1
|
Mascia D, Santoro A, Saracino C, Kahlberg AL, Chiesa R, Melissano G. Five-factors Modified Frailty Index role as predictors of outcomes after proximal abdominal aortic aneurysms. INT ANGIOL 2023; 42:520-527. [PMID: 37943290 DOI: 10.23736/s0392-9590.23.05071-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
BACKGROUND The aim of the study was to evaluate the correlation between frailty, measured by the Five-Factor Modified Frailty Index (mFI-5) and mortality and all major adverse events (MAE) in patients who underwent proximal abdominal aortic aneurysm (p-AAA) open surgery (OS). METHODS Data of all elective patients submitted to p-AAA OS from 2010 to 2021 were recorded. Primary endpoints were 30-day mortality and mid-term survival and secondary endpoints included postoperative acute kidney injury (AKI), freedom from aortic reintervention and any MAE. The impact of frailty was assessed by univariate and multivariate analysis; mid-term overall survival were estimated using Kaplan-Meier method (log-rank test). RESULTS Two-hundred twenty-one patients (197 male, 24 female; aged 72.2±7.4) were included. Thirty-seven (16.4%) were octogenarians (>80 years). The mFI-5 was assessed in the entire group: mean mFI-5 was 0.29±0.12. One-hundred patients (100/221, 45.25%, 91:9 male-to-female ratio) were defined "frail" considering the mFI-5 cut-off >0.25. At univariate analysis a correlation was found between mFI-5>0.25 and mid-term mortality (Pearson correlation [r] 0.280, P<0.001) and AKI (r=0.146, P=0.030). No correlation with 30-day mortality was found (P not significant). At multivariate analysis mFI-5>0.25 increased the risk for midterm mortality (odds ratio 3.32, P=0.021) and postoperative AKI (OR 2.09, P<0.001). The effect of mFI-5>0.25 on mid-term mortality persisted after adjustment for age (P<0.001). Survival was estimated with Kaplan-Meyer method (mean follow-up of 52.7 months, 95% CI: 48.6-56.8); 68 (30.7%) deaths were recorded: 23 among non-frail patients (19.0%) and 45 among frail patients (45/100, 45%, P<0.001). CONCLUSIONS These findings suggest that mFI-5 is a tool capable to identify "frail" patients, who appear to be at increased risk of postoperative AKI and mid-term mortality, but not 30-day mortality. Five-factor modified Frailty Index assessment is simple, fast and can be widely applied in surgical practice to perform appropriate risk stratifications.
Collapse
Affiliation(s)
- Daniele Mascia
- Department of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Annarita Santoro
- Department of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy -
| | - Concetta Saracino
- Department of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea L Kahlberg
- Department of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Germano Melissano
- Department of Vascular Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
2
|
Gallitto E, Faggioli G, Logiacco A, Mascoli C, Spath P, Palermo S, Pini R, Gargiulo M. Anatomical feasibility of the current endovascular solutions for Juxtarenal aortic abdominal aneurysm repair. Vascular 2023; 31:833-840. [PMID: 35513794 DOI: 10.1177/17085381221097304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Endovascular repair of juxta-renal aneurysms (JAAAs) can be achieved by fenestrated endografts (FEVAR), parallel-grafts (CHEVAR) and standard abdominal endografts + endoanchors (ESAR). Aim of this study was to evaluate the incidence of their anatomical feasibility in JAAAs. MATERIALS AND METHODS All patients submitted to JAAAs treatment from 2006 to 2019 were retrospectively analyzed, irrelevant of the procedure performed. Juxta-renal aneurysm was defined according with the current ESVS clinical practice guidelines. Preoperative computed tomography angiographies were analyzed to evaluate the anatomical feasibility of: FEVAR (Cook Zenith-platform; CE-marked or custom-made device), CHEVAR (Medtronic Endurant + Atrium Advanta - CE marked combination) and ESAR (Medtronic Endurant + Helifix - CE marked combination) according with the manufactures' instruction for use. The anatomical feasibility of these three endovascular solutions was assessed according with the proximal neck, target visceral vessels (TVVS) and iliac access characteristics. RESULTS Ninety-nine cases were considered. There were no cases of frank aortic rupture and in all patients at least one arterial access from above was available. Fenestrated endograft, CHEVAR, and ESAR were anatomically feasible in 93 (94%), 37 (37%), and 27 (27%) cases, respectively (p <. 001). Fenestrated endograft requires design with <3, three and >3 fenestrations in 29 (31%), 33 (36%), and 31 (33%) cases, respectively. Parallel graft technique have required 1 or 2 parallel graft configurations in 12 (12%) and 25 (25%) cases, respectively. Among the 14 cases with aneurysm diameter >70 mm, the anatomical feasibility of FEVAR, CHEVAR, and ESAR was 13(93%), 4(29%), and 4 (29%) cases, respectively (p < .001). CONCLUSION Fenestrated endograft is more frequently applicable than CHEVAR and ESAR as endovascular treatment of JAAAs. Since this difference is valid also in aneurysms with diameter >70 mm, the issue of a rapid availability is of paramount importance. The 6% of cases have not any endovascular solution and requires open surgery.
