND In a proportion of patients with an endovascular abdominal aortic aneurysm repair (EVAR), aortic cuffs or iliac graft limb extensions are required to enhance sealing or to fix the position of the device. This requirement arises when these goals are not primarily obtained with the basic stent-graft configuration. The aim of this study was to assess the influence of the use of endograft extensions during the primary EVAR procedure on the short- and long-term outcome. METHODS The study was based on the data of the EUROSTAR registry. Patient and anatomic characteristics, data regarding the procedure, postoperative complications, and the mortality of patients undergoing EVAR were retrieved from the database. Patients were divided into three groups: (1) no extensions, (2) proximal aortic cuffs, and (3) iliac limb extensions. Logistic regression and Cox proportional hazards models were used to compare significant influences of the use of cuffs or extensions on different outcomes relative to control patients, adjusted for patient and anatomic factors. RESULTS The overall cohort comprised 6668 patients: 4932 (74.0%) without extensions, 259 (3.9%) with an aortic cuff, and 1477 (22.2%) with an iliac endograft extension. Both the 30-day (2.3%-3.9%) and the all-cause mortality rates (23%-27% at 4 years) were similar in the three study groups. The use of proximal cuffs or iliac extensions did not have an effect on the incidence of endoleaks of any type (24%-32% at 4 years). The incidences of device kinking (P = .0344) and secondary transfemoral interventions (P = .0053) during follow-up were increased in patients in whom iliac limb extensions were used. In patients with aortic cuffs, no significant associations with altered outcome were observed. CONCLUSIONS The use of iliac graft limb extensions at EVAR was associated with a higher incidence of kinking and secondary transfemoral interventions, whereas proximal aortic cuffs did not influence outcome.
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Affiliation(s)
- Roel Hobo
- EUROSTAR Data registry center, Catharina Hospital, Eindhoven, The Netherlands
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577
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Sarac TP, Altinel O, Ouriel K. Current trends in the management of small abdominal aortic aneurysms. Future Cardiol 2007; 3:65-9. [PMID: 19804208 DOI: 10.2217/14796678.3.1.65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Over the past decade, there have been revolutionary changes in the diagnosis and treatment of abdominal aortic aneurysms. Minimally invasive endovascular technologies have decreased length of stay and, more importantly, improved at least the early outcomes compared with conventional open surgical therapy. Several large, randomized, prospective trials have re-evaluated the optimal size to treat abdominal aortic aneurysms. The guidelines and conclusions from these studies, the UK Small Aneurysm Trial and The Veterans Affairs Administration aneurysm Detection And Management Trial recommend intervening on aortic aneurysms when they reach 5.5 cm in transverse diameter. However, these studies do not bear direct relevance to contemporary management of aneurysms with endovascular techniques. Clinical trials are currently underway to assess the optimal size for treating abdominal aortic aneurysms with endovascular stent grafts.
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Affiliation(s)
- Timur P Sarac
- The Cleveland Clinic-Lerner School of Medicine, Department of Vascular Surgery, S 40, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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578
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Ahn CM, Choi D, Shim WH. Endovascular Abdominal Aortic Aneurysmal Repair: A Korean Perspective. Korean Circ J 2007. [DOI: 10.4070/kcj.2007.37.10.459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Chul Min Ahn
- Cardiology Division, Department of Internal Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Donghoon Choi
- Cardiology Division, Department of Internal Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won-Heum Shim
- Cardiology Division, Department of Internal Medicine, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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579
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Analysis of Early and Distant Results Following Endovascular Repair of the Descending and Abdominal Aorta. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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580
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Feezor RJ, Huber TS, Martin TD, Beaver TM, Hess PJ, Klodell CT, Nelson PR, Berceli SA, Seeger JM, Lee WA. Perioperative differences between endovascular repair of thoracic and abdominal aortic diseases. J Vasc Surg 2007; 45:86-9. [PMID: 17210388 DOI: 10.1016/j.jvs.2006.09.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Accepted: 09/06/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND With the US Food and Drug Administration approval of the TAG thoracic device, more thoracic pathologies are being treated using endovascular techniques. Although endovascular abdominal and thoracic aortic repairs have some apparent similarities, there are substantive anatomic, pathologic, and technical differences that could impact perioperative outcomes. The purpose of this study is to identify these differences. METHODS During a 5-year period, 121 endovascular thoracic aortic repairs (TEVAR) and 450 abdominal aortic repairs (EVAR) were performed at a single institution. Preoperative, intraoperative, and early postoperative data were prospectively collected and retrospectively reviewed. Aggregate outcome measures were compared between the two cohorts, with statistical significance achieved at P < .05. RESULTS The mean age of patients undergoing EVAR was 72.8 +/- 8.3 compared with 68.3 +/- 13.9 for TEVAR (P = .02). More women underwent TEVAR (30.6% vs 11.1%, P < .001). Aneurysms undergoing TEVAR were larger than those for EVAR (62.0 mm vs 58.3 mm, P = .01). Intraoperatively, EVAR required 26.2 minutes of fluoroscopy compared with 22.1 minutes for TEVAR (P < .001). The amount of contrast used was higher in TEVAR (133.6 mL vs 93.6 mL, P < .001). The mean procedure times were 164 minutes for EVAR and 115 minutes for TEVAR (P < .001). Iliac conduits were required in 46 patients (10.2%) undergoing EVAR, and in 24 (19.8%) undergoing TEVAR (P = .007). The 30-day or in-hospital mortality was 2.0% for EVAR and 5.0% for TEVAR (P = NS). The median length of stay was longer for TEVAR (3 days vs 2 days, P =.034). There were 54 postoperative complications in 36 TEVAR patients (29.8%), including 13 neurologic (10.7%), 8 renal (6.6%), 7 pulmonary (5.8%), 6 ischemic (5.0), and 5 (4.1%) hemorrhagic events. Among the EVAR group, 136 (30.2%) patients had postoperative complications, which included 45 ischemic (10.0%), 34 wound (7.6%), 22 renal (4.9%), 12 cardiac (2.7%), 8 pulmonary (1.8%), 5 gastrointestinal (1.1%), and 4 neurologic (0.9%) events. CONCLUSIONS A relatively higher proportion of women underwent TEVAR than EVAR, and this was reflected in the greater need for iliac conduits to accommodate the larger delivery catheters of the thoracic devices. Intraoperative imaging techniques were also different, and TEVAR required higher contrast volumes despite shorter overall procedure times. The incidence of strokes and spinal cord ischemia was also higher during TEVAR. Despite apparent similarities of devices and techniques, EVAR and TEVAR are fundamentally different procedures with different perioperative outcomes.
