Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm

Aortic Balloon Occlusion in Repair of Ruptured Abdominal Aortic Aneurysm

This case report details a novel technique implemented in Vietnam. When full equipment is unavailable, we adapt it by using aortic balloon occlusion to enhance the patient's hemodynamics and mitigate the risk of intraprocedural exsanguination. This approach effectively addresses the rupture of abdominal aortic aneurysms in patients with unstable hemodynamic conditions.

Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results

BACKGROUND

Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality.

METHODS

The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality.

RESULTS

Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25).

CONCLUSIONS

LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.

The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair

OBJECTIVE

Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs).

METHODS

Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation.

RESULTS

We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients.

CONCLUSIONS

Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.

Hypertension during transfer is associated with poor outcomes in unstable patients with ruptured abdominal aortic aneurysm

OBJECTIVE

Limited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock.

METHODS

We performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality.

RESULTS

Detailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality.

CONCLUSIONS

Hypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible.

Use of Spinal Anesthesia during Thoracic Endovascular Aortic Repair

BACKGROUND

The purpose of this study was to assess outcomes after spinal anesthesia (SA) versus general anesthesia (GA) in patients undergoing thoracic endograft placement and to evaluate the adjunctive use of cerebrospinal fluid drainage (CSFD) placement.

METHODS

A single-center retrospective review of patients that underwent thoracic endograft placement from 2001 to 2019 was performed. Patients were stratified based on the type of anesthesia they received: GA, SA or epidural, GA with CSFD, and SA with CSFD. Primary outcomes included 30-day mortality and length of stay (LOS). Baseline characteristics were analyzed with Student's t-test and Pearson's chi-squared test. Multivariate logistic regression analysis was performed to identify risk factors for 30-day mortality and longer LOS.

RESULTS

A total of 333 patients underwent thoracic endograft placement; 104 patients received SA, 180 patients received GA, 30 patients received GA and CSFD, and 19 patients received SA and CSFD. Of the total patients, 16.2% underwent thoracic endograft placement for type B aortic dissection, 3.3% for type A aortic dissection, and 12.3% for penetrating ulcer. The mean age of the study population was 68.7 years old. Patients undergoing SA were older with a mean age of 73.4 years versus 64.7 years for patients undergoing GA (P < 0.001). Spinal anesthesia (SA) was preferred in patients at high risk for GA (>75 years old: 52.9% vs. 33.3%, P < 0.001; renal comorbidities: 20.6% vs. 10.6%, P = 0.03, and current smokers: 26.7% vs. 9.6%, P < 0.001). Length of stay (LOS) was decreased in the SA group (4.29 days vs. 9.70 days, P < 0.001). There was a lower incidence of spinal cord ischemia in the SA group (1.0% vs. 2.2%, P = 0.44), as well as significantly decreased 30-day mortality (0% vs. 5.6%, P = 0.01), reintervention (19.2% vs. 26.8%, P = 0.02), and return to the operating room (6.8% vs. 12.7%, P = 0.02). Of the 19 patients that had SA + CSFD, there were no signs and symptoms of spinal cord ischemia and decreased incidence of perioperative complications (0% vs. 33.3%, P = 0.01). There was no difference in the risk for intraoperative complications, neurologic complications, or 30-day mortality between GA + CSFD patients versus SA + CSFD patients. Age >75 (P = 0.002), intraoperative complications (P < 0.001), and perioperative complications (P = 0.02) were associated with increased mortality after thoracic endograft placement per multivariate logistic regression analysis.

CONCLUSIONS

Spinal anesthesia (SA) in select high-risk patients was associated with reduced 30-day mortality, neurologic complications, and LOS compared to GA. The concurrent use of spinal drainage and SA had satisfactory results compared to spinal drainage and GA.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Conservative Treatment of Ruptured Abdominal Aortic Aneurysm

Although nonsurgical management of ruptured abdominal aortic aneurysm (rAAA) is still used among a significant number of patients, survival after conservative treatment is extremely rare. We report a case of an 86-year-old female who presented with an rAAA that was confirmed clinically and radiologically via computed tomography angiography. Although the patient was not deemed a candidate for surgery owing to significant comorbidities and poor baseline function, she survived the episode with no surgical intervention. Given the growing aging and frail population, it is vital to explore this further, with the aim of improving both mortality and advanced care planning in the nonsurgical management of rAAA.

Evaluation of national institute for health and care excellence guidance for ruptured abdominal aortic aneurysms by emulating a hypothetical target trial

Objective

This retrospective study evaluates the performance of UK National Institute for Health and Care Excellence (NICE) Guidelines on management of ruptured abdominal aortic aneurysms in a "real world setting" by emulating a hypothetical target trial with data from two European Aortic Centers.

Methods

Clinical data was retrospectively collected for all patients who had undergone ruptured endovascular aneurysm repair (rEVAR) and ruptured open surgical repair (rOSR). Survival analysis was performed comparing NICE compliance to usual care strategy. NICE compliers were defined as: female patients undergoing rEVAR; male patients >70 years old undergoing rEVAR; and male patients ≤70 years old undergoing rOSR. Hemodynamic instability was considered additionally.

Results

This multicenter study included 298 patients treated for rAAA. The majority of patients were treated with rOSR (186 rOSR vs. 112 rEVAR). Overall, 184 deaths (68 [37%] with rEVAR and 116 [63%] with rOSR) were observed during the study period. Overall survival under usual care was 69.2% at 30 days, 56.5% at one year, and 42.4% at 5 years. NICE compliance gave survival outcomes of 73.1% at 30 days, 60.2% at 1 year and 42.9% at 5 years. The risk ratios at these time points, comparing NICE-compliance to usual care, were 0.88, 0.92 and 0.99, respectively.

Conclusions

We support NICE recommendations to manage men below the age of 71 years and hemodynamic stability with rOSR. There was a slight survival advantage for NICE compliers overall, in men >70 years and women of all ages.

Arterial Monitoring in Hypertensive Emergencies: Significance for the Critical Care Resuscitation Unit

INTRODUCTION

Blood pressure measurement is important for treating patients. It is known that there is a discrepancy between cuff blood pressure vs arterial blood pressure measurement. However few studies have explored the clinical significance of discrepancies between cuff (CPB) vs arterial blood pressure (ABP). Our study investigated whether differences in CBP and ABP led to change in management for patients with hypertensive emergencies and factors associated with this change.

METHODS

This prospective observational study included adult patients admitted between January 2019-May 2021 to a resuscitation unit with hypertensive emergencies. We defined clinical significance of discrepancies as a discrepancy between CBP and ABP that resulted in change of clinical management. We used stepwise multivariable logistic regression to measure associations between clinical factors and outcomes.

