Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms

Strain Mapping From Four-Dimensional Ultrasound Reveals Complex Remodeling in Dissecting Murine Abdominal Aortic Aneurysms

Current in vivo abdominal aortic aneurysm (AAA) imaging approaches tend to focus on maximum diameter but do not measure three-dimensional (3D) vascular deformation or strain. Complex vessel geometries, heterogeneous wall compositions, and surrounding structures can all influence aortic strain. Improved understanding of complex aortic kinematics has the potential to increase our ability to predict aneurysm expansion and eventual rupture. Here, we describe a method that combines four-dimensional (4D) ultrasound and direct deformation estimation to compute in vivo 3D Green-Lagrange strain in murine angiotensin II-induced suprarenal dissecting aortic aneurysms, a commonly used small animal model. We compared heterogeneous patterns of the maximum, first-component 3D Green-Lagrange strain with vessel composition from mice with varying AAA morphologies. Intramural thrombus and focal breakage in the medial elastin significantly reduced aortic strain. Interestingly, a dissection that was not detected with high-frequency ultrasound also experienced reduced strain, suggesting medial elastin breakage that was later confirmed via histology. These results suggest that in vivo measurements of 3D strain can provide improved insight into aneurysm disease progression. While further work is needed with both preclinical animal models and human imaging studies, this initial murine study indicates that vessel strain should be considered when developing an improved metric for predicting aneurysm growth and rupture.

Screening women aged 65 years or over for abdominal aortic aneurysm: a modelling study and health economic evaluation

BACKGROUND

Abdominal aortic aneurysm (AAA) screening programmes have been established for men in the UK to reduce deaths from AAA rupture. Whether or not screening should be extended to women is uncertain.

OBJECTIVE

To evaluate the cost-effectiveness of population screening for AAAs in women and compare a range of screening options.

DESIGN

A discrete event simulation (DES) model was developed to provide a clinically realistic model of screening, surveillance, and elective and emergency AAA repair operations. Input parameters specifically for women were employed. The model was run for 10 million women, with parameter uncertainty addressed by probabilistic and deterministic sensitivity analyses.

SETTING

Population screening in the UK.

PARTICIPANTS

Women aged ≥ 65 years, followed up to the age of 95 years.

INTERVENTIONS

Invitation to ultrasound screening, followed by surveillance for small AAAs and elective surgical repair for large AAAs.

MAIN OUTCOME MEASURES

Number of operations undertaken, AAA-related mortality, quality-adjusted life-years (QALYs), NHS costs and cost-effectiveness with annual discounting.

DATA SOURCES

AAA surveillance data, National Vascular Registry, Hospital Episode Statistics, trials of elective and emergency AAA surgery, and the NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP).

REVIEW METHODS

Systematic reviews of AAA prevalence and, for elective operations, suitability for endovascular aneurysm repair, non-intervention rates, operative mortality and literature reviews for other parameters.

RESULTS

The prevalence of AAAs (aortic diameter of ≥ 3.0 cm) was estimated as 0.43% in women aged 65 years and 1.15% at age 75 years. The corresponding attendance rates following invitation to screening were estimated as 73% and 62%, respectively. The base-case model adopted the same age at screening (65 years), definition of an AAA (diameter of ≥ 3.0 cm), surveillance intervals (1 year for AAAs with diameter of 3.0-4.4 cm, 3 months for AAAs with diameter of 4.5-5.4 cm) and AAA diameter for consideration of surgery (5.5 cm) as in NAAASP for men. Per woman invited to screening, the estimated gain in QALYs was 0.00110, and the incremental cost was £33.99. This gave an incremental cost-effectiveness ratio (ICER) of £31,000 per QALY gained. The corresponding incremental net monetary benefit at a threshold of £20,000 per QALY gained was -£12.03 (95% uncertainty interval -£27.88 to £22.12). Almost no sensitivity analyses brought the ICER below £20,000 per QALY gained; an exception was doubling the AAA prevalence to 0.86%, which resulted in an ICER of £13,000. Alternative screening options (increasing the screening age to 70 years, lowering the threshold for considering surgery to diameters of 5.0 cm or 4.5 cm, lowering the diameter defining an AAA in women to 2.5 cm and lengthening the surveillance intervals for the smallest AAAs) did not bring the ICER below £20,000 per QALY gained when considered either singly or in combination.

LIMITATIONS

The model for women was not directly validated against empirical data. Some parameters were poorly estimated, potentially lacking relevance or unavailable for women.

CONCLUSION

The accepted criteria for a population-based AAA screening programme in women are not currently met.

FUTURE WORK

A large-scale study is needed of the exact aortic size distribution for women screened at relevant ages. The DES model can be adapted to evaluate screening options in men.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020444 and CRD42016043227.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The long-term outcomes of open and endovascular repair for abdominal aortic aneurysm: A meta-analysis

To provide a meta-analysis of studies evaluating long-term all-cause mortality, aneurysm-related mortality and re-intervention after open or endovascular repair for abdominal aortic aneurysm. Electronic bibliographic sources were interrogated using a combination of free text and controlled vocabulary searches to identify studies comparing the long-term outcomes of open and endovascular repair for abdominal aortic aneurysm. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Fixed effect or random effects models were used. We retrieved 4 randomized controlled trials (RCTs; 2,783 patients), 7 nonrandomized trials (86,035 patients). The primary outcome was all-cause mortality. Heterogeneity was high and publication bias could not be excluded. Despite these limitations, the analysis showed that open and endovascular abdominal aortic aneurysm repair had similar all-cause mortality (OR 1.16, 95% CI, 0.89-1.51) over 5 years follow up, which was maintained after at least 10 years of follow-up (OR 0.87, 95% CI, 0.73-1.03). There was no significant difference in aneurysm-related mortality by 5 years or longer follow-up. A significantly lower proportion of patients undergoing open repair required reintervention (OR 0.38, 95% CI 0.24-0.64), which was maintained over 5 years of follow-up. There is no long-term survival difference between the patients who underwent open or endovascular aneurysm repair. There is significantly higher risk of reinterventions after endovascular aneurysm repair.