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Affiliation(s)
- Robert J Feezor
- Department of Surgery, Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, USA
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581
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Zankl AR, Schumacher H, Krumsdorf U, Katus HA, Jahn L, Tiefenbacher CP. Pathology, natural history and treatment of abdominal aortic aneurysms. Clin Res Cardiol 2006; 96:140-51. [PMID: 17180573 DOI: 10.1007/s00392-007-0472-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2006] [Accepted: 10/10/2006] [Indexed: 11/30/2022]
Abstract
With increasing age of the population and improvement of diagnostic tools, the incidence of abdominal aortic aneurysms (AAA) has been rising steadily. Despite an improvement in operative and interventional treatment options, AAA is the cause of death in 1-3% of men over 65 years of age in industrial countries, mostly due to rupture [1]. Therefore, routine screening for AAA by ultrasonography has been postulated in the past: a 60 year old man with an abdominal aortic diameter of less than 3 cm has a life-time risk of developing AAA close to zero. However, routine screening has not been found to be cost effective. Despite of the results of two well-designed studies, the limits of AAA qualifying the patient for surgery or intervention in contrast to conservative treatment is still a matter of debate. The present review article summarizes the current knowledge of the pathology, incidence, risks, natural course as well as symptoms and current treatment strategies of AAA on the basis of the recent literature.
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Affiliation(s)
- A R Zankl
- Department of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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582
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Wilson WRW, Choke EC, Dawson J, Loftus IM, Thompson MM. Contemporary management of the infra-renal abdominal aortic aneurysm. Surgeon 2006; 4:363-71. [PMID: 17152201 DOI: 10.1016/s1479-666x(06)80112-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abdominal aortic aneurysms (AAAs) principally affect men over 60 years of age. Aneurysms are usually asymptomatic and detected coincidentally or following the onset of symptoms. Elective repair of an AAA is considered when the diameter reaches 5.5cm or annual expansion exceeds 1 cm. Rupture represents a catastrophic event and carries an unacceptably high mortality. The advent of endovascular repair heralds an improvement in operative outcome for this disease process. In this review we provide an overview of the recent trials investigating the management of non-ruptured and ruptured aneurysms and the strategies that may be invoked to lower the mortality of this disease process
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Affiliation(s)
- W R W Wilson
- Department of Vascular Surgery, University Hospital Nottingham, Queen's Medical Centre, Nottingham, UK
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583
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Abstract
Abdominal aortic aneurysm is associated with high mortality rate. For over 50 years, open surgical repair was the standard approach for large aneurysms. However, over the past decade, endovascular aneurysm repair (EVAR) has emerged as a viable alternative. EVAR is associated with lower operative and short-term morbidity and mortality and similar long-term survival (up to 4 years) compared with surgical repair. Endoleak remains a significant limitation associated with aneurysm expansion and reintervention. With newer, more versatile endograft designs, improvements in durability, and better surveillance techniques, the utilization of EVAR is likely to continue to expand.