RESULTS

Of 212 patients we analyzed, 88 (42%) had change in management. Mean difference between CBP and ABP was 17 milligrams of mercury (SD 14). Increasing the existing rate of antihypertensive infusion occurred in 38 (44%) patients. Higher body mass index (odds ratio [OR] 1.04, 95% confidence Interval [CI] 1.0001-1.08, P-value <0.05) and history of peripheral arterial disease (OR 0.16, 95% CI 0.03-0.97, P-value <0.05) were factors associated with clinical significance of discrepancies.

CONCLUSION

Approximately 40% of hypertensive emergencies had a clinical significance of discrepancy warranting management change when arterial blood pressure was initiated. Further studies are necessary to confirm our observations and to investigate the benefit-risk ratio of ABP monitoring.

The anesthesiologist's perspective on emergency aortic surgery: Preoperative optimization, intraoperative management, and postoperative surveillance

The management of emergencies related to the aorta requires a multidisciplinary approach involving various health care professionals. Despite technological advancements in treatment methods, the risks and mortality rates associated with surgery remain high. In the emergency department, definitive diagnosis is usually obtained through computed tomography angiography, and management focuses on controlling blood pressure and treating symptoms to prevent further deterioration. Preoperative resuscitation is the main focus, followed by intraoperative management aimed at stabilizing the patient's hemodynamics, controlling bleeding, and protecting vital organs. After the operation, factors such as organ protection, transfusion management, pain control, and overall patient care must be taken into account. Endovascular techniques are becoming more common in surgical treatment, but they also present new challenges in terms of complications and outcomes. It is recommended that patients with suspected ruptured abdominal aortic aneurysms be transferred to facilities with both open and endovascular treatment options and a track record of successful outcomes to ensure the best patient care and long-term results. To achieve optimal patient outcomes, close collaboration and regular case discussions between health care professionals are necessary, as well as participation in educational programs to promote a culture of teamwork and continuous improvement.

Inter-Hospital Transfer of Patients With Ruptured Abdominal Aortic Aneurysm in Switzerland

OBJECTIVE

To analyse the association between inter-hospital transfer and hospital mortality in patients with ruptured abdominal aortic aneurysms (rAAA) in Switzerland.

METHODS

Secondary data analysis of case related hospital discharge data from the Swiss Federal Statistical Office for the years 2009 - 2018. All cases with rAAA as primary or secondary diagnosis were included. Cases with rAAA as a secondary diagnosis without surgical treatment and cases that had been transferred to another hospital without surgical treatment at the referring hospital were excluded. Logistic regression models for hospital mortality were constructed with age, sex, type of admission, van Walraven comorbidity score, type of treatment, insurance class, hospital level, and year of treatment as independent variables.

RESULTS

A total of 1 798 cases with rAAA were treated either surgically (62.5%) or palliatively (37.5%) in Switzerland from 1 January 2009 to 31 December 2018. Of these cases, 72.9% were treated directly (surgically or palliatively) at the hospital of first presentation, whereas 27.1% of all cases with rAAA were transferred between hospitals. The overall crude hospital mortality was 50.3%; being 23.1% in the surgically treated cohort and 95.7% in the palliatively treated cohort. Inter-hospital transfer was associated with better survival compared with patients who were admitted directly (OR 0.52; 95% CI 0.36 - 0.75; p < .001). Treatment in major hospitals was associated with significantly higher mortality rate compared with university hospitals (OR 1.98; 1.41 - 2.79; p < .001). There was no evidence of an association between open repair and hospital mortality (OR 1.06; 0.77 - 1.48; p = .72) compared with endovascular repair.

CONCLUSION

In a healthcare system such as Switzerland's with a highly specialised rescue chain, transfer of haemodynamically stable patients with rAAA is probably safe. In this setting, centralised medical care might outweigh the potential disadvantages of a short delay due to patient transfer. Further studies are needed to address potential confounding factors such as haemodynamic and anatomical features.

Anaesthesia for vascular emergencies - a state of the art review

In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.

Open Surgery for Abdominal Aortic Aneurysm: 980 Consecutive Patient Outcomes from a High-Volume Centre in the United Kingdom

BACKGROUND

Controversy persists regarding the optimal treatment for large abdominal aortic aneurysm (AAA), highlighted by the publication of the National Institute for Health and Care Excellence (NICE) guideline (NG156) on March 2020. The pendulum of opinion swings once more from endovascular to open surgical treatment. We report our experience over the last 15 years in treating consecutive AAA by open surgery.

METHODS

A retrospective review of a prospectively collected vascular database of all patients undergoing infra-renal open abdominal aortic aneurysm repair (OR) repair from 2004 to 2019 at the largest aneurysm centre in the United Kingdom. OR for elective and emergency (ruptured and symptomatic) outcomes included early morbidity and 30-day mortality, and long-term survival.

RESULTS

1017 patients underwent OR between 2004-2019, on application of our inclusion-criteria 994 patients formed our cohort for analysis (81.2% male) with a mean age 73.6 ± 7.8 years treated by OR for AAA. In that group 672 were elective and 308 were emergency (for ruptured or symptomatic). Overall 30 day mortality was 11.3%, elective 30 day mortality was 2.5%, and emergency 30 day mortality was 29.9%. 30 day re-intervention rate was 9.5%, (elective 7.0%, emergency 15.9%). Survival at 1000 days for elective repair was 72 v 46.7% for emergency and at 2000 days was 43.4% for elective v 25% for emergency.

CONCLUSION

Our data confirm that open surgery for AAA can be performed in large volume centres quite safely. Elective and Emergency surgery does affect early 30 day mortality but does not influence long-term outcome.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Patient Blood Management in Vascular Surgery

Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.

Association Between Type of Anaesthesia and Clinical Outcome in Patients Undergoing Endovascular Repair of Thoraco-Abdominal Aortic Aneurysms by Fenestrated and Branched Endografts

OBJECTIVE

Although endovascular repair of thoraco-abdominal aortic aneurysm (TAAA) is the treatment of choice in the high risk population that is ineligible for an open surgical approach, little is known about the association between the type of anaesthesia and complications. This study compared the short term clinical outcomes of patients undergoing the visceral step of TAAA with fenestrated endograft aortic repair (FEVAR) and branched endograft aortic repair (BEVAR) under general anaesthesia (GA) with sedation with monitored care anaesthesia (MAC).

METHODS

This single centre, retrospective, observational study recruited 124 consecutive patients undergoing elective F/BEVAR from 2014 - 2021. The primary endpoint was the short term complication rate according to the type of anaesthesia. Secondary endpoints included: need for inotropes or vasopressors for hypotension, time spent in the operating room, and admission to the intensive care unit. Propensity score matching was generated to account for the between group imbalance in the pre-operative covariables.