Predicting risk of rupture and rupture-preventing reinterventions following endovascular abdominal aortic aneurysm repair

Background

Clinical and imaging surveillance practices following endovascular aneurysm repair (EVAR) for intact abdominal aortic aneurysm (AAA) vary considerably and compliance with recommended lifelong surveillance is poor. The aim of this study was to develop a dynamic prognostic model to enable stratification of patients at risk of future secondary aortic rupture or the need for intervention to prevent rupture (rupture‐preventing reintervention) to enable the development of personalized surveillance intervals.

Methods

Baseline data and repeat measurements of postoperative aneurysm sac diameter from the EVAR‐1 and EVAR‐2 trials were used to develop the model, with external validation in a cohort from a single‐centre vascular database. Longitudinal mixed‐effects models were fitted to trajectories of sac diameter, and model‐predicted sac diameter and rate of growth were used in prognostic Cox proportional hazards models.

Results

Some 785 patients from the EVAR trials were included, of whom 155 (19·7 per cent) experienced at least one rupture or required a rupture‐preventing reintervention during follow‐up. An increased risk was associated with preoperative AAA size, rate of sac growth and the number of previously detected complications. A prognostic model using predicted sac growth alone had good discrimination at 2 years (C‐index 0·68), 3 years (C‐index 0·72) and 5 years (C‐index 0·75) after operation and had excellent external validation (C‐index 0·76–0·79). More than 5 years after operation, growth rates above 1 mm/year had a sensitivity of over 80 per cent and specificity over 50 per cent in identifying events occurring within 2 years.

Conclusion

Secondary sac growth is an important predictor of rupture or rupture‐preventing reintervention to enable the development of personalized surveillance intervals. A dynamic prognostic model has the potential to tailor surveillance by identifying a large proportion of patients who may require less intensive follow‐up.

Potential to tailor surveillance

Influence of psoas muscle area on mortality following elective abdominal aortic aneurysm repair

BACKGROUND

The effect of sarcopenia based on the total psoas muscle area (TPMA) on CT is inconclusive in patients undergoing abdominal aortic aneurysm (AAA) intervention. The aim of this prospective cohort study was to evaluate morphometric sarcopenia as a method of risk stratification in patients undergoing elective AAA intervention.

METHODS

TPMA was measured on preintervention CT images of patients undergoing elective endovascular aneurysm repair (EVAR) or open aneurysm repair. Mortality was assessed in relation to preintervention TPMA using Cox regression analysis, with calculation of hazard ratios at 30 days, 1 year and 4 years. Postintervention morbidity was evaluated in terms of postintervention care, duration of hospital stay and 30-day readmission. Changes in TPMA on surveillance EVAR imaging were also evaluated.

RESULTS

In total, 382 patient images acquired between March 2008 and December 2016 were analysed. There were no significant intraobserver and interobserver differences in measurements of TPMA. Preintervention TPMA failed to predict morbidity and mortality at all time points. The mean(s.d.) interval between preintervention and surveillance imaging was 361·3(111·2) days. A significant reduction in TPMA was observed in men on surveillance imaging after EVAR (mean reduction 0·63(1·43) cm2 per m2 ; P < 0·001). However, this was not associated with mortality (adjusted hazard ratio 1·00, 95 per cent c.i. 0·99 to 1·01; P = 0·935).

CONCLUSION

TPMA is not a suitable risk stratification tool for patients undergoing effective intervention for AAA.

Risk factors and short and medium-term survival after open and endovascular repair of abdominal aortic aneurysms

Background

Infrarenal abdominal aortic aneurysms (AAA) are responsible for high rates of rupture-associated morbidity and mortality and can be treated by open or endovascular surgery.

Objectives

To analyze risk factors and survival associated with surgical and endovascular AAA treatment methods.

Methods

A retrospective, longitudinal study involving 41 patients who underwent endovascular or open AAA repair, whether elective or emergency, over a 48-month period, with analysis of preoperative comorbidities, 30-day and 1-year survival, in-hospital mortality, length of hospital stay, transfusion of blood products, duration of surgery, and development of acute kidney failure. Inferential statistics and survival analysis considered a 95% CI and p < 0.05 as significant.

Results

Twelve of the 41 patients were treated with open surgery and 29 with endovascular techniques. The majority were male (75%), with an average age of 71 (range: 56 – 90 years). There were no differences in demographic or risk factors between the groups. Overall survival rates for open and endovascular repair were different for both 30 days (37 vs. 72%, p = 0.01) and 360 days (37 vs. 67%, p = 0.01). However, survival rates in elective cases were similar at 30 days (71 vs. 76%, p = 0.44) and 360 days (both 71%, p = 0.34). Endovascular repair showed shorter length of hospital stay (3.0 vs. 4.4 days; p = 0.02) and duration of surgery (111 vs. 163 min; p < 0.01) compared to open repair.

Conclusions

There was no difference in short- or medium-term survival of AAA patients treated electively with endovascular or open surgery. Hospital stays and duration of surgery were both shorter with minimally invasive treatment.

What Did Endovascular Aortic Repair Bring for the Treatment Strategy of Abdominal Aortic Aneurysm?

Objective: We examined the effects of the introduction of endovascular aortic repair (EVAR) on treatment for abdominal aortic aneurysms (AAAs).

Subjects: We compared patients in the following three periods: period I (January 2002–December 2006, 105 patients), period II (January 2007–December 2011, 242 patients, duration of 5 years after the introduction of EVAR), and period III (January 2012–December 2016, 237 patients, duration of 5 years after period II). We used the American Society of Anesthesiologists (ASA) classification for risk assessment.

