251
|
Analysis of the Learning Curve and Patient Outcomes of Endovascular Repair of Thoracoabdominal Aortic Aneurysms Using Fenestrated and Branched Stent Grafts. Ann Surg 2018; 268:640-649. [DOI: 10.1097/sla.0000000000002960] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
252
|
Principles of three-dimensional printing and clinical applications within the abdomen and pelvis. Abdom Radiol (NY) 2018; 43:2809-2822. [PMID: 29619525 DOI: 10.1007/s00261-018-1554-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Improvements in technology and reduction in costs have led to widespread interest in three-dimensional (3D) printing. 3D-printed anatomical models contribute to personalized medicine, surgical planning, and education across medical specialties, and these models are rapidly changing the landscape of clinical practice. A physical object that can be held in one's hands allows for significant advantages over standard two-dimensional (2D) or even 3D computer-based virtual models. Radiologists have the potential to play a significant role as consultants and educators across all specialties by providing 3D-printed models that enhance clinical care. This article reviews the basics of 3D printing, including how models are created from imaging data, clinical applications of 3D printing within the abdomen and pelvis, implications for education and training, limitations, and future directions.
Collapse
|
253
|
Zhorzel S, Busch A, Trenner M, Reutersberg B, Salvermoser M, Eckstein HH, Zimmermann A. Open Versus Endovascular Repair of Isolated Iliac Artery Aneurysms. Vasc Endovascular Surg 2018; 53:12-20. [PMID: 30180791 DOI: 10.1177/1538574418798418] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE: Outcomes of open iliac artery repair (OIR) and endovascular iliac artery repair (EVIR) were compared at a tertiary referral vascular center. METHODS: From 2004 to 2015, all patients treated for isolated iliac artery aneurysms (IAAs) were retrospectively identified, and patient records and computed tomography (CT) scans were analyzed. The primary end point was overall survival; secondary end points were 30-day mortality and morbidity and freedom from reintervention. For follow-up, data from outpatient visits and CT scans following a standard surveillance protocol were used. RESULTS: A total of 106 IAAs in 94 patients were treated (mean follow-up: 35.7 months; 66 OIR; 40 EVIR). Six (15%) aneurysms from the EVIR group and 4 (6.1%) from open-operated IAA presented in the state of rupture. There was no difference in overall survival between EVIR and OIR ( P = .14). In multivariable analysis, higher risk of death was associated with ruptured IAA (rIAA; hazard ratio [HR]: 40.44, 95% confidence interval [CI]: 2.05-796.18; P = .02) and coronary heart disease (HR: 11.07, 95% CI: 1.94-63.36; P < .01). The 30-day mortality was 1.9% overall (0% OIR, 5.0% EVIR, P = .27), but there were no differences between OIR and EVIR in 30-day morbidity ( P = .11). Freedom from reintervention was higher for OIR than for EVIR ( P < .01). In multivariable analysis, a higher reintervention rate was seen in EVIR (HR: 10.80, 95% CI: 2.20-53.01; P < .01) and in rIAA (HR: 12.02, 95% CI: 1.31-111.11; P = .03). CONCLUSION: Iliac artery aneurysmss can be safely and effectively treated by EVIR or OIR regarding 30-day morbidity, mortality, and long-term survival, although freedom from reintervention is significantly lower after EVIR.
Collapse
Affiliation(s)
- Sven Zhorzel
- 1 Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre (MAC), Technical University Munich, Munich, Germany
| | - Albert Busch
- 1 Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre (MAC), Technical University Munich, Munich, Germany
| | - Matthias Trenner
- 1 Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre (MAC), Technical University Munich, Munich, Germany
| | - Benedikt Reutersberg
- 1 Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre (MAC), Technical University Munich, Munich, Germany
| | - Michael Salvermoser
- 1 Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre (MAC), Technical University Munich, Munich, Germany
| | - Hans-Henning Eckstein
- 1 Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre (MAC), Technical University Munich, Munich, Germany
| | - Alexander Zimmermann
- 1 Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar and Munich Aortic Centre (MAC), Technical University Munich, Munich, Germany
| |
Collapse
|
254
|
Choi K, Han Y, Ko GY, Cho YP, Kwon TW. Early and Late Outcomes of Endovascular Aortic Aneurysm Repair versus Open Surgical Repair of an Abdominal Aortic Aneurysm: A Single-Center Study. Ann Vasc Surg 2018; 51:187-191. [DOI: 10.1016/j.avsg.2018.02.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 02/16/2018] [Accepted: 02/18/2018] [Indexed: 10/14/2022]
|
255
|
Belvroy VM, Houben IB, Trimarchi S, Patel HJ, Moll FL, Van Herwaarden JA. Identifying and addressing the limitations of EVAR technology. Expert Rev Med Devices 2018; 15:541-554. [PMID: 30058398 DOI: 10.1080/17434440.2018.1505496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Endovascular aortic repair (EVAR) has improved over the last two decades. Approximately 80% of the patients presenting with an abdominal aortic aneurysm (AAA) is nowadays primarily treated with EVAR. AREAS COVERED In this review, the differences between endovascular and open repair, the clinical characteristics needed for EVAR, the role of clinical imaging and the developments in EVAR technology will be discussed. Early mortality is lower in EVAR as compared to open repair, whereas this benefit is lost after 3 years postoperatively. EVAR comes with a high reintervention rate, with endoleak being the most important predictive factor for reintervention. Expanding technical possibilities have allowed surgeons to choose from a palate of endovascular approaches in aneurysm patients with challenging anatomies. EXPERT COMMENTARY Although EVAR has taken a giant leap forward in development, the new developments have seemed to surpass the long-term limitations with older devices. It is important to start focusing on the current limitations of EVAR, in particular the durability of devices in the human variable anatomic and dynamic environment.
