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Settembrini AM, Aronici M, Martelli E, Casella F, Martelli M, Renghi A, Coppi G, De Simeis L, Porta C, Brustia P. Is Mini-Invasive Surgery an Alternative for the Treatment of Juxtarenal Aortic Aneurysms? Ann Vasc Surg 2021; 78:220-225. [PMID: 34455043 DOI: 10.1016/j.avsg.2021.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/02/2021] [Accepted: 06/06/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Aim of our study is to evaluate the outcomes of mini-laparotomy, suprarenal cross-clamping, and enhanced recovery after elective open surgical repair for juxta-renal abdominal aortic aneurysms (JAAA) in a tertiary referral center. METHODS Data of all consecutive patients with abdominal aortic aneurysms (AAA) electively treated with left sub-costal mini-laparotomy requiring infrarenal or suprarenal cross-clamping between 2013 and 2018 were retrospectively collected. Patients were divided into two groups: infra-renal cross-clamping (group A) and JAAA requiring supra-renal cross-clamping (group B). Early and mid-term mortality, postoperative renal dysfunction according to RIFLE criteria and factors affecting postoperative outcome were analysed. RESULTS Four hundred one patients, 356 (88.8%) men, mean age 70.8 yrs, underwent open surgical repair (OSR), 343 (85.5%) AAA in group A, 58 (14.5%) JAAA in group B. Mean diameter of the aneurysms was 54 ± 11.4 mm vs. 52 ± 9 mm and mean time of intervention 154.9 ± 56.3 min vs. 180.1 ± 65.7 min respectively. Total clamp time was 72.27 ± 31.4 vs. 75 ± 33.1 and suprarenal clamp time in group B 27.82 ± 14.1 min. Mean hospital length of stay was 5.1 ± 2.8 vs. 5.37 ± 3.4 days respectively. At 30 days, 3 (0.9%) patients died in group A and no one in group B; at 24 months 7 (2%) deaths in group A and 4 (6.9%) in group B. Preoperative, postoperative and discharge serum creatinine mean value, in group B, were 1.07 ± 0.32, 1.31 ± 0.36 and 1.83 ± 1.24 respectively. Based on RIFLE criteria for renal function, we observed Risk in 14.2% and Injury in 12.7% of patients after suprarenal cross clamping. CONCLUSIONS Our results show that mini-invasive open repair for JAAA with a suprarenal cross-clamping can be performed with acceptable morbidity and mortality rates similar to traditional surgical approach without significant modifications of renal functions.
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Affiliation(s)
- Alberto M Settembrini
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy.
| | - Michele Aronici
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Eugenio Martelli
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Francesco Casella
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Massimiliano Martelli
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Alessandra Renghi
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Giovanni Coppi
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Letizia De Simeis
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Carla Porta
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
| | - Piero Brustia
- Division of Vascular Surgery, University Hospital of Novara "Maggiore della Carità", Novara, Italy
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Chisci E, Pigozzi C, Alberti A, Masciello F, Troisi N, Turini F, Michelagnoli S. Staged in situ aorto-iliac hybrid technique: an original technique to treat complex juxtarenal and iliac aneurysms. INT ANGIOL 2020; 39:517-524. [PMID: 33140625 DOI: 10.23736/s0392-9590.20.04457-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To report a novel staged hybrid technique to treat complex juxtarenal abdominal aortic aneurysm (JAAA) associated with at least one iliac artery aneurysm (IA) with no adequate distal fixation zone. METHODS The novel technique herein described has two main "staged" steps. The first step consists in creating an adequate distal fixation zone by endovascular means; after hypogastric embolization an iliac stent-graft has placed from 5 mm above the aortic bifurcation to the external iliac artery. The second step is the surgical resection of the JAAA and graft placement sutured distally to the stent-graft which was always performed the day after. RESULTS The five cases included (mean age 74 years), were rejected for fenestrated or branched endovascular aortic repair or iliac branch devices. Four tube grafts and one aorto-bi-iliac graft were sutured to one stent-graft (N.=3), two stent-grafts in iliac kissing configuration (N.=1) and to a main body of a bifurcated stent-graft (N.=1). Mean follow-up duration was 14 (4-27) months with no mortality. Technical success was obtained in all cases (2 suprarenal clamping). Postoperative complications included two pleural effusions, two transient gluteal intermittent claudications, and one renal failure. CONCLUSIONS The technique herein described seems to be a feasible and cost-effective alternative treatment for selected concomitant complex JAAAs and IAs unsuitable for totally endovascular treatment.