Results: In the Open repair (OR) group, the incidences of ASA class 2 increased and classes 3 and 4 decreased significantly in periods II and III compared with period I. In all periods, there were no in-hospital deaths. Suprarenal aortic cross-clamping was required in 18 patients (19.1%) in period III and 5 patients (6.3) in period I, and the difference was significant (P<0.05). In the EVAR group, no differences in age, sex, or ASA classification class were observed between periods II and III. In period II, one patient died due to aneurysm rupture during surgery. Significant differences were observed when comparing both groups in periods II and III: patients in the EVAR group were older (P<0.01) and the OR group had a higher proportion of ASA class 2 patients and the EVAR group had a higher proportion of ASA class 3 or 4 patients (P<0.01). Among all AAA surgeries, rupture occurred in 25 patients (23.8%) in period I, 18 patients (7.4) in period II, and 16 patients (6.8) in period III. The number of ruptures was significantly lower in periods II and III than in period I (P<0.01).

Conclusions: The findings of this study suggest that EVAR should be indicated for high-risk patients and had the good outcome of AAA treatment. (This is a translation of Jpn J Vasc Surg 2018; 27: 27–32.)

Duplex scanning as an alternative to computer tomography with contrast enhancement for the control of complications after endovascular aneurysm repair

EVAR (endovascular aneurism repair) is the preferred method for the surgical treatment of ananeurysm. The advantage of this type of surgical intervention is that a smaller number of postoperative complications will occur. The main diagnostic tasks for patients after EVAR are to determine the size of the aneurysmal sac, detection of an endoleak, detection of the endoprosthesis migration and the deformation of the stent graft itself. Conclusion: early detection of complications in the postoperative period remains the main problem for monitoring patients after EVAR. Duplex scanning is a safe, non-invasive and effective method of measuring the size of an aneurysmal sac and detecting possible complications after EVAR.

Post-EVAR aneurysm sac shrinkage is prognostically favorable, but does not justify withholding follow-up

BACKGROUND

One of the main drawbacks of endovascular aortic aneurysm repair (EVAR) compared to open aortic surgery is the possibility of developing endoleaks and secondary aneurysm rupture, requiring frequent imaging follow-up. This study aims to identify prognostic factors that could be incorporated in follow-up protocols, which might lead to better personalized, lower cost and safe EVAR follow-up.

METHODS

A retrospective study was performed including all patients who underwent elective EVAR from January 2000 to December 2015. Follow-up data were gathered by reviewing medical files for radiographic imaging. Linear and logistic regressions were used to assess predictive factors for aneurysm shrinkage.

RESULTS

In 361 patients, aneurysm sac shrinkage of 10 mm or more was measured in 152 (42.1%) patients. Patients with ≥10-mm aneurysm shrinkage had fewer endoleaks (4.3% vs. 24.6%, P<0.0001) and fewer re-interventions for endoleak (3.0% vs. 10.1%, P=0.007). Aneurysm sac shrinkage was correlated with the absence of endoleak development (OR 0.36, 95% CI 0.19-0.66, P=0.001). In patients who had achieved ≥10-mm shrinkage of the aneurysm sac, no further significant growth was seen, compared to 38 (15.3%) patients who did not attain size reduction (P<0.001).

CONCLUSIONS

Once patients achieve ≥10-mm aneurysm sac shrinkage, they are less prone to developing subsequent aneurysm growth and have significantly lower risk of requiring surgery for endoleaks. However, a small number of patients remain at risk of requiring endoleak surgery after aneurysm shrinkage. Therefore, we would not recommend ceasing life-long imaging follow-up after significant aneurysm sac shrinkage, though it might be safe to increase the interval of follow-up.

Analysis of intraoperative radiation use in vascular surgery: Catalyst for quality improvement in patient and personnel safety

OBJECTIVES

There is paucity in the literature reporting radiation usage analysis in vascular surgery. In the era of endovascular surgeries, analyzing the surgeons' use of radiation in vascular procedures can help establish quality improvement initiatives.

METHODS

A retrospective review was undertaken of intraoperative fluoroscopic-guided vascular surgery procedures at a single institution from 2010 to 2017. Mobile C-arms were utilized to gather the six radiation usage metrics and cases were categorized into 6 anatomic surgical fields and 10 surgical procedure types.

RESULTS

Three hundred and eighteen vascular surgery cases were analyzed and notable trends in all radiation usage metrics were identified both across the surgical field location and type of surgical procedure. The highest cumulative dose was identified in embolization cases with a mean of 932.5 mGy. The highest fluoroscopic time was seen in atherectomies with a mean of 2629.6 s. In terms of surgical field, the highest cumulative does and fluoroscopic time was identified in abdomen/pelvis procedures with a mean of 352.1 mGy and 1186.8 s, respectively. Analysis of dose reduction techniques also demonstrated notable trends.

CONCLUSIONS

There were notable trends in the analyzed radiation usage variables both across the surgical field location and type of surgical procedure. Specifically, cases that involve the abdomen/pelvis, embolization and atherectomy have the highest radiation use. These types of cases can be targeted for future improved dose reduction techniques or staged procedures. This data can serve as baseline information for future quality improvement initiatives for patient and personnel radiation exposure safety.

Abdominal aortic aneurysms

An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.

Global Post-Market Clinical Follow-up of the Treovance Stent-Graft for Endovascular Aneurysm Repair: One-Year Results From the RATIONALE Registry

PURPOSE:

To evaluate the safety and performance of the Treovance stent-graft.

METHODS:

The global, multicenter RATIONALE registry ( ClinicalTrials.gov; identifier NCT03449875) prospectively enrolled 202 patients (mean age 73.0±7.8 years; 187 men) with abdominal aortic aneurysms (AAA) suitable for endovascular aneurysm repair (EVAR) using the Treovance. The composite primary safety endpoint was site-reported all-cause mortality and major morbidity. The primary efficacy outcome was clinical success. Further outcomes evaluated included technical success; stent-graft migration, patency, and integrity; endoleak; and aneurysm size changes.