RESULTS

After propensity score matching, 42 patients under GA were matched with 42 under MAC. The two groups showed no difference in cardiac and non-cardiac complications. Among the secondary outcomes, a higher number of patients in the GA group required inotropes or vasopressors compared with MAC (33% vs. 9%; p = .031). Although GA and MAC showed the same 30 day technical success (81% vs. 83%; p = .078), non-significant lower rates of major adverse events (10% vs. 12%; p = .72), one year re-intervention (14% vs. 21%; p = .39), and one year target vessel instability (10% vs. 21%; p = .39) were observed in the GA group. Overall, the in hospital mortality rate was 4%, with no difference between GA and MAC (2% vs. 5%; p = 1.0).

CONCLUSION

The type of anaesthesia seemed to have no effect on procedure success, peri-operative morbidity, or mortality in patients undergoing F/BEVAR.

Local versus general anesthesia for endovascular aneurysm repair in ruptured abdominal aortic aneurysm: A systematic review and meta-analysis

OBJECTIVES/BACKGROUND

In the endovascular treatment of ruptured abdominal aortic aneurysm (RAAA), there is no effective evidence to show preference for a specific anesthetic option. A meta-analysis was conducted to assess the result of different anesthesia in endovascular aneurysm repair (EVAR) of RAAA.

METHODS

Randomized controlled trials (RCTs) and cohort studies were searched in PubMed, Embase, Ovid, and the Cochrane Library. Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool were applied to evaluate the quality of cohort studies and RCTs, respectively. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to express differences for primary and secondary outcomes. Subgroup analyses and sensitivity analyses were applied in the primary outcome to illustrate the results further. Significance was set at p < 0.05. Random-effects models were used considering limited research regardless of I²  < 50%.

RESULTS

Ten cohort studies were included in this meta-analysis. Perioperative mortality was presented as the primary outcome by analyzing eight of these research. Among the included patients, local anesthesia (LA) was considered as a better choice considering perioperative mortality (n = 156/902) rather than general anesthesia (n = 907/3434) with significant difference (OR: 0.49; 95% CI: 0.35-0.67; p < 0.00001; I²  = 42%). However, no significant difference was found in the secondary outcome: the complication rate, ICU admission rate, postoperative morbidity of pneumonia, myocardial infarction, leg ischemia, and wound complication.

CONCLUSIONS

There exists some evidence in this review that LA appears to improve perioperative mortality, especially in hemodynamically stable patients and should be recommended for patients undergoing EVAR with RAAA when appropriate.

[Abdominal aortic aneurysms-open vs. endovascular treatment : Decision-making from the perspective of the vascular surgeon]

CLINICAL/METHODICAL ISSUE

In the last 20 years, the treatment of abdominal aortic aneurysms has essentially evolved from surgical to minimally invasive endovascular treatment.

ACHIEVEMENTS

There are still a number of clinical situations that make surgical intervention useful or even necessary. This underlines the importance of interdisciplinary vascular centers for the treatment of complex aortic pathologies and their sequelae.

PRACTICAL RECOMMENDATIONS

In the following article, the arguments for the choice of procedure for the treatment of infrarenal aortic aneurysms are discussed and the recommendations of various guidelines are compared.

A Comparison of Endovascular Aneurysm Repair and Open Repair for Ruptured Aortic Abdominal Aneurysms

Management modalities of ruptured abdominal aortic aneurysm (AAA) include ruptured open aneurysm repair (rOAR) and ruptured endovascular aneurysm repair (rEVAR). In this study, we aim to systematically review all the previously published randomized controlled trials (RCTs) that compared rOAR and rEVAR. A systematic search was performed in the following databases: PubMed, Scopus, Web of Science, Google Scholar, Clinical trials, and others with all the potentially relevant keywords that were adjusted to meet the search strategy for each database to collect all the relevant studies that were published up to January 2021. A total of 11 studies were identified through our comprehensive search. Among these studies, seven represented the IMPROVE trial, two represented the AJAX trial, and two represented the Nottingham and ECAR trials, each, while the remaining four studies were not RCTs; however, these were included in the discussion as they obtained data from the IMPROVE trial. The IMPROVE trials preferred EVAR use due to the potential survival benefit and improved quality of life, although the EVAR and OAR had similar mortality rates. In the AJAX and ECAR, the mortality rates favored EVAR over OAR with no significance while the opposite was noticed in the Nottingham trial with no significance also. Similar rates of re-interventions and complications were also noticed and some studies reported that EVAR is cost-effective. Overall evidence slightly favors EVAR over OAR and further studies are needed.

Practicalities of Impracticability: An Interim Review of Randomized Controlled Trials

Impracticability is an ethical standard for waiver of informed consent in research. We examine how well the criterion of impracticability appears to have been fulfilled in a set of 36 completed randomized controlled trials (RCTs) that secured consent from some subjects or LARs and employed waivers to enroll others. These trials were identified among 155 RCTs using waivers of consent in a convenience sample drawn from 7 systematic reviews. Recruitment data were available for 19 of the 36 trials, revealing an average of 41.6% of subjects (range 0.2-98.7%, 95% CI: 24.8-58.4%) were enrolled without consent. Six trials enrolled less than 10% of subjects without consent and an overlapping set of 9 trials sought consent from all subjects or LARs at some sites while waiving consent at other sites. We question whether these trials were practicable without waivers and identify issues for consideration by investigators and ethics review boards.

Helicopter emergency medical service for time critical interfacility transfers of patients with cardiovascular emergencies

Background

The goal of improving quality through centralisation of specialised medical services must be balanced against potential harm caused by delayed access to emergency treatments in rural areas. This study aims to assess the duration of transfers of critically ill patients with cardiovascular emergencies from smaller hospitals to major medical centres by a helicopter emergency medical service (HEMS) in Switzerland.

Methods

This retrospective observational cohort study includes all consecutive emergency interfacility transfers (IFTs) conducted by Switzerland’s largest HEMS provider between July 3rd, 2019, and March 31st, 2021. All patients with acute myocardial infarction, non-traumatic strokes, ruptured aortic aneurysms, and other acute vascular emergencies were included. The duration and distance of each HEMS IFT were compared to calculated distances and duration of travel for the same missions using ground-based transportation (GEMS). The ground-based mission distance beyond which the total mission duration of HEMS is expected to be faster than GEMS was calculated.