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Affiliation(s)
- Emiliano Chisci
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Giovanni di Dio Hospital, Florence, Italy -
| | - Clara Pigozzi
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Giovanni di Dio Hospital, Florence, Italy
| | - Aldo Alberti
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Giovanni di Dio Hospital, Florence, Italy
| | - Fabrizio Masciello
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Giovanni di Dio Hospital, Florence, Italy
| | - Nicola Troisi
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Giovanni di Dio Hospital, Florence, Italy
| | - Filippo Turini
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Giovanni di Dio Hospital, Florence, Italy
| | - Stefano Michelagnoli
- Unit of Vascular and Endovascular Surgery, Department of Surgery, San Giovanni di Dio Hospital, Florence, Italy
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Končar IB, Jovanović AL, Dučič SM. The role of fEVAR, chEVAR and open repair in treatment of juxtarenal aneurysms: a systematic review. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:24-36. [PMID: 32079378 DOI: 10.23736/s0021-9509.19.11187-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Open repair (OR), fenestrated endovascular aneurysm repair (fEVAR) and endovascular exclusion using parallel graft (chEVAR) are complementary procedures used for treatment of juxtarenal abdominal aortic aneurysm (jrAAA). The aim of our study was to assess available literature and analyze dispersion of OR, fEVAR and chEVAR procedures among reported papers related to treatment of jrAAA. EVIDENCE ACQUISITION The PubMed database was systematically searched using predefined strategy and key words related to treatment of jrAAA on September 28th, 2019. Studies were assessed for eligibility using the inclusion and exclusion criteria with at least five patients treated with at least one of the procedures while systematic reviews, meta-analysis, reviews, comments, editorials and letters were excluded as well as studies without clear classification of the location of the aneurysm, studies not specifying the number of patients treated with each of the techniques or not discriminated between aortic pathologies (juxtarenal, paravisceral and thoracoabdominal), hybrid procedures, endoanchors or with branched stent-graft. EVIDENCE SYNTHESIS Overall, 1533 papers were identified while papers that met inclusion criteria were either representing experience of single institution (87 papers) or from multicenter studies (6 papers), national or international registries (18 papers). In the period between January 1977 and December 2017, treatment of 5664 patients with jrAAA was reported in 87 papers as a single institution report. Out of them 2531 (45%) were treated with OR, 2592 (46%) with fEVAR and 541 (9%) with chEVAR. Out of 29 institutions reporting OR, there were 11 (37.9%) with more than 100 treated patients while 21 (41.1%) out of 51 institutions that reported more than 50 jrAAA treated with fEVAR. Only four institutions reported results of all three treatment modalities. CONCLUSIONS Based on the results reported in the literature, regardless of its complexity and costs, fEVAR for jrAAA has been accepted in substantial number of hospitals worldwide, while number of reported procedures is reaching OR.