RESULTS:

Technical success was 96% (194/202); 8 patients had unresolved type I endoleaks at the end of the procedure. There was no 30-day mortality and 1% major morbidity (1 myocardial infarction and 1 bowel ischemia). Clinical success at 1 year was confirmed in 194 (96%) patients; 6 of 8 patients had new/persistent endoleaks and 2 had aneurysm expansion without identified endoleak. A total of 8 (4%) reinterventions were required during the mean 13.7±3.1 months of follow-up (median 12.8). At 1 year, the Kaplan-Meier estimate for freedom from reintervention was 95.6% (95% CI 91.4% to 97.8%). Other estimates were 95.5% (95% CI 91.7% to 97.6%) for freedom from endoleak type I/III and 97.4% (95% CI 94.2% to 98.9%) for freedom from aneurysm expansion. Thirteen (6.4%) patients died; no death was aneurysm related.

CONCLUSION:

The RATIONALE registry showed favorable safety and clinical performance of the Treovance stent-graft for the treatment of infrarenal AAAs in a real-world setting.

[Endovascular aneurysm repair (EVAR) : Complication management]

A variety of complications may be experienced during or after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA). Acute procedure-related complications include injury to the access vessels, improper endograft placement, ischaemic and systemic complications as well as the postimplantation syndrome. Femoral pseudoaneurysms, endograft migration, kinking or occlusion, endoleaks and endograft infection are complications that have been observed at follow-up. Meticulous patient selection and preprocedural work-up can reduce the incidence of these complications. The majority of the complications, acute as well those at follow-up, can be dealt with endoluminally. It is of essence, however, that a wide variety of catheters, guidewires, stents, stent-grafts and embolics are readily available in the repertoire of the interventionalist. In a small number of patients with endograft occlusion or infection or with bleeding complications/pseudoaneurysms of the access vessels, open surgical intervention may become necessary. To obtain optimal results, close interdisciplinary co-operation, especially between the interventionist, the vascular surgeon and the anaesthetist is mandatory.

General anesthesia versus local anesthesia for endovascular aortic aneurysm repair

The aim of this study was to compare general and local anesthesia techniques in patients treated with elective endovascular aortic aneurysm repair (EVAR) for infrarenal aortic aneurysms.In this single-center, observational cohort study, in all, 259 consecutive patients who underwent elective EVAR was included; 144 patients (55.6%, 126 men, mean age 72.8 years) operated on under general anesthesia (GA group) and 115 (44.4%, 100 men, mean age 72.3 years) operated on under local anesthesia (LA group). A retrospective analysis regarding technical feasibility, endoleaks, length of hospital stay, and 30-day clinical outcomes was performed.There was no anesthetic conversion (from LA to GA) during EVAR, and no significant difference was noted in the incidence of endoleaks and its types in relation to anesthetic techniques on final completion angiograms (14.1% vs 18.4%; P = .347) and follow-up computed tomography angiogram at 30 days after EVAR (23.6% vs 19.1%; P = .384). Significant differences were not observed with regard to a prolonged length of hospital stay in relation to anesthetic techniques (8.6 ± 16.3 vs 7.2 ± 3.3; P = .348), and the main outcomes showed no significant differences in morbidity (20.1% vs 16.5%; P = .457), mortality (0.0% vs 0.0%), and the rates of secondary therapeutic procedures (9.7% vs 4.3%; P = .099) between the 2 groups during the 30-day follow-up.We have not shown a definite difference in 30-day outcomes between GA and LA for EVAR. The anesthetist and surgeon, in consultation with the patient, should decide which anesthetic technique to use on an individual basis.

Pain management in patients with vascular disease

Vascular disease covers a wide range of conditions, including arterial, venous, and lymphatic disorders, with many of these being more common in the elderly. As the population ages, the incidence of vascular disease will increase, with a consequent increase in the requirement to manage both acute and chronic pain in this patient population. Pain management can be complex, as there are often multiple co-morbidities to be considered. An understanding of the underlying pain mechanisms is helpful in the logical direction of treatment, particularly in chronic pain states, such as phantom limb pain or complex regional pain syndrome. Acute pain management for vascular surgery presents a number of challenges, including coexisting anticoagulant medication, that may preclude the use of regional techniques. Within the limited evidence base, there is a suggestion that epidural analgesia provides better pain relief and reduced respiratory complications after major vascular surgery. For carotid endarterectomy, there is again some evidence supporting the use of local anaesthetic analgesia, either by infiltration or by superficial cervical plexus block. Chronic pain in vascular disease includes post-amputation pain, for which well-known risk factors include high pain levels before amputation and in the immediate postoperative period, emphasizing the importance of good pain control in the perioperative period. Complex regional pain syndrome is another challenging chronic pain syndrome with a wide variety of treatment options available, with the strongest evidence being for physical therapies. Further research is required to gain a better understanding of the underlying pathophysiological mechanisms in pain associated with vascular disease and the best analgesic approaches to manage it.

Short- and long-term survival after open versus endovascular repair of abdominal aortic aneurysm-Polish population analysis

OBJECTIVES

The aim of the study was to compare short and long-term mortality and readmissions in patients with non-ruptured abdominal aortic aneurysm (AAA) treated with endovascular aortic repair (EVAR) or open aneurysm repair (OAR).

DESIGN

Retrospective survival analysis based on prospectively collected medical records of the national Polish public health insurer.

MATERIALS

In the National Health Fund database we identified all patients who underwent elective open or endovascular treatment of AAA between January 1st 2011 and March 22nd 2016. The data on mortality, selected concomitant diseases and readmissions were collected. A total of 7805 patients (mean age 70.9±8.1 yrs, 85.8% males) underwent OAR (n = 2336) or EVAR (n = 5469). A median follow up was 27.5 months (IQR range 10.0-38.4 months).