Collapse
Affiliation(s)
- Viony M Belvroy
- a Department of Vascular Surgery II , Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan , Milan , Italy
| | - Ignas B Houben
- b Department of Cardiovascular Surgery , Frankel Cardiovascular Center, University of Michigan Health Center , Ann Arbor , Michigan , USA
| | - Santi Trimarchi
- a Department of Vascular Surgery II , Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan , Milan , Italy
| | - Himanshu J Patel
- b Department of Cardiovascular Surgery , Frankel Cardiovascular Center, University of Michigan Health Center , Ann Arbor , Michigan , USA
| | - Frans L Moll
- c Department of Vascular Surgery , University Medical Center Utrecht , Utrecht , the Netherlands
| | - Joost A Van Herwaarden
- c Department of Vascular Surgery , University Medical Center Utrecht , Utrecht , the Netherlands
| |
Collapse
|
256
|
Georgakarakos E. Editorial: Clinical and Hemodynamic Performance of Aortic Endografts. Front Surg 2018; 5:44. [PMID: 29988320 PMCID: PMC6024003 DOI: 10.3389/fsurg.2018.00044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/01/2018] [Indexed: 11/20/2022] Open
Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| |
Collapse
|
257
|
Devanabanda AR, Tummala R, Galmer A, Grines C, Weinberg MD. Peripheral vascular interventional advances in 2017. J Interv Cardiol 2018; 31:553-561. [PMID: 29926509 DOI: 10.1111/joic.12530] [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: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 12/24/2022] Open
Abstract
Aim of this review is to inform major clinical trials in peripheral vascular interventions in the year of 2017.
Collapse
Affiliation(s)
- Arvind R Devanabanda
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Ramyashree Tummala
- St. Vincent Charity Medical Center, An Affiliate of Case Western Reserve University, Cleveland, Ohio
| | - Andrew Galmer
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Cindy Grines
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Mitchell D Weinberg
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| |
Collapse
|
258
|
Symonides B, Śliwczyński A, Gałązka Z, Pinkas J, Gaciong Z. Short- and long-term survival after open versus endovascular repair of abdominal aortic aneurysm-Polish population analysis. PLoS One 2018; 13:e0198966. [PMID: 29902236 PMCID: PMC6002078 DOI: 10.1371/journal.pone.0198966] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/28/2018] [Indexed: 11/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Bartosz Symonides
- Department of Internal Medicine, Hypertension and Vascular Diseases, The Medical University of Warsaw, Warsaw, Poland
- * E-mail:
| | - Andrzej Śliwczyński
- Department of Analysis and Strategy, The National Health Fund, Warsaw, Poland
| | - Zbigniew Gałązka
- Department of Vascular and Endocrine Surgery, The Medical University of Warsaw, Warsaw, Poland
| | - Jarosław Pinkas
- Department of Healthcare Organizations and Medical Jurisprudence, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, The Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|
259
|
Dubois L, Allen B, Bray-Jenkyn K, Power AH, DeRose G, Forbes TL, Duncan A, Shariff SZ. Higher surgeon annual volume, but not years of experience, is associated with reduced rates of postoperative complications and reoperations after open abdominal aortic aneurysm repair. J Vasc Surg 2018; 67:1717-1726.e5. [DOI: 10.1016/j.jvs.2017.10.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/02/2017] [Indexed: 11/26/2022]
|
260
|
Maurel B, Martin-Gonzalez T, Chong D, Irwin A, Guimbretière G, Davis M, Mastracci TM. A prospective observational trial of fusion imaging in infrarenal aneurysms. J Vasc Surg 2018; 68:1706-1713.e1. [PMID: 29804734 DOI: 10.1016/j.jvs.2018.04.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 04/04/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Use of three-dimensional fusion has been shown to significantly reduce radiation exposure and contrast material use in complex (fenestrated and branched) endovascular aneurysm repair (EVAR). Cydar software (CYDAR Medical, Cambridge, United Kingdom) is a cloud-based technology that can provide imaging guidance by overlaying preoperative three-dimensional vessel anatomy from computed tomography scans onto live fluoroscopy images both in hybrid operating rooms and on mobile C-arms. The aim of this study was to determine whether radiation dose reduction would occur with the addition of fusion imaging to infrarenal repair in all imaging environments. METHODS All patients who consented to involvement in the trial and who were treated with EVAR in our center from March 2016 until April 2017 were included. A teaching session about radiation protection and Cydar fusion software use was provided to all operators before the start of the fusion group enrollment. This group was compared with a retrospective cohort of patients treated in the same center from March 2015 to March 2016, after a dedicated program of radiation awareness and reduction was introduced. Ruptured aneurysms and complex EVAR were excluded. Preoperative and perioperative characteristics were recorded, including parameters of radiation dose, such as air kerma and dose-area product. Results were expressed in median and interquartile range. RESULTS Forty-four patients were prospectively enrolled and compared with 21 retrospective control patients. No significant differences were found in comparing sex, body mass index, and age at repair. The median operation time (wire to wire) and fluoroscopy time were 90 (75-105) minutes and 30 (22-34) minutes, respectively, without significant differences between groups (P = .56 and P = .36). Dose-area product was nonsignificantly higher in the control group, 21.7 (8.9-85.9) Gy cm2, compared with the fusion group, 12.4 (7.5-23.4) Gy cm2 (P = .10). Air kerma product was significantly higher in the control group, 142 (61-541) mGy, compared with 82 (51-115) mGy in the fusion group (P = .03). The number of digital subtraction angiography runs was significantly lower in the fusion group (8 [6-11]) compared with the control group (10 [9-14]); (P = .03). There were no significant differences in the frequency of adverse events, endoleaks, or additional procedures required. CONCLUSIONS When it is used in simple procedures such as infrarenal aneurysm repair, image-based fusion technology is feasible both in hybrid operating rooms and on mobile systems and leads to an overall 50% reduction in radiation dose. Fusion technology should become standard of care for centers attempting to maximize radiation dose reduction, even if capital investment of a hybrid operating room is not feasible.