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Affiliation(s)
- Igor B Končar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Center, Belgrade, Serbia - .,Faculty of Medicine, University of Belgrade, Belgrade, Serbia -
| | - Aleksa L Jovanović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Institute of Epidemiology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Stefan M Dučič
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Center, Belgrade, Serbia
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Mascia D, Bertoglio L, Kahlberg AL, Grandi A, Melissano G, Chiesa R. Open Repair of Proximal Abdominal Aneurysms Analyzed According to the Anatomy, Clamping Site, and Theoretical Fenestrated Endovascular Design. Ann Vasc Surg 2020; 63:83-91. [DOI: 10.1016/j.avsg.2019.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/07/2019] [Indexed: 10/26/2022]
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Doonan RJ, Girsowicz E, Dubois L, Gill HL. A systematic review and meta-analysis of endovascular juxtarenal aortic aneurysm repair demonstrates lower perioperative mortality compared with open repair. J Vasc Surg 2019; 70:2054-2064.e3. [DOI: 10.1016/j.jvs.2019.04.464] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/06/2019] [Indexed: 11/16/2022]
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Jones AD, Waduud MA, Walker P, Stocken D, Bailey MA, Scott DJA. Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10 years. BJS Open 2019; 3:572-584. [PMID: 31592091 PMCID: PMC6773647 DOI: 10.1002/bjs5.50178] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 04/01/2019] [Indexed: 11/12/2022] Open
Abstract
Background Juxtarenal abdominal aortic aneurysms pose a significant challenge whether managed endovascularly or by open surgery. Fenestrated endovascular aneurysm repair (FEVAR) is now well established, but few studies have compared it with open surgical repair (OSR). The aim of this systematic review was to compare short- and long-term outcomes of FEVAR and OSR for the management of juxtarenal aortic aneurysms. Methods A literature search was conducted of the Ovid Medline, EMBASE and PubMed databases. Reasons for exclusion were series with fewer than 20 patients, studies published before 2007 and those concerning ruptured aneurysms. Owing to variance in definitions, the terms 'juxta/para/suprarenal' were used; thoracoabdominal aortic aneurysms were excluded. Primary outcomes were 30-day/in-hospital mortality and renal insufficiency. Secondary outcomes included major complication rates, rate of reintervention and rates of endoleak. Results Twenty-seven studies were identified, involving 2974 patients. Study designs included 11 case series, 14 series within retrospective cohort studies, one case-control study and a single prospective non-randomized trial. The pooled early postoperative mortality rate following FEVAR was 3·3 (95 per cent c.i. 2·0 to 5·0) per cent, compared with 4·2 (2·9 to 5·7) per cent after OSR. After FEVAR, the rate of postoperative renal insufficiency was 16·2 (10·4 to 23·0) per cent, compared with 23·8 (15·2 to 33·6) per cent after OSR. The major early complication rate following FEVAR was 23·1 (16·8 to 30·1) per cent versus 43·5 (34·4 to 52·8) per cent after OSR. The rate of late reintervention after FEVAR was higher than that after OSR: 11·1 (6·7 to 16·4) versus 2·0 (0·6 to 4·3) per cent respectively. Conclusion No significant difference was noted in 30-day mortality; however, FEVAR was associated with significantly lower morbidity than OSR. Long-term durability is a concern, with far higher reintervention rates after FEVAR.
