Kurzfassung S3-Leitlinie zu Screening, Diagnostik, Therapie und Nachsorge des Bauchaortenaneurysmas

Wound healing and hernia after abdominal aortic aneurysm repair: Onlay self-gripping polyester mesh reinforcement compared with small bite sutured closure

BACKGROUND

Prophylactic mesh implantation following open surgical repair of abdominal aortic aneurysm is a debatable subject.

OBJECTIVE

To assess the efficacy of a self-gripping polyester mesh used in on-lay technique to prevent incisional hernia after open abdominal aortic aneurysm repair.

METHODS

We retrospectively reviewed the records of 495 patients who underwent aortic surgery between May 2017 and May 2021. Patients included in the study underwent open surgical repair for infrarenal abdominal aortic aneurysm (AAA) with closure of the abdominal wall with either small bite suture technique or prophylactic mesh reinforcement. Primary endpoint of the study was the occurrence of incisional hernia during a two-year follow-up period. Secondary endpoints were mesh-related complications.

RESULTS

Mesh implantation with the on-lay technique was successful in all cases. No patient in the mesh group developed an incisional hernia during the 24-month follow-up period. Two patients in the non-mesh group developed a symptomatic incisional hernia during the follow-up period at 6 months. Three cases of post-operative access site complications were observed in the mesh group.

CONCLUSIONS

Application of a self-gripping polyester mesh using the on-lay technique demonstrates acceptable early-durability after open surgical repair of abdominal aortic aneurysms. However, it appears to be associated with a number of post-operative access site complications.

[Results of a single center vascular screening program in Germany]

BACKGROUND

Cardiovascular diseases are the main cause of death in Europe with a relevant socioeconomic burden. A screening program for vascular diseases in asymptomatic persons with a defined risk constellation can lead to an early diagnosis.

OBJECTIVE

The study examined a screening program for carotid stenosis, peripheral arterial occlusive disease (PAOD) and abdominal aortic aneurysms (AAA) in persons without any known vascular disease with respect to demographic data, risk factors, pre-existing conditions, medication intake, detection of pathological findings and/or findings requiring treatment.

MATERIAL AND METHODS

Test subjects were invited using various information material and filled in a questionnaire on cardiovascular risk factors. The screening took place with measurement of the ABI and duplex sonography as a monocentric prospective single arm study within 1 year. Endpoints were the prevalence of risk factors and pathological and/or results requiring treatment.

RESULTS

A total of 391 persons participated, 36% presented with at least 1 cardiovascular risk factor, 35.5% with 2 and 14.4% with 3 or more. The sonography showed results requiring control with a carotid stenosis of < 50-> 75% or occlusion in 9%. An AAA with a diameter of 3.0-4.5 cm was diagnosed in 0.9% and a pathological ABI < 0.9 or > 1.3 in 12.3%. The indications for a pharmacotherapy were found in 17% and no operation was recommended.

CONCLUSION

The practicability of a screening program for carotid stenosis, PAOD and AAA of a defined risk population was shown. Vascular pathologies that required treatment were hardly found in the catchment area of the hospital. Consequently, the implementation of this screening program in Germany based on the collected data cannot currently be recommended in this form.

Infrarenal Remains Infrarenal-EVAR Suitability of Small AAA Is Rarely Compromised despite Morphological Changes during Surveillance

The aim was to analyze small abdominal aortic aneurysm (AAA) morphology during surveillance with regard to standard endovascular aortic repair (EVAR) suitability. This retrospective single-center study included all patients (n = 52, 48 male, 70 ± 8 years) with asymptomatic AAA ≤ 5.4 cm undergoing ≥2 computed tomography angiography(CTA)/magnetic resonance imaging (MRI) studies (interval: ≥6 months) between 2010 and 2018. Aneurysm diameter, neck quality (shape, length, angulation, thrombus/calcification), aneurysm thrombus, and distal landing zone diameters were compared between first and last CTA/MRI. Resulting treatment plan changes were determined. Neck shortening occurred in 25 AAA (mean rate: 2.0 ± 4.2 mm/year). Neck thrombus, present in 31 patients initially, increased in 16. Average AAA diameters were 47.7 ± 9.3 mm and 56.3 ± 11.6 mm on first and last CTA/MRI, mean aneurysm growth rate was 4.2 mm/year. Aneurysm thrombus was present in 46 patients primarily, increasing in 32. Neck thrombus growth and neck length change, aneurysm thrombus amount and aneurysm growth and aneurysm growth and neck angulation were significantly correlated. A total of 46 (88%) patients underwent open (12/46) or endovascular (34/46) surgery. The planned procedure changed from EVAR to fenestrated EVAR in two patients and from double to triple fenestrated EVAR in one. Thus, standard EVAR suitability was predominantly maintained as the threshold diameter for surgery was reached despite morphological changes. Consecutively, a possibly different pathogenesis of infra- versus suprarenal AAA merits further investigation.