Collapse
Affiliation(s)
- Blandine Maurel
- Aortic Team, Vascular Surgery Directorate, The Royal Free London, London, United Kingdom; Department of Vascular Surgery, Institut du Thorax, CHU Nantes, Nantes, France
| | - Teresa Martin-Gonzalez
- Aortic Team, Vascular Surgery Directorate, The Royal Free London, London, United Kingdom
| | - Debra Chong
- Aortic Team, Vascular Surgery Directorate, The Royal Free London, London, United Kingdom
| | - Andrew Irwin
- Aortic Team, Vascular Surgery Directorate, The Royal Free London, London, United Kingdom
| | | | - Meryl Davis
- Aortic Team, Vascular Surgery Directorate, The Royal Free London, London, United Kingdom
| | - Tara M Mastracci
- Aortic Team, Vascular Surgery Directorate, The Royal Free London, London, United Kingdom.
| |
Collapse
|
261
|
Tasso P, Raptis A, Matsagkas M, Lodi Rizzini M, Gallo D, Xenos M, Morbiducci U. Abdominal aortic aneurysm endovascular repair: profiling post-implantation morphometry and hemodynamics with image-based computational fluid dynamics. J Biomech Eng 2018; 140:2682796. [PMID: 30029263 DOI: 10.1115/1.4040337] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Indexed: 11/08/2022]
Abstract
Endovascular aneurysm repair (EVAR) has disseminated rapidly as an alternative to open surgical repair for the treatment of abdominal aortic aneurysms (AAAs), because of its reduced invasiveness, low mortality and morbidity rate. The effectiveness of the endovascular devices used in EVAR is always at question as postoperative adverse events can lead to re-intervention or to a possible fatal scenario for the circulatory system. Motivated by the assessment of the risks related to thrombus formation, here the impact of two different commercial endovascular grafts on local hemodynamics is explored through 20 image-based computational hemodynamic models of EVAR-treated patients (N=10 per each endograft model). Hemodynamic features, susceptible to promote thrombus formation, such as flow separation and recirculation, are quantitatively assessed and compared with the local hemodynamics established in image-based infrarenal abdominal aortic models of healthy subjects (N=10). The hemodynamic analysis is complemented by a geometrical characterization of the EVAR-induced reshaping of the infrarenal abdominal aortic vascular region. The findings of this study indicate that: (1) the clinically observed propensity to thrombus formation in devices used in EVAR strategies can be explained in terms of local hemodynamics by means of image-based computational hemodynamics approach; (2) reportedly pro-thrombotic hemodynamic structures are strongly correlated with the geometry of the aortoiliac tract postoperatively. In perspective, our study suggests that future clinical follow up studies could include a geometric analysis of the region of the implant, monitoring shape variations that can lead to hemodynamic disturbances of clinical significance.
Collapse
Affiliation(s)
- Paola Tasso
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino 10129, Italy
| | - Anastasios Raptis
- Laboratory for Vascular Simulations, Institute of Vascular Diseases, Ioannina 45500, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, Larissa 41334, Greece
| | - Maurizio Lodi Rizzini
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino 10129, Italy
| | - Diego Gallo
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino 10129, Italy
| | - Michalis Xenos
- Department of Mathematics, University of Ioannina, Ioannina 45500, Greece
| | - Umberto Morbiducci
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino 10129, Italy
| |
Collapse
|
262
|
Chiang N, Baird SM, Ratinam R, Chuen J. A Novel Technique for Sutureless Proximal Aortic Endograft Revision in Type 1A Endoleak. Ann Vasc Surg 2018; 51:320-323. [PMID: 29772316 DOI: 10.1016/j.avsg.2018.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/12/2018] [Accepted: 02/23/2018] [Indexed: 10/14/2022]
Abstract
Management of type 1A endoleaks can be challenging. In the endovascular era, this condition is expected to become more frequent. Conventionally, surgical explant of the endograft remains the "last-resort" surgical treatment when all endovascular or other open options are exhausted. Endograft removal is a difficult and morbid procedure. An alternative technique is described that involves cinching the endograft after disengagement of the proximal fixation hooks. The endograft is redeployed within a prosthetic aortic replacement graft with an overlapping zone. This can reduce complications such as from additional anastomoses, graft bleeding, prolonged clamping, operative time, and associated comorbidities.
Collapse
Affiliation(s)
- Nathaniel Chiang
- Department of Vascular Surgery, Austin Health, Melbourne, Australia
| | - Samantha M Baird
- Department of Vascular Surgery, Austin Health, Melbourne, Australia
| | - Ratheesraj Ratinam
- Department of Anatomy and Developmental Biology, Monash University, Melbourne, Australia
| | - Jason Chuen
- Department of Vascular Surgery, Austin Health, Melbourne, Australia; Department of Surgery, The University of Melbourne, Melbourne, Australia.
| |
Collapse
|
263
|
Maeda K, Ohki T, Kanaoka Y. Endovascular Treatment of Various Aortic Pathologies: Review of the Latest Data and Technologies. Int J Angiol 2018; 27:81-91. [PMID: 29896040 DOI: 10.1055/s-0038-1645881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The technologies and innovations applicable to endovascular treatment for complex aortic pathologies have progressed rapidly over the last two decades. Although the initial outcomes of an endovascular aortic repair have been excellent, as long-term data became available, complications including endoleaks, endograft migration, and endograft infection have become apparent and are of concern. Previously, the indication for endovascular therapy was restricted to descending thoracic aortic aneurysms and abdominal aortic aneurysms. However, its indication has expanded along with the improvement of techniques and devices, and currently, it has become possible to treat pararenal aortic aneurysms and Crawford type 4 thoracoabdominal aortic aneurysm (TAAA) using the off-the-shelf devices. Additionally, custom-made devices allow for the treatment of arch or more extensive TAAAs. Endovascular treatment is applied not only to aneurysms but also to acute/chronic dissections. However, long-term outcomes are still unclear. This article provides an overview of available devices and the results of endovascular treatment for various aortic pathologies.
