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Stonier TW, Patel K, Bhrugubanda V, Choong AMTL. Carotid Access for Endovascular Repair of Aortic Pathology: A Systematic Review. Ann Vasc Surg 2018; 49:206-218. [PMID: 29428538 DOI: 10.1016/j.avsg.2018.01.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 09/06/2017] [Accepted: 01/29/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Endovascular repair is now preferred to open access for the management of aortic diseases. This is typically performed via the femoral artery; however, not all patients are eligible for this. This systematic review summarizes the current evidence for utilizing the carotid artery as an alternative access route. METHODS A systematic review was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines using 4 electronic databases. RESULTS The search found 11 case reports representing 12 patients eligible for analysis (mean age 64.5 years). This included 3 thoracic aneurysms, 3 abdominal aneurysms, 4 penetrating ulcers, 1 endoleak, and 1 pseudoaneurysm. An open procedure was contraindicated in 83% (10/12) due to the poor physiological fitness of the patient. In 75% (9/12) of cases, traditional endovascular access was contraindicated by severe iliac disease. The remainder were contraindicated because of an existing ligated aortic stump (1/12, 8.3%) or technical difficulty with graft deployment via the femoral artery (2/12, 16.7%). There was 1 death, with the 30-day mortality 8.3%. The same patient suffered the only spinal ischemia before death (8.3%). There were no cases of stroke (0%), with one case of transient ischemic attack (8.3%). CONCLUSIONS Although there is a relative paucity of literature, this study demonstrates when traditional endovascular access is impossible and an open procedure contraindicated, carotid artery access for endovascular repair of aortic pathology is a viable alternative with good 30-day survival and low rates of neurological sequelae.
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Affiliation(s)
- Thomas W Stonier
- SingVaSC, Singapore Vascular Surgical Collaborative; Department of Urology, Princess Alexandra Hospital, Harlow, UK
| | - Kirtan Patel
- SingVaSC, Singapore Vascular Surgical Collaborative; Department of Vascular Surgery, Southend University Hospital NHS Foundation Trust, Essex, UK
| | - Vamsee Bhrugubanda
- SingVaSC, Singapore Vascular Surgical Collaborative; Department of Accident & Emergency, Royal Preston Hospital, Lancashire, UK
| | - Andrew M T L Choong
- SingVaSC, Singapore Vascular Surgical Collaborative; Cardiovascular Research Institute, National University of Singapore, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Vascular Surgery, National University Heart Centre, Singapore.
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102
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Yang JH, Kim JW, Choi HC, Park HO, Jang IS, Lee CE, Moon SH, Byun JH, Choi JY. Comparison of Clinical Outcomes between Surgical Repair and Endovascular Stent for the Treatment of Abdominal Aortic Aneurysm. Vasc Specialist Int 2018; 33:140-145. [PMID: 29354624 PMCID: PMC5754071 DOI: 10.5758/vsi.2017.33.4.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 08/28/2017] [Accepted: 09/10/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose This study was performed to compare the treatment outcomes between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) in a South Korean population. Materials and Methods We performed a retrospective review of the medical records of 99 patients with AAAs who were managed at Gyeongsang National University Hospital between January 2005 and December 2014. We reviewed the demographic characteristics and perioperative treatment outcomes of patients with AAA undergoing EVAR or OSR. In-hospital mortality and reintervention rates were assessed and compared between the EVAR and OSR groups. Results In-hospital mortality was not significantly higher in the OSR group versus the EVAR group (3.8% vs. 8.7%, respectively, P=0.41). Intervention time (209.6 mins vs. 350.9 mins, P<0.001) and length of hospital stay (7.79 days vs. 17.46 days, P<0.001) were significantly longer in the OSR group vs. the EVAR group. Median follow-up time was 24.1±20 months for the EVAR group and 43.9±28 months for the OSR group. The cumulative rate of freedom from reintervention at 60 months was 62.0% for the EVAR group and 100% for the OSR group (P<0.001). Conclusion EVAR was favorable in terms of intervention time and length of hospital stay, but the long-term durability of EVAR remains open for further debate.
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Affiliation(s)
- Jun Ho Yang
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Jong Woo Kim
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Ho Chul Choi
- Department of Imaging Radiology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Hyun Oh Park
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - In Seok Jang
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Chung Eun Lee
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Seong Ho Moon
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Jeong Hun Byun
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Jun Young Choi
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea
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Skripochnik E, Labropoulos N, Loh SA. Delayed migration of a thrombosed aortic endograft within a thrombosed aneurysm sac resulting in continued sac expansion and rupture. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2018; 3:115-118. [PMID: 29349395 PMCID: PMC5764865 DOI: 10.1016/j.jvscit.2017.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 03/04/2017] [Indexed: 11/16/2022]
Abstract
We present the case of delayed migration of a thrombosed aortic endograft within a thrombosed aneurysm sac that expanded and ruptured. Dilation of the aortic neck likely led to endograft migration and exposure of the occluded endograft and aneurysm sac to systemic pressure. Although no endoleak was identified, a key finding on ultrasound showed mobility of the sac thrombus. This may be an indicator of flow within the sac that may predict potential for rupture. Despite thrombosis of the aortic sac and endograft, the risk of rupture still lingers, and thus continued surveillance of occluded endografts may be prudent.
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Affiliation(s)
- Edvard Skripochnik
- Division of Vascular and Endovascular Surgery, Department of Surgery, Health Sciences Center T19-090, Stony Brook Medicine, Stony Brook, NY
| | - Nicos Labropoulos
- Division of Vascular and Endovascular Surgery, Department of Surgery, Health Sciences Center T19-090, Stony Brook Medicine, Stony Brook, NY
| | - Shang A Loh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Health Sciences Center T19-090, Stony Brook Medicine, Stony Brook, NY
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104
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De Silva S. High risk endovascular aneurysm repair: a case report. J Perioper Pract 2018; 27:234-235. [PMID: 29328848 DOI: 10.1177/175045891702701006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/26/2016] [Indexed: 11/16/2022]
Abstract
Mr AB is a 66-year old gentleman who presented for elective endovascular aneurysm repair (EVAR) following a routine screening scan identifying a 5.5cm abdominal aortic aneurysm (AAA). He had a past history of chronic obstructive pulmonary disease (COPD) with FEV1/FVC ratio of 48% on pre-assessment. He was hypertensive with a history of ischaemic heart disease (IHD), which has remained asymptomatic following coronary artery bypass grafting (CABG) eight years prior to this presentation.
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105
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Sharifpour M, Hemani S. Anaesthesia for Endovascular Aortic Aneurysm Repair (EVAR). Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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106
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Krylov VP, Shevtsov DE, Popel GA, Zhigalkovich AS, Gaiduk VN, Reut LI, Smolyakov AL, Shestakova LG, Mankevich NV. Sparing Treatment of Thoracic and Abdominal Aortic Aneurysms. Health (London) 2018. [DOI: 10.4236/health.2018.104037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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107
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Massara M, Notarstefano S, Gerardi P, Menna D, Cito D, Lillo A, Prunella R, Impedovo G. Endovascular and open surgical treatment of complications after endovascular aortic aneurysm repair: A single-center experience. Semin Vasc Surg 2018; 31:81-87. [PMID: 30876645 DOI: 10.1053/j.semvascsurg.2018.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
While endovascular aortic aneurysm repair (EVAR) has proven to be a safer alternative to open surgical repair for infrarenal abdominal aortic aneurysms (AAA) repair, the development of stent-graft complications mandates follow-up computed tomography imaging to minimize AAA-related mortality. In this single-institution report, adverse EVAR events identified in 150 consecutive patients are detailed. Early morbidity was low (<3%), with only 1 patient death on post-procedure day 2. After discharge (mean follow-up of 24 months), 2 patients died from cancer and one AAA-related mortality occurred after open conversion for stent-graft migration. Although computed tomography imaging detected no EVAR endoleak at 30 days, 19 patients developed an endoleak, including three Type I and four Type III leaks. Our institutional series review confirmed that EVAR of infrarenal AAA is a safe and valid alternative to open surgical repair, but sac embolization at the primary procedure in patients judged to be at high risk for Type II endoleak should be considered.
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Affiliation(s)
- Mafalda Massara
- Unit of Vascular and Endovascular Surgery, SS Annunziata Hospital, Via F. Bruno, Taranto, Italy.