Findings

A total of 645 patients were transferred for stroke (n = 364), myocardial infarction (n = 252) and other acute vascular emergencies (n = 29). The median total mission duration from emergency call to landing at the destination was 59.9 (IQR 51.5 to 70.5) minutes. The median road distance for the same missions was 60 (IQR 43 to 72) km. Regression analysis revealed that HEMS is expected to be faster if the road distance is more than 51.3 km.

Interpretation

Centralisation of specialised medical services should be accompanied by a comprehensive and specialised rescue chain. HEMS in Switzerland ensures time-sensitive IFT in medical emergencies, even in topographically challenging terrain.

Graphical Abstract

"Awake" Spinal Cord Monitoring Under Local Anesthesia and Conscious Sedation in Fenestrated and Branched Endovascular Aortic Repair

INTRODUCTION

Endovascular repair of thoracoabdominal aortic aneurysms carries a risk of spinal cord ischemia, the causes of which remain uncertain. We hypothesized that local anesthesia (LA) with conscious sedation could abrogate the potential suppressive cardiovascular effects of general anesthesia (GA) and facilitate intraoperative monitoring of neurological function. Here, we examine the feasibility of this technique during fenestrated (FEVAR) or branched endovascular aortic repair (BEVAR).

MATERIALS AND METHODS

Consecutive patients undergoing FEVAR or BEVAR under LA and conscious sedation by a team at a single center were analyzed. Patients received conscious sedation using intravenous remifentanil and propofol infusions in conjunction with a local anesthetic agent. No patient had a prophylactic spinal drain inserted. Outcome measures included conversion to GA, need for vasopressors and/or spinal drainage, length of stay, complications, and patient survival.

RESULTS

A total of 44 patients underwent FEVAR or BEVAR under LA and conscious sedation. The cohort included thoracoabdominal aortic aneurysms (n=41) and pararenal aneurysms treated with endografts covering the supraceliac segment (n=3). Four patients (9%) required conversion to GA at a median operative duration of 198 minutes (range 97-495 minutes). Vasopressors were required intraoperatively in 3 of the cases that were converted to GA. No patient developed spinal cord ischemia and none had insertion of a spinal drain. The median hospital length of stay was 4 days (range 2-41 days). Postoperative delirium and hospital-acquired pneumonia was seen in 7% of patients. All patients survived to 30 days, with 95% alive at a median follow-up of 15 months (range 3-26 months).

CONCLUSION

LA and conscious sedation is a feasible anesthetic technique for the endovascular repair of thoracoabdominal aortic aneurysms.

Compensated Patient Injuries in the Treatment of Abdominal Aortic and Iliac Artery Aneurysms in Finland: A Nationwide Patient Insurance Registry Study

OBJECTIVES

Patient injury claims data and insurance records provide detailed information on patient injuries. This study aimed to identify the errors and adverse events that led to patient injuries in vascular surgery for the treatments of abdominal aortic aneurysms (AAA) and iliac artery aneurysms (IAA) in Finland. The study also assessed the severity and preventability of the injuries.

MATERIALS AND METHODS

A retrospective analysis of Finnish Patient Insurance Centre's insurance charts of compensated patient injuries in the treatment of AAA and IAA. Records of all compensated patient injury claims involving AAA and IAA between 2004 and 2017 inclusive were reviewed. Contributing factors to injury were identified and classified. The injuries were assessed for their preventability by using the WHO Surgical Safety Checklist correctly. The degree of harm was graded by Clavien-Dindo classification.

RESULTS

Twenty-six patient injury incidents were identified in the treatment of 23 patients. Typical injuries involved delays in diagnosis or treatment, errors in surgical technique or injuries to adjacent anatomic organs. Three (13.0%) patients died due to patient injury. Two deaths were caused by delays in diagnosis of ruptured abdominal aortic aneurysm (RAAA) and the third death was due to missed diagnosis of post-operative myocardial infarction. Retained foreign material caused injuries to two (8.7%) patients. One (4.3%) patient had a severe postoperative infection. Three (13.0%) patients experienced an injury to an adjacent organ. One patient had a bilateral and another a unilateral above-the-knee amputation due to patient injury. Three injuries were considered preventable. Most harms were grade IIIb Clavien-Dindo classification in which injured patients required a surgical intervention under general anesthesia.

CONCLUSIONS

Compensated patient injuries involving the treatment of AAA and IAA are rare, but are often serious. Injuries were identified during all stages of care. Most injuries involved open surgical procedures.

Percutaneous EVAR for Ruptured Abdominal Aortic Aneurysms Using the Cordis INCRAFT Endograft

OBJECTIVES

Low profile endovascular aneurysm repair (EVAR) devices such as the Cordis INCRAFT AAA Stent Graft System may expand the category of patients suitable for endovascular repair. We report our experience with the INCRAFT system in treating ruptured abdominal aortic aneurysms (rAAA).

METHODS

We included all patients presenting with rAAA from 2015 to 2019 in our hospital who were treated by percutaneous EVAR with the INCRAFT system. The primary outcome was technical success, referring to adequate stent graft placement. Secondary outcomes included completion of the procedure under local anesthesia and mortality at 30-days, one year and long-term follow-up.

RESULTS

Fifteen male patients (mean age: 74 years, SD 6.7) were treated for rAAA with a median aneurysm diameter of 8.25 cm (SD 1.66). The device was successfully delivered and deployed in all subjects. Per-procedurally one type I endoleak required additional stent placement and one patient developed an acute thrombosis of the device main body and iliac limbs requiring thrombectomy. 80.0% of patients were successfully treated under local anesthesia only. The 30 day and one year mortality were 26.6% and 33.3% respectively. Long-term survival was 60.0% at a median follow-up period of 57 months, with two patients requiring late reintervention for an endoleak.

CONCLUSIONS

The INCRAFT system can be used to percutaneously treat rAAA with a high technical success rate and mortality similar to reported in the literature for other devices. The large majority of procedures can be completed with only local anesthesia.

Aortic Neck IFU Violations During EVAR for Ruptured Infrarenal Aortic Aneurysms are Associated with Increased In-Hospital Mortality

OBJECTIVE

Vascular surgeons treating patients with ruptured abdominal aortic aneurysm must make rapid treatment decisions and sometimes lack immediate access to endovascular devices meeting the anatomic specifications of the patient at hand. We hypothesized that endovascular treatment of ruptured abdominal aortic aneurysm (rEVAR) outside manufacturer instructions-for-use (IFU) guidelines would have similar in-hospital mortality compared to patients treated on-IFU or with an infrarenal clamp during open repair (ruptured open aortic aneurysm repair [rOAR]).