Collapse
Affiliation(s)
- Koji Maeda
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuji Kanaoka
- Division of Vascular Surgery, Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
264
|
Hallett RL, Ullery BW, Fleischmann D. Abdominal aortic aneurysms: pre- and post-procedural imaging. Abdom Radiol (NY) 2018; 43:1044-1066. [PMID: 29460048 DOI: 10.1007/s00261-018-1520-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abdominal aortic aneurysm (AAA) is a relatively common, potentially life-threatening disorder. Rupture of AAA is potentially catastrophic with high mortality. Intervention for AAA is indicated when the aneurysm reaches 5.0-5.5 cm or more, when symptomatic, or when increasing in size > 10 mm/year. AAA can be accurately assessed by cross-sectional imaging including computed tomography angiography and magnetic resonance angiography. Current options for intervention in AAA patients include open surgery and endovascular aneurysm repair (EVAR), with EVAR becoming more prevalent over time. Cross-sectional imaging plays a crucial role in AAA surveillance, pre-procedural assessment, and post-EVAR management. This paper will discuss the current role of imaging in the assessment of AAA patients prior to intervention, in evaluation of procedural complications, and in long-term follow-up of EVAR patients.
Collapse
Affiliation(s)
- Richard L Hallett
- Department of Radiology, Cardiovascular Imaging Section, Stanford University Hospital and Clinics, 300 Pasteur Drive, Grant Building, S-072, Stanford, CA, 94305, USA.
- St. Vincent Heart Center of Indiana, Indianapolis, IN, USA.
- Northwest Radiology Network, Indianapolis, IN, USA.
| | - Brant W Ullery
- Department of Cardiovascular Surgery, Providence Heart and Vascular Institute, Portland, OR, USA
| | - Dominik Fleischmann
- Department of Radiology, Cardiovascular Imaging Section, Stanford University Hospital and Clinics, 300 Pasteur Drive, Grant Building, S-072, Stanford, CA, 94305, USA
| |
Collapse
|
265
|
Williamson JS, Ambler GK, Twine CP, Williams IM, Williams GL. Elective Repair of Abdominal Aortic Aneurysm and the Risk of Colonic Ischaemia: Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2018; 56:31-39. [PMID: 29636250 DOI: 10.1016/j.ejvs.2018.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 03/05/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Colon ischaemia (CI) is a significant complication of open (OR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With a rapid increase in EVAR uptake, contemporary data demonstrating the differing rates and outcomes of CI between EVAR and OR, particularly in the elective setting, are lacking. The aim was to characterise the risk and consequences of CI in elective AAA repair comparing EVAR with OR. METHODS A systematic review and meta-analysis of the literature was performed using the Cochrane collaboration protocol and reported according to the PRISMA guidelines. PubMed, MedLine, and EMBASE were searched for studies reporting CI rates after elective AAA repair. Ruptured AAAs were excluded from analysis. RESULTS Thirteen studies reporting specific outcomes of CI after elective AAA repair, containing 162,750 evaluable patients (78,151 EVAR and 84,599 OR) were included. All studies found a higher risk of CI with OR than with EVAR. Three studies performed confounder adjustment with CI rates of 0.5-1% versus 2.1-3.6% (EVAR vs. OR) and combined odds ratio of 2.7 (2.0-3.5) for the development of CI with OR versus EVAR. The majority of cases of CI occurred within 30 days and were associated with variable mortality (0-73%) and re-intervention rates (27-54%). GRADE assessment of evidence strength was very low for all outcomes. There was a high degree of heterogeneity between studies both methodologically and in terms of CI rates, re-intervention, mortality, and time to development of CI. CONCLUSIONS EVAR is associated with a reduced incidence of CI compared with OR.
Collapse
Affiliation(s)
| | - Graeme K Ambler
- Department of Colorectal Surgery, Royal Gwent Hospital, Newport, UK
| | | | - Ian M Williams
- Vascular Unit, University Hospital of Wales, Cardiff, UK
| | | |
Collapse
|
266
|
Tzani A, Doulamis IP, Katsaros I, Martinou E, Schizas D, Economopoulos KP. Mortality after endovascular treatment of infrarenal abdominal aortic aneurysms – the newer the better? VASA 2018; 47:187-196. [PMID: 29334334 DOI: 10.1024/0301-1526/a000685] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Abstract. Although endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) presents a delicate alternative treatment for abdominal aortic aneurysms (AAA) with lower perioperative mortality, its long-term efficacy remains a matter of concern. The purpose of this study was to evaluate the currently reported mortality evidence after EVAR and to examine the possible effect of aneurysm status and the study period on mortality rates. The PubMed and Cochrane bibliographical databases were thoroughly searched for studies reporting on more than 1 000 patients with non-ruptured or ruptured infrarenal AAA, treated with EVAR from August 1991 to September 2016. A total of 10 910 titles/abstracts were retrieved and 121 studies were deemed relevant. Twenty-six studies met the inclusion criteria and reported on 354 500 patients with a mean age of 74.6 years. Almost all of the studies referred to elective EVAR and the mean aneurysm size was 5.58 cm. The most common early complication for elective EVAR was perioperative bleeding (1.9 %), whereas hospital-acquired pneumonia was a major concern in urgent EVAR (28.5 %). Conversion rate to open surgery was 1.2 %. The 30-day all-cause mortality rate was 4.84 % (1.7 % for non- ruptured aneurysms, 33.8 % for ruptured aneurysms).The overall all-cause late mortality in a mean follow-up period of 23.8 months was 19.1 %. The aneurysm-related late mortality rate was 3.4 %. With respect to the time period of patient enrollment, studies reporting on patients recruited before 2006 were found to face more secondary complications and higher late mortality rates than patients enrolled after 2005.The endovascular treatment of large and anatomically suitable infrarenal AAA in selected patients remains a safe alternative to open repair. Our findings demonstrate that newer studies show better long-term outcomes than the older ones, proposing a possible improvement of EVAR techniques and perioperative care and providing encouraging evidence for a wider application of EVAR.