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Affiliation(s)
- Majed Chane
- Division of Cardiology, University of Arizona, Arizona, USA
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584
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Lee WA, Nelson PR, Berceli SA, Seeger JM, Huber TS. Outcome after hypogastric artery bypass and embolization during endovascular aneurysm repair. J Vasc Surg 2006; 44:1162-8; discussion 1168-9. [PMID: 17145415 DOI: 10.1016/j.jvs.2006.08.047] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2006] [Accepted: 08/17/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Multiple strategies have been devised to extend the applicability of endovascular aneurysm repair (EVAR) in patients with common iliac artery (CIA) aneurysms. This study was designed to examine outcome in patients undergoing EVAR with either hypogastric artery embolization or common iliac artery bifurcation advancement by hypogastric bypass. METHODS A retrospective review of all patients undergoing EVAR since the inception of our program (1997-2006) was performed. Data were prospectively collected in an EVAR registry. Patients with large common iliac artery aneurysms (> or = 20 mm) and patent hypogastric arteries not amenable to a cuff or "bell bottom" technique were treated with coil embolization (EMBO) and/or hypogastric revascularization (BYPASS). The perioperative and mid-term outcomes were compared with the larger group of patients undergoing EVAR that did not require either treatment (CTRL). Bilateral common iliac artery aneurysms were treated with unilateral coil embolization and contralateral bypass. RESULTS Common iliac artery aneurysms were present in 137 (31%) of the 444 patients undergoing EVAR, but only 57 (42%) of 137 required direct management. This included hypogastric artery embolization alone (EMBO) in 31 or hypogastric artery revascularization (BYPASS) in 26, with and without contralateral embolization (both revascularization/embolization in 46%). The procedure length (CTRL, 159 +/- 72 minutes; EMBO, 153 +/- 39 minutes; BYPASS, 283 +/- 75 minutes) and estimated blood loss (CTRL, 251 +/- 313 mL; EMBO, 233 +/- 158 mL; BYPASS, 400 +/- 287 mL) were significantly greater (P < .05) in the BYPASS group. The incidence of any postoperative complication (CTRL, 26%; EMBO, 68%; BYPASS, 54%), any ischemic complication (CTRL, 6%; EMBO, 55%; BYPASS, 27%), and new-onset buttock claudication (CTRL, 3%; EMBO, 39%; BYPASS, 27%) were all significantly greater in the BYPASS and EMBO group relative to the control (CTRL) group (n = 387). The incidence of new-onset buttock claudication ipsilateral to the hypogastric bypass was 4%; the balance of the new onset claudication in the BYPASS group was due to the contralateral embolization. The primary hypogastric artery bypass patency was 91 +/- 11% (SE) at 36 months by life-table analysis. CONCLUSIONS Despite its increased complexity, hypogastric artery bypass is an excellent alternative to embolization in terms of patency and freedom from ischemic symptoms for patients with large common iliac artery aneurysms undergoing EVAR.
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Affiliation(s)
- W Anthony Lee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida College of Medicine, Gainesville, Fl 32610-0286, USA
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585
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Legemate DA, Bossuyt PM. From Innumeracy to Insight: The Uncertainty of Help versus Harm in Treatment of Asymptomatic Aortic Aneurysms. Eur J Vasc Endovasc Surg 2006; 32:620-3. [PMID: 16931067 DOI: 10.1016/j.ejvs.2006.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2006] [Accepted: 06/09/2006] [Indexed: 11/19/2022]
Abstract
There is insufficient evidence that the surgical treatment of asymptomatic infrarenal aneurysms > 5.5 cm. is beneficial to patients. This is the result of serious complications of aneurysm surgery and the dearth of information from randomized trials. Based on evidence from the literature we defined scenarios and translated data into natural frequency trees to improve understanding of the uncertainty of help versus harm due to treatment of aneurysms. Our analysis shows that the majority of patients can expect little on longevity from surgery while they are at risk of dying from surgery or suffering from serious morbidity. We conclude that, as long as uncertainty persist, patients should be treated in hospitals that can show very low surgical mortality and major morbidity rates. To further resolve the problem of uncertainty randomized trials for larger aneurysms should be performed. Important issues to discuss are the lower and upper limits of the diameter of the aneurysms and the age and risk profiles of the patients to be included in such trials.
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Affiliation(s)
- D A Legemate
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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586
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Aljabri B, Al Wahaibi K, Abner D, Mackenzie KS, Corriveau MM, Obrand DI, Meshefedjian G, Steinmetz OK. Patient-reported quality of life after abdominal aortic aneurysm surgery: A prospective comparison of endovascular and open repair. J Vasc Surg 2006; 44:1182-1187. [PMID: 17145419 DOI: 10.1016/j.jvs.2006.08.015] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 08/04/2006] [Indexed: 11/26/2022]
Abstract
PURPOSE This study evaluated and compared changes over time in health-related quality of life reported by patients with infrarenal abdominal aortic aneurysm (AAA) undergoing elective endovascular (EVAR) and open aneurysm (OR) repair. METHODS A prospective, nonrandomized cohort of 76 patients (62 men, 14 women; age range, 42 to 89 years) undergoing elective, infrarenal AAA repair (EVAR, n = 43; OR, n = 33) at two university teaching hospitals during a 15-month period were administered the Medical Outcomes Study Short-Form 36-item (SF-36) health survey preoperatively and then 1 week, 1 month, and 6 months postoperatively. Patient demographics, procedural details, postoperative follow-up data, and SF-36 scores were compared between groups. RESULTS Both groups had total SF-36 scores that were significantly lower than preoperative scores at 1 week and 1 month after surgery but were not significantly different from the preoperative scores at 6 months (OR 66.2 +/- 21.1 to 72.3 +/- 19.8, P > .1; and EVAR 61.0 +/- 17.7 to 58.7 +/- 19.4, P > .1). Six-month total SF-36 scores were significantly higher in the OR group compared with the EVAR group (mean 72.3 +/- 19.8 OR vs 58.7 +/- 19.4 EVAR; P = .009). In the postoperative period, a significant drop occurred in mean scores in six of the eight domains of the SF-36 in the OR patients (physical function, PF; role physical, RP; bodily pain, BP; vitality, VT; social function, SF; role emotional, RE) and five domains for EVAR patients (PF, RP, BP, SF, RE). In two domains, RE and PF, scores returned to baseline values significantly sooner in EVAR patients than in OR patients (RE, EVAR 1 month vs OR 6 months; and PF, EVAR 1 month vs OR 6 months). In the VT domain, no significant postoperative drop occurred in the EVAR group, but in the OR group, mean scores were significantly lower at 1 week and 1 month compared with preoperative values. In the domains of general health and mental health, no significant drop occurred in SF-36 score postoperatively in either group. CONCLUSIONS Patient reported health-related quality of life after infrarenal AAA repair is significantly impaired in the early postoperative period but returns to baseline by 6 months in patients treated with EVAR and OR. Patients having EVAR had significantly more rapid return to preoperative scores in selected domains of the SF-36. Even though EVAR is associated with shorter and less invasive perioperative hospital course and fewer postoperative complications, EVAR patients had lower quality of life scores 6 months after surgery than OR patients.