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Affiliation(s)
- A. D. Jones
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
| | - M. A. Waduud
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
- The Leeds Institute of Cardiovascular and Metabolic Medicine, School of MedicineUniversity of LeedsLeedsUK
| | - P. Walker
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
| | - D. Stocken
- The Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - M. A. Bailey
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
- The Leeds Institute of Cardiovascular and Metabolic Medicine, School of MedicineUniversity of LeedsLeedsUK
| | - D. J. A. Scott
- The Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
- The Leeds Institute of Cardiovascular and Metabolic Medicine, School of MedicineUniversity of LeedsLeedsUK
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Varkevisser RR, O'Donnell TF, Swerdlow NJ, Liang P, Li C, Ultee KH, Pothof AB, De Guerre LE, Verhagen HJ, Schermerhorn ML. Fenestrated endovascular aneurysm repair is associated with lower perioperative morbidity and mortality compared with open repair for complex abdominal aortic aneurysms. J Vasc Surg 2019; 69:1670-1678. [DOI: 10.1016/j.jvs.2018.08.192] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/31/2018] [Indexed: 10/27/2022]
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Deery SE, Lancaster RT, Baril DT, Indes JE, Bertges DJ, Conrad MF, Cambria RP, Patel VI. Contemporary outcomes of open complex abdominal aortic aneurysm repair. J Vasc Surg 2016; 63:1195-200. [DOI: 10.1016/j.jvs.2015.12.038] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 12/03/2015] [Indexed: 10/21/2022]
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Rao R, Lane TR, Franklin IJ, Davies AH. Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms. J Vasc Surg 2015; 61:242-55. [DOI: 10.1016/j.jvs.2014.08.068] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 08/11/2014] [Indexed: 11/29/2022]
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Patel BN, Gayer G. Imaging of iatrogenic complications of the urinary tract: kidneys, ureters, and bladder. Radiol Clin North Am 2014; 52:1101-16. [PMID: 25173661 DOI: 10.1016/j.rcl.2014.05.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Iatrogenic complications of various severities may arise from many, if not all, forms of medical and surgical treatment. Most of these occur in spite of proper precautions. Every system in the human body may be affected, and the urinary tract is no exception. Radiologists are often the first to suspect and identify such iatrogenic injuries and, therefore, awareness of the pertinent imaging findings is vital. This review explores and illustrates many of the common and less common iatrogenic complications affecting the kidney, ureters, and bladder.
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Affiliation(s)
- Bhavik N Patel
- Division of Abdominal Imaging, Department of Radiology, Duke University Medical Center, 3808, Durham, NC 27710, USA
| | - Gabriela Gayer
- Division of Abdominal Imaging, Department of Radiology, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94304, USA; Department of Radiology, Sheba Medical Center, 2 Derech Sheba, Tel-Hashomer, Ramat-Gan 52621, Israel.
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Belczak SQ, Lanziotti L, Botelho Y, Aun R, Silva ESD, Puech-Leão P, Luccia ND. Open and endovascular repair of juxtarenal abdominal aortic aneurysms: a systematic review. Clinics (Sao Paulo) 2014; 69:641-6. [PMID: 25318097 PMCID: PMC4192422 DOI: 10.6061/clinics/2014(09)11] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/10/2014] [Indexed: 11/18/2022] Open
Abstract
This systematic review focuses on the 30-day mortality associated with open surgery and fenestrated endografts for short-necked (<15 mm) juxtarenal abdominal aortic aneurysms. A search for studies published in English and indexed in the PubMed and Medline electronic databases from 2002 to 2012 was performed, using "juxtarenal abdominal aortic aneurysm" and "treatment" as the main keywords. Among the 110 potentially relevant studies that were initially identified, eight were in accordance with the inclusion criteria in the analysis. Similar outcomes for open and endovascular repair were observed for 30-day mortality. No differences were observed regarding the secondary outcomes (duration of surgery, hospital stay, postoperative renal dysfunction and late mortality), except that the late mortality rate was significantly higher for the patients treated with open repair after a median follow-up of 24 months. Fenestrated endografting is a viable alternative to conventional surgery in juxtarenal abdominal aortic aneurysms with a proximal neck <15 mm.
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Affiliation(s)
- Sergio Quilici Belczak
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luiz Lanziotti
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Yuri Botelho
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ricardo Aun
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Erasmo Simão da Silva
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Pedro Puech-Leão
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Nelson de Luccia
- Vascular Surgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
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Abstract
Among the most important factors driving morbidity and mortality after aortic surgery is post operative renal insufficiency. The attendant metabolic derangements greatly complicate surgical care, expedite arrhythmias, and can significantly prolong hospital stay and cost. This article seeds to define factors contributory to renal complications after aortic surgery and offers a review of techniques to protect renal mass from post operative declines.
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Affiliation(s)
- James H Black
- Department of Surgery, Division of Vascular Surgery and Endovascular Surgery, Johns Hopkins Hospital, Halsted 668, 600 North Wolfe Street, Baltimore, MD 21287.