Collapse
Affiliation(s)
- Aspasia Tzani
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | | | - Ioannis Katsaros
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Eirini Martinou
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | - Dimitrios Schizas
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
- First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos P. Economopoulos
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|
267
|
Stather PW, Ferguson J, Awopetu A, Boyle JR. Meta-analysis of Renal Function Following Infrarenal EVAR using Suprarenal or Infrarenal Fixation Devices. Eur J Vasc Endovasc Surg 2018; 56:486-496. [PMID: 29506944 DOI: 10.1016/j.ejvs.2018.01.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/27/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE/BACKGROUND The effect of suprarenal (SR) as opposed to infrarenal (IR) fixation on renal outcomes post-endovascular aneurysm repair (EVAR) remains controversial. This meta-analysis aims to update current understanding of this issue. METHODS A prior meta-analysis was updated through a Preferred Reporting Items for Systematic reviews and Meta-Analyses search for additional studies published in the last 3 years reporting on renal dysfunction or related outcomes post-EVAR. Random effects meta-analysis was undertaken using SPSS. RESULTS A total of 25 non-randomised studies comparing SR with IR fixation were included, totalling 54,832 patients. In total, 16,634 underwent SR and 38,198 IR. Baseline characteristics, including age, baseline estimated glomerular filtration rate, diabetes, cardiac disease, and smoking, were similar between the groups. There was a small but significant difference in outcomes for renal dysfunction at the study end point (SR 5.98% vs. IR 4.83%; odds ratio [OR] 1.29, 95% confidence interval [CI] 1.18-1.40 [p < .001]); however, at 30 days and 12 months there was no significant difference, and this did not hold up to sensitivity analysis. Incidence of renal infarcts (SR 6.6% vs. IR 2.3%; OR 2.78, 95% CI 1.46-5.29 [p = .002]), renal stenosis (SR 2.4% vs. IR 0.8%; OR 2.89, 95% CI 1.00-8.38 [p = .05]), and renal artery occlusion (SR 2.4% vs. IR 1.2%; OR 2.21, 95% CI 1.15-4.25 [p = 0.02]) favoured IR fixation; however, there was no difference in haemodialysis rates. CONCLUSION This meta-analysis has identified small but significantly worse renal outcomes in patients having SR fixation devices compared with IR; however, there was no difference in dialysis rates and a small effect on renal dysfunction, which did not stand up to rigorous sensitivity analysis. This should be taken into consideration during graft selection, and further studies must assess renal outcomes in the longer term, and in those with pre-existing renal dysfunction.
Collapse
Affiliation(s)
- Philip W Stather
- Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK.
| | - James Ferguson
- Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK
| | - Ayoola Awopetu
- Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK
| | - Jonathan R Boyle
- Department of Vascular Surgery, Cambridge University Hospital, Hills Road, Cambridge, UK
| |
Collapse
|
268
|
Tam G, Chan YC, Chong KC, Lee KP, Cheung GCY, Cheng SWK. Epidemiology of abdominal aortic aneurysms in a Chinese population during introduction of endovascular repair, 1994 to 2013: A retrospective observational study. Medicine (Baltimore) 2018; 97:e9740. [PMID: 29489676 PMCID: PMC5851770 DOI: 10.1097/md.0000000000009740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/27/2017] [Accepted: 01/06/2018] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to examine changes in abdominal aortic aneurysm repair and mortality during a period when endovascular aneurysm repair (EVAR) was introduced.Open repair surgery was the mainstay of treatment for abdominal aortic aneurysm (AAA), but EVAR is increasingly utilized. Studies in the Western population have reported improved short-term or postoperative mortality and shorter length of hospital stay with EVAR. However, scant data are available in the Chinese population.We conducted a retrospective observational study using the database of the Hospital Authority, which provides public health care to most of the Hong Kong population. AAA patients admitted to public hospitals for intact repair or rupture from 1994 to 2013 were included in this study. We calculated the incidence of ruptured AAA, annual repair rates according to type of AAA and surgery, as well as death rates (operative and overall short-term). We calculated whether there were significant changes over time and compared short-term mortality between open surgery and EVAR.One thousand eight hundred eighty-five patients were admitted for intact repair and 1306 patients were admitted for AAA rupture, of whom 795 underwent rupture repair. Intact repair rates significantly increased in all age groups (7.3-37.8%, P < .001) over the study period.The incidence of ruptured AAA increased, in all age groups, except in < 64 years old. By 2013, 85% of intact repairs and 55.4% of rupture repair were done by EVAR. Over time, there was a significant decrease in operative mortality for intact repair (16.5 in 1994 to 7.1 in 2013, P = .01) and rupture repair (59.7 in 1994 to 30.8 in 2013, P = .003). Over the same time period, short-term AAA-related deaths decreased by more than half (73% in 1994 to 24% in 2013, P < .001), with a significant decline in all age groups, except < 64 years old. Short-term mortality was significantly lower for EVAR than for open repair (17.2% vs 40.3%, P < .01).Short-term AAA-related deaths have declined likely due to decreased operative mortality and rupture deaths during the period of EVAR introduction and expansion.