METHODS

The primary outcome variable was all-cause mortality, secondary outcomes included 30-day mortality and readmissions. Kaplan-Meier (K-M), Cox proportional-hazards and propensity score analyses were performed for primary and secondary outcomes adjusting for repair type of AAA (OAR vs. EVAR), age, sex and concomitant diseases.

RESULTS

EVAR patients had higher all-cause mortality (6.4% vs. 4.6% P = 0.002, adjHR 1.34, 95%CI 1.07-1.67, P = 0.010) compared with OAR. The mortality risks for OAR patients decreased below those for EVAR patients after 9.9 months. Of all the tested confounding factors only age independently and significantly influenced long-term mortality. Readmissions occurred more often in EVAR than in OAR (16.5% vs. 8.4% P<0.001, adjHR 2.15, 95%CI 1.84-2.52, P<0.001) independently from other covariants. Survival and readmissions Kaplan-Meier curves remained statistically different between OAR and EVAR patients after propensity score matching.

CONCLUSIONS

Survival benefit of EVAR over OAR disappeared early during the first year after procedure, particularly in patients below 70 years of age, accompanied by an increased frequency of readmissions of EVAR patients. Our data suggest re-evaluation of the strategy for AAA management in vascular units in the country.

A Long-Time Follow-Up Study of a Single-Center Endovascular Aneurysm Repair (Evar) Endoleak Outcomes

Purpose:

The aim of this study was to evaluate the incidence, risk factors, and outcome of endoleaks related to endovascular aneurysm repair (EVAR) procedure at a single center with up to 10 years’ surveillance.

Materials and Methods:

All patients treated with EVAR for an abdominal aorta or iliac aneurysm in a 10-year period at a single cardiovascular center in Denmark were included. Data were collected from a national database and patient journals. Follow-up computed tomography angiography and plain abdominal X-ray reports were reviewed.

Results:

A total of 421 patients were included. There were 125 endoleaks observed in 117 (27.8%) patients after a median 95 days (interquartile range: 90-106 days). There were 16 type I, 107 type II, 1 type III, and 1 type V endoleaks. A total of 33 (7.8%) patients had at least 1 reintervention. Patients with type II endoleaks had significantly fewer active smokers and lower plasma creatinine at baseline. They also more often had one, or both, internal iliac arteries embolized as well as an identified endoleak at the procedural completion angiogram. Non-type II endoleaks were associated with internal iliac artery embolization. There was no association between the occurrence of endoleaks and increased mortality.

Conclusion:

Type II endoleaks are common after EVAR, yet few lead to reintervention. Absence of smoking, low plasma creatinine, embolized iliac arteries, and endoleak on completion angiogram were associated with type II endoleaks, whereas only embolized iliac arteries were associated with non-type II endoleaks. Overall, endoleaks are not associated with increased mortality.

Abdominal Aortic Aneurysm: Evolving Controversies and Uncertainties

Abdominal aortic aneurysm (AAA) is defined as a permanent dilatation of the abdominal aorta that exceeds 3 cm. Most AAAs arise in the portion of abdominal aorta distal to the renal arteries and are defined as infrarenal. Most AAAs are totally asymptomatic until catastrophic rupture. The strongest predictor of AAA rupture is the diameter. Surgery is indicated to prevent rupture when the risk of rupture exceeds the risk of surgery. In this review, we aim to analyze this disease comprehensively, starting from an epidemiological perspective, exploring etiology and pathophysiology, and concluding with surgical controversies. We will pursue these goals by addressing eight specific questions regarding AAA: (1) Is the incidence of AAA increasing? (2) Are ultrasound screening programs for AAA effective? (3) What causes AAA: Genes versus environment? (4) Animal models: Are they really relevant? (5) What pathophysiology leads to AAA? (6) Indications for AAA surgery: Are surgeons over-eager to operate? (7) Elective AAA repair: Open or endovascular? (8) Emergency AAA repair: Open or endovascular?

Prospective, single UK centre, comparative study of the predictive values of contrast-enhanced ultrasound compared to time-resolved CT angiography in the detection and characterisation of endoleaks in high-risk patients undergoing endovascular aneurysm repair surveillance: a protocol

INTRODUCTION

Diagnosis of endoleaks is imperative to prevent failure of endovascular aneurysm repairs (EVARs). The gold standard for diagnosis of endoleaks is catheter-directed subtraction angiography, which is not a practicable choice for surveillance. CT angiography (CTA) is the historical surveillance modality of choice. Concerns over cost, potential nephrotoxicity of contrast agents and repeated radiation exposure led to colour duplex ultrasound scan (CDUS) becoming an established alternative. CDUS has a lower sensitivity and specificity for endoleaks detection compared to CTA. Contrast-enhanced ultrasound scan (CEUS) represents an improvement of ultrasound imaging but comparisons against CTA report widely varying results, likely due to technical factors of CEUS and limitations of single-phase CTA.The development of time-resolved CTA (tCTA) offers timing information that much more closely mirrors the dynamic information available from CEUS. Theoretically, these two imaging modalities have the best potential for diagnostic accuracy. The aim of this study will be to compare CEUS to tCTA and investigate the utility of other measurements available from tCTA.

METHODS AND ANALYSIS

This is a prospective, single UK centre, comparative study of paired binary diagnostic imaging modalities. Patients identified in routine post-EVAR surveillance as at risk of having a graft-related endoleak will undergo a CEUS and tCTA on the same day. This will allow the first comparison of CEUS to a semidynamic form of CTA. CEUS sensitivity and specificity to endoleak detection will be calculated.