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Affiliation(s)
- Badr Aljabri
- Division of Vascular Surgery, McGill University, Montréal, Québec, Canada
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587
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Macari M, Chandarana H, Schmidt B, Lee J, Lamparello P, Babb J. Abdominal Aortic Aneurysm: Can the Arterial Phase at CT Evaluation after Endovascular Repair Be Eliminated to Reduce Radiation Dose? Radiology 2006; 241:908-14. [PMID: 17065562 DOI: 10.1148/radiol.2413051571] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively determine if arterial phase computed tomographic (CT) imaging is necessary for follow-up imaging of patients who have undergone endovascular stent-graft therapy for abdominal aortic aneurysm. MATERIALS AND METHODS This HIPAA-compliant study was exempt from institutional review board approval; informed patient consent was waived. Eighty-five patients (66 men, 19 women; mean age, 66 years; range, 45-81 years) underwent 110 multidetector CT examinations after endovascular repair of abdominal aortic aneurysms. Nonenhanced CT images were obtained. Intravenous contrast material was then injected at 4 mL/sec, and arterial and venous phase (60 seconds) CT images were obtained. The nonenhanced and venous phase images were evaluated to determine if an endoleak was present. Subsequently, arterial phase images were analyzed. The effective dose was calculated. Ninety-five percent confidence intervals as indicators of how often arterial phase imaging would contribute to the diagnosis of endoleak were determined. RESULTS Twenty-eight type II endoleaks were detected by using combined nonenhanced and venous phase acquisitions. Twenty-five of the 28 endoleaks were also visualized during the arterial phase. Three type II endoleaks were seen only during the venous phase. The arterial phase images depicted no additional endoleaks. Seventy-eight CT examinations performed in 67 patients revealed no endoleak during the venous phase. The arterial phase images also depicted no endoleaks at these examinations. Thus, for no more than 3.1% of all examinations, there was 95% confidence that arterial phase imaging would depict an endoleak missed at venous phase imaging. Arterial phase imaging contributed to a mean of 36.5% of the effective dose delivered. CONCLUSION Study results indicate that arterial phase imaging may not be necessary for the routine detection of endoleaks. Radiation exposure can be decreased by eliminating this phase.
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Affiliation(s)
- Michael Macari
- Department of Radiology, New York University School of Medicine, Suite HW 211, 560 First Ave, New York, NY 10016, USA.
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588
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Haveman JW, van den Berg AP, Verhoeven ELG, Nijsten MWN, van den Dungen JJAM, The TH, Zwaveling JH. HLA-DR expression on monocytes and systemic inflammation in patients with ruptured abdominal aortic aneurysms. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R119. [PMID: 16899122 PMCID: PMC1751002 DOI: 10.1186/cc5017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Accepted: 08/09/2006] [Indexed: 12/21/2022]
Abstract
Introduction Mortality from ruptured abdominal aortic aneurysms (RAAA) remains high. Severe systemic inflammation, leading to multi-organ failure, often occurs in these patients. In this study we describe the level of HLA-DR expression in a consecutive group of patients following surgery for RAAA and compare results between survivors and non-survivors. A similar comparison is made for IL-6 and IL-10 levels and Sequential Organ Failure Assessment (SOFA) scores. Methods This is a prospective observational study. Patients with RAAA were prospectively analysed. Blood samples were collected on days 1, 3, 5, 7, 10 and 14. The fraction of CD-14 positive monocytes expressing HLA-DR was measured by flow-cytometry. IL-6 and IL-10 levels were measured by ELISA. Results The study included 30 patients with a median age of 70 years, of which 27 (90%) were men. Six patients died from multiple organ failure, all other patients survived. The SOFA scores were significantly higher in non-survivors on days 1 through 14. HLA-DR expression on monocytes was significantly lower on days 3, 5, 7, 10 and 14 in non-survivors. IL-6 and IL-10 levels were significantly higher in non-survivors on day 1 and days 1 and 3, respectively. Conclusion HLA-DR expression on monocytes was decreased, especially in non-survivors. All patients with RAAA displayed a severe inflammatory and anti-inflammatory response with an increased production of IL-6 and IL-10. Poor outcome is associated with high levels of IL-6 and IL-10 and a high SOFA score in the first three days after surgery, while low levels of HLA-DR expression are observed from day three after RAAA repair.