[Debate on Infrarenal AAA in Young and Fit Patients ('Fit for Open Repair'): Open Repair is Safe and Long-term Results are Better]

Endovascular aortic repair, initially developed for patients at prohibitively high risk for an open repair, has undergone significant technical evolution and refinement and has emerged as the preferred treatment option for patients with an infrarenal aortic aneurysm. However, analysis of long-term data of the randomised studies revealed inferior results with regards to survival and freedom-from-reintervention after eight years. Open aortic repair has been performed for more than seven decades and especially for the younger patients with few comorbidities, results are excellent. Potential drawbacks of open repair like incisional hernias, erectile dysfunction and quality of life can either be effectively prevented (mesh reinforcement) or actually failed to show a significant difference compared to open repair in recent studies. Therefore, meticulous assessment of patient comorbidites using validated parameters is the key element for decision-making and parameters such as young age, low comorbidity profile, large aneurysm and presence of atopic renal arteries or a dominant inferior mesenteric artery should prompt a recommendation of open repair.

Association between operation volume and postoperative mortality in the elective open repair of infrarenal abdominal aortic aneurysms: systematic review

Background

An inverse association between the case volume per hospital and surgeon and perioperative mortality has been shown for many surgical interventions. There are numerous studies on this issue for the open treatment of infrarenal aortic aneurysms.

Aim

To present the available data on the association between the case volume per hospital and surgeon and perioperative mortality in the elective open repair of infrarenal aortic aneurysms in a systematic review.

Materials and methods

Using the PubMed, Cochrane Library, Web of Science Core Collection, CINAHL, Current Contents Medicine (CCMed), and ClinicalTrials.gov databases, a systematic search was performed using defined keywords. From the search results, all original papers were included that compared the elective open repair of an infrarenal aortic aneurysm in a “high volume” center with a “low volume” center or by a “high volume” surgeon with a “low volume” surgeon, as defined in the respective study.

Results

After deduplication, the literature search yielded 1021 hits of which 60 publications met the inclusion criteria. Of these, 37/43 studies showed a lower mortality in “high volume” compared to “low volume” centers and 14/17 comparisons showed a lower mortality for “high volume” compared to “low volume” surgeons. The effect measures, usually odds ratios, ranged from 0.37 to 0.99 for volume per hospital and 0.31 to 0.92 for volume per surgeon. Regarding the threshold values for the definition of “high volume” and “low volume,” a clear heterogeneity was shown between the individual studies.

Discussion

The available data on the association between the case volume per hospital and surgeon and perioperative mortality in the elective open repair of infrarenal aortic aneurysms show that interventions performed in “high volume” centers or by “high volume” surgeons are associated with lower mortality. To ensure the best possible outcome in terms of low perioperative mortality in the open repair of infrarenal aortic aneurysms, the aim should be centralization with high case volume per hospital and surgeon.

The Effects of Minimum Caseload Requirements on Management and Outcome in Abdominal Aortic Aneurysm Repair

BACKGROUND

The German quality assurance guideline on abdominal aortic aneurysm (AAA) was implemented by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) in 2008. The aims of this study were to verify the association between hospital case volume and outcome and to assess the hypothetical effect of minimum caseload requirements.

METHODS

The German diagnosis-related groups statistics for the years 2012 to 2016 were scrutinized for AAA (ICD-10 GM I71.3/4) with procedure codes for endo - vascular or open surgical treatment. The primary endpoint was in-hospital mortality. Logistic regression models were used for risk adjustment, and odds ratios (OR) were calculated as a function of the annual hospital-level case volume of AAA. In a hypo - thetical approach, the linear distances for various minimum caseloads (MC) were evaluated to assess accessibility.

RESULTS

The mortality of intact AAA (iAAA) was 2.7% (men [M] 2.4%, women [W] 4.2%); ruptured AAA (rAAA), 36.9% (M 36.9%, F 37.5%). An inverse relationship between annual hospital case volume of AAA and mortality was confirmed (iAAA/rAAA: from 3.9%/51% [<10 cases/year] through 3.3%/37% [30-39 cases/year] to 1.9%/28% [≥ 75 cases/year]). For a reference category of 30 AAA procedures/year, the following significant OR were found: 10 AAA cases/year, OR 1.21 (95% confidence interval [1.20; 1.21]); 20 cases, OR 1.09 [1.09; 1.09]; 50 cases, OR 0.89 [0.89; 0.89]; 75 cases, OR 0.82 [0.82; 0.82]. In a hypothetical centralization scenario with assumed MC of 30/year, 86% of the population would have to travel less than 100 km to the nearest hospital; with an MC of 40, this would apply to only 50% (without redistribution effects).