| | - Stefano Notarstefano
- Unit of Vascular and Endovascular Surgery, SS Annunziata Hospital, Via F. Bruno, Taranto, Italy
| | - Pasquale Gerardi
- Unit of Vascular and Endovascular Surgery, SS Annunziata Hospital, Via F. Bruno, Taranto, Italy
| | - Danilo Menna
- Unit of Vascular and Endovascular Surgery, SS Annunziata Hospital, Via F. Bruno, Taranto, Italy
| | - Domenico Cito
- Unit of Vascular and Endovascular Surgery, SS Annunziata Hospital, Via F. Bruno, Taranto, Italy
| | - Antonio Lillo
- Unit of Vascular and Endovascular Surgery, SS Annunziata Hospital, Via F. Bruno, Taranto, Italy
| | - Roberto Prunella
- Unit of Vascular and Endovascular Surgery, SS Annunziata Hospital, Via F. Bruno, Taranto, Italy
| | - Giovanni Impedovo
- Unit of Vascular and Endovascular Surgery, SS Annunziata Hospital, Via F. Bruno, Taranto, Italy
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Patel R, Powell JT, Sweeting MJ, Epstein DM, Barrett JK, Greenhalgh RM. The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-132. [PMID: 29384470 PMCID: PMC5817412 DOI: 10.3310/hta22050] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Short-term survival benefits of endovascular aneurysm repair (EVAR) compared with open repair (OR) of intact abdominal aortic aneurysms have been shown in randomised trials, but this early survival benefit is soon lost. Survival benefit of EVAR was unclear at follow-up to 10 years. OBJECTIVE To assess the long-term efficacy of EVAR against OR in patients deemed fit and suitable for both procedures (EVAR trial 1; EVAR-1); and against no intervention in patients unfit for OR (EVAR trial 2; EVAR-2). To appraise the long-term significance of type II endoleak and define criteria for intervention. DESIGN Two national, multicentre randomised controlled trials: EVAR-1 and EVAR-2. SETTING Patients were recruited from 37 hospitals in the UK between 1 September 1999 and 31 August 2004. PARTICIPANTS Men and women aged ≥ 60 years with an aneurysm of ≥ 5.5 cm (as identified by computed tomography scanning), anatomically suitable and fit for OR were randomly assigned 1 : 1 to either EVAR (n = 626) or OR (n = 626) in EVAR-1 using computer-generated sequences at the trial hub. Patients considered unfit were randomly assigned to EVAR (n = 197) or no intervention (n = 207) in EVAR-2. There was no blinding. INTERVENTIONS EVAR, OR or no intervention. MAIN OUTCOME MEASURES The primary end points were total and aneurysm-related mortality until mid-2015 for both trials. Secondary outcomes for EVAR-1 were reinterventions, costs and cost-effectiveness. RESULTS In EVAR-1, over a mean of 12.7 years (standard deviation 1.5 years; maximum 15.8 years), we recorded 9.3 deaths per 100 person-years in the EVAR group and 8.9 deaths per 100 person-years in the OR group [adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.97 to 1.27; p = 0.14]. At 0-6 months after randomisation, patients in the EVAR group had a lower mortality (adjusted HR 0.61, 95% CI 0.37 to 1.02 for total mortality; HR 0.47, 95% CI 0.23 to 0.93 for aneurysm-related mortality; p = 0.031), but beyond 8 years of follow-up patients in the OR group had a significantly lower mortality (adjusted HR 1.25, 95% CI 1.00 to 1.56, p = 0.048 for total mortality; HR 5.82, 95% CI 1.64 to 20.65, p = 0.0064 for aneurysm-related mortality). The increased aneurysm-related mortality in the EVAR group after 8 years was mainly attributable to secondary aneurysm sac rupture, with increased cancer mortality also observed in the EVAR group. Overall, aneurysm reintervention rates were higher in the EVAR group than in the OR group, 4.1 and 1.7 per 100 person-years, respectively (p < 0.001), with reinterventions occurring throughout follow-up. The mean difference in costs over 14 years was £3798 (95% CI £2338 to £5258). Economic modelling based on the outcomes of the EVAR-1 trial showed that the cost per quality-adjusted life-year gained over the patient's lifetime exceeds conventional thresholds used in the UK. In EVAR-2, patients died at the same rate in both groups, but there was suggestion of lower aneurysm mortality in those who actually underwent EVAR. Type II endoleak itself is not associated with a higher rate of mortality. LIMITATIONS Devices used were implanted between 1999 and 2004. Newer devices might have better results. Later follow-up imaging declined, particularly for OR patients. Methodology to capture reinterventions changed mainly to record linkage through the Hospital Episode Statistics administrative data set from 2009. CONCLUSIONS EVAR has an early survival benefit but an inferior late survival benefit compared with OR, which needs to be addressed by lifelong surveillance of EVAR and reintervention if necessary. EVAR does not prolong life in patients unfit for OR. Type II endoleak alone is relatively benign. FUTURE WORK To find easier ways to monitor sac expansion to trigger timely reintervention. TRIAL REGISTRATION Current Controlled Trials ISRCTN55703451. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and the results will be published in full in Health Technology Assessment; Vol. 22, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rajesh Patel
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Michael J Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - David M Epstein
- Centre for Health Economics, University of York, York, UK.,Department of Applied Economics, University of Granada, Granada, Spain
| | - Jessica K Barrett
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Machado R, Teixeira G, Oliveira P, Loureiro L, Pereira C, Almeida R. Is Age a Determinant Factor in EVAR as a Predictor of Outcomes or in the Selection Procedure? Our Experience. Braz J Cardiovasc Surg 2017; 31:132-9. [PMID: 27556312 PMCID: PMC5062736 DOI: 10.5935/1678-9741.20160037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/25/2016] [Indexed: 11/26/2022] Open
Abstract
Introduction Endovascular aneurysm repair (EVAR) is the therapy of choice in high risk
patients with abdominal aortic aneurysm. The good results described are
leading to the broadening of clinical indications to younger patients.
However, reintervention rates seem higher and even with successful treatment
sometimes there is growth of the aneurysm sac and rupture, meaning a failure
of the therapeutic goal. This study proposes to analyse the impact of age in
patients' selection and post-EVAR results. Methods The clinical records of consecutive patients undergoing endovascular aneurysm
repair, between 2001 and 2013, were retrospectively reviewed. Patients were
divided according to age groups (<70, 70-80 and >80 years). Gender,
body mass index, aneurysm anatomic features, neck characteristics, iliac
morphology, surgical indication, endograft type, anesthesic risk
classification, length of stay, reinterventions and mortality were analysed
and compared. Results The study included 171 patients, 161 (94.1%) men, and mean age
74.1±8.9 years. The age group under 70 had 32% of the patients. Only
three characteristics were found different among age groups: 1) body mass
index was higher in younger patients, with a considerable trend toward
significance (P=0.06); 2) surgical indication, in the younger group,
surgeon's and the patient's option were more proeminent
(P<0.05); 3) erectile dysfunction was higher in elderly
group (P<0.05). No other clinical and anatomical
characteristics or final outcomes were found statisticaly different among
age groups. Conclusion The absence of statistically differences in mortality and reinterventions
among age groups suggests that age by itself is not a relevant factor in
endovascular aneurysm repair. Indeed, the three characteristics different in
younger (obesity, sexual function and patient's choice) favor endovascular
aneurysm repair.
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Affiliation(s)
- Rui Machado
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Gabriela Teixeira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Pedro Oliveira
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Luís Loureiro
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Carlos Pereira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Rui Almeida
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
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110
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Endotension after Abdominal Aortic Aneurysm Endovascular Repair in Cirrhotic Patients. Ann Vasc Surg 2017; 45:265.e5-265.e8. [DOI: 10.1016/j.avsg.2017.06.148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 06/26/2017] [Accepted: 06/27/2017] [Indexed: 11/18/2022]
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111
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Endovascular Repair of Abdominal Aortic Aneurysm in Patients Physically Ineligible for Open Repair. Ann Surg 2017; 266:713-719. [DOI: 10.1097/sla.0000000000002392] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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112
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Abstract
Endovascular aneurysm repair (EVAR) has become the intervention of choice for supra-threshold aortic aneurysms due to the lower 30-day mortality of EVAR as compared with open surgery, despite no long-term longevity gains. Trials such as EVAR-1 that established the current status of endovascular aortic intervention often excluded participants over the age of 80, and specific studies of EVAR in the elderly reveal higher mortality than accepted averages. Analyses of the cost-effectiveness of EVAR have not demonstrated superiority of endovascular intervention over open repair, in particular when considering complications such as endoleak. Post-intervention surveillance and the frequent need for re-intervention following EVAR has a detrimental impact on quality of life. Taking these factors into consideration, combined with an ageing population and the likely increase in octogenarian endovascular intervention, there is a clear clinical need for appropriate risk-stratification of elderly patients with supra-threshold aneurysms to determine who will benefit from endovascular repair.
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Affiliation(s)
- Mahim I Qureshi
- MRCS Section of Vascular Surgery, Imperial College London, London, UK
| | - Alun H Davies
- MRCS Section of Vascular Surgery, Imperial College London, London, UK
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113
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Abstract
Objectives Stent grafts for endovascular repair of infrarenal aneurysms are commercially available for aortic necks up to 32 mm in diameter. The aim of this study was to evaluate the feasibility of endovascular repair with large thoracic stent grafts in the infrarenal position to obtain adequate proximal seal in wider necks. Methods All patients who underwent endovascular aneurysm repair using thoracic stent grafts with diameters greater than 36 mm between 2012 and 2016 were included. Follow-up consisted of CT angiography after six weeks and annual duplex thereafter. Results Eleven patients with wide infrarenal aortic necks received endovascular repair with thoracic stent grafts. The median diameter of the aneurysms was 60 mm (range 52–78 mm) and the median aortic neck diameter was 37 mm (range 28–43 mm). Thoracic stent grafts were oversized by a median of 14% (range 2–43%). On completion angiography, one type I and two type II endoleaks were observed but did not require reintervention. One patient experienced graft migration with aneurysm sac expansion and needed conversion to open repair. Median follow-up time was 14 months (range 2–53 months), during which three patients died, including one aneurysm-related death. Conclusions Endovascular repair using thoracic stent grafts for patients with wide aortic necks is feasible. In these patients, the technique may be a reasonable alternative to complex endovascular repair with fenestrated, branched, or chimney grafts. However, more experience and longer follow-up are required to determine its position within the endovascular armamentarium.
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114
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Abstract
Ruptured abdominal aortic aneurysms have an alarmingly high mortality rate that often exceeds 50%, even when patients survive long enough to be transported to hospitals. Historical data have shown that ruptures are especially likely to occur with aneurysms measuring ≥6 cm in diameter, but there are so many exceptions to this that several randomized clinical trials have been done in an attempt to determine whether smaller aneurysms should be repaired electively as soon as they are discovered. More recently, further trials have been conducted in order to compare the relative benefits and disadvantages of modern endovascular aneurysm repair to those of traditional open surgery. This review summarizes current evidence from randomized trials and large population-based datasets regarding two questions that are uppermost in the mind of virtually every patient who is found to have an abdominal aortic aneurysm. Should it be fixed? What are the risks?