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Mooney JF, Ranasinghe I, Chow CK, Perkovic V, Barzi F, Zoungas S, Holzmann MJ, Welten GM, Biancari F, Wu VC, Tan TC, Cass A, Hillis GS. Preoperative estimates of glomerular filtration rate as predictors of outcome after surgery: a systematic review and meta-analysis. Anesthesiology 2013; 118:809-24. [PMID: 23377223 DOI: 10.1097/aln.0b013e318287b72c] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Kidney dysfunction is a strong determinant of prognosis in many settings. METHODS A systematic review and meta-analysis was undertaken to explore the relationship between estimated glomerular filtration rate (eGFR) and adverse outcomes after surgery. Cohort studies reporting the relationship between eGFR and major outcomes, including all-cause mortality, major adverse cardiovascular events, and acute kidney injury after cardiac or noncardiac surgery, were included. RESULTS Forty-six studies were included, of which 44 focused exclusively on cardiac and vascular surgery. Within 30 days of surgery, eGFR less than 60 m l · min · 1.73 m(-2) was associated with a threefold increased risk of death (multivariable adjusted relative risk [RR] 2.98; 95% confidence interval [CI] 1.95-4.96) and acute kidney injury (adjusted RR 3.13; 95% CI 2.22-4.41). An eGFR less than 60 ml · min · 1.73(-2) m was associated with an increased risk of all-cause mortality (adjusted RR 1.61; 95% CI 1.38-1.87) and major adverse cardiovascular events (adjusted RR 1.49; 95% CI 1.32-1.67) during long-term follow-up. There was a nonlinear association between eGFR and the risk of early mortality such that, compared with patients having an eGFR more than 90 ml · min · 1.73m(-2) the pooled RR for death at 30 days in those with an eGFR between 30 and 60 ml · min · 1.73 m(-2) was 1.62 (95% CI 1.43-1.80), rising to 2.85 (95% CI 2.49-3.27) in patients with an eGFR less than 30 ml · min · 1.73 m(-2) and 3.75 (95% CI 3.44-4.08) in those with an eGFR less than 15 ml · min · 1.73 m(-2). CONCLUSION : There is a powerful relationship between eGFR, and both short- and long-term prognosis after, predominantly cardiac and vascular, surgery.
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Affiliation(s)
- John F Mooney
- The George Institute for Global Health, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050 Australia.
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Katsargyris A, Oikonomou K, Klonaris C, Töpel I, Verhoeven EL. Comparison of Outcomes With Open, Fenestrated, and Chimney Graft Repair of Juxtarenal Aneurysms: Are We Ready for a Paradigm Shift? J Endovasc Ther 2013; 20:159-69. [PMID: 23581756 DOI: 10.1583/1545-1550-20.2.159] [Citation(s) in RCA: 186] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Patient survival after open and endovascular mesenteric revascularization for chronic mesenteric ischemia. J Vasc Surg 2013; 57:747-55; discussion 754-5. [PMID: 23332245 DOI: 10.1016/j.jvs.2012.09.047] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 09/11/2012] [Accepted: 09/18/2012] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate long-term patient survival and causes of death after open (OR) or endovascular (ER) mesenteric revascularization for atherosclerotic chronic mesenteric ischemia using propensity score-matched comparison and clinical risk stratification. METHODS The clinical data of 343 patients treated with mesenteric revascularization for chronic mesenteric ischemia between 1991 and 2010 were retrospectively reviewed. Clinical, anatomical, and procedure-related variables were analyzed using a multivariate model to identify independent predictors of any-cause early and late (>30 days) mortality. Cause of death was retrieved from review of the National Death Index. Patient survival was analyzed using Society for Vascular Surgery (SVS) comorbidity scores and propensity score-matched comparison based on independent predictors of any-cause mortality. RESULTS There were 187 patients treated by OR and 156 patients treated by ER. Early procedure-related mortality was 2.6% (9/343), including five OR (2.7%) and four ER (2.6%) patients. Median follow-up was 96 ± 54 months (range, 1-168 months). There were 144 late deaths, most commonly from cardiac causes in 35% (51/144), followed by cancer in 15% (21/144), pulmonary complications in 13% (19/144), and mesenteric ischemia in 11% (16/144). A further 21 patients died from various identifiable causes, and 14 patients (10%) died of unknown causes. Overall, 25 patients (7.3%) died of mesenteric-related causes, including nine early and 16 late deaths (OR, 10/187; 8.0%, and ER, 6/156; 6.4%). Multivariate analysis identified age >80, diabetes, chronic kidney disease (CKD) stage IV or V, and home oxygen therapy as independent predictors (P < .05) of any cause of death. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death (P < .05). Late patient survival at 5 years in the OR and ER groups was 75% ± 4% and 60% ± 9% for low SVS risk (<9), 52% ± 8% and 43% ± 9% for intermediate SVS risk (9-16), and 67% ± 15% and 30% ± 8% for high SVS risk (>16). Using propensity matched scores, 5-year survival was nearly identical for patients treated by OR (60%) or ER (57%; P = .7). CONCLUSIONS Long-term patient survival after mesenteric revascularization was not influenced by type of arterial reconstruction. Age >80 years, diabetes, CKD stage IV or V, and home oxygen were independent predictors of any-cause mortality. Diabetes and CKD stage IV or V were independently associated with mesenteric-related death.
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Dubois L, Durant C, Harrington DM, Forbes TL, Derose G, Harris JR. Technical factors are strongest predictors of postoperative renal dysfunction after open transperitoneal juxtarenal abdominal aortic aneurysm repair. J Vasc Surg 2013; 57:648-54. [PMID: 23312936 DOI: 10.1016/j.jvs.2012.09.043] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 09/05/2012] [Accepted: 09/11/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Juxtarenal abdominal aortic aneurysms (AAAs) have predominantly been repaired using an open technique. We present a series of patients with juxtarenal AAAs and analyze multiple factors predictive of postoperative renal dysfunction. METHODS Between March 2000 and September 2011, all patients in our prospectively maintained database undergoing juxtarenal AAA repair were evaluated for demographics, operative details, and in-hospital outcomes. Postoperative renal dysfunction was classified using the RIFLE (risk, injury, failure, loss, end-stage renal disease) criteria (glomerular filtration rate decrease >25%). The relationship between perioperative factors and postoperative renal dysfunction was explored using both univariate and multivariate analysis (logistic regression). RESULTS Of 169 patients, 76 (45%) required clamping above one renal artery, whereas 93 patients (55%) required clamping above both renal arteries. Mean (standard deviation) renal ischemia time was 29.2 (8.9) minutes (range, 12-65 minutes). Twenty-seven patients (16%) underwent adjunctive renal procedures, 19 (11.3%) required left renal vein division, and 130 (76.9%) received intraoperative mannitol. Postoperative renal dysfunction occurred in 63 patients (37.3%), with the majority (69%) resolving during hospital stay. Seven patients (4.1%) required postoperative dialysis, which was permanent in two cases. Patients who developed postoperative renal dysfunction had significantly longer mean renal ischemia times (34.7 [9.3] minutes vs 25.9 [6.6] minutes; P < .001), a higher rate of bilateral suprarenal aortic clamping (68.3% vs 47.2%; P = .008), higher rates of adjunctive renal artery procedures (26.7% vs 8.8%; P = .002), and higher rates of left renal vein division (20.6% vs 5.7%; P = .003). Logistic regression identified left renal vein division, renal ischemia time, and aortic clamp position as the strongest predictors of renal dysfunction. The use of mannitol was seen to be protective. Overall in-hospital mortality was 4.1% and was 9.5% among patients with postoperative renal dysfunction. CONCLUSIONS Postoperative transient renal dysfunction occurred in 37.3% of patients after open juxtarenal AAA repair, with a low incidence of dialysis and a low rate of permanent dysfunction. Technical factors including renal ischemia time, aortic clamp position, and left renal vein division are the strongest predictors of renal dysfunction. The use of intraoperative mannitol was associated with decreased postoperative renal dysfunction.