METHODS

Vascular Quality Initiative datasets for endovascular and open aortic repair were queried for patients presenting with ruptured infrarenal AAA between 2013-2018. Graft-specific IFU criteria were correlated with case-specific proximal neck dimension data to classify rEVAR cases as on- or off-IFU. Univariate comparisons between the on- and off-IFU groups were performed for demographic, operative and in-hospital outcome variables. To investigate mortality differences between rEVAR and rOAR approaches, coarsened exact matching was used to match patients receiving off-IFU rEVAR with those receiving complex rEVAR (requiring at least one visceral stent or scallop) or rOAR with infrarenal, suprarenal or supraceliac clamps. A multivariable logistic regression was used to identify factors independently associated with in-hospital mortality.

RESULTS

621 patients were treated with rEVAR, with 65% classified as on-IFU and 35% off-IFU. The off-IFU group was more frequently female (25% vs. 18%, P = 0.05) and had larger aneurysms (76 vs. 72 mm, P= 0.01) but otherwise was not statistically different from the on-IFU cohort. In-hospital mortality was significantly higher in patients treated off-IFU vs. on-IFU (22% vs. 14%, P= 0.02). Off-IFU rEVAR was associated with longer operative times (135 min vs. 120 min, P= 0.004) and increased intraoperative blood product utilization (2 units vs. 1 unit, P= 0.002). When off-IFU patients were matched to complex rEVAR and rOAR patients, no baseline differences were found between the groups. Overall in-hospital complications associated with off-IFU were reduced compared to more complex strategies (43% vs. 60-81%, P< 0.001) and in-hospital mortality was significantly lower for off-IFU rEVAR patients compared to the supraceliac clamp group (18% vs. 38%, P= 0.006). However, there was no significantly increased mortality associated with complex rEVAR, infrarenal rOAR or suprarenal rOAR compared to off-IFU rEVAR (all P> 0.05). This finding persisted in a multivariate logistic regression.

CONCLUSIONS

Off-IFU rEVAR yields inferior in-hospital survival compared to on-IFU rEVAR but remains associated with reduced in-hospital complications when compared with more complex repair strategies. When compared with matched patients undergoing rOAR with an infrarenal or suprarenal clamp, survival was no different from off-IFU rEVAR. Taken together with the growing available evidence suggesting reduced long-term durability of off-IFU EVAR, these data suggest that a patient's comorbidity burden should be key in making the decision to pursue off-IFU rEVAR over a more complex repair when proximal neck violations are anticipated preoperatively.

Configuration of vascular services: a multiple methods research programme

Background

Vascular services is changing rapidly, having emerged as a new specialty with its own training and specialised techniques. This has resulted in the need for reconfiguration of services to provide adequate specialist provision and accessible and equitable services.

Objectives

To identify the effects of service configuration on practice, resource use and outcomes. To model potential changes in configuration. To identify and/or develop electronic data collection tools for collecting patient-reported outcome measures and other clinical information. To evaluate patient preferences for aspects of services other than health-related quality of life.

Design

This was a multiple methods study comprising multiple systematic literature reviews; the development of a new outcome measure for users of vascular services (the electronic Personal Assessment Questionnaire – Vascular) based on the reviews, qualitative studies and psychometric evaluation; a trade-off exercise to measure process utilities; Hospital Episode Statistics analysis; and the development of individual disease models and a metamodel of service configuration.

Setting

Specialist vascular inpatient services in England.

Data sources

Modelling and Hospital Episode Statistics analysis for all vascular inpatients in England from 2006 to 2018. Qualitative studies and electronic Personal Assessment Questionnaire – Vascular evaluation with vascular patients from the Sheffield area. The trade-off studies were based on a societal sample from across England.

Interventions

The data analysis, preference studies and modelling explored the effect of different potential arrangements for service provision on the resource use, workload and outcomes for all interventions in the three main areas of inpatient vascular treatment: peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. The electronic Personal Assessment Questionnaire – Vascular was evaluated as a potential tool for clinical data collection and outcome monitoring.

Main outcome measures

Systematic reviews assessed quality and psychometric properties of published outcome measures for vascular disease and the relationship between volume and outcome in vascular services. The electronic Personal Assessment Questionnaire – Vascular development considered face and construct validity, test–retest reliability and responsiveness. Models were validated using case studies from previous reconfigurations and comparisons with Hospital Episode Statistics data. Preference studies resulted in estimates of process utilities for aneurysm treatment and for travelling distances to access services.

Results

Systematic reviews provided evidence of an association between increasing volume of activity and improved outcomes for peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. Reviews of existing patient-reported outcome measures did not identify suitable condition-specific tools for incorporation in the electronic Personal Assessment Questionnaire – Vascular. Reviews of qualitative evidence, primary qualitative studies and a Delphi exercise identified the issues to be incorporated into the electronic Personal Assessment Questionnaire – Vascular, resulting in a questionnaire with one generic and three disease-specific domains. After initial item reduction, the final version has 55 items in eight scales and has acceptable psychometric properties. The preference studies showed strong preference for endovascular abdominal aortic aneurysm treatment (willingness to trade up to 0.135 quality-adjusted life-years) and for local services (up to 0.631 quality-adjusted life-years). A simulation model with a web-based interface was developed, incorporating disease-specific models for abdominal aortic aneurysm, peripheral arterial disease and carotid artery disease. This predicts the effects of specified reconfigurations on workload, resource use, outcomes and cost-effectiveness. Initial exploration suggested that further reconfiguration of services in England to accomplish high-volume centres would result in improved outcomes, within the bounds of cost-effectiveness usually considered acceptable in the NHS.

Limitations

The major source of evidence to populate the models was Hospital Episode Statistics data, which have limitations owing to the complexity of the data, deficiencies in the coding systems and variations in coding practice. The studies were not able to address all of the potential barriers to change where vascular services are not compliant with current NHS recommendations.

Conclusions

There is evidence of potential for improvement in the clinical effectiveness and cost-effectiveness of vascular services through further centralisation of sites where major vascular procedures are undertaken. Preferences for local services are strong, and this may be addressed through more integrated services, with a range of services being provided more locally. The use of a web-based tool for the collection of clinical data and patient-reported outcome measures is feasible and can provide outcome data for clinical use and service evaluation.

Future work

Further evaluation of the economic models in real-world situations where local vascular service reconfiguration is under consideration and of the barriers to change where vascular services do not meet NHS recommendations for service configuration is needed. Further work on the electronic Personal Assessment Questionnaire – Vascular is required to assess its acceptability and usefulness in clinical practice and to develop appropriate report formats for clinical use and service evaluation. Further studies to assess the implications of including non-health-related preferences for care processes, and location of services, in calculations of cost-effectiveness are required.