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Affiliation(s)
- Norman R Hertzer
- Department of Vascular Surgery, Cleveland Clinic Emeritus Office, Beechwood, OH, USA
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115
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Porretta AP, Alerci M, Wyttenbach R, Antonucci F, Cattaneo M, Bogen M, Toderi M, Guerra A, Sartori F, Di Valentino M, Tutta P, Limoni C, Gallino A, von Segesser LK. Long-term Outcomes of a Telementoring Program for Distant Teaching of Endovascular Aneurysm Repair. J Endovasc Ther 2017; 24:852-858. [DOI: 10.1177/1526602817730841] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Alessandra Pia Porretta
- Division of Cardiology and Vascular Medicine, Department of Internal Medicine, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
- Division of Cardiology, Heart and Vessel Department, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Mario Alerci
- Department of Radiology, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Rolf Wyttenbach
- Department of Radiology, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
- University of Bern, Switzerland
| | - Francesco Antonucci
- Department of Radiology, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Mattia Cattaneo
- Division of Cardiology and Vascular Medicine, Department of Internal Medicine, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Marcel Bogen
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Marco Toderi
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Adriano Guerra
- Department of Surgery, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Fabio Sartori
- Division of Cardiology and Vascular Medicine, Department of Internal Medicine, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Marcello Di Valentino
- Division of Cardiology and Vascular Medicine, Department of Internal Medicine, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Paolo Tutta
- Division of Cardiology and Vascular Medicine, Department of Internal Medicine, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Costanzo Limoni
- University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
| | - Augusto Gallino
- Division of Cardiology and Vascular Medicine, Department of Internal Medicine, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
| | - Ludwig K. von Segesser
- Cardiovascular Research Division, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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116
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Outcome after Turndown for Elective Abdominal Aortic Aneurysm Surgery. Eur J Vasc Endovasc Surg 2017; 54:579-586. [PMID: 28874329 DOI: 10.1016/j.ejvs.2017.07.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 07/24/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The aim was to assess the survival of patients who had been turned down for repair of an abdominal aortic aneurysm (AAA) and to examine the factors influencing this. METHODS This was a retrospective observational study of a prospectively maintained database of all patients turned down for AAA intervention by the Black Country Vascular Network multidisciplinary team (MDT) from January 2013 to December 2015. Data on AAA size, cardiopulmonary exercise testing (CPET) and cause of death were recorded. RESULTS There were 112 patients. The median age at turndown was 83.9 years (IQR 10.2 years). The median AAA size at turndown was 63 mm (IQR 16.7 mm). The median follow-up time after turndown was 324 days (IQR 537.5 days). Sixty-four patients (57.1%) were deceased after 2 years, with a median survival time of 462 days (IQR 579 days). Patients who died had a significantly larger AAA dimension (median 65 mm, IQR 18.5 mm) than those surviving to date (median 59 mm, IQR 10 mm, p = .004). Using Cox regression analysis, the probability of 1 year survival in the whole population was 0.614. The probability of 2 year survival was 0.388. When accounting for age, gender, AAA dimension, and British Aneurysm Repair risk score, no factors had significant influence over survival. Of the 64 deceased patients, 30 had an accessible cause of death: 36.7% of these were due to ruptured AAAs. There was no significant difference in AAA size between those dying of ruptures and those dying of other causes (p = .225, mean 74 mm and 67 mm respectively). CONCLUSIONS Being turned down for AAA repair carries a significant short-term risk of mortality. Those turned down for repair carried significant levels of comorbid disease but no factors considered were found to be independently predictive of the length of survival.
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117
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External validation of a 5-year survival prediction model after elective abdominal aortic aneurysm repair. J Vasc Surg 2017; 67:151-156.e3. [PMID: 28807385 DOI: 10.1016/j.jvs.2017.05.104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/07/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The benefit of prophylactic repair of abdominal aortic aneurysms (AAAs) is based on the risk of rupture exceeding the risk of death from other comorbidities. The purpose of this study was to validate a 5-year survival prediction model for patients undergoing elective repair of asymptomatic AAA <6.5 cm to assist in optimal selection of patients. METHODS All patients undergoing elective repair for asymptomatic AAA <6.5 cm (open or endovascular) from 2002 to 2011 were identified from a single institutional database (validation group). We assessed the ability of a prior published Vascular Study Group of New England (VSGNE) model (derivation group) to predict survival in our cohort. The model was assessed for discrimination (concordance index), calibration (calibration slope and calibration in the large), and goodness of fit (score test). RESULTS The VSGNE derivation group consisted of 2367 patients (70% endovascular). Major factors associated with survival in the derivation group were age, coronary disease, chronic obstructive pulmonary disease, renal function, and antiplatelet and statin medication use. Our validation group consisted of 1038 patients (59% endovascular). The validation group was slightly older (74 vs 72 years; P < .01) and had a higher proportion of men (76% vs 68%; P < .01). In addition, the derivation group had higher rates of advanced cardiac disease, chronic obstructive pulmonary disease, and baseline creatinine concentration (1.2 vs 1.1 mg/dL; P < .01). Despite slight differences in preoperative patient factors, 5-year survival was similar between validation and derivation groups (75% vs 77%; P = .33). The concordance index of the validation group was identical between derivation and validation groups at 0.659 (95% confidence interval, 0.63-0.69). Our validation calibration in the large value was 1.02 (P = .62, closer to 1 indicating better calibration), calibration slope of 0.84 (95% confidence interval, 0.71-0.97), and score test of P = .57 (>.05 indicating goodness of fit). CONCLUSIONS Across different populations of patients, assessment of age and level of cardiac, pulmonary, and renal disease can accurately predict 5-year survival in patients with AAA <6.5 cm undergoing repair. This risk prediction model is a valid method to assess mortality risk in determining potential overall survival benefit from elective AAA repair.
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Fort AC, Rubin LA, Meltzer AJ, Schneider DB, Lichtman AD. Perioperative Management of Endovascular Thoracoabdominal Aortic Aneurysm Repair. J Cardiothorac Vasc Anesth 2017; 31:1440-1459. [DOI: 10.1053/j.jvca.2017.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Indexed: 01/16/2023]
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Gray D, Shahverdyan R, Reifferscheid V, Gawenda M, Brunkwall J. EVAR with Flared Iliac Limbs has a High Risk of Late Type 1b Endoleak. Eur J Vasc Endovasc Surg 2017; 54:170-176. [DOI: 10.1016/j.ejvs.2017.05.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 05/10/2017] [Indexed: 11/16/2022]
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Wooster M, Tanious A, Jones RW, Armstrong P, Shames M. A Novel Off-the-Shelf Technique for Endovascular Repair of Type III and IV Thoracoabdominal Aortic Aneurysms Using the Gore Excluder and Viabahn Branches. Ann Vasc Surg 2017; 46:30-35. [PMID: 28689952 DOI: 10.1016/j.avsg.2017.06.155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/29/2017] [Accepted: 06/29/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this study is to describe the use of a novel off-the-shelf technique to repair type III and type IV thoracoabdominal aortic aneurysms (TAAAs) in the absence of available prefabricated branched devices. METHODS All patients undergoing endovascular repair of type III and IV TAAAs using this technique were included from a prospectively maintained registry at a regional aortic referral center. The proximal bifurcated Gore C3 Excluder device is positioned in the descending thoracic aorta with the contralateral gate 2-3 cm above the celiac artery. From an axillary approach, the contralateral gate renovisceral branches are sequentially cannulated and simultaneously stented using Viabahn covered stents. In cases were the celiac artery could not be excluded, a parallel stent (snorkel) was added adjacent to the proximal endograft. All branches are simultaneously balloon dilated to ensure proximal gutter seal in the contralateral gate. Via the ipsilateral limb, the device can then be extended with a flared iliac extension and/or additional bifurcated device to obtain seal in the distal aorta (previous open repair) or common iliac arteries. RESULTS Eight patients (male = 6, mean 78 years of age) were treated in this manner since January 2015. All patients underwent repair using Gore C3 device with 3 (n = 5) or 4 (n = 3) renovisceral branches. The celiac artery was sacrificed in 4 patients and 1 renal artery in 1 patient. Mean fluoroscopy time was 88.7 min with a mean of 92.3 cc contrast utilized. Median length of stay was 7 days with 3 days spent in the intensive care unit. No major cardiac, respiratory, renal, neurologic, or wound complications occurred. Three patients had early endoleaks treated with additional endovascular techniques (n = 2) or open surgical ligation (n = 1) during the index hospitalization. Two late endoleaks were identified; 1 type II with stable sac size and 1 type III requiring iliac limb relining. All limbs and branches remain patent at the time of the last imaging study (mean 6.8 months). CONCLUSIONS We present an endovascular technique for repair of type III and IV TAAAs which appears to be both feasible and safe with good short-term outcomes.
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Affiliation(s)
- Mathew Wooster
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of South Florida, College of Medicine, Tampa, FL.
| | - Adam Tanious
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of South Florida, College of Medicine, Tampa, FL
| | - R Wesley Jones
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of South Florida, College of Medicine, Tampa, FL
| | - Paul Armstrong
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of South Florida, College of Medicine, Tampa, FL
| | - Murray Shames
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of South Florida, College of Medicine, Tampa, FL
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Budtz-Lilly J, Venermo M, Debus S, Behrendt CA, Altreuther M, Beiles B, Szeberin Z, Eldrup N, Danielsson G, Thomson I, Wigger P, Björck M, Loftus I, Mani K. Editor's Choice – Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years. Eur J Vasc Endovasc Surg 2017; 54:13-20. [DOI: 10.1016/j.ejvs.2017.03.003] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 03/02/2017] [Indexed: 01/01/2023]
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Healy GM, Redmond CE, Gray S, Iacob L, Sheehan S, Dowdall JF, Barry M, Cantwell CP, Brophy DP. Midterm Analysis of Survival and Cause of Death Following Endovascular Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2017. [DOI: 10.1177/1538574417703268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To assess rates of complications, secondary interventions, survival, and cause of death following endovascular abdominal aortic aneurysm (AAA) repair over a 10-year period. Materials and Methods: Single-institution retrospective cohort study of all patients undergoing primary endovascular aortic aneurysm repair (EVAR) between July 2006 and June 2015. The population constituted 175 patients with 163 fusiform and 12 saccular AAAs. Of these, 149 (85%) were male, with mean age 75.4 (±7.1) years. Patients were followed up until June 30, 2016. Cause of death was determined from the national death register. Results: Mean follow-up was 34.4 (±24.4) months. The secondary intervention rate was 9.7%, and there were 4 aneurysm ruptures (0.8% annual incidence). Thirty-day mortality was 0.6%. Survival at 1, 3, and 5 years was 93.1%, 84%, and 64.9%, respectively. Forty-eight patients died during follow-up, 3 secondary to rupture, leading to overall and aneurysm-related death rates of 9.7 and 0.6 per 100 person-years. All other deaths were due to nonaneurysm causes, most commonly cardiovascular (n = 15), pulmonary (n = 13), and malignancy (n = 9). Baseline renal impairment ( P < .001), ischemic heart disease ( P < .05), age greater than 75 years ( P < .05), and urgent/emergency EVAR were associated with inferior long-term survival. Type II endoleak negatively influenced fusiform aneurysm sac regression ( P = .02), but there was no association between survival and occurrence of any complication or secondary intervention. Conclusion: The majority of deaths during medium-term follow-up post-EVAR are due to nonaneurysm-related causes. Survival is determined by the following baseline factors: renal impairment, ischemic heart disease, advanced age, and the presence of a symptomatic/ruptured aneurysm.