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Affiliation(s)
- Jan Willem Haveman
- Department of Surgery; Surgical Intensive Care Unit, University Medical Center Groningen, University of Groningen, Hanzeplein, 9700 RB Groningen, The Netherlands
| | - Aad P van den Berg
- Department of Gastoenterology and Hepatology, University Medical Center Groningen, University of Groningen, Hanzeplein, 9700 RB Groningen, The Netherlands
| | - Eric LG Verhoeven
- Department of Surgery; Vascular Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein, 9700 RB Groningen, The Netherlands
| | - Maarten WN Nijsten
- Department of Surgery; Surgical Intensive Care Unit, University Medical Center Groningen, University of Groningen, Hanzeplein, 9700 RB Groningen, The Netherlands
| | - Jan JAM van den Dungen
- Department of Surgery; Vascular Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein, 9700 RB Groningen, The Netherlands
| | - T Hauw The
- Department of Clinical Immunology, University Medical Center Groningen, University of Groningen, Hanzeplein, 9700 RB Groningen, The Netherlands
| | - Jan Harm Zwaveling
- Department of Surgery; Surgical Intensive Care Unit, University Medical Center Groningen, University of Groningen, Hanzeplein, 9700 RB Groningen, The Netherlands
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589
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Hertzer NR. Current Status of Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms in the Context of 50 Years of Conventional Repair. Ann N Y Acad Sci 2006; 1085:175-86. [PMID: 17182934 DOI: 10.1196/annals.1383.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The operative risk for conventional open repair of nonruptured infrarenal abdominal aortic aneurysms (AAAs) has steadily declined during the past several decades to the point that open procedures now can be done with a mortality rate of approximately 2% at tertiary referral centers. Nevertheless, population-based studies suggest that the mortality rate for open AAA repair remains nearly 7% in many communities, a finding that undoubtedly is influenced by a substantial risk for unfavorable outcomes in patients who represent less than ideal candidates for major abdominal operations on the basis of advanced age and the medical comorbidities that so often accompany it. Endovascular aneurysm repair (EVAR) is a landmark contribution to the management of such patients and has been associated with significant overall reductions in the operative mortality rate in statewide and national audits. This early advantage of EVAR comes at the price of a unique set of complications, secondary interventions, and related expenses, however, and randomized clinical trials of EVAR versus open repair have not yet demonstrated differences in survival or quality of life within 4 years of follow-up. Data from the Nationwide Inpatient Sample and other sources indicate that the mortality rate for open AAA repair appears to be less than 2% in patients who are 65 years of age or younger. This low operative risk may not justify exposure to whatever incidence of late complications the current generation of endografts may prove to have during the relatively long survival times that can be anticipated for these patients.
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Affiliation(s)
- Norman R Hertzer
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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590
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Abstract
An estimated 10 million people in the U.S. have symptomatic peripheral arterial disease (PAD); 20 to 30 million have asymptomatic PAD. The prevalence of intermittent claudication increases with age, affecting >5% of patients over 70. The incidence of claudication doubles or triples in patients with diabetes. As people grow older, symptoms from peripheral vascular disease increasingly limit daily activity. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, advances in minimally invasive percutaneous interventions have made endovascular procedures the primary modality for revascularization in most patients. Compared with open surgical procedures, endovascular interventions offer comparable or superior long-term rates of success with very low rates for morbidity and mortality. Furthermore, most of these interventions are performed on an outpatient basis, reducing hospital stays considerably. In this monograph we discuss current endovascular interventions for treating occlusive PAD, aneurysmal arterial disease, and increasingly common venous occlusive diseases.
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Affiliation(s)
- Suhail Allaqaband
- School of Medicine and Public Health-Milwaukee Clinical Campus, University of Wisconsin, Milwaukee, WI, USA
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591
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Sandford RM, Bown MJ, Fishwick G, Murphy F, Naylor M, Sensier Y, Sharpe R, Walker J, Hartshorn T, London NJ, Sayers RD. Duplex Ultrasound Scanning is Reliable in the Detection of Endoleak Following Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2006; 32:537-41. [PMID: 16875850 DOI: 10.1016/j.ejvs.2006.05.013] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2006] [Accepted: 05/23/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate the value of duplex ultrasound scanning (DUSS) in the routine follow up of patients following EVAR. METHODS Imaging was reviewed for 310 consecutive patients undergoing EVAR at a single centre. Concurrent ultrasound and CT scans were defined as having occurred within 6 months of each other. There were 244 paired concurrent DUSS and CT scans which were used for further analysis. These modalities were compared with respect to sensitivity, specificity, positive and negative predictive values and level of agreement (by Kappa statistics) using CT as the 'gold standard'. RESULTS DUSS failed to detect a number of endoleaks which were seen on CT and the sensitivity of this test was therefore poor (67%). However, the specificity of DUSS compared more favourably with a value of 91%. Positive predictive values ranged from 33-100% but negative predictive values were more reliable with values of 91-100% at all time points post operatively. There were no type I leaks, or endoleaks requiring intervention which were missed on DUSS. Overall, there was a 'fair' level of agreement between the two imaging modalities using Kappa statistics. CONCLUSION Although DUSS is not as sensitive as CT scanning in the detection of endoleak, no leaks requiring intervention were missed on DUSS in this study. DUSS is much cheaper than CT and avoids high doses of radiation. DUSS therefore remains a valuable method of follow up after EVAR and can reduce the need for repeated CT scans.