Collapse
Affiliation(s)
- Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Antonino Logiacco
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Chiara Mascoli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Paolo Spath
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Sergio Palermo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Rodolfo Pini
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, IRCCS Sant'Orsola-Malpighi Hospital, Bologna, Italy
| |
Collapse
|
3
|
E G, G F, G M, A F, G I, M L, C P, R C, M G. Pre and postoperative predictors of clinical outcome of fenestrated and branched endovascular repair for complex abdominal and thoracoabdominal aortic aneurysms in an Italian multicenter registry. J Vasc Surg 2021; 74:1795-1806.e6. [PMID: 34098004 DOI: 10.1016/j.jvs.2021.04.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 04/17/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Complex aortic aneurysms (juxtarenal j-AAA, pararenal p-AAAs, thoracoabdominal TAAAs) are treated with increasing frequency through fenestrated and branched endovascular repair (F/B-EVAR), however the outcome of these procedures is usually reported separately by single experiences and wider overviews are not frequent. The aim of this study was therefore to report an Italian experience analyzing the results obtained in 4 academic centers in order to evaluate predictors of outcome. METHODS Between 2008 and 2019, all consecutive patients undergoing F/B-EVAR in 4 Italian university centers were prospectively recorded and retrospectively analyzed. Preoperative comorbidities and postoperative complications were classified according with the SVS-reporting standard. Postoperative complications and 30-day / in-hospital mortality were assessed as early outcomes. Survival, freedom from reinterventions (FFRs) and target visceral vessels (TVVs) patency were assessed as follow-up outcomes by Kaplan-Meier analysis. Risk factors for 30-day / in-hospital mortality and spinal cord ischemia (SCI) were determined by multivariate analysis. Risk factors for follow-up mortality and reinterventions were evaluated by Cox-regression model. RESULTS Five hundred and ninety-six patients underwent F/B-EVAR for 124(21%) j-AAAs, 121(20%) p-AAAs and 351(59%) TAAAs. Elective and urgent procedures were performed in 520(87%) and 76(13%) cases, respectively. Postoperative cardiac, pulmonary and renal complications were reported in 41(7%), 50(8%) and 80(13%) patients, respectively. Seven (1%) bowel ischemia and 23(4%) cerebrovascular complications occurred. Forty-seven (8%) patients suffered SCI with 17(3%) cases of permanent paraplegia. Crawford's extent I-II-III TAAAs (OR:13.41; 95%CI:1.77-101.65; P=.012) and postoperative renal complications (OR:3.84; 95%CI:1.70-8.69; P=.001) independently predicted SCI. Thirty-two (5%) patients died in the perioperative period. Preoperative chronic renal failure (OR:7.81; 95%CI:7.81-26.31; P=.001), postoperative bowel ischemia (OR:26.97; 95%CI:3.37-215.5; P=.002), cardiac (OR:5.77; 95%CI:1.41-23.64; P=<.001),cerebrovascular (OR:28.63; 95%CI:5.20-157.5; P:<.001) complications and SCI (OR:5.99; 95%CI:1.12-32.5; P=.036) were independently correlated with 30-day/hospital mortality. The mean follow-up was 25+7months. Freedom from TVVs occlusion and FFR were 96% and 92% at 1 year and 93% and 85% at 3 years, respectively. TAAAs (HR:3.16; 95%CI:1.68-5.92; P=<.001), post dissection TAAAs (HR:2.20; 95%CI:1.30-4.90; P=.05) and postoperative bowel ischemia (HR:11.98; 95%CI:1.53-93.31; P=.018) were independent predictors of reinterventions. Survival was 88% and 78% at 1 and 3 years, respectively. Preoperative chronic renal failure (HR:2.39; 95%CI:1.59-3.59; P=<.001), urgent repair (HR:1.80; 95%CI:1.03-3.20; P=.039), TAAAs (HR:2.01; 95%CI:1.13-3.56; P=.017),postoperative bowel ischemia (HR:5.55; 95%CI:2.11-14.59; P=.001), cardiac (HR:3.89; 95%CI:2.25-6.71; P=<.001) and pulmonary (HR:1.97; 95%CI:1.56-3.35; P=.013) complications were independent predictors of mortality during follow up. CONCLUSION F/B-EVAR is associated with satisfactory mid-term outcomes in a nationwide experience. A variety of risk factors should be considered in FB-EVAR indication and post-operative patients management in order to reduce the risk of postoperative complications and improve mid-term outcome.