Collapse
Affiliation(s)
- Greta Tam
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin
| | - Yiu Che Chan
- Department of Surgery, University of Hong Kong Medical Centre, Pokfulam, Hong Kong
| | - Ka Chun Chong
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin
| | - Kam Pui Lee
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin
| | | | | |
Collapse
|
269
|
Majd P, Ahmad W, Galas N, Brunkwall JS. Patients Older Than 80 Years Can Reach Their Normal Life Expectancy After Abdominal Aortic Aneurysm Repair: A Comparison Between Endovascular Aneurysm Repair and Open Surgery. J Endovasc Ther 2018; 25:247-251. [DOI: 10.1177/1526602818759757] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Payman Majd
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Germany
| | - Wael Ahmad
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Germany
| | - Noemi Galas
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Germany
| | - Jan S. Brunkwall
- Department of Vascular and Endovascular Surgery, University Hospital of Cologne, Germany
| |
Collapse
|
270
|
Dangelmaier J, Bar-Ness D, Daerr H, Muenzel D, Si-Mohamed S, Ehn S, Fingerle AA, Kimm MA, Kopp FK, Boussel L, Roessl E, Pfeiffer F, Rummeny EJ, Proksa R, Douek P, Noël PB. Experimental feasibility of spectral photon-counting computed tomography with two contrast agents for the detection of endoleaks following endovascular aortic repair. Eur Radiol 2018; 28:3318-3325. [PMID: 29460069 PMCID: PMC6028848 DOI: 10.1007/s00330-017-5252-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/30/2017] [Accepted: 12/08/2017] [Indexed: 12/27/2022]
Abstract
Objectives After endovascular aortic repair (EVAR), discrimination of endoleaks and intra-aneurysmatic calcifications within the aneurysm often requires multiphase computed tomography (CT). Spectral photon-counting CT (SPCCT) in combination with a two-contrast agent injection protocol may provide reliable detection of endoleaks with a single CT acquisition. Methods To evaluate the feasibility of SPCCT, the stent-lined compartment of an abdominal aortic aneurysm phantom was filled with a mixture of iodine and gadolinium mimicking enhanced blood. To represent endoleaks of different flow rates, the adjacent compartments contained either one of the contrast agents or calcium chloride to mimic intra-aneurysmatic calcifications. After data acquisition with a SPCCT prototype scanner with multi-energy bins, material decomposition was performed to generate iodine, gadolinium and calcium maps. Results In a conventional CT slice, Hounsfield units (HU) of the compartments were similar ranging from 147 to 168 HU. Material-specific maps differentiate the distributions within the compartments filled with iodine, gadolinium or calcium. Conclusion SPCCT may replace multiphase CT to detect endoleaks without sacrificing diagnostic accuracy. It is a unique feature of our method to capture endoleak dynamics and allow reliable distinction from intra-aneurysmatic calcifications in a single scan, thereby enabling a significant reduction of radiation exposure. Key Points • SPCCT might enable advanced endoleak detection. • Material maps derived from SPCCT can differentiate iodine, gadolinium and calcium. • SPCCT may potentially reduce radiation burden for EVAR patients under post-interventional surveillance.
Collapse
Affiliation(s)
- Julia Dangelmaier
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany.
| | | | - Heiner Daerr
- Philips GmbH Innovative Technologies, Research Laboratories, Hamburg, Germany
| | - Daniela Muenzel
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Salim Si-Mohamed
- CREATIS, CNRS UMR 5220, INSERM U1206, INSA, Lyon, France.,Radiology Department, Lyon University Hospital, Lyon, France.,University Lyon1 Claude Bernard, Lyon, France
| | - Sebastian Ehn
- Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technische Universität München, 85748 Garching, Germany
| | - Alexander A Fingerle
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Melanie A Kimm
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Felix K Kopp
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Loic Boussel
- CREATIS, CNRS UMR 5220, INSERM U1206, INSA, Lyon, France.,Radiology Department, Lyon University Hospital, Lyon, France.,University Lyon1 Claude Bernard, Lyon, France
| | - Ewald Roessl
- Philips GmbH Innovative Technologies, Research Laboratories, Hamburg, Germany
| | - Franz Pfeiffer
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany.,Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technische Universität München, 85748 Garching, Germany
| | - Ernst J Rummeny
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Roland Proksa
- Philips GmbH Innovative Technologies, Research Laboratories, Hamburg, Germany
| | - Philippe Douek
- CREATIS, CNRS UMR 5220, INSERM U1206, INSA, Lyon, France.,Radiology Department, Lyon University Hospital, Lyon, France.,University Lyon1 Claude Bernard, Lyon, France
| | - Peter B Noël
- Department of Diagnostic and Interventional Radiology, Technische Universität München, Ismaningerstr. 22, 81675, Munich, Germany.,Chair of Biomedical Physics, Department of Physics and Munich School of BioEngineering, Technische Universität München, 85748 Garching, Germany
| |
Collapse
|
271
|
Chowdhury MM, Zieliński LP, Sun JJ, Lambracos S, Boyle JR, Harrison SC, Rudd JHF, Coughlin PA. Editor's Choice - Calcification of Thoracic and Abdominal Aneurysms is Associated with Mortality and Morbidity. Eur J Vasc Endovasc Surg 2018; 55:101-108. [PMID: 29225032 PMCID: PMC5772171 DOI: 10.1016/j.ejvs.2017.11.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/07/2017] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Cardiovascular events are common in people with aortic aneurysms. Arterial calcification is a recognised predictor of cardiovascular outcomes in coronary artery disease. Whether calcification within abdominal and thoracic aneurysm walls is correlated with poor cardiovascular outcomes is not known. PATIENTS AND METHODS Calcium scores were derived from computed tomography (CT) scans of consecutive patients with either infrarenal (AAA) or descending thoracic aneurysms (TAA) using the modified Agatston score. The primary outcome was subsequent all cause mortality during follow-up. Secondary outcomes were cardiovascular mortality and morbidity. RESULTS A total of 319 patients (123 TAA and 196 AAA; median age 77 [71-84] years, 72% male) were included with a median follow-up of 30 months. The primary outcome occurred in 120 (37.6%) patients. In the abdominal aortic aneurysm group, the calcium score was significantly related to both all cause mortality and cardiac mortality (odds ratios (OR) of 2.246 (95% CI 1.591-9.476; p < 0.001) and 1.321 (1.076-2.762; p = 0.003)) respectively. In the thoracic aneurysm group, calcium score was significantly related to all cause mortality (OR 6.444; 95% CI 2.574-6.137; p < 0.001), cardiac mortality (OR 3.456; 95% CI 1.765-4.654; p = 0.042) and cardiac morbidity (OR 2.128; 95% CI 1.973-4.342; p = 0.002). CONCLUSIONS Aortic aneurysm calcification, in either the thoracic or the abdominal territory, is significantly associated with both higher overall and cardiovascular mortality. Calcium scoring, rapidly derived from routine CT scans, may help identify high risk patients for treatment to reduce risk.