ETHICS AND DISSEMINATION

The study has achieved ethical approval. We hope the results will define the diagnostic accuracy of CEUS in comparison to a semidynamic form of CTA, representing a methodological improvement from previous studies. Results will be submitted for presentation at national and international vascular surgeryandradiology meetings. The full results are planned to be published in a medical journal.

TRIAL REGISTRATION NUMBER

NCT02688751.

Volumetric Nephrogram Represents Renal Function and Complements Aortic Anatomic Severity Grade in Predicting EVAR Outcomes

INTRODUCTION

Chronic kidney disease (CKD) is a predictor of poor outcomes for patients undergoing endovascular aortic aneurysm repair (EVAR). Anatomic severity grade (ASG) represents a quantitative mechanism for assessing anatomical suitability for endovascular aortic repair. Anatomic severity grade has been correlated with repair outcomes and resource utilization. The purpose of this study was to identify a novel renal perfusion metric as a way to assist ASG with predicting EVAR outcomes.

METHODS

Retrospective review of a prospectively maintained database identified elective infrarenal aortic aneurysm repair cases. Anatomic grading was undertaken by independent reviewers. Using volumetric software, kidney volume, and a novel measure of kidney functional volume, the volumetric nephrogram (VN) was recorded. Systematic evaluation of the relationship of kidney volume and VN to CKD and ASG was undertaken using linear regression and receiver-operator statistical tools.

RESULTS

A total of 386 cases with patient and anatomic data were identified and graded. Mean age was 72.9 ± 0.4 years. Renal volume <281 mL correlated with CKD (area under the curve [AUC] = .708; P ≤ .0001). Volumetric nephrogram <22.5 HU·L correlated with CKD (AUC = 0.764; P ≤ .0001). High (≥15) ASG scores correlated with both renal volume (AUC = .628; P ≤ .0001) and VN (AUC = .628; P ≤ .0001). Regression analysis demonstrated a strong, inverse relationship between ASG and VN ( R² = .95).

CONCLUSION

These data demonstrate that VN is a strong predictor of CKD in a large database of patients undergoing elective aneurysm repair. We demonstrate an inverse relationship between renal function and ASG that has not been previously described in the literature. Additionally, we have shown that VN complements ASG as a model of overall cardiovascular health and atherosclerotic burden. Outcomes in patients with poor renal function may be related to anatomical issues in addition to well-described systemic ramifications.

Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging

Background

Lifelong postoperative surveillance is recommended following endovascular aneurysm repair (EVAR). Although the purpose is to prevent and/or identify complications early, it also results in increased cost and workload. This study was designed to examine whether it may be possible to identify patients at low risk of complications based on their first postoperative CT angiogram (CTA).

Methods

All patients undergoing EVAR in two Swedish centres between 2001 and 2012 were identified retrospectively and categorized based on the first postoperative CTA as at low risk (proximal and distal sealing zone at least 10 mm and no endoleak) or high risk (sealing zone less than 10 mm and/or presence of any endoleak) of complications.

Results

Some 326 patients (273 men) with a CTA performed less than 1 year after EVAR were included (low risk 212, 65·0 per cent; high risk 114, 35·0 per cent). There was no difference between the groups in terms of sex, age, co-morbidities, abdominal aortic aneurysm (AAA) diameter, preoperative AAA neck anatomy, stent-graft type or duration of follow-up (mean(s.d.) 4·8(3·2) years). Five-year freedom from AAA-related adverse events was 97·1 and 47·7 per cent in the low- and high-risk groups respectively (P &lt; 0·001). The corresponding freedom from AAA-related reintervention was 96·2 and 54·1 per cent (P &lt; 0·001). The method had a sensitivity of 88·3 per cent, specificity of 77·0 per cent and negative predictive value of 96·6 per cent to detect AAA-related adverse events. The number of surveillance imaging per AAA-related adverse event was 168 versus 11 for the low-risk versus high-risk group.

Conclusion

Two-thirds of patients undergoing EVAR have an adequate seal and no endoleak on the first postoperative CTA, and a very low risk of AAA-related events up to 5 years. Less vigilant follow-up after EVAR may be considered for these patients.

Complications and Reinterventions After Fenestrated and Branched EVAR in Patients with Paravisceral and Thoracoabdominal Aneurysms

The application of endovascular strategies to treat aneurysms involving the abdominal and thoracoabdominal aorta has evolved significantly since the inception of endovascular aneurysm repair. Advances in endograft technology and operator experience have enabled the management of a wider spectrum of challenging aortic anatomy. Fenestrated endovascular and branched endovascular aneurysm repair represent two technical innovations, which have expanded endovascular treatment options to include patients with paravisceral and thoracoabdominal aortic aneurysms. Although similar in many ways to standard aortic endografts, fenestrated and branched endografts have specific short- and long-term complications due to their unique modular endograft design and their sophisticated deployment mechanisms. This article aims to examine the commonly encountered complications with these devices and the endovascular reintervention strategies.

Trends in endovascular aneurysm repair research: bibliometric analysis from 1994 to 2017

Purpose

Since endovascular aneurysm repair (EVAR) was first introduced in 1991, it has undergone rapid technical and quantitative developments. We analyzed the characteristics and trends of EVAR research through bibliometric analysis.

Methods

Comprehensive online searches focused on EVAR were performed from January 1994 to August 2017. The following information was collected: title, year of publication, countries' contribution, authorship, subspecialty, institution, subject category, and top 10 cited articles.

Results

A significant increase was demonstrated globally in the number of annual publications on EVAR. The highest number of publications was from the United States (n = 849, 35.08%), followed by England (n = 343, 14.17%), and the institutions with highest number of publications were Stanford University (n = 61, 2.52%) and Skane University Hospital Malmo (n = 45, 1.86%). The Journal of Vascular Surgery published approximately one quarter of the total publications. Vascular surgeons produced the most publications (n = 1871, 78.14%), followed by radiologists (n = 377, 15.58%) and cardiologists (n = 73, 3.02%). The most studied topics on EVAR were complications and procedures. The number of publications on complex EVAR and EVAR in juxtarenal aneurysm has increased more from 2013 to 2017 (5.1%, 9.5%) compared with from 1998 to 2002 (2.1%, 1.8%).