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Affiliation(s)
- Gerard M. Healy
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Ciaran E. Redmond
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Sam Gray
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Lucian Iacob
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Stephen Sheehan
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Joseph F. Dowdall
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Mary Barry
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Colin P. Cantwell
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - David P. Brophy
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
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Wijeysundera DN. Precise mathematics yet hazy predictions: Can validated risk indices help improve patient selection for major elective surgery? Can J Anaesth 2017. [PMID: 28623499 DOI: 10.1007/s12630-017-0910-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Duminda N Wijeysundera
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada.
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada.
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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Jhaveri KD, Saratzis AN, Wanchoo R, Sarafidis PA. Endovascular aneurysm repair (EVAR)– and transcatheter aortic valve replacement (TAVR)–associated acute kidney injury. Kidney Int 2017; 91:1312-1323. [DOI: 10.1016/j.kint.2016.11.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 11/04/2016] [Accepted: 11/08/2016] [Indexed: 01/20/2023]
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Chronic Kidney Disease Class Predicts Mortality After Abdominal Aortic Aneurysm Repair in Propensity-matched Cohorts From the Medicare Population. Ann Surg 2017; 264:386-91. [PMID: 27414155 DOI: 10.1097/sla.0000000000001519] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Chronic kidney disease (CKD) predicts mortality after abdominal aortic aneurysm (AAA) repair. Few studies are adequately powered to stratify outcomes by CKD severity. This study assesses the effect of CKD severity on survival after AAA repair. METHODS Patients who underwent AAA repair from 2006 to 2007 were retrospectively identified in the Medicare database and stratified by CKD class as follows: normal (CKD class 1 and 2), moderate (CKD class 3), and severe (CKD class 4 and 5). Propensity matching (30:1) by clinical factors and procedure type was performed to derive well-matched comparative cohorts. Primary outcomes were 30-day and long-term mortality; secondary outcomes included hospital length of stay and cost. RESULTS A total of 47,715 patients were included (96.7% normal, 1.88% moderate, and 1.65% severe). Propensity matching was corrected for differences between cohorts. Thirty-day mortality was higher in moderate (5.7% vs normal 2.5%; P < 0.01) and severe (9.9% vs normal 1.8%; P < 0.01) groups. Hospital length of stay increased with CKD severity (4.4 ± 3.7 days normal vs 6.5 ± 4.2 days moderate CKD; P < 0.01/4.7 ± 3.8 days normal vs 9.1 ± 4.5 days severe CKD; P < 0.01) as did cost ($23 ± 14K normal vs $25 ± 16K moderate; P < 0.01 /$22 ± 11K normal vs $29 ± 22K severe; P < 0.01). Three-year survival favored the normal cohort (80% vs 64% moderate; log rank P < 0.01 /82% normal vs 44% severe; log rank P < 0.01). CONCLUSIONS CKD severity is an important predictor of perioperative mortality and long-term survival after AAA repair in propensity-matched cohorts. The 5-fold increase in 30-day mortality and 44% in 3-year survival suggest that elective AAA repair is contraindicated in most severe CKD patients.
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Abstract
Abdominal aortic pathology is a diverse topic, ranging through a broad span of possible pathologies. The treatment options are equally vast, particularly with the ever-expanding endovascular techniques. In this article, we discuss management strategies for abdominal aortic aneurysms and aortic occlusive disease, because they represent some of the most common pathologies encountered in clinical scenarios.
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Affiliation(s)
- Karol Meyermann
- Division of Vascular Surgery, Department of Surgery, Cooper University Hospital, Suite 411, 3 Cooper Plaza, Camden, NJ 08103, USA
| | - Francis J Caputo
- Division of Vascular Surgery, Department of Surgery, Cooper University Hospital, Suite 411, 3 Cooper Plaza, Camden, NJ 08103, USA.
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Badger S, Forster R, Blair PH, Ellis P, Kee F, Harkin DW. Endovascular treatment for ruptured abdominal aortic aneurysm. Cochrane Database Syst Rev 2017; 5:CD005261. [PMID: 28548204 PMCID: PMC6481849 DOI: 10.1002/14651858.cd005261.pub4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND An abdominal aortic aneurysm (AAA) (pathological enlargement of the aorta) is a condition that can occur as a person ages. It is most commonly seen in men older than 65 years of age. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, which is fatal unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. Endovascular aneurysm repair (EVAR), a minimally invasive technique, has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. More recently emergency endovascular aneurysm repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in select patients; however, it is unclear if eEVAR will lead to significant improvements in outcomes for these patients or if indeed it can replace conventional open repair as the preferred treatment for this lethal condition. This is an update of the review first published in 2006. OBJECTIVES To assess the advantages and disadvantages of emergency endovascular aneurysm repair (eEVAR) in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm (RAAA). This will be determined by comparing the effects of eEVAR and conventional open surgical repair on short-term mortality, major complication rates, aneurysm exclusion (specifically endoleaks in the eEVAR treatment group), and late complications. SEARCH METHODS For this update the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (last searched June 2016), CENTRAL (2016, Issue 5), and trials registries. We also checked reference lists of relevant publications. SELECTION CRITERIA Randomised controlled trials in which participants with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies identified for potential inclusion for eligibility. Two review authors also independently completed data extraction and quality assessment. Disagreements were resolved through discussion. We performed meta-analysis using fixed-effect models with odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data and mean differences with 95% CIs for continuous data. MAIN RESULTS We included four randomised controlled trials in this review. A total of 868 participants with a clinical or radiological diagnosis of RAAA were randomised to receive either eEVAR or open surgical repair. Overall risk of bias was low, but we considered one study that performed randomisation in blocks by week and performed no allocation concealment and no blinding to be at high risk of selection bias. Another study did not adequately report random sequence generation, putting it at risk of selection bias, and two studies were underpowered. There was no clear evidence to support a difference between the two interventions for 30-day (or in-hospital) mortality (OR 0.88, 95% CI 0.66 to 1.16; moderate-quality evidence). There were a total of 44 endoleak events in 128 participants from three studies (low-quality evidence). Thirty-day complication outcomes (myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation, and respiratory failure) were reported in between one and three studies, therefore we were unable to draw a robust conclusion. We downgraded the quality of the evidence for myocardial infarction, renal complications, and respiratory failure due to imprecision, inconsistency, and risk of bias. Odds ratios for complications outcomes were OR 2.38 (95% CI 0.34 to 16.53; 139 participants; 2 studies; low-quality evidence) for myocardial infarction; OR 1.07 (95% CI 0.21 to 5.42; 255 participants; 3 studies; low-quality evidence) for renal complications; and OR 3.62 (95% CI 0.14 to 95.78; 32 participants; 1 study; low-quality evidence) for respiratory failure. There was low-quality evidence of a reduction in bowel ischaemia in the eEVAR treatment group, but very few events were reported (OR 0.37, 95% CI 0.14 to 0.94), and we downgraded the evidence due to imprecision and risk of bias. Six-month and one-year outcomes were evaluated in three studies, but only results from a single study could be used for each outcome, which showed no clear evidence of a difference between the interventions. We rated six-month mortality evidence as of moderate quality due to imprecision (OR 0.89, 95% CI 0.40 to 1.98; 116 participants). AUTHORS' CONCLUSIONS The conclusions of this review are currently limited by the paucity of data. We found from the data available moderate-quality evidence suggesting there is no difference in 30-day mortality between eEVAR and open repair. Not enough information was provided for complications for us to make a well-informed conclusion, although it is possible that eEVAR is associated with a reduction in bowel ischaemia. Long-term data were lacking for both survival and late complications. More high-quality randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.
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Affiliation(s)
- Stephen Badger
- Mater Misericordiae University HospitalDepartment of Vascular SurgeryEccles StreetDublinIreland
| | - Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
| | - Paul H Blair
- Royal Victoria HospitalBelfast Vascular CentreBelfast Health & Social Care TrustBelfastNorthern IrelandUKBT12 6BA
| | - Peter Ellis
- Royal Victoria HospitalBelfast Vascular CentreBelfast Health & Social Care TrustBelfastNorthern IrelandUKBT12 6BA
| | - Frank Kee
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University BelfastUniversity RoadBelfastNorthern IrelandUK
| | - Denis W Harkin
- Royal Victoria HospitalBelfast Vascular CentreBelfast Health & Social Care TrustBelfastNorthern IrelandUKBT12 6BA
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Management of Difficult Access during Endovascular Aneurysm Repair. Ann Vasc Surg 2017; 44:77-82. [PMID: 28479422 DOI: 10.1016/j.avsg.2017.03.190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/03/2016] [Accepted: 03/05/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND To describe a large single-institutional experience in managing challenging access situations during endovascular aneurysm repair (EVAR). METHODS Data from all patients undergoing EVAR at a tertiary academic medical center between 2009 and 2013 were collected retrospectively, including demographics, size of iliac arteries, type of device used, approach to managing difficult access (DA), and outcomes. The median follow-up was 38 months. DA was defined as iliac arteries with a diameter of less than 7 mm bilaterally. Fenestrated and snorkel repairs were excluded. RESULTS Of 400 EVARs performed during the study period, 191 (48%) were done in patients with DA. Of the DA patients, 35 (18.3%) underwent 42 adjuncts before the introduction of the main body device: including 15 dilators, 11 balloon angioplasties, 9 aortouniiliac devices, 3 SoloPath sheaths, 1 retroperitoneal cutdown, and 3 iliac stents. In another 29 patients, iliac stents were used to correct stenoses or kinks in the limbs after EVAR devices were deployed. The average diameter of the iliac artery used to deliver main body component was 4.6 mm in the group of patients requiring adjuncts and 5.4 mm in the remainder of the patients with small iliac arteries (P = 0.008). The median size of the main body device was 28 mm. Two cases were aborted due to inability to deliver the device. Other complications included 7 (3.6%) iliac ruptures, 3 (1.6%) instances of limb ischemia, and 5 (2.6%) patients needed early reoperation (within 30 days). Two patients (1%) had type I endoleaks at the conclusion of EVAR. During follow-up, 12 (6.3%) patients required EVAR revisions. Seven patients (3.6%) had limb thrombosis which occurred only in patients who did not have adjective procedures during the initial EVAR. Limb thrombosis and rate of revisions in patients with DA were not significantly different from the rates observed in non-DA patients. Perioperative mortality after elective repairs was 1.6% in DA patients and 0% in non-DA patients (P = 0.12). CONCLUSIONS EVAR can be successfully performed in patients with bilateral small iliac arteries. Adjunctive procedures might increase the technical success rate of EVAR in these patients and should definitely be considered in patients with iliac arteries less than 5 mm in diameter. Next generation and "low-profile" devices might minimize the need for adjunctive procedures and facilitate EVAR in these patients.