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Affiliation(s)
- R M Sandford
- Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Level 2 RKCSB, Leicester Royal Infirmary, Leicester LE2 7LX, United Kingdom.
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592
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Zarins CK, Crabtree T, Bloch DA, Arko FR, Ouriel K, White RA. Endovascular aneurysm repair at 5 years: does aneurysm diameter predict outcome? J Vasc Surg 2006; 44:920-29; discussion 929-31. [PMID: 17098519 DOI: 10.1016/j.jvs.2006.06.048] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2006] [Accepted: 06/27/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The appropriate size threshold for endovascular repair of small abdominal aortic aneurysms (AAA) is unclear. We studied the outcome of endovascular aneurysm repair (EVAR) as a function of preoperative aneurysm diameter to determine the relationship between aneurysm size and long-term outcome of endovascular repair. METHODS We reviewed the results of 923 patients treated in a prospective, multicenter clinical trial of EVAR. Small aneurysms were defined according to two size thresholds of 5.5 cm and 5.0 cm. Two-way analysis was used to compare patients with small aneurysms (<5.5 cm, n = 441) to patients with large aneurysms (> or =5.5 cm, n = 482). An ordered three-way analysis was used to compare patients with small AAA (<5.0 cm, n = 145), medium AAA (5.0 to 5.9 cm, n = 461), and large AAA (> or =6.0 cm, n = 317). The primary outcome measures of rupture, AAA-related death, surgical conversion, secondary intervention, and survival were compared using Kaplan-Meier estimates at 5 years. RESULTS Median aneurysm size was 5.5 cm. The two-way comparison showed that 5 years after EVAR, patients with small aneurysms (<5.5 cm) had a lower AAA-related death rate (1% vs 6%, P = .006), a higher survival rate (69% vs 57%, P = .0002), and a lower secondary intervention rate (25% vs 32%, P = .03) than patients with large aneurysms (> or =5.5 cm). Three-way analysis revealed that patients with small AAAs (<5.0 cm) were younger (P < .0001) and were more likely to have a family history of aneurysm (P < .05), prior coronary intervention (P = .003), and peripheral occlusive disease (P = .008) than patients with larger AAAs. Patients with smaller AAAs also had more favorable aortic neck anatomy (P < .004). Patients with large AAAs were older (P < .0001), had higher operative risk (P = .01), and were more likely to have chronic obstructive pulmonary disease (P = .005), obesity (P = .03), and congestive heart failure (P = .004). At 5 years, patients with small AAAs had better outcomes, with 100% freedom from rupture vs 97% for medium AAAs and 93% for large AAAs (P = .02), 99% freedom from AAA-related death vs 97% for medium AAAs and 92% for large AAAs (P = .02) and 98% freedom from conversion vs 92% for medium AAAs and 89% for large AAAs (P = .01). Survival was significantly improved in small (69%) and medium AAAs (68%) compared to large AAAs (51%, P < .0001). Multivariate Cox proportional hazards modeling revealed that aneurysm size was a significant independent predictor of rupture (P = .04; hazard ratio [HR], 2.195), AAA-related death (P = .03; HR, 2.007), surgical conversion (P = .007; HR, 1.827), and survival (P = .001; HR, 1.351). There were no significant differences in secondary intervention, endoleak, or migration rates between small, medium, and large AAAs. CONCLUSIONS Preoperative aneurysm size is an important determinant of long-term outcome following endovascular repair. Patients with small AAAs (<5.0 cm) are more favorable candidates for EVAR and have the best long-term outcomes, with 99% freedom from AAA death at 5 years. Patients with large AAAs (> or =6.0 cm) have shorter life expectancy and have a higher risk of rupture, surgical conversion, and aneurysm-related death following EVAR compared to patients with smaller aneurysms. Nonetheless, 92% of patients with large AAAs are protected from AAA-related death at 5 years. Patients with AAAs of intermediate size (5 to 6 cm) represent most of the patients treated with EVAR and have a 97% freedom from AAA-related death at 5 years.
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Affiliation(s)
- Christopher K Zarins
- Division of Vascular Surgery, Stanford University, Stanford, CA 94305-5450, USA.
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593
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Killewich LA. Strategies to Minimize Postoperative Deconditioning in Elderly Surgical Patients. J Am Coll Surg 2006; 203:735-45. [PMID: 17084337 DOI: 10.1016/j.jamcollsurg.2006.07.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2006] [Revised: 07/12/2006] [Accepted: 07/13/2006] [Indexed: 12/20/2022]
Affiliation(s)
- Lois A Killewich
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555-0735, USA
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594
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Lederle FA. A Summary of the Contributions of the VA Cooperative Studies on Abdominal Aortic Aneurysms. Ann N Y Acad Sci 2006; 1085:29-38. [PMID: 17182920 DOI: 10.1196/annals.1383.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The Department of Veterans Affairs Cooperative Studies Program has completed two studies on abdominal aortic aneurysm (AAA) and is currently conducting a third. The first, the Aneurysm Detection and Management (ADAM) Study, consisted of both a screening program, which provided information on the prevalence and associations of AAA, and a randomized trial, which found that survival is not improved by repair of small AAA. The second was a prospective observational study to determine the incidence of rupture in patients with large AAA for whom elective repair was not planned due to medical contraindications or patient refusal. AAA in this population had a high risk of rupture, about 10% per year for AAA > 5.5 cm, and 25% within 6 months for AAA larger than 8.0 cm. The third, the Open Versus Endovascular Repair (OVER) Trial, is a multicenter randomized trial comparing long-term survival following two methods of elective AAA repair.