Study registration

This study is registered as PROSPERO CRD42016042570, CRD42016042573, CRD42016042574, CRD42016042576, CRD42016042575, CRD42014014850, CRD42015023877 and CRD42015024820.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Effect of endovascular therapy on the expression levels of serum T lymphocyte subsets, Notch1 and TACE proteins in patients with abdominal aortic aneurysm

To investigate the effect of endovascular therapy on the expression levels of serum T lymphocyte subsets, Notch1 and TACE proteins in patients with abdominal aortic aneurysm (AAA). A total of 84 AAA patients treated in the General Hospital of Northern Theater Command of Chinese PLA from January 2018 to October 2019 were equally divided into the control group and research group according to different surgical methods. The control group underwent laparotomy and the research group received endoluminal repair. The expression levels of serum T-cell subsets, plasma Notch1 and TACE proteins were compared before and 1 week after surgery between the two groups; the expression levels of plasma Notch1 and TACE proteins in patients with different tumor diameters in the research group were compared; the comparison of the surgical indexes and the incidence of complications was conducted. After treatment, the molecular level of CD3⁺ and CD4⁺ in the research group was significantly higher than that in the control group, whereas the molecular level of CD8⁺, and the expression levels of Notch1 and TACE proteins in the plasma were significantly lower than that in the control group (P < 0.05). In the research group, the expression levels of plasma Notch1 and TACE proteins were in direct proportion with tumor diameter (P < 0.05). The intraoperative blood loss in the research group was significantly less than that in the control group, the operation time, postoperative fasting time and postoperative hospital stay were significantly shorter than that in the control group, and the total incidence of complications (11.90%) was significantly lower than that in the control group (38.09%) (P < 0.05). At 12 months after operation, there was no statistically significant difference in the incidence of complications and mortality between the two groups. Endovascular therapy fro AAA can greatly improve the expression levels of T-lymphocyte subsets, Notch1 and TACE proteins, and markedly reduce the incidence of complications.

[Summary of the S3 guideline on abdominal aortic aneurysm from an anesthesiological perspective]

The current article is a summary of the 2018 revised S3 guideline on screening, diagnosis, therapy, and follow-up of the abdominal aortic aneurysm (AAA) from an anesthesiological point of view. It is the only interdisciplinary guideline that describes in particular the perioperative anesthesiological and intensive care management.

Vogl T, T. Grundmann R. Endovascular and Open Repair of Abdominal Aortic Aneurysm

BACKGROUND

This review presents the surgical indications, surgical procedures, and results in the treatment of asymptomatic and ruptured abdominal aortic aneurysms (AAA).

METHODS

An updated search of the literature on screening, diagnosis, treatment, and follow-up of AAA, based on the German clinical practice guideline published in 2018.

RESULTS

Surgery is indicated in men with an asymptomatic AAA ≥ 5.5 cm and in women, ≥ 5.0 cm. The indication in men is based on four randomized trials, while in women the data are not conclusive. The majority of patients with AAA (around 80%) meanwhile receive endovascular treatment (endovascular aortic repair, EVAR). Open surgery (open aneurysm repair, OAR) is reserved for patients with longer life expectancy and lower morbidity. The pooled 30-day mortality is 1.16% (95% confidence interval [0.92; 1.39]) following EVAR, 3.27% [2.7; 3.83] after OAR. Women have higher operative/interventional mortality than men (odds ratio 1.67%). The mortality for ruptured AAA is extremely high: around 80% of women and 70% of men die after AAA rupture. Ruptured AAA should, if possible, be treated via the endovascular approach, ideally with the patient under local anesthesia. Treatment at specialized centers guarantees the required expertise and infrastructure. Long-term periodic monitoring by mean of imaging (duplex sonography, plus computed tomography if needed) is essential, particularly following EVAR, to detect and (if appropriate) treat endoleaks, to document stable diameter of the eliminated aneurysmal sac, and to determine whether reintervention is necessary (long-term reintervention rate circa 18%).

CONCLUSION

Vascular surgery now offers a high degree of safety in the treatment of patients with asymptomatic AAA. Endovascular intervention is preferred.

Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms

Since its inception in the 1990s, endovascular aortic repair has quickly replaced traditional open aortic repair (OAR) as the most common method for elective treatment of abdominal aortic aneurysms (AAA). After numerous iterations and failures of different endografts, the technology has undergone dramatic improvements with evidence pointing to this technology serving as a safe and durable modality, albeit with the requirement of routine surveillance. Not surprisingly, the ability to treat patients with AAAs with minimally invasive technology that could theoretically mitigate some of the risks associated with OAR, such as aortic cross clamping and significant blood loss, was also adopted in patients with ruptured AAAs and is now the preferred treatment method if anatomically feasible.

Involvement of Myeloid Cells and Noncoding RNA in Abdominal Aortic Aneurysm Disease

Significance: Abdominal aortic aneurysm (AAA) is a potentially fatal condition, featuring the possibility of high-mortality rupture. To date, prophylactic surgery by means of open surgical repair or endovascular aortic repair at specific thresholds is considered standard therapy. Both surgical options hold different risk profiles of short- and long-term morbidity and mortality. Targeting early stages of AAA development to decelerate disease progression is desirable. Recent Advances: Understanding the pathomechanisms that initiate formation, maintain growth, and promote rupture of AAA is crucial to developing new medical therapeutic options. Inflammatory cells, in particular macrophages, have been investigated for their contribution to AAA disease for decades, whereas evidence on lymphocytes, mast cells, and neutrophils is sparse. Recently, there has been increasing interest in noncoding RNAs (ncRNAs) and their involvement in disease development, including AAA. Critical Issues: The current evidence on myeloid cells and ncRNAs in AAA largely originates from small animal models, making clinical extrapolation difficult. Although it is feasible to collect surgical human AAA samples, these tissues reflect end-stage disease, preventing examination of critical mechanisms behind early AAA formation. Future Directions: Gaining more insight into how myeloid cells and ncRNAs contribute to AAA disease, particularly in early stages, might suggest nonsurgical AAA treatment options. The utilization of large animal models might be helpful in this context to help bridge translational results to humans.

A meta-analysis of locoregional anesthesia versus general anesthesia in endovascular repair of ruptured abdominal aortic aneurysm

OBJECTIVE

To conduct a meta-analytic review of studies investigating the effect of the anesthesia modality on perioperative mortality in endovascular repair of ruptured abdominal aortic aneurysms (REVAR).

METHODS

The present meta-analysis was performed in accordance with the PRISMA guidelines. Multiple electronic databases were comprehensively searched from database inception to January 2020. Eligible studies included cohort studies that reported the 30-day/in-hospital mortality rate or the multivariate adjusted odds ratio (OR) or hazard ratio of the mortality risk for patients who underwent emergency REVAR under locoregional anesthesia (LA) vs general anesthesia (GA). A random effects model was used to estimate the ORs by pooling the related data from individual studies.