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Diard A, Becker F, Pichot O. [Quality standards for duplex ultrasonographic assessment (duplex us) of abdominal aortic stent grafts]. JOURNAL DE MÉDECINE VASCULAIRE 2017; 42:170-184. [PMID: 28705406 DOI: 10.1016/j.jdmv.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 02/28/2017] [Indexed: 10/19/2022]
Abstract
The quality standards of the French Society of Vascular Medicine for the ultrasound assessment of lower limb arteries in vascular medicine practice are based on the principle that these examinations have to meet two requirements: technical know-how (knowledge of devices and methodologies); medical know-how (level of examination matching the indication and purpose of the examination, interpretation and critical analysis of results). OBJECTIVES OF THE QUALITY STANDARDS To describe an optimal level of examination adjusted to the indication or clinical hypothesis; to establish harmonious practices, methodologies, terminologies, results description and report; to provide good practice reference points and to promote a high quality process. THEMES OF THE QUALITY STANDARDS The three levels of examination, indications and objectives for each level; the reference standard examination (level 2) and its variants according to indications; the minimal content of the exam report, the medical conclusion letter to the corresponding physician (synthesis, conclusion and management suggestions); commented glossary (anatomy, hemodynamics, signs and symptoms); technical basis; device settings. Here, we discuss duplex ultrasound for the supervision of the aortic stent grafts.
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Affiliation(s)
- A Diard
- 25, route de Créon, 33550 Langoiran, France.
| | - F Becker
- Service d'angiologie et d'hémostase, hôpitaux universitaires de Genève, hôpital Cantonal, 1211 Genève, France
| | - O Pichot
- 7, rue Lesdiguières, 38000 Grenoble, France
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Setacci C, Sirignano P, Fineschi V, Frati P, Ricci G, Speziale F. A clinical and ethical review on late results and benefits after EVAR. Ann Med Surg (Lond) 2017; 16:1-6. [PMID: 28275425 PMCID: PMC5328746 DOI: 10.1016/j.amsu.2017.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/16/2017] [Accepted: 02/16/2017] [Indexed: 01/09/2023] Open
Abstract
Introduction The aim of this review is to assess if late mortality after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is a real problem, and whether it could be an issue in the case of medical litigation. Material and methods A review of all English language literature was performed on PubMed web-site, looking for all papers reporting EVAR long-term mortality rate. EVAR performances were reviewed also from an ethical and medico-legal point of view, based on current Italian laws. Results Mono-centric studies, and international registers suggest that today EVAR offers similar (if not better) results than open repair (OR) in the treatment of AAAs with standard and complex anatomies, even if performed outside the devices-specific instructions for use. In contrast, large randomized trials, and consequently current guidelines, suggest that EVAR still has an ancillary role compared to OR, only to be used for highly selected patients. Recently, specific litigation cases on surgical options related to the treatment of aortic aneurysms has developed. The informed consent process needs to include not only mortality and major complications related to the procedure but also the chance of patients' outcomes. For those reasons, the generic nature of informed consent has been criticized. Conclusions No conclusive data is currently available to assess the initial question of late mortality after EVAR but results are still improving. In the meantime, widespread use of EVAR as first choice for treating AAA may only be acceptable in high-volume centres validating their results by a strict follow up protocol. The long-term results after endovascular repair (EVAR) for abdominal aortic aneurysms (AAA) are still considered one of the main limitations of this treatment option. This paper is a comprehensive review of the current literature on long-term mortality after EVAR procedures. An analysis on informed consent for EVAR from a non-surgical point of view is reported for the very first time.
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Affiliation(s)
- Carlo Setacci
- Vascular and Endovascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Italy
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", "Sapienza" University of Rome, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, "Sapienza" University of Rome, Italy; Neuromed, Istituto Mediterraneo Neurologico (IRCCS) di Pozzili, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, "Sapienza" University of Rome, Italy; Neuromed, Istituto Mediterraneo Neurologico (IRCCS) di Pozzili, Italy
| | | | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of Surgery "Paride Stefanini", "Sapienza" University of Rome, Italy
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Abstract
Background The most important structural proteins of the vascular wall are collagen and elastin. Genetically linked connective tissue diseases lead to degeneration, aneurysm formation and spontaneous dissection or rupture of arteries. The most well-known are Marfan syndrome, vascular Ehlers-Danlos syndrome (type IV), Loeys-Dietz syndrome and familial aortic aneurysms and dissections. Objective This review article addresses the current status of endovascular treatment options for important connective tissue diseases. Material and methods Evaluation of currently available randomized studies and registry data. Results The treatment of choice for patients that are mostly affected at a young age is primarily conservative or open repair. There is only limited evidence for endovascular aortic repair (EVAR) of abdominal aneurysms or thoracic endovascular aortic repair (TEVAR). Conclusion The progression of the disease with dilatation leads to secondary endoleaks and high reintervention rates with uncertain long-term results. For this reason, there is currently consensus that EVAR and TEVAR should be limited to justified exceptional cases and emergency situations in patients with genetically linked aortic diseases.
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Predisposing Factors for Re-interventions with Additional Iliac Stent Grafts After Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2017; 53:89-94. [DOI: 10.1016/j.ejvs.2016.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 10/20/2016] [Indexed: 11/20/2022]
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Zarkowsky DS, Hicks CW, Bostock IC, Stone DH, Eslami M, Goodney PP. Renal dysfunction and the associated decrease in survival after elective endovascular aneurysm repair. J Vasc Surg 2016; 64:1278-1285.e1. [PMID: 27478004 PMCID: PMC5079759 DOI: 10.1016/j.jvs.2016.04.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/10/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The reported frequency of renal dysfunction after elective endovascular aneurysm repair (EVAR) varies widely in current surgical literature. Published research establishes pre-existing end-stage renal disease as a poor prognostic indicator. We intend to quantify the mortality effect associated with renal morbidity developed postoperatively and to identify modifiable risk factors. METHODS All elective EVAR patients with preoperative and postoperative renal function data captured by the Vascular Quality Initiative between January 2003 and December 2014 were examined. The primary study end point was long-term mortality. Preoperative, intraoperative, and postoperative parameters were analyzed to estimate mortality stratified by renal outcome and to describe independent risk factors associated with post-EVAR renal dysfunction. RESULTS This study included 14,475 elective EVAR patients, of whom 96.8% developed no post-EVAR renal dysfunction, 2.9% developed acute kidney injury, and 0.4% developed a new hemodialysis requirement. Estimated 5-year survival was significantly different between groups, 77.5% vs 53.5%, respectively, for the no dysfunction and acute kidney injury groups, whereas the new hemodialysis group demonstrated 22.8% 3-year estimated survival (P < .05). New-onset postoperative congestive heart failure (odds ratio [OR], 3.50; 95% confidence interval [CI], 1.18-10.38), return to the operating room (OR, 3.26; 95% CI, 1.49-7.13), and postoperative vasopressor requirement (OR, 2.68; 95% CI, 1.40-5.12) predicted post-EVAR renal dysfunction, whereas a preoperative estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 was protective (OR, 0.33; 95% CI, 0.21-0.53). Volume of contrast material administered during elective EVAR varies 10-fold among surgeons in the Vascular Quality Initiative database, but the average volume administered to patients is statistically similar, regardless of preoperative eGFR. Multivariable logistic regression demonstrated nonsignificant correlation between contrast material volume and postoperative renal dysfunction. CONCLUSIONS Any renal dysfunction developing after elective EVAR is associated with decreased estimated long-term survival. Protecting renal function with a rational dosing metric for contrast material linked to preoperative eGFR may better guide treatment.