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Affiliation(s)
- Frank A Lederle
- University of Minnesota, Center for Epidemiological and Clinical Research, VA Medical Center, Minneapolis, MN 55417, USA.
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595
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Brewster DC, Jones JE, Chung TK, Lamuraglia GM, Kwolek CJ, Watkins MT, Hodgman TM, Cambria RP. Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade. Ann Surg 2006; 244:426-38. [PMID: 16926569 PMCID: PMC1856532 DOI: 10.1097/01.sla.0000234893.88045.dc] [Citation(s) in RCA: 225] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The proper role of endovascular abdominal aortic aneurysm repair (EVAR) remains controversial, largely due to uncertain late results. We reviewed a 12-year experience with EVAR to document late outcomes. METHODS During the interval January 7, 1994 through December 31, 2005, 873 patients underwent EVAR utilizing 10 different stent graft devices. Primary outcomes examined included operative mortality, aneurysm rupture, aneurysm-related mortality, open surgical conversion, and late survival rates. The incidence of endoleak, migration, aneurysm enlargement, and graft patency was also determined. Finally, the need for reintervention and success of such secondary procedures were evaluated. Kaplan-Meier and multivariate methodology were used for analysis. RESULTS Mean patient age was 75.7 years (range, 49-99 years); 81.4% were male. Mean follow-up was 27 months; 39.3% of patients had 2 or more major comorbidities, and 19.5% would be categorized as unfit for open repair. On an intent-to-treat basis, device deployment was successful in 99.3%. Thirty-day mortality was 1.8%. By Kaplan-Meier analysis, freedom from AAA rupture was 97.6% at 5 years and 94% at 9 years. Significant risk factors for late AAA rupture included female gender (odds ratio OR, 6.9; P = 0.004) and device-related endoleak (OR, 16.06; P = 0.009). Aneurysm-related death was avoided in 96.1% of patients, with the need for any reintervention (OR, 5.7 P = 0.006), family history of aneurysmal disease (OR, 9.5; P = 0.075), and renal insufficiency (OR, 7.1; P = 0.003) among its most important predictors. 87 (10%) patients required reintervention, with 92% of such procedures being catheter-based and a success rate of 84%. Significant predictors of reintervention included use of first-generation devices (OR, 1.2; P < 0.01) and late onset endoleak (OR, 64; P < 0.001). Current generation stent grafts correlated with significantly improved outcomes. Cumulative freedom from conversion to open repair was 93.3% at 5 through 9 years, with the need for prior reintervention (OR, 16.7; P = 0.001) its most important predictor. Cumulative survival was 52% at 5 years. CONCLUSIONS EVAR using contemporary devices is a safe, effective, and durable method to prevent AAA rupture and aneurysm-related death. Assuming suitable AAA anatomy, these data justify a broad application of EVAR across a wide spectrum of patients.
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596
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Johnson ML, Bush RL, Collins TC, Lin PH, Liles DR, Henderson WG, Khuri SF, Petersen LA. Propensity score analysis in observational studies: outcomes after abdominal aortic aneurysm repair. Am J Surg 2006; 192:336-43. [PMID: 16920428 DOI: 10.1016/j.amjsurg.2006.03.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2005] [Revised: 03/15/2006] [Accepted: 03/15/2006] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Large databases composed of well-designed prospectively collected cohort data provide an opportunity to examine and compare healthcare treatments in actual clinical practice settings. Because the analysis of these data often leads to a retrospective cohort design, it is essential to adequately adjust for lack of balance in patient characteristics when making treatment comparisons. We used matched propensity scoring in a cohort of patients undergoing elective aneurysm repair as an illustrative example of this important statistical method that adjusts for baseline characteristics and selection bias by matching covariables. METHODS By using prospectively collected clinical data from the National Surgical Quality Improvement Program of the Department of Veterans Affairs, we studied 30-day mortality, 1-year survival, and postoperative complications in 1904 patients who underwent elective AAA repair (endovascular aneurysm repair [EVAR], n=717 (37.7%); open aneurysm repair, n=1187 [62.3%]) at 123 Veterans Health Administration's hospitals between May 1, 2001, and September 30, 2003. In bivariate analysis, patient characteristics and operative and hospital variables were associated with both type of surgery and outcomes of surgery. Therefore, the predicted probability of receiving EVAR was tabulated for all patients by using multiple logistic regression to control for 32 independent demographic and clinical characteristics and then stratified into 5 groups. Patients were matched within strata based on similar levels of the independent measures (a propensity score technique), creating a pseudo-randomized control design. The proportion of patients with the morbidity and mortality outcomes was then compared between the EVAR and open procedures within strata to control for selection. RESULTS Patients undergoing EVAR had significantly lower unadjusted 30-day (3.1% versus 5.6%, P=.01) and 1-year mortality (8.7% versus 12.1%, P=.018) than patients undergoing open repair. By using propensity scoring, the proportions of EVAR patients experiencing 30-day mortality were equal or less than patients undergoing open procedures for all levels of probability and decreased as the probability of EVAR increased. Furthermore, propensity scoring also showed that patients having EVAR had lower 1-year mortality and experienced fewer perioperative complications. CONCLUSIONS We used a propensity score approach to examine outcomes after elective AAA repair to statistically control for many factors affecting both treatment selection and outcome. Patients who underwent elective EVAR had substantially lower perioperative mortality and morbidity rates compared with patients having open repair, which was not explained solely by patient selection in an observational dataset.