Collapse
Affiliation(s)
- Mohammed M Chowdhury
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK.
| | - Lukasz P Zieliński
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - James J Sun
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Simon Lambracos
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Jonathan R Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Seamus C Harrison
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - James H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Patrick A Coughlin
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| |
Collapse
|
272
|
Georgakarakos E, Kratimenos T, Koutsoumpelis A, Georgiadis GS. The Bolton Treo endograft for treatment of abdominal aortic aneurysms: just another trimodular platform? Expert Rev Med Devices 2017; 15:5-14. [DOI: 10.1080/17434440.2018.1419864] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Theodoros Kratimenos
- Department of Interventional Radiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - George S. Georgiadis
- Department of Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| |
Collapse
|
273
|
Comparative clinical effectiveness and cost effectiveness of endovascular strategy v open repair for ruptured abdominal aortic aneurysm: three year results of the IMPROVE randomised trial. BMJ 2017; 359:j4859. [PMID: 29138135 PMCID: PMC5682594 DOI: 10.1136/bmj.j4859] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Objective To assess the three year clinical outcomes and cost effectiveness of a strategy of endovascular repair (if aortic morphology is suitable, open repair if not) versus open repair for patients with suspected ruptured abdominal aortic aneurysm.Design Randomised controlled trial.Setting 30 vascular centres (29 in UK, one in Canada), 2009-16.Participants 613 eligible patients (480 men) with a clinical diagnosis of ruptured aneurysm, of whom 502 underwent emergency repair for rupture.Interventions 316 patients were randomised to an endovascular strategy (275 with confirmed rupture) and 297 to open repair (261 with confirmed rupture).Main outcome measures Mortality, with reinterventions after aneurysm repair, quality of life, and hospital costs to three years as secondary measures.Results The maximum follow-up for mortality was 7.1 years, with two patients in each group lost to follow-up by three years. After similar mortality by 90 days, in the mid-term (three months to three years) there were fewer deaths in the endovascular than the open repair group (hazard ratio 0.57, 95% confidence interval 0.36 to 0.90), leading to lower mortality at three years (48% v 56%), but by seven years mortality was about 60% in each group (hazard ratio 0.92, 0.75 to 1.13). Results for the 502 patients with repaired ruptures were more pronounced: three year mortality was lower in the endovascular strategy group (42% v 54%; odds ratio 0.62, 0.43 to 0.88), but after seven years there was no clear difference between the groups (hazard ratio 0.86, 0.68 to 1.08). Reintervention rates up to three years were not significantly different between the randomised groups (hazard ratio 1.02, 0.79 to 1.32); the initial rapid rate of reinterventions was followed by a much slower mid-term reintervention rate in both groups. The early higher average quality of life in the endovascular strategy versus open repair group, coupled with the lower mortality at three years, led to a gain in average quality adjusted life years (QALYs) at three years of 0.17 (95% confidence interval 0.00 to 0.33). The endovascular strategy group spent fewer days in hospital and had lower average costs of -£2605 (95% confidence interval -£5966 to £702) (about €2813; $3439). The probability that the endovascular strategy is cost effective was >90% at all levels of willingness to pay for a QALY gain.Conclusions At three years, compared with open repair, an endovascular strategy for suspected ruptured abdominal aortic aneurysm was associated with a survival advantage, a gain in QALYs, similar levels of reintervention, and reduced costs, and this strategy was cost effective. These findings support the increasing use of an endovascular strategy, with wider availability of emergency endovascular repair.Trial registration Current Controlled Trials ISRCTN48334791; ClinicalTrials NCT00746122.
Collapse
|
274
|
Open versus endovascular aneurysm repair trial review. Surgery 2017; 162:974-978. [DOI: 10.1016/j.surg.2017.04.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 04/17/2017] [Accepted: 04/19/2017] [Indexed: 11/19/2022]
|
275
|
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?