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Affiliation(s)
- Devin S Zarkowsky
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Caitlin W Hicks
- Department of Surgery, The Johns Hopkins Medical Institutes, Baltimore, Md
| | - Ian C Bostock
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David H Stone
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mohammad Eslami
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - Philip P Goodney
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Davidovic LB, Maksic M, Koncar I, Ilic N, Dragas M, Fatic N, Markovic M, Banzic I, Mutavdzic P. Open Repair of AAA in a High Volume Center. World J Surg 2016; 41:884-891. [DOI: 10.1007/s00268-016-3788-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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135
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Menezes FH, Ferrarezi B, Souza MAD, Cosme SL, Molinari GJDP. Results of Open and Endovascular Abdominal Aortic Aneurysm Repair According to the E-PASS Score. Braz J Cardiovasc Surg 2016; 31:22-30. [PMID: 27074271 PMCID: PMC5062688 DOI: 10.5935/1678-9741.20160006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 01/19/2016] [Indexed: 12/18/2022] Open
Abstract
Introduction: Endovascular repair (EVAR) of abdominal aortic aneurysm has become the
standard of care due to a lower 30-day mortality, a lower morbidity, shorter
hospital stay and a quicker recovery. The role of open repair (OR) and to
whom this type of operation should be offered is subject to discussion. Objective: To present a single center experience on the repair of abdominal aortic
aneurysm, comparing the results of open and endovascular repairs. Methods: Retrospective cross-sectional observational study including 286 patients
submitted to OR and 91 patients submitted to EVAR. The mean follow-up for
the OR group was 66 months and for the EVAR group was 39 months. Results: The overall mortality was 11.89% for OR and 7.69% for EVAR
(P=0.263), EVAR presented a death relative risk of
0.647. It was also found a lower intraoperative bleeding for EVAR
(OR=1417.48±1180.42 mL versus
EVAR=597.80±488.81 mL, P<0.0002) and a shorter
operative time for endovascular repair (OR=4.40±1.08 hours
versus EVAR=3.58±1.26 hours,
P<0.003). The postoperative complications presented no
statistical difference between groups (OR=29.03% versus
EVAR=25.27%, P=0.35). Conclusion: EVAR presents a better short term outcome than OR in all classes of
physiologic risk. In order to train future vascular surgeons on OR, only
young and healthy patients, who carry a very low risk of adverse events,
should be selected, aiming at the long term durability of the procedure.
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Affiliation(s)
| | - Bárbara Ferrarezi
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | - Susyanne Lavor Cosme
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
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136
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Stefanov F, McGloughlin T, Morris L. A computational assessment of the hemodynamic effects of crossed and non-crossed bifurcated stent-graft devices for the treatment of abdominal aortic aneurysms. Med Eng Phys 2016; 38:1458-1473. [PMID: 27773830 DOI: 10.1016/j.medengphy.2016.09.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 08/22/2016] [Accepted: 09/23/2016] [Indexed: 10/20/2022]
Abstract
There are several issues attributed with abdominal aortic aneurysm endovascular repair. The positioning of bifurcated stent-grafts (SG) may affect SG hemodynamics. The hemodynamics and geometrical parameters of crossing or non-crossing graft limbs have not being totally accessed. Eight patient-specific SG devices and four pre-operative cases were computationally simulated, assessing the hemodynamic and geometrical effects for crossed (n= 4) and non-crossed (n= 4) configurations. SGs eliminated the occurrence of significant recirculations within the sac prior treatment. Dean's number predicted secondary flow locations with the greatest recirculations occurring at the outlets especially during the deceleration phase. Peak drag force varied from 3.9 to 8.7N, with greatest contribution occurring along the axial and anterior/posterior directions. Average resultant drag force was 20% smaller for the crossed configurations. Maximum drag force orientation varied from 1.4° to 51°. Drag force angle varied from 1° to 5° during one cardiac cycle. 44% to 62% of the resultant force acted along the proximal centerline where SG migration is most likely to occur. The clinician's decision for SG positioning may be a critical parameter, and should be considered prior to surgery. All crossed SG devices had an increased spiral flow effect along the distal legs with reductions in drag forces.
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Affiliation(s)
- Florian Stefanov
- Galway Medical Technologies Centre, Department of Mechanical and Industrial Engineering, Galway Mayo Institute of Technology, Galway, Ireland
| | - Tim McGloughlin
- Department of Biomedical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Liam Morris
- Galway Medical Technologies Centre, Department of Mechanical and Industrial Engineering, Galway Mayo Institute of Technology, Galway, Ireland.
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137
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Machado R, Teixeira G, Oliveira P, Loureiro L, Pereira C, Almeida R. Endovascular Abdominal Aneurysm Repair in Women: What are the Differences Between the Genders? Braz J Cardiovasc Surg 2016; 31:232-238. [PMID: 27737406 PMCID: PMC5062709 DOI: 10.5935/1678-9741.20160047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 07/04/2016] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION: Abdominal aortic aneurysm has a lower incidence in the female population, but
a higher complication rate. It was been hypothesized that some anatomical
differences of abdominal aortic aneurysm in women could be responsible for
that. We proposed to analyze our data to understand the differences in the
clinical and anatomical characteristics and the outcomes of patients
undergoing endovascular aneurysm repair, according to gender. METHODS: A retrospective analysis of patients undergoing endovascular aneurysm repair
between 2001-2013 was performed. Patients were divided according gender and
evaluated regarding age, atherosclerotic risk factors, aneurysm anatomic
features, endograft type, anesthesic risk classification, length of stay,
reinterventions and mortality. Two statistical studies were performed, first
comparing women and men (Group A) and a second one comparing women and men,
adjusted by age (Group B). RESULTS: Of the 171 patients, only 5.8% (n=10) were females. Women were older
(P<0.05) and the number of women with no
atherosclerotic risk factor was significantly higher. The comparison
adjusted by age revealed women with statistically less smoking history, less
cerebrovascular disease and ischemic heart disease. Women had a trend to
more complex anatomy, with more iliac intern artery aneurysms, larger
aneurysm diameter and neck angulations statistically more elevated. No other
variables were statistically different between age groups, neither
reintervention nor mortality rates. CONCLUSION: Our study showed a clear difference in the clinical characteristics of women.
The female population was statistically older, and when compared with men
adjusted by age, had less atherosclerotic risk factors and less target organ
disease. Women showed a more complex anatomy but with the same outcomes.
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Affiliation(s)
- Rui Machado
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
| | - Gabriela Teixeira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Pedro Oliveira
- Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
| | - Luís Loureiro
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Carlos Pereira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Rui Almeida
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Porto, Portugal
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138
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Kothandan H, Haw Chieh GL, Khan SA, Karthekeyan RB, Sharad SS. Anesthetic considerations for endovascular abdominal aortic aneurysm repair. Ann Card Anaesth 2016; 19:132-41. [PMID: 26750684 PMCID: PMC4900395 DOI: 10.4103/0971-9784.173029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aneurysm is defined as a localized and permanent dilatation with an increase in normal diameter by more than 50%. It is more common in males and can affect up to 8% of elderly men. Smoking is the greatest risk factor for abdominal aortic aneurysm (AAA) and other risk factors include hypertension, hyperlipidemia, family history of aneurysms, inflammatory vasculitis, and trauma. Endovascular Aneurysm Repair [EVAR] is a common procedure performed for AAA, because of its minimal invasiveness as compared with open surgical repair. Patients undergoing EVAR have a greater incidence of major co-morbidities and should undergo comprehensive preoperative assessment and optimization within the multidisciplinary settings. In majority of cases, EVAR is extremely well-tolerated. The aim of this article is to outline the Anesthetic considerations related to EVAR.
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Affiliation(s)
- Harikrishnan Kothandan
- Department of Anaesthesiology, National Heart Centre, Singapore General Hospital, Singapore
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140
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Böckler D, Holden A, Krievins D, de Vries JPPM, Peters AS, Geisbüsch P, Reijnen M. Extended use of endovascular aneurysm sealing for ruptured abdominal aortic aneurysms. Semin Vasc Surg 2016; 29:106-113. [PMID: 27989315 DOI: 10.1053/j.semvascsurg.2016.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endovascular repair of abdominal aortic aneurysms (EVAR) is now an established treatment modality for suitable patients presenting with aneurysm rupture. EVAR for ruptured aneurysms reduces transfusion, mechanical ventilation, intensive care. and hospital stay when compared with open surgery. In the emergency setting, however, EVAR is limited by low applicability due to adverse clinical or anatomical characteristics and increased need for reintervention. In addition, ongoing bleeding from aortic side branches post-EVAR can cause hemodynamic instability, larger hematomas, and abdominal compartment syndrome. Endovascular aneurysm sealing, based on polymer filling of the aneurysm, has the potential to overcome some of the limitations of EVAR for ruptured aneurysms and to improve outcomes. Recent literature suggests that endovascular aneurysm sealing can be performed with early mortality similar to that of EVAR for ruptured aortic aneurysms, but experience is limited to a few centers and a small number of patients. The addition of chimney grafts can increase the applicability of endovascular aneurysm sealing in order to treat short-neck and juxtarenal aneurysms as an alternative to fenestrated endografts. Further evaluation of the technique, with larger longitudinal studies, is necessary before advocating wider implementation of endovascular aneurysm sealing in the emergency setting.
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Affiliation(s)
- Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
| | | | | | | | - Andreas S Peters
- Department of Vascular and Endovascular Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Philipp Geisbüsch
- Department of Vascular and Endovascular Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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141
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Lee JH, Park KH. Self expandable stent application to prevent limb occlusion in external iliac artery during endovascular aneurysm repair. Ann Surg Treat Res 2016; 91:139-44. [PMID: 27617255 PMCID: PMC5016604 DOI: 10.4174/astr.2016.91.3.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 05/02/2016] [Accepted: 05/25/2016] [Indexed: 11/30/2022] Open
Abstract
Purpose Iliac extension of stent-graft during endovascular aneurysm repair (EVAR) increases the incidence of limb occlusion (LO). Hypothetically, adjunctive iliac stent (AIS) could offer some additional protection to overcome this anatomic hostility. But still there is no consensus in terms of effective stent characteristics or configuration. We retrospectively reviewed our center's experience to offer a possible answer to this question. Methods Our study included 30 patients (38 limbs) with AIS placed in the external iliac artery (EIA) from January 2010 to December 2013. We classified iliac tortuosity based on anatomic characteristics. AIS's were deployed in EIA with a minimum 5-mm stick-out configuration from the distal edge of the stent-graft. Results According to the iliac artery tortuosity index, grade 0, grade 1, and grade 2 were 5 (13.2%), 30 (78.9%), and 3 (7.9%), respectively. The diameter of all AIS was 12 mm, which was as large as or larger than the diameter of the stent-graft distal limb. SMART stents were preferred in 34 limbs (89.5%) and stents with 60-mm length were usually used (89.5%). During a mean follow-up of 9.13 ± 10.78 months, ischemic limb pain, which could be the sign of LO, was not noticed in any patients. There was no fracture, kinking, migration, in-stent restenosis, or occlusion of AIS. Conclusion The installation of AIS after extension of stent-graft to EIA reduced the risk of LO without any complications. AIS should be considered as a preventive procedure of LO if stent-graft needs to be extended to EIA during EVAR.