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Affiliation(s)
- Michael L Johnson
- Houston Center for Quality of Care and Utilization Studies, and Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston VAMC, 2002 Holcomb Blvd (112), Houston, TX 77030, USA
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597
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Katzen BT, MacLean AA. Complications of Endovascular Repair of Abdominal Aortic Aneurysms: A Review. Cardiovasc Intervent Radiol 2006; 29:935-46. [PMID: 16967225 DOI: 10.1007/s00270-005-0191-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The endovascular procedure for repair of abdominal aortic aneurysms has had an enormous impact on the treatment of this challenging disease. Complications, however, do occur and it is important to have a thorough understanding of the array of complications and appropriate management strategies. In this review of endovascular complications, we describe early and late complications paying particular attention to preventive, treatment and surveillance strategies.
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Affiliation(s)
- Barry T Katzen
- Department of Interventional Radiology, Baptist Cardiac and Vascular Institute, Baptist Health Systems, Miami, Florida, USA.
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598
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Utikal P, Koecher M, Koutna J, Bachleda P, Drac P, Cerna M. Conversion to open surgery after endovascular abdominal aortic aneurysms repair. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2006; 150:165-9. [PMID: 16936921 DOI: 10.5507/bp.2006.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The authors describe experience with conversions to open surgery after endovascular abdominal aneurysm repair and evaluate the frequency, causes and results of a total of 7 cases in their series of 165 patients treated over a 10-year period.
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Affiliation(s)
- Petr Utikal
- 2nd Clinic of Surgery, University Hospital Olomouc, Czech Republic.
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599
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Utikal P, Koecher M, Koutna J, Bachleda P, Drac P, Cerna M, Herman J. Surgical corrections of endovascular aneurysms: repair complications. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2006; 150:147-53. [PMID: 16936919 DOI: 10.5507/bp.2006.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The authors describe their experience with the use of 21 open surgical corrections after endovascular abdominal aneurysm repair, reporting the frequency, type and outcome of these procedures in their group of 165 patients treated during a 10-year period.
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Affiliation(s)
- Petr Utikal
- 2nd Clinic of Surgery, University Hospital Olomouc, Czech Republic.
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600
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Muhs BE, Verhoeven ELG, Zeebregts CJ, Tielliu IFJ, Prins TR, Verhagen HJM, van den Dungen JJAM. Mid-term results of endovascular aneurysm repair with branched and fenestrated endografts. J Vasc Surg 2006; 44:9-15. [PMID: 16828419 DOI: 10.1016/j.jvs.2006.02.056] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2005] [Accepted: 02/07/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE The technique of fenestrated and branched endovascular aneurysm repair (EVAR) has been used for the treatment a variety of aortic aneurysms. Although technically successful, longer-term results have been lacking. This article reports on the mid-term results of aneurysm repair with fenestrated and branched endografts from a European center with a large endovascular experience. METHODS Between 2001 and 2005, 38 patients were prospectively enrolled in a single institution, investigational device protocol database. Indications for fenestrated or branched EVAR included unfavorable anatomy for traditional EVAR and an abdominal aortic aneurysm >5.5 cm in maximum diameter. Customized stent-grafts were either fenestrated or branched and based on the Zenith system. Data were analyzed on an intention-to-treat basis. Differences between groups were determined using analysis of variance with P < .05 considered significant. RESULTS The mean (SD) follow-up was 25.8 +/- 12.7 months (median, 25.0 months; range, 9 to 46 months), and no patients were lost to follow-up. All cause mortality was 13% (5/38), with all deaths occurring within the first postoperative year; 30-day mortality was 2.6%. No patient died during the operation. Completion angiography demonstrated successful sealing in 37 of 38 patients and an overall operative visceral vessel perfusion rate of 94% (82/87). Cumulative visceral branch patency was 92% at 46 months. Stent occlusions, when they did occur, all happened within the first postoperative year. All postoperative occlusions occurred in unstented fenestrations or scallops. No occlusions occurred in stented vessels. The difference in serum creatinine preoperatively and postoperatively at 6 months, 1, 2, and 3 years was not significant (P = NS). No patient required dialysis. The aneurysm sac size decreased significantly during the first year and then remained stable (P < .05). Limb perfusion as assessed by the ankle/brachial index was not affected by the presence of a fenestrated or branched endograft. CONCLUSIONS The intermediate-term results of fenestrated and branched endografts support their continued use in patients with anatomic contraindications for standard EVAR. Close surveillance is mandatory for early identification of visceral or branched vessel stenosis and preocclusion. All cases of failure appear to occur during the first year and then level off in subsequent longer-term follow-up. This includes death, secondary interventions, branch vessel patency, and complications. As the procedure matures, long-term results and randomized clinical trials will ultimately be required to determine the safety, efficacy, and stability of this system.
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Affiliation(s)
- Bart E Muhs
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
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