RESULTS

A total of eight studies were included in this analysis. The first meta-analysis of seven studies that reported the 30-day/in-hospital mortality with a total of 3116 patients (867 in the LA group and 2249 in the GA group) revealed that LA was associated with a lower 30-day/in-hospital mortality than GA (16.4% vs 25.4%; unadjusted OR, 0.47; 95% confidence interval [CI], 0.32-0.68). The second meta-analysis of three of these seven studies (including 586 patients in the LA group and 1945 in the GA group) that reported the perioperative variables revealed comparable baseline characteristics but a lower 30-day/in-hospital mortality in the LA group (unadjusted OR, 0.55; 95% CI, 0.42-0.71). The third meta-analysis of the adjusted ORs or hazard ratios that were reported from four studies (including 501 patients in the LA group and 1136 in the GA group) showed a similar trend (adjusted OR,0.37; 95% CI, 0.19-0.75).

CONCLUSIONS

REVAR under LA is associated with a lower 30-day/in-hospital mortality than REVAR under GA. However, because the included studies may have had some observation bias, further randomized controlled trials are warranted to validate the present results.

Endograft type and anesthesia mode are associated with mortality of endovascular aneurysm repair for ruptured abdominal aortic aneurysms

OBJECTIVE

Endovascular aneurysm repair has become the primary treatment modality for ruptured infrarenal abdominal aortic aneurysm. This study examines the impact of endograft type on perioperative outcomes for ruptured infrarenal abdominal aortic aneurysm.

METHOD

The targeted endovascular aneurysm repair files of the American College of Surgeons National Surgical Quality Improvement Program database (2012-2017) were used. Only patients treated for ruptured infrarenal abdominal aortic aneurysm were included. All patients requiring concomitant stenting of the visceral arteries or aneurysmal iliac arteries or open abdominal surgery were excluded. The characteristics of patients treated with the different endografts and the corresponding outcomes were compared using Stata software.

RESULTS

There were 479 patients treated with the three most common endografts: Cook Zenith (n = 127), Gore Excluder (n = 239), and Medtronic Endurant (n = 113). The number of other endografts was too small for statistical analysis. Compared to patients treated with Excluder or Endurant, the patients treated with Zenith had significantly lower body mass index (P < .001) and were less likely to be white (P < .001). On the other hand, patients treated with Endurant were less likely to be smoker (P = .016). Patients treated with Zenith had significantly larger ruptured infrarenal abdominal aortic aneurysm diameter (P = .045). The overall mortality was 18% and morbidity 74.3%. There was a statistically significant difference in overall mortality (Zenith = 11.8%, Excluder = 18%, Endurant = 24.8%, P = .033) but not morbidity (P = .808) between the three groups. Post hoc analysis for overall mortality showed only significant difference between Zenith and Endurant. The difference in mortality was not significant in patients presenting with ruptured infrarenal abdominal aortic aneurysm without hypotension (P = .065). On multivariable analysis, treatment with the Endurant endograft was associated with increased mortality compared to Zenith (odds ratio = 3.0 [confidence interval 1.31-6.7]). General anesthesia (odds ratio = 2.67 [confidence interval 1.02-7.02]), rupture with hypotension (odds ratio = 4.49 [confidence interval 2.54-7.95]), and dependent functional status (odds ratio = 5.7 [confidence interval 1.96-16.59]) were independently associated with increased mortality while increasing body mass index (odds ratio = 0.97 [confidence interval 0.95-0.99]) was associated with reduced risk of mortality.

CONCLUSIONS

This study highlights contemporary outcomes of endovascular aneurysm repair for ruptured infrarenal abdominal aortic aneurysm with relatively low mortality. Endograft type and anesthesia technique are modifiable factors that can potentially improve outcomes. Significant variation in the outcomes of the different endografts warrants further research.

Scoping review of mode of anaesthesia in emergency surgery

BACKGROUND

Emergency surgery encompasses more than 50 per cent of the surgical workload; however, research efforts are disproportionally low. The mode of anaesthesia used during emergency surgery may affect outcomes, but the extent of research and the impact of the different modes of anaesthesia used are unclear.

METHODS

MEDLINE and Embase were searched using scoping review methodology with a rapid systematic search strategy, identifying any study comparing locoregional (local, nerve block, subarachnoid, epidural) anaesthesia with general anaesthesia. All studies describing outcomes of emergency surgery with differing modes of anaesthesia were identified. Excluded were: studies published before 2003, studies enrolling patients aged less than 18 years and studies using sedation only.

RESULTS

Forty-two studies were identified, describing 11 surgical procedures. Most publications were retrospective cohort studies (32). A very broad range of clinical and patient-reported outcomes were described, with wide variation in the outcomes reported in different studies.

CONCLUSION

Reporting of mode of anaesthesia is inconsistent across different procedures and is often absent. There is a need for directed research efforts to improve the reporting standards of anaesthesia interventions, to understand the role of different modes of anaesthesia in specific emergency surgical procedures, and to standardize outcome reporting using core outcome sets.

Inverse probability of treatment analysis of open vs endovascular repair in ruptured infrarenal aortic aneurysm - Cohort study

BACKGROUND

To compare open repair (OR) with EVAR for the management of ruptured infrarenal abdominal aortic aneurysms (RAAA) in a cohort study over a time period of 15 years with inverse probability of treatment weights.

MATERIAL AND METHODS

From 2000/01 through 2015/12 136 patients were treated for RAAA, 98 (72.1%) underwent OR, 38 (27.9%) were treated with EVAR. Thirty-day and long-term mortality (survival) were analyzed in this IRB-approved retrospective cohort study. Treatment modalities were compared using inverse probability of treatment weights to adjust for imbalances in demographic data and risk factors.

RESULTS

EVAR patients were older (75.11 ± 7.17 vs 69.79 ± 10.24; p=0.001). There was no statistical difference in gender, hypertension, COPD, CAD, or diabetes. GFR was significantly higher in OR patients (71.4 ± 31.09 vs. 53.68 ± 25.73). Postoperative dialysis was required more frequently in EVAR patients: 11% vs. 2% (p = 0.099). In the OR group, adjusted cumulative survival was 70.4% (61.1, 81.1) at 30 days, 47.0% (37.1, 59.6) at one year and 38.3% (28.6, 51.3) at 5 years. In the EVAR group the corresponding numbers were 77.0% (67.7, 87.5), 67.5% (57.0, 80.0) and 41.7% (30.4, 57.4), respectively.