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Affiliation(s)
- Jae Hoon Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ki Hyuk Park
- Division of Vascular and Endovascular Surgery, Department of Surgery, Catholic University of Daegu School of Medicine, Daegu, Korea
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142
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van Lammeren GW, Ünlü Ç, Verschoor S, van Dongen EP, Wille J, van de Pavoordt ED, de Vries-Werson DA, De Vries JPP. Results of open pararenal abdominal aortic aneurysm repair: single centre series and pooled analysis of literature. Vascular 2016; 25:234-241. [PMID: 27565511 DOI: 10.1177/1708538116665268] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Endovascular treatment of pararenal abdominal aortic aneurysm has gained terrain over the past decade, despite the substantial need for reinterventions during follow-up. However, open repair is still a well-established treatment option. With the current study we report the results of a consecutive series of elective primary open pararenal abdominal aortic aneurysm repair in a tertiary vascular referral centre, combined with an overview of current literature and pooled data analysis of perioperative mortality of open and endovascular pararenal abdominal aortic aneurysm repair. Methods A retrospective analysis of a prospective database of all elective open pararenal abdominal aortic aneurysm repairs in the St. Antonius Hospital between 2005 and 2014 was performed. Primary endpoint was 30-day mortality. Secondary endpoints were 30-day morbidity, new onset dialysis, reintervention free survival, and overall survival during follow-up. Results Between 2005 and 2014, 214 consecutive patients underwent elective open pararenal abdominal aortic aneurysm repair. Mean age was 69.8 (±7.1) years, 82.7% (177/214) were men, and mean abdominal aortic aneurysm diameter was 62 (±11) mm. Thirty-day mortality was 3.4%. Thirty-day morbidity was 27.1%, which predominantly consisted of pneumonia (18.7% (40/214)), cardiac events (3.3% (7/214)), and new onset dialysis (2.8% (6/214)). Estimated five-year overall survival rate was 74.2%. 0.9% (2/214) of patients required abdominal aortic aneurysm-related reintervention, and an additional 2.3% (5/214) required surgical repair of an incisional hernia. Pooled analysis of literature revealed a 30-day mortality of 3.0% for open pararenal repair and 1.9% for fenestrated endovascular repair. Conclusion Open pararenal abdominal aortic aneurysm repair in the era of increasing endovascular options results in acceptable perioperative morbidity and mortality rates. Mid-term reintervention rate is low compared to fenestrated endovascular aneurysm repair. Expertise with open repair still remains essential for treatment of pararenal abdominal aortic aneurysms in the near future, especially for those patients that are declined for endovascular treatment.
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Affiliation(s)
- Guus W van Lammeren
- 1 Department of Vascular Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Çağdaş Ünlü
- 1 Department of Vascular Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Sjoerd Verschoor
- 1 Department of Vascular Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Eric P van Dongen
- 2 Department of Anaesthesiology, Intensive Care and Pain Therapy, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Jan Wille
- 1 Department of Vascular Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | | | | | - Jean-Paul Pm De Vries
- 1 Department of Vascular Surgery, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
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143
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Sajid MS, Tai NRM, Iftikhar M, Platts A, Baker DM, Hamilton G. Single-Center Experience of Endovascular Abdominal Aortic Aneurysm Repair (EVAR) in Patients Not Participating in the U.K. EVAR Trials. Vasc Endovascular Surg 2016; 41:383-8. [DOI: 10.1177/1538574407303678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective was to evaluate outcomes of a high-risk patient cohort following endovascular abdominal aortic aneurysm repair (EVAR) treatment not entered into the U.K. endovascular stent-graft aortic aneurysm repair trials (EVAR-1 or -2) because of equipoise absence but where EVAR was judged to be the most appropriate intervention option on compassionate grounds. A single-center retrospective analysis was performed involving all patients undergoing compassionate EVAR treatment during the EVAR-1 and -2 trial period. Over an 8-year period, 34 patients underwent compassionate EVAR procedure. The mean (SD) age was 76 (79) years. The mean (SD) preoperative physiology score (P-POSSUM) was 25 (8.3) with a mean (SD) predicted early mortality of 9.9% (16%). The actual early mortality in our study was 2.9% and morbidity was 35%. There were 8 cases of endoleak: type I (n = 2), type II (n = 5), and type IV (n = 1). Aneurysm-related mortality and all-cause mortality after 8 years were 5.8% and 23.5% respectively. Satisfactory outcome with low mortality (2.9%) and morbidity can be achieved in patients with compassionate indications, where clinicians judge EVAR to be an advantage over open abdominal aortic aneurysm repair. Based on our study, the early mortality (2.9%) in our compassionate EVAR group is comparable to EVAR-1 outcomes (1.7%) and better than EVAR-2 mortality results (9%). EVAR should therefore not be denied to a significant number of high-risk abdominal aortic aneurysm patients who fall between the EVAR-1 and EVAR-2 criteria.
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Affiliation(s)
- Muhammad S. Sajid
- Department of Vascular Surgery, Royal Free Hospital, Pond Street, Hampstead, London, United Kingdom,
| | - Nigel R. M. Tai
- Department of Vascular Surgery, Royal Free Hospital, Pond Street, Hampstead, London, United Kingdom
| | - Mawara Iftikhar
- Department of Vascular Surgery, Royal Free Hospital, Pond Street, Hampstead, London, United Kingdom
| | - Andrew Platts
- Department of Radiology Royal Free Hospital, Pond Street, Hampstead, London, United Kingdom
| | - Daryll M. Baker
- Department of Vascular Surgery, Royal Free Hospital, Pond Street, Hampstead, London, United Kingdom
| | - George Hamilton
- Department of Vascular Surgery, Royal Free Hospital, Pond Street, Hampstead, London, United Kingdom
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144
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Nagpal AD, Forbes TL, Novick TV, Lovell MB, Kribs SW, Lawlor DK, Harris KA, DeRose G. Midterm Results of Endovascular Infrarenal Abdominal Aortic Aneurysm Repair in High-Risk Patients. Vasc Endovascular Surg 2016; 41:301-9. [PMID: 17704332 DOI: 10.1177/1538574407301430] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Short-term and midterm clinical outcomes after endovascular repair of abdominal aortic aneurysms (AAAs) have been well documented. Evaluation of longer term outcomes is now possible. Here we describe our initial 100 high-risk patients treated with endovascular aneurysm repair (EVAR), all with a minimum of 5 years of follow-up. A retrospective review of prospectively recorded data in a departmental database was undertaken for the first 100 consecutive EVAR patients with a minimum of 5 years (range, 60-105 months) of follow-up performed between December 1997 and June 2001. Information was obtained from surgical follow-up visits and family doctors' offices. Endovascular repair of AAA in high-risk patients can be achieved with acceptably low postoperative mortality and morbidity. Longer term results in this high-risk cohort suggest that EVAR is effective in preventing aneurysm-related deaths at 5 years and beyond. All late mortalities were due to patients' comorbid diseases.
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Affiliation(s)
- A David Nagpal
- Division of Vascular Surgery, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
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145
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Humphries MD, Suckow BD, Binks JT, McAdam-Marx C, Kraiss LW. Elective Endovascular Aortic Aneurysm Repair Continues to Cost More than Open Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2016; 39:111-118. [PMID: 27521831 DOI: 10.1016/j.avsg.2016.05.091] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 04/17/2016] [Accepted: 05/01/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) is now established as first-line treatment for infrarenal aortic aneurysms in the United States. Recent data from randomized trials suggest that elective EVAR is cost-effective compared with open abdominal aortic aneurysm repair (oAAA). Cost analysis for urgent aneurysm repair has not been reported. We evaluated the cost of elective and urgent EVAR and compared it with oAAA at a tertiary academic medical center. METHODS All infrarenal AAA repairs performed from 2004 to 2010 were retrospectively reviewed (n = 172). Clinical characteristics of patients receiving EVAR and oAAA repair were compared. Direct costs, payments, and direct cost margin for the index inpatient episode were obtained from the hospital for all patients. Subsequent financial information including clinical, radiologic, and procedural cost was also available for 52 patients who had received all follow-up care in our institution for at least 1 year (EVAR 34, oAAA 18). RESULTS Overall, elective EVAR patients were older, but oAAA patients had more comorbidities, with significantly more patients having dyspnea at rest and being totally dependent for activities of daily living. EVAR patients had significantly shorter lengths of stay, regardless of urgency and urgent AAA repair occurred more often by oAAA than EVAR (P < 0.001; χ2). For elective patients, EVAR costs were 34.21% greater than for oAAA. There was a trend toward lower costs with EVAR versus oAAA in patients treated urgently by a ratio of 1.28:1. The hospital experienced a negative cost margin more often after elective EVAR versus oAAA. Negative cost margins were less frequent following urgent repair but still occurred twice as often in EVAR versus oAAA patients. Cost margins remained negative in all EVAR patients for at least 1 year and only 18% converted to a positive cost margin at a mean of 31 months. CONCLUSIONS At a tertiary academic institution, costs for elective EVAR are significantly higher than oAAA. EVAR may be relatively more cost-effective in urgent situations. Negative cost margins were more common in EVAR patients and 1-year follow-up with imaging in the same institution did not result in a positive margin.