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Affiliation(s)
- Luc Dubois
- Division of Vascular Surgery, London Health Sciences Centre & Western University, London, Ontario, Canada
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Patel VI, Lancaster RT, Conrad MF, Lamuraglia GM, Kwolek CJ, Brewster DC, Cambria RP. Comparable mortality with open repair of complex and infrarenal aortic aneurysm. J Vasc Surg 2011; 54:952-9. [PMID: 21723071 DOI: 10.1016/j.jvs.2011.03.231] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 03/07/2011] [Accepted: 03/07/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND A consequence of endovascular aneurysm repair (EVAR) of anatomically straightforward infrarenal abdominal aortic aneurysm repair cohort (AAA) is that open aneurysm repair is more commonly performed for complex anatomy. Complex aneurysm repair with visceral vessel involvement (CAA) or combined aneurysm repair and visceral vessel reconstruction (VVR) has traditionally been considered to increase morbidity and mortality compared with repair of infrarenal AAA. This study evaluated contemporary outcomes of open abdominal aneurysm surgery, including AAA, CAA, and VVR using the National Surgical Quality Improvement Program (NSQIP) database. METHODS The NSQIP Participant Use File was queried by CPT code to identify patients undergoing AAA, CAA, and VVR (2005-2008). Comparative analysis of clinical features, technical details and 30-day outcomes was performed using univariate methods. Logistic regression analysis was used to identify predictors of morbidity and mortality. RESULTS A total of 2820 patients underwent AAA and 592 CAA. Renal insufficiency (ie, creatinine >1.4 mg/dL) rates were similar in AAA and CAA patients, however, more frequent in patients with VVR (51% vs 31% [no bypass]; P < .01). CAA was less likely to be performed urgently (6.3% vs 9.1%; P < .05) and was associated with increased operative time (254 ± 100 vs 224 ± 93; P < .01) compared with AAA. Univariate analysis showed that CAA did not increase mortality (5.7% vs 5.1%; P = .5). CAA slightly increased overall complications (32% vs 27%; P = .01) compared with AAA. 73 (2.5%) AAA and 84 (12%) CAA patients had simultaneous VVR and these patients exhibited a trend toward increased mortality (8.9% vs 5.2%; P = .07). VVR increased complications (43% (VVR) vs 26% [no bypass]; P < .01), including ventilation >48 hours (21% [VVR] vs 12% [no bypass]; P < .01), renal failure (7.6% [VVR] vs 4.1% [no bypass]; P = .04), and sepsis (13% [VVR] vs 6.3% ([no bypass]; P < .01). Multivariate analysis demonstrated that CAA (odds ratio [OR], 1.3 [95% confidence interval (CI), 1.1-1.6]; P = .01) and VVR (OR, 2.2 [95% CI, 1.8-3.6]; P < .01) increased the odds of any complication. Independent predictors of mortality included dependent functional status (OR, 3.6 [95% CI, 2.3-5.4]; P < .01), elevated pre-op creatinine (OR, 2.9 [95% CI, 2.2-4.0]; P < .01), type II diabetes (OR, 1.6 [95% CI, 1.05-2.4]; P = .03), and age (OR, 1.06 [95% CI, 1.03-1.08]; P < .01). Neither CAA (OR, 1.2 [95% CI, 0.84-1.8]; P = .3) nor VVR (OR, 1.6 [95% CI, 0.89-2.9]; P = .11) were associated with increased mortality compared with AAA. CONCLUSION In contemporary practice the migration of open repair to increasingly complex cases has been achieved with 30-day mortality essentially equivalent to open repair of infrarenal AAA. Patients who require VVR do sustain increased complications, in particular renal failure. These data also emphasize the importance of baseline renal insufficiency in clinical decision making. CAA and VVR are associated with increased morbidity in comparison to AAA repair; however, both procedures can be safely performed in patients without increased risk of operative mortality.