Conclusion

Our bibliometric analysis showed the characteristics and trends of publications on EVAR over a period of 25 years. The results of the bibliometric analysis revealed the quantitative improvements of publications and the qualitative improvements in challenging EVAR.

Lower extremity compartment syndrome after elective percutaneous fenestrated endovascular repair of an abdominal aortic aneurysm

Ischemic complications after fenestrated endovascular aortic aneurysm repair (FEVAR) can result in significant morbidity and mortality. We present a case of a 65-year-old man who underwent a FEVAR complicated by bilateral lower extremity compartment syndrome requiring four-compartment fasciotomies. This ischemic complication was likely caused by sheath occlusion because the patient had no evidence of arterial injury or distal plaque embolization. This case highlights the importance of careful postoperative monitoring after FEVAR, because the larger sheaths required can be occlusive and result in lower extremity ischemia, even for relatively short cases.

Femorofemoral Crossover Bypass Graft Has Excellent Patency When Performed with EVAR for AAA with UIOD

OBJECTIVES

To compare the durability of the crossover femorofemoral bypass graft (CFFBG) in combination with aorto-uni-iliac stent graft (AUIS) for abdominal aortic aneurysm with the durability of CFFBG used in the treatment of unilateral iliac occlusive disease (UIOD).

METHODS

We analyzed the clinical records of 69 patients who underwent CFFBG from 1992 until 2010. Group I consisted of 34 patients who received CFFBGs in combination with AUIS. Group II consisted of 35 patients treated with CFFBG for UIOD. The mean period of follow up was 2.7 years. Outcomes analyzed included primary graft patency, secondary graft patency, and postoperative morbidity and mortality.

RESULTS

There was one death in each group. Wound infection complicated 11.4% of CFFBGs performed as a sole procedure for UIOD and 5.8% of cases in combination with AUIS (P = 0.673). Primary graft patency was 96.5% and 96.5% at 2 and 5 years in group I, compared with 76.6% and 53.7% in group II (P = 0.046, 0.009). Secondary graft patency at 5 years was 100% and 92.9% for groups I and II, respectively. No variables independently influenced primary graft patency. Patients in group I experienced complications that could be linked to the bypass graft in 20.5% of cases, after long-term follow-up.

CONCLUSIONS

The CFFBG possesses superior long-term durability and patency when implemented in combination with aorto-uni-iliac stent grafts and does not seem to compromise the endpoint success of endovascular treatment.

The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis

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.

Gender differences in abdominal aortic aneurysms in Germany using health insurance claims data

Abstract. Background: Endovascular aortic repair (EVAR) has emerged as standard of care for abdominal aortic aneurysm (AAA). Real-world evidence is limited to compare this technology to open repair (OAR). Major gaps exist related to short-term and long-term outcomes, particularly in respect of gender differences. Materials and methods: Health insurance claims data from Germany’s third largest insurance provider, DAK-Gesundheit, was used to investigate invasive in-hospital treatment of intact (iAAA) and ruptured AAA (rAAA). Patients operated between October 2008 and April 2015 were included in the study. Results: A total of 5,509 patients (4,966 iAAA and 543 rAAA) underwent EVAR or OAR with a median follow-up of 2.44 years. Baseline demographics, comorbidities, and clinical characteristics of DAK-G patients were assessed. In total, 84.6 % of the iAAA and 79.9 % of the rAAA were male. Concerning iAAA repair, the median age (74 vs. 73 years, p < .001) compared to men was higher in females, but their EVAR-rate (66.8 % vs. 71.1 %, p = .018) was lower. Besides higher age of female patients (80 vs. 75 years, p < .001), no further statistically significant differences were seen following rAAA repair. In-hospital mortality was slightly lower in males compared to females following iAAA (2.3 % vs. 3.1 %, p = .159) and rAAA (37.3 % vs. 43.1 %, p = .273) repair. Concerning iAAA repair, a higher rate of female patients was transferred to another hospital (3.7 % vs. 2.0 %, p = 0.008) or discharged to rehabilitation (6.0 % vs. 2.7 %, p < .001) compared to male patients. Conclusions: In this large German claims data cohort, women are generally older and more often transferred to another hospital or discharged to rehab following iAAA repair. Nonetheless, no significantly increased risk of in-hospital or late death appeared for women in multivariate analyses. Further studies are necessary to evaluate the impact of recent gender-specific treatment strategies on overall outcome under real-world settings.

Preservation of internal iliac arteries during endovascular aneurysm repair using "eye of the tiger" technique

Parallel endografts were introduced as a way to expand endovascular repair of aneurysms involving branch vessels. However, endoleaks as a result of the gutters between the parallel endografts made this technique less favorable. The “eye of the tiger” technique was introduced to reduce the gutters between the parallel endografts proximally in the aorta. We report endovascular repair of infrarenal abdominal aortic aneurysm using eye of the tiger technique distally to preserve the internal iliac arteries.

Open versus endovascular repair of ruptured abdominal aortic aneurysms: What have we learned after more than 2 decades of ruptured endovascular aneurysm repair?

BACKGROUND

Ruptured abdominal aortic aneurysm is one of the most difficult clinical problems in surgical practice, with extraordinarily high morbidity and mortality. During the past 23 years, the literature has become replete with reports regarding ruptured endovascular aneurysm repair.

METHODS

A variety of study designs and databases have been utilized to compare ruptured endovascular aneurysm repair and open surgical repair for ruptured abdominal aortic aneurysm and studies of various designs from different databases have yielded vastly different conclusions. It therefore remains controversial whether ruptured endovascular aneurysm repair improves outcomes after ruptured abdominal aortic aneurysm in comparison to open surgical repair.