Collapse
Affiliation(s)
- Norman R Hertzer
- Department of Vascular Surgery, Cleveland Clinic Emeritus Office, Beechwood, OH, USA
| |
Collapse
|
276
|
Bastos Gonçalves F, Verhagen HJM. Commentary: New Tools on the Horizon to Assess the Accuracy of Aortic Stent-Graft Deployment. J Endovasc Ther 2017; 24:707-708. [PMID: 28925336 DOI: 10.1177/1526602817725060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Frederico Bastos Gonçalves
- 1 Angiology and Vascular Surgery Department, Hospital de Santa Marta, CHLC & NOVA Medical School, Lisbon, Portugal
| | - Hence J M Verhagen
- 2 Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
277
|
Systematic review of laparoscopic ligation of inferior mesenteric artery for the treatment of type II endoleak after endovascular aortic aneurysm repair. J Vasc Surg 2017; 66:1878-1884. [PMID: 28822664 DOI: 10.1016/j.jvs.2017.07.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/07/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Type II endoleak after endovascular aneurysm repair (EVAR) is frequently caused by persistent flow from the inferior mesenteric artery (IMA). The aim of this study was to assess the perioperative and midterm efficacy of laparoscopic ligation of the IMA for treatment of endoleak. METHODS MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane databases and key references were searched with Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for studies reporting on laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR. RESULTS Eight case studies and one study of a retrospective nature were identified. In total, 20 patients (18 men; mean age, 73.6 ± 2 years; with a mean abdominal aortic aneurysm diameter of 64.3 ± 10 mm) who underwent post-EVAR laparoscopic ligation of the IMA for type II endoleak were analyzed. The mean time from EVAR until intervention ranged from 6 to 18 months. All but one patient were asymptomatic; in 9, the aneurysm sac was enlarged, and in 11, the endoleak was considered persistent without sac enlargement. The mean procedural duration was 99 ± 24 minutes, with technical success rate of 90% (18/20); in two cases, the patients were successfully reoperated on laparoscopically in 24 hours. The mean hospitalization was 3.6 ± 1.2 days, with 0% (0/20) perioperative and 30-day mortality. No patient underwent open conversion or showed signs of intestinal ischemia. During follow-up of 32.6 ± 12 months, 13 of 20 patients had aneurysm sac regression, whereas the rest had a stable sac diameter without evidence of persistent type II endoleak. CONCLUSIONS Laparoscopic ligation of the IMA for treatment of type II endoleak after EVAR is a feasible and safe technique in specialized centers with high technical success rate and good midterm outcomes.
Collapse
|
278
|
Impressions from EuroPCR Course 2017. Anatol J Cardiol 2017; 18:165-166. [PMID: 28766515 PMCID: PMC5731271 DOI: 10.14744/anatoljcardiol.2017.7983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
279
|
Ulug P, Sweeting MJ, von Allmen RS, Thompson SG, Powell JT. Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis. Lancet 2017; 389:2482-2491. [PMID: 28455148 PMCID: PMC5483509 DOI: 10.1016/s0140-6736(17)30639-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/15/2017] [Accepted: 02/22/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Prognosis for women with abdominal aortic aneurysm might be worse than the prognosis for men. We aimed to systematically quantify the differences in outcomes between men and women being assessed for repair of intact abdominal aortic aneurysm using data from study periods after the year 2000. METHODS In these systematic reviews and meta-analysis, we identified studies (randomised, cohort, or cross-sectional) by searching MEDLINE, Embase, CENTRAL, and grey literature published between Jan 1, 2005, and Sept 2, 2016, for two systematic reviews and Jan 1, 2009, and Sept 2, 2016, for one systematic review. Studies were included if they were of both men and women, with data presented for each sex separately, with abdominal aortic aneurysms being assessed for aneurysm repair by either endovascular repair (EVAR) or open repair. We conducted three reviews based on whether studies reported the proportion morphologically suitable (within manufacturers' instructions for use) for EVAR (EVAR suitability review), non-intervention rates (non-intervention review), and 30-day mortality (operative mortality review) after intact aneurysm repair. Studies had to include at least 20 women (for the EVAR suitability review), 20 women (for the non-intervention review), and 50 women (for the operative mortality review). Studies were excluded if they were review articles, editorials, letters, or case reports. For the operative review, studies were also excluded if they only provided hazard ratios or only reported in-hospital mortality. We assessed the quality of the studies using the Newcastle-Ottawa scoring system, and contacted authors for the provision of additional data if needed. We combined results across studies by random-effects meta-analysis. This study is registered with PROSPERO, number CRD42016043227. FINDINGS Five studies assessed the morphological eligibility for EVAR (1507 men, 400 women). The overall pooled proportion of women eligible (34%) for EVAR was lower than it was in men (54%; odds ratio [OR] 0·44, 95% CI 0·32-0·62). Four single-centre studies reported non-intervention rates (1365 men, 247 women). The overall pooled non-intervention rates were higher in women (34%) than men (19%; OR 2·27, 95% CI 1·21-4·23). The review of 30-day mortality included nine studies (52 018 men, 11 076 women). The overall pooled estimate for EVAR was higher in women (2·3%) than in men (1·4%; OR 1·67, 95% CI 1·38-2·04). The overall estimate for open repair also was higher in women (5·4%) than in men (2·8%; OR 1·76, 95% CI 1·35-2·30). INTERPRETATION Compared with men, a smaller proportion of women are eligible for EVAR, a higher proportion of women are not offered intervention, and operative mortality is much higher in women for both EVAR and open repair. The management of abdominal aortic aneurysm in women needs improvement. FUNDING National Institute for Health Research (UK).
Collapse
Affiliation(s)
- Pinar Ulug
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, UK
| | - Michael J Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Regula S von Allmen
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, UK; Clinic for Vascular Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Simon G Thompson
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, UK.
| |
Collapse
|
280
|
Kontopodis N, Galanakis N, Tsetis D, Ioannou CV. Commentary: Preoperative Aortic Morphology Identifies Patients at High Risk for Late Failure of Endovascular Aneurysm Repair. J Endovasc Ther 2017; 24:418-420. [PMID: 28440114 DOI: 10.1177/1526602817704627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nikolaos Kontopodis
- 1 Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Nikolaos Galanakis
- 2 Interventional Radiology Unit, Department of Radiology, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Dimitrios Tsetis
- 2 Interventional Radiology Unit, Department of Radiology, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| | - Christos V Ioannou
- 1 Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete Medical School, Heraklion, Crete, Greece
| |
Collapse
|