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Affiliation(s)
- Virendra I Patel
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Tallarita T, Sobreira ML, Oderich GS. Results of Open Pararenal Abdominal Aortic Aneurysm Repair: Tabular Review of the Literature. Ann Vasc Surg 2011; 25:143-9. [DOI: 10.1016/j.avsg.2010.10.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 10/06/2010] [Indexed: 11/28/2022]
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Juxtarenal aortic aneurysm repair. J Vasc Surg 2010; 52:760-7. [PMID: 20382492 DOI: 10.1016/j.jvs.2010.01.049] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 01/12/2010] [Accepted: 01/16/2010] [Indexed: 11/22/2022]
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Speziale F, Ruggiero M, Sbarigia E, Marino M, Menna D. Factors Influencing Outcome after Open Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms. Vascular 2010; 18:141-6. [DOI: 10.2310/6670.2010.00035] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to seek factors predicting outcome after open surgical repair of juxtarenal abdominal aortic aneurysms (AAAs). From a series of 733 patients treated for AAAs, 92 patients underwent elective conventional open repair with suprarenal clamping. We assessed postoperative cardiorespiratory and renal morbidity and mortality and survival at 1, 3, and 5 years. One patient (1.1%) died after an acute myocardial infarction. Postoperative complications including myocardial infarction and renal failure arose in 22 patients (23.9%). Significant predicting factors of renal failure were a preoperative creatinine clearance ≤ 40 mL/min ( p = .03) and female sex ( p = .004). Kaplan-Meier survival analysis showed an overall survival rate of 98.9% at 1 year and 88.6% at 3 and 5 years. In patients carefully selected by preoperative imaging criteria to undergo open juxtarenal AAA repair, appropriate intraoperative management guarantees a good immediate postoperative outcome.
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Affiliation(s)
- Francesco Speziale
- *Vascular Surgery Unit, Department “Paride Stefanini,” Policlicnico Umberto I, “Sapienza” University Rome, Rome, Italy
| | - Massimo Ruggiero
- *Vascular Surgery Unit, Department “Paride Stefanini,” Policlicnico Umberto I, “Sapienza” University Rome, Rome, Italy
| | - Enrico Sbarigia
- *Vascular Surgery Unit, Department “Paride Stefanini,” Policlicnico Umberto I, “Sapienza” University Rome, Rome, Italy
| | - Mario Marino
- *Vascular Surgery Unit, Department “Paride Stefanini,” Policlicnico Umberto I, “Sapienza” University Rome, Rome, Italy
| | - Danilo Menna
- *Vascular Surgery Unit, Department “Paride Stefanini,” Policlicnico Umberto I, “Sapienza” University Rome, Rome, Italy
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Verhoeven E, Vourliotakis G, Bos W, Tielliu I, Zeebregts C, Prins T, Bracale U, van den Dungen J. Fenestrated Stent Grafting for Short-necked and Juxtarenal Abdominal Aortic Aneurysm: An 8-Year Single-centre Experience. Eur J Vasc Endovasc Surg 2010; 39:529-36. [PMID: 20202868 DOI: 10.1016/j.ejvs.2010.01.004] [Citation(s) in RCA: 261] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Accepted: 01/04/2010] [Indexed: 10/19/2022]
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Modern Treatment of Juxtarenal Abdominal Aortic Aneurysms with Fenestrated Endografting and Open Repair – A Systematic Review. Eur J Vasc Endovasc Surg 2009; 38:35-41. [DOI: 10.1016/j.ejvs.2009.02.012] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Accepted: 02/23/2009] [Indexed: 11/21/2022]
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