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Affiliation(s)
- Misty D Humphries
- Division of Vascular Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA.
| | - Bjoern D Suckow
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | - Larry W Kraiss
- Division of Vascular Surgery, University of Utah Medical Center, Salt Lake City, UT
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146
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Dijkstra ML, van Sterkenburg SMM, Lardenoye JW, Zeebregts CJ, Reijnen MMPJ. One-Year Outcomes of Endovascular Aneurysm Repair in High-Risk Patients Using the Endurant Stent-Graft. J Endovasc Ther 2016; 23:574-82. [DOI: 10.1177/1526602816648455] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To evaluate the outcome and survival of patients with extensive comorbid conditions after endovascular aneurysm repair (EVAR) and objectify which of 2 medical comorbidity classifications is more accurate in predicting adverse outcomes. Methods: All 1263 patients (mean age 73.1 years; 1129 men) treated using the Endurant Stent Graft system and entered in the prospective global postmarketing ENGAGE registry ( ClinicalTrials.gov identifier NCT00870051) were grouped using the American Society of Anesthesiologists (ASA) classification and the Society for Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) medical comorbidity grading system. Patients assigned to ASA III and IV and SVS/AAVS 2 and 3 categories were considered high risk. Primary outcome was 1-year all-cause mortality. Secondary outcomes included technical and clinical success, major adverse events (MAE), aneurysm rupture, endoleaks, and secondary endovascular procedures. One-year follow-up of the entire ENGAGE cohort was the endpoint of the study. Results: A total of 1263 patients were included. The overall technical success rate was high, the lowest being 97.4% in the ASA I group. The overall 30-day and 1-year Kaplan-Meier survival estimates were 98.7% and 92.5%, respectively. All cause 1-year mortality was higher in the ASA III and IV groups, but this did not reach statistical significance (5.2% and 5.7% for ASA I and II vs 9.0% and 9.9% for ASA III and IV, p=0.12). In the SVS/AAVS groups, 1-year all-cause mortality significantly increased with the SVS/AAVS score to 11.3% in the SVS/AAVS 3 group (p=0.002). There were significantly more MAEs in the SVS/AAVS 3 group at 1 year (p<0.001 for group 1 vs 3 and group 2 vs 3). Conclusion: Endovascular aneurysm repair has evolved, and high technical success and low mortality and morbidity can be achieved in high-risk patients. When treating high-risk patients, the perioperative risks should always be weighed against the expected gains. In contrast to the ASA classification, the SVS/AAVS medical comorbidity grading system is a useful tool to predict occurrence of MAEs and 1-year survival in patients undergoing EVAR.
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Affiliation(s)
- Martijn L. Dijkstra
- Department of Surgery, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | | | | | - Clark J. Zeebregts
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
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147
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Scott SWM, Batchelder AJ, Kirkbride D, Naylor AR, Thompson JP. Late Survival in Nonoperated Patients with Infrarenal Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2016; 52:444-449. [PMID: 27374814 DOI: 10.1016/j.ejvs.2016.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 05/06/2016] [Indexed: 01/03/2023]
Abstract
OBJECTIVE/BACKGROUND Historical studies report high rupture rates in patients with nonoperated abdominal aortic aneurysms (AAAs) of > 5.5 cm diameter, although a recent audit has questioned this. METHODS This was a retrospective review of 138/764 (18%) patients with AAAs evaluated in a preassessment anaesthetic clinic (PAC) between 2006 and 2012, who either did not undergo elective AAA repair or who underwent deferred repair. The remaining 626 underwent repair. Patients with severe comorbidities (dementia, advanced malignancy, life-expectancy < 1 year) and not referred to PAC were excluded. RESULTS At a median of 27 months, 71 (52%) died, 36 (51%) following rupture. Cumulative survival, free from rupture or surgery for acute symptoms, was 96% at 1 year, 84% at 3 years, and 64% at 5 years, where baseline AAA diameters were 5.5-6.9 cm. For diameters ≥ 7 cm, survival, free from rupture, was 65% at 1 year, 29% at 3 years, and 0% at 5 years. Median interval to rupture was 47 months (AAA diameter 5.5-6.9 cm) and 21 months where baseline diameters were ≥ 7 cm. Rupture accounted for 32% of late deaths in patients with AAAs of 5.5-5.9 cm diameter, 46% in those with AAAs measuring 6.0-6.9 cm in diameter, and 71% in patients with AAA measuring ≥ 7 cm in diameter. CONCLUSION Approximately half of all late deaths in this nonoperated cohort were not AAA related, suggesting that even had repair been undertaken, it would not have prolonged patient survival. The incidence of rupture in "high-risk" patients with an AAA < 7 cm diameter was < 5% at 1 year, thereby giving ample time to optimise risk factors and improve pre-existing medical conditions prior to undertaking a deferred intervention. Even if these patients did not undergo surgical repair, the risk of late rupture was relatively low. By contrast, nonoperated patients with AAAs ≥ 7 cm in diameter face a very high risk of rupture and will probably benefit from elective surgery, with the caveat that a higher procedural risk might have to be incurred.
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Affiliation(s)
- S W M Scott
- Departments of Vascular Anaesthesia and Vascular Surgery, Leicester Royal Infirmary, Leicester, UK
| | - A J Batchelder
- Departments of Vascular Anaesthesia and Vascular Surgery, Leicester Royal Infirmary, Leicester, UK.
| | - D Kirkbride
- Departments of Vascular Anaesthesia and Vascular Surgery, Leicester Royal Infirmary, Leicester, UK
| | - A R Naylor
- Departments of Vascular Anaesthesia and Vascular Surgery, Leicester Royal Infirmary, Leicester, UK
| | - J P Thompson
- Departments of Vascular Anaesthesia and Vascular Surgery, Leicester Royal Infirmary, Leicester, UK
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148
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Ziegler P, Avgerinos ED, Umscheid T, Perdikides T, Stelter WJ. Fenestrated Endografting for Aortic Aneurysm Repair: A 7-Year Experience. J Endovasc Ther 2016; 14:609-18. [DOI: 10.1177/152660280701400502] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To present a 7-year single-center clinical experience with fenestrated endografts and side branches. Methods: Between April 1999 and August 2006, 63 patients (57 men; mean age 70.5611.6 years, range 25–89) received custom-designed Zenith fenestrated endoprostheses for a variety of aneurysms (59 abdominal, 1 thoracoabdominal, and 3 thoracic). They were all unsuitable for standard EVAR owing to short aortic necks and high risk for open surgery. Results: Nineteen tube grafts and 44 composite bifurcated grafts with a total of 122 fenestrations and 58 side branches were used. Technical success was achieved in 55 (87.3%) patients and in 118 (96.7%) vessels. Treatment success was 93.7%. The mean follow-up was 23±18 months (median 14, range 6–77). Overall, 9 (7.4%) visceral branches were lost: 4 intraoperative, 2 perioperative, and 3 late. There were 12 (19.0%) endoleaks identified: 5 (7.9%: 4 type Ia and 1 fenestration-related type III) primary and 7 (11.1%: 4 type II, 1 type I, and 2 type III) secondary endoleaks; 4 resolved, 4 were treated, and 4 are under observation. At 77 months, 75.3% of patients were free of a reintervention. All reinterventions were performed within the first 14 months. Fourteen cases of renal impairment were seen [6 permanent (only 1 on dialysis) and 8 transient]. One (1.6%) conversion and 1 (1.6%) rupture were recorded; aneurysm-related mortality was 4.8% (3/63). Conclusion: The favorable outcomes in this study, which encompasses the team's learning curve with fenestrated endografts and side branches, support the use of these devices in selected patients.
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Affiliation(s)
- Peter Ziegler
- Department of Surgery, Städtische Kliniken, Frankfurt a.M. Höchst, Germany
| | | | - Thomas Umscheid
- Department of Vascular Surgery, St Franziskus-Hospital, Münster, Germany
| | | | - Wolf J. Stelter
- Department of Surgery, Städtische Kliniken, Frankfurt a.M. Höchst, Germany
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149
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Falkensammer J, Hakaim AG, Klocker J, Biebl M, Lau LL, Neuhauser B, Mordecai M, Crawford C, Greengrass R. Paravertebral Blockade with Propofol Sedation versus General Anesthesia for Elective Endovascular Abdominal Aortic Aneurysm Repair. Vascular 2016; 14:17-22. [PMID: 16849018 DOI: 10.2310/6670.2006.00009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The objective of this study was to evaluate the applicability of paravertebral blockade (PVB) for endovascular abdominal aortic aneurysm repair compared with general anesthesia (GA). Data from patients who underwent elective infrarenal endovascular abdominal aortic aneurysm repair between August 2001 and July 2002 using PVB or GA were retrospectively reviewed and compared with respect to risk factors, intraoperative hemodynamic characteristics, operative outcome, and complications. Ten patients underwent elective infrarenal endovascular abdominal aortic aneurysm repair under PVB, whereas 15 patients were operated on under GA. One conversion from PVB to GA was necessary for block failure. The perioperative (< 30 days) cardiovascular morbidity and overall mortality were zero in both groups. The PVB group benefited significantly with respect to the incidence of intraoperative hypotension ( p < .05) and blood pressure lability ( p < .01), as well as postoperative nausea ( p < .01). Our preliminary results indicate that PVB is feasible and can be performed safely in a patient population with significant comorbidities.
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150
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Hinchliffe RJ, Braithwaite BD. Ruptured Abdominal Aortic Aneurysm: Endovascular Repair Does Not Confer Any Long-term Survival Advantage Over Open Repair. Vascular 2016; 15:191-6. [PMID: 17714633 DOI: 10.2310/6670.2007.00045] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Recent studies have suggested that endovascular aneurysm repair (EVAR) may reduce the perioperative mortality of ruptured abdominal aortic aneurysm (AAA). Whether EVAR confers any long-term survival advantage over published results for open repair of ruptured AAA has not been established. We conducted a single-center retrospective study over a 10-year period (1994–2004) examining the long-term outcome of patients who have undergone endovascular repair of ruptured AAA. Fifty-four patients underwent endovascular repair of a ruptured AAA. The median age was 75 years (interquartile range 69.5–79.5 years); 42 (78%) patients were male. The perioperative mortality rate was 37%. During a median follow-up of 32 months (range 14–48 months), there were 5 aneurysm-related and 13 non-aneurysm-related deaths. Overall, the 3- and 5-year survival rates were 36% and 26%, respectively. EVAR does not appear to confer any overall survival advantage in the mid- to long term compared with the published results for open repair. The reasons for this remain unclear. Further, larger studies are required to confirm these results.
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Affiliation(s)
- Robert J Hinchliffe
- Department of Vascular and Endovascular Surgery, University Hospital, Nottingham, UK.
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