CONCLUSION

In the observed period, a significant correlation was confirmed between high annual case volume and low in-hospital mortality. A minimum caseload requirement of 30 AAA operations/year seems reasonable in view of the accessibility of hospitals. Cite this.

Screening cardiovascular patients for aortic aneurysms (SCAN) - high prevalence of abdominal aortic aneurysms in coronary heart disease patients requiring intervention

Background: Since the prevalence of abdominal aortic aneurysms (AAA) in Europe has declined to about 2.5%, general screening programs of elderly men are being called into question. On the other hand, other vascular diseases (e.g. coronary heart disease, CHD) are associated with a higher prevalence of AAA. This might have an impact on future targeted AAA screening programs. This study aimed to reevaluate the current prevalence of AAA in male patients with CHD, in order to assess whether CHD patients should be offered a targeted AAA ultrasound screening program. Patients and methods: The SCAN (Screening Cardiovascular Patients for Aortic Aneurysms) study prospectively evaluated the AAA prevalence in 1000 consecutive male CHD patients (70.1 ± 11.2 years) requiring any coronary intervention at an university hospital. All patients received transverse and longitudinal ultrasound scans of the abdominal aorta. Aortic diameter was assessed using the outer-to-outer measurement-technique. Primary endpoint was the prevalence of AAA. Secondary outcomes included stratification in 1-, 2-, or 3-vessel CHD. Results: AAA was detected in 85 patients (median diameter 38 mm, range 30-80 mm), corresponding to an overall prevalence of 8.5%. AAA prevalence was significantly associated with CHD severity: 5.6% in 1-vessel, 7.1% in 2-vessel, and 10.8% in 3-vessel CHD (P = 0.037). The multivariable analysis showed, that age per 10 years increase (OR 1.5, 95% CI 1.2-1.9, P = 0.001) and hyperlipidemia (OR 2.2, 95% CI 1.3-3.8, P = 0.003) were significantly associated with an AAA. The likelihood to be diagnosed with an AAA was significantly lower in non-smokers (OR 0.24, 95% CI, P < 0.001). Conclusions: This study confirms that CHD requiring any type of coronary intervention is strongly associated with AAA in male patients. AAA prevalence increases with CHD severity. Since the AAA prevalence is still significantly higher than in the general population, targeted ultrasound screening should be considered for all CHD patients.

[The DIGG risk score : A risk predictive model of perioperative mortality after elective treatment of intact abdominal aortic aneurysms in the DIGG register]

OBJECTIVE

The aim of the study was to develop a specific risk score for the aortic register of the German Institute for Vascular Health Care Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine (DGG) for the prediction of postoperative mortality in elective treatment of intact abdominal aortic aneurysms (iAAA). The score should also enable a risk-adjusted presentation of the register results in the near future.

METHODS

The method of binary logistic regression analysis was used to calculate the model. The data from 10,404 patients were included in the analysis, of whom 7870 (75.6%) were treated by endovascular (EVAR) and 2534 (24.4%) by open (OR) aortic repair. It was examined which factors have an independent influence on hospital mortality and the effect size was determined as a score.

RESULTS

For EVAR, the influencing factors with their effect sizes (score in brackets) were: age >85 years (2), female gender (2), juxtarenal AAA (5), maximum diameter >65 mm (2), diabetes mellitus (2), American Society of Anesthesiologists (ASA) score >3 (2), cardiac comorbidities (3) and renal insufficiency stage >3 (5). For OR the factors were: age >80 years (2), female gender (2), juxtarenal AAA (2), ASA score >3 (3), previous myocardial infarction (2), renal comorbidities (3) and previous stroke (2). The estimated hospital mortality was calculated for the individual case from the sum of the risk factors (scores). The accuracy of the model (correlation between observed and expected results) was determined using the receiver operating characteristic (ROC) curve. An area under the curve (AUC) of 0.817 (confidence interval 0.789-0.844) demonstrated an excellent discrimination. In a validation group of 3831 patients, the good agreement between observed and calculated results was confirmed.

CONCLUSION

The DIGG risk score can predict risk-adjusted hospital mortality after EVAR and OR of iAAA in the DIGG register. Improvements with respect to the prediction are desirable for OR and should be strived for by extending the model in the future.