RESULTS

The purpose of this article is to review the best available evidence comparing ruptured endovascular aneurysm repair and open surgical repair of ruptured abdominal aortic aneurysm, including single institution and multi-institutional retrospective observational studies, large national population-based studies, large national registries of prospectively collected data, and randomized controlled clinical trials.

CONCLUSION

This article will analyze the study designs and databases utilized with their attendant strengths and weaknesses to understand the sometimes vastly different conclusions the studies have reached. This article will attempt to integrate the data to distill some of the lessons that have been learned regarding ruptured endovascular aneurysm repair and identify ongoing needs in this field.

A primer on infrarenal abdominal aortic aneurysms

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?

Early reintervention after open and endovascular abdominal aortic aneurysm repair is associated with high mortality

OBJECTIVE

Although reinterventions are generally considered more common after endovascular aneurysm repair (EVAR) than after open surgical repair (OSR), less is known about reintervention in the early postoperative period. Furthermore, there are few data regarding the impact of early reintervention on 30-day mortality. We sought to evaluate the rates and types of reintervention after abdominal aortic aneurysm (AAA) repair and the impact of reintervention on postoperative mortality.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried from 2012 to 2014 for all intact, infrarenal AAA repairs. The 30-day reintervention was classified by Current Procedural Terminology (CPT) codes. Univariate analysis comparing patients with and without reintervention was performed with the Fisher exact test and Mann-Whitney U test. Logistic regression was used to identify predictors of reintervention and to assess the association between 30-day reintervention and mortality.

RESULTS

We identified 5877 patients (OSR, 658 [11%]; EVAR, 5219 [89%]), of whom 261 underwent reintervention (OSR, 7.1%; EVAR, 4.1%; P < .01). Patients who underwent reintervention had larger aortic diameter (median, 5.7 cm vs 5.5 cm; P < .01), were more often symptomatic at presentation (16% vs 9.1%; P < .01), and were more likely to have renal insufficiency (7.7% vs 3.6%; P < .01) and history of prior abdominal operations (32% vs 26%; P = .04). Patients who underwent reintervention had higher 30-day mortality (OSR, 28% vs 2.8% [P < .001]; EVAR, 12% vs 1.0% [P < .001]) and major complications. Factors significantly associated with reintervention included open repair, diameter, symptom status, hypertension, and renal insufficiency. After adjusting for demographics, comorbidities, and type of repair, reintervention was independently associated with 30-day mortality after EVAR and OSR (odds ratio, 13; 95% confidence interval, 8-22; P < .001).

CONCLUSIONS

Compared with EVAR, patients undergoing open infrarenal AAA repair were significantly more likely to undergo 30-day reintervention, which could be related to higher open anatomic complexity and lower experience of the surgeon with open repair. Reintervention after both EVAR and OSR was associated with a >10-fold increase in postoperative mortality, emphasizing the need to minimize the complications associated with reintervention.

Surgical Versus Endovascular Aortic Aneurysm Repair: Evidence to Guide the Optimal Approach for the Individual Patient

The choice between an open surgical and an endovascular approach for abdominal aortic aneurysm (AAA) repair remains an individualized clinical decision. As the technology and applications of endovascular aortic aneurysm repair (EVAR) continue to evolve, so does the literature investigating its outcomes. Multiple high-quality, randomized controlled trials comparing EVAR to open surgical repair (OSR) have now been published with long-term follow-up. Experience with ruptured aneurysms and the use of complex endografts is growing as well. This review is an up-to-date compilation of pertinent clinical trials for practitioners placed in the context of individual patient considerations to guide the choice of an optimal approach to the management of AAAs.

A Comparative Study of Abdominal Aortic Aneurysm: Endovascular Aneurysm Repair versus Open Repair

BACKGROUND

Endovascular aneurysm repair (EVAR) has dramatically changed the management of abdominal aortic aneurysms (AAAs) as the number of open aneurysm repairs have declined over time. This report compares AAA-related demographics, operative data, complications, and mortality after treatment by open aneurysm repair or EVAR.

METHODS

We retrospectively reviewed 136 patients with AAAs who were treated over an 8-year time period with open aneurysm repair or EVAR.

RESULTS

The mean age of the EVAR group was higher than that of the open repair group (p=0.001), and hospital mortality did not differ significantly between groups (p=0.360). However, overall survival was significantly lower in the EVAR group (p=0.033).

CONCLUSION

Although EVAR is the primary treatment modality for elderly patients, it would be ideal to set slightly more stringent criteria within the anatomical guidelines contained in the instructions for use of the EVAR device when treating younger patients.

Evaluating the Effectiveness of Internal Iliac Artery Branched Endovascular Stent Grafts

BACKGROUND

The aim of this study is to describe our institutional experience using iliac branch grafts (IBGs) in aortoiliac aneurysm repair.

METHODS

From October 2009 to April 2016, 41 consecutive patients (all men), mean age 71.7 years (range 55-87), underwent IBG implantation. Abdominal aortic aneurysm with common iliac artery involvement (n = 21) or bilateral common iliac artery aneurysms (n = 20) were indications. Computed tomography was used to evaluate patency and postoperative endoleaks within 1 month of implantation and after 1 year.

RESULTS

A total of 42 IBGs were deployed in 41 patients successfully. One hundred percent of grafts implanted were patent at 1 month and at annual follow-up. There was 1 mortality at 30 days, due to acute renal failure. Sixteen type II and 1 type Ib endoleaks were found, for which 3 reinterventions were performed and the remainder treated conservatively. Five patients had complications which required reintervention.

CONCLUSIONS

IBG placement has excellent short-term outcomes and potential to limit buttock claudication in the treatment of abdominal aortic aneurysms involving the iliac arteries.