CONCLUSION

There is evidence for EVAR patients exhibiting a benefit in one-year survival, while patients treated with OR may have more favorable long-term survival given they survive for at least one year. Herein we provide a statistically rigorous comparison of OR and EVAR in short and long-term outcomes with up to 15 years of follow-up.

The Effect of Mode of Anaesthesia on Outcomes After Elective Endovascular Repair of Abdominal Aortic Aneurysm

OBJECTIVE

Endovascular aneurysm repair (EVAR) is the most commonly used method to repair abdominal aortic aneurysms. EVAR can be performed using a variety of anaesthetic techniques, including general anaesthetic (GA), regional anaesthetic (RA), and local anaesthetic (LA), but little is known about the effects that each of these anaesthetic modes have on patient outcome. The aim of this study was to assess the effect of anaesthetic technique on early outcomes after elective EVAR.

METHODS

Data from the UK's National Vascular Registry were analysed. All patients undergoing elective standard infrarenal EVAR between 1 January 2014 and 31 December 2016 were included. Patients with a symptomatic aneurysm treated semi-electively were excluded. The primary outcome was in hospital death within 30 days of surgery. Secondary outcomes included post-operative complications and length of hospital stay. Time to event outcomes were compared using Cox proportional hazards regression adjusted for confounders, including British Aneurysm Repair score (a validated aneurysm risk prediction score that is calculated using age, sex, creatinine, cardiac disease, electrocardiogram, previous aortic surgery, white blood cell count, serum sodium, abdominal aortic aneurysm diameter, and American Society of Anaesthesiologists grade) and chronic lung disease.

RESULTS

A total of 9783 patients received an elective, standard infrarenal EVAR (GA, n = 7069; RA, n = 2347; and LA, n = 367) across 89 hospitals. RA and/or LA was used in 82 hospitals. There were 64 in hospital deaths within 30 days, 50 (0.9% mortality at 30 days, 95% confidence interval [CI] 0.7-1.2) in the GA group, 11 (0.6%, 95% CI 0.3-1.1) in the RA group, and three (1.5%, 95% CI 0.5-4.7) in the LA group. The mortality rate differed between groups (p = .03) and was significantly lower in the RA group compared with the GA group (adjusted hazard ratio [aHR] RA/GA 0.37 [95% CI 0.17-0.81]; LA/GA 0.63 [95% CI 0.15-2.69]). The median length of stay was two days for all modes of anaesthesia, but patients were discharged from hospital more quickly in the RA and LA groups than the GA group (aHR RA/GA 1.10 [95% CI 1.03-1.17]; LA/GA 1.15 [95% CI 1.02-1.29]). Overall, 20.7% of patients experienced one or more complications (GA group, 22.1%; RA group, 16.8%; LA group, 17.7%) and pulmonary complications occurred with similar frequency in the three groups (overall 2.4%, adjusted odds ratio RA/GA 0.93 [95% CI 0.66-1.32]; LA/GA 0.82 [95% CI 0.41-1.63]).

CONCLUSION

Thirty day mortality was lower with RA than with GA, but mode of anaesthesia was not associated with increased complications for patients undergoing elective standard infrarenal EVAR.

Trends in management and outcomes of vascular emergencies in the nationwide inpatient sample

Summary: Background: To evaluate trends in frequency, mortality and treatment for non-traumatic vascular emergencies (VE) in the US. Methods: VE in the Nationwide Inpatient Sample (2005–2014) were identified. ICD-9 CM diagnosis and procedures codes captured six common VE. Results: 228,210,504 emergency admissions with 317,396 procedures for VE were estimated. Mean age was 67.8 years and were primarily men (56.1 %; p < 0.0001). The commonest VE was Acute Limb Ischemia (ALI) (82.4 %) followed by ruptured AAA (10.8 %) and Acute Mesenteric Ischemia (4.71 %). VE increased from 132.8 per 100,000 admissions in 2005 to 153.6 in 2014 (p < 0.001), with mortality decrease for all VE (13.8 % vs. 9.1 %; p < 0.0001). Length of stay decreased (median 8 vs. 7 days; p < 0.0001) but cost of care increased (median $ 25,443 vs. $ 29,353; p < 0.0001). Endovascular treatment increased overall for VE from 23.7 % in 2005 to 37.2 % in 2014 (p < 0.0001). Hospital mortality for VE decreased overall, except ruptured thoracoabdominal aortic aneurysm with mortality decrease with endovascular treatment (34.3 vs. 11.1; p = 0.04) and mortality increase with open treatment (44.7 vs. 47.6; p = 0.06). ALI overall mortality decreased from 8.1 % to 5.7 % (p < 0.0001) due to reduced open surgical mortality from 9.6 % to 7.4 % (p < 0.0001); endovascular mortality did not improve over time (4.0 % vs. 3.4 %; p = 0.45). Hospital mortality also increased for endovascular treatment of ruptured thoracic aortic aneurysm (rTAA) from 14.9 % to 27.4 % (p = 0.0003) during this period. Conclusions: VE frequency increased with a decrease in overall mortality over time. Overall hospital stay has decreased but with an increase in the cost of care. Open surgical mortality for VE has also decreased overall, suggesting perioperative care improvements, with the exception of ruptured thoracoabdominal aortic aneurysm. Endovascular utilization for VE has significantly increased; associated with lower mortality for most VE, although an increase in hospital mortality after endovascular repair of rTAA was seen. This may be due to an increased implementation of endovascular repair for patients not previously eligible for surgery due to high risk. We recommend careful selection of patients for rTAA treatment as mortality has increased despite endovascular therapy and at an increased cost of care.

Regional anesthesia for vascular surgery: does the anesthetic choice influence outcome?

PURPOSE OF REVIEW

Outcomes following surgery are of major importance to clinicians, institutions and most importantly patients. This review examines whether regional anesthesia and analgesia influence outcome after vascular surgery.

RECENT FINDINGS

Large database analyses of contemporary practice suggest that utilizing regional anesthesia for both open and endovascular aortic aneurysm repair, lower limb revascularization and carotid endarterectomy reduces morbidity, length of stay and possibly even mortality. Results from such analyses are limited by an inherent risk of bias but are nevertheless important given the number of patients required in randomized trials to detect differences in rare outcomes. There is minimal evidence that regional anesthesia influences longer term outcomes except for arteriovenous fistula surgery where brachial plexus blocks appear to improve 3-month fistula patency.

SUMMARY

Patients undergoing vascular surgery often have multiple comorbidities and it is important to be able to outline both benefits and risks of regional anesthesia techniques. Regional anesthesia in vascular surgery allows avoidance of general anesthesia and does provide short-term benefits beyond superior analgesia. Evidence of long-term benefits is lacking in most procedures. Further work is required on newer patient centered outcomes.