Collapse
Affiliation(s)
- Gallitto E
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Faggioli G
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy.
| | - Melissano G
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fargion A
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Isernia G
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Lenti M
- Vascular and Endovascular Surgery Unit, Hospital S. Maria Misericordia, University of Perugia, Perugia, Italy
| | - Pratesi C
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Chiesa R
- Division of Vascular Surgery, Vita - Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gargiulo M
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| |
Collapse
|
4
|
MASCIA D, GRANDI A, BERTOGLIO L, KAHLBERG A, SARACINO C, MELISSANO G, CHIESA R. The revascularization technique does not impact renal function after proximal abdominal aortic aneurysm open repair. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:42-50. [DOI: 10.23736/s0021-9509.20.11202-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
5
|
Proximal Aortic Coverage and Clinical Results of the Endovascular Repair of Juxta-/Para-renal and Type IV Thoracoabdominal Aneurysm with Custom-made Fenestrated Endografts. Ann Vasc Surg 2021; 73:397-406. [PMID: 33412242 DOI: 10.1016/j.avsg.2020.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/30/2020] [Accepted: 12/05/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Juxta-renal (JAAA)/para-renal (PAAA) and type IV-thoracoabdominal (TAAA) aneurysms can be repaired by custom-made fenestrated endografts (CM-FEVAR). Differently from open repair, a relatively long segment of healthy proximal aorta needs to be covered to achieve a durable sealing, and this may be considered a disadvantage of the endovascular approach. We aimed to quantify the additional proximal aortic coverage in JAAAs, PAAAs, and type-IV TAAAs treated with CM-FEVAR and to evaluate its impact on early/follow-up clinical outcomes. METHODS Between 2006 and 2018, preoperative, intraoperative, and postoperative data of JAAAs, PAAAs, and type-IV TAAAs submitted to CM-FEVAR were collected. The length of proximal healthy aortic coverage was evaluated on the preoperative endograft planning as the distance between the top of the CM-FEVAR endograft and the hypothetical level of aortic cross-clamping in case of open repair (type-IV TAAA-above the celiac trunk; PAAA-above the superior mesenteric artery; JAAA-above the lowest renal artery). Spinal cord ischemia (SCI), bowel ischemia (BI), renal function worsening (RFW) (estimated glomerular filtration rate reduction > 25% of the baseline level - RFW), and mortality were assessed at 30-day. Survival, target visceral vessel (TVV) patency, and freedom from reinterventions (FFRs) were assessed during follow-up by Kaplan-Meier analysis R2. RESULTS One hundred forty-seven cases were submitted to CM-FEVAR, for 72 (49%) JAAAs, 46 (31%) PAAAs, and 29 (20%) type IV-TAAAs, with 1(4-3%), 2 (28-19%), 3 (48-33%), and 4 (67-45%) fenestrations. JAAAs required a fenestration + bridging stent graft for the superior mesenteric artery and celiac trunk, in 46(64%) and 24(33%) cases, respectively. Nineteen (41%) PAAAs required a fenestration + bridging stent graft for the celiac trunk. The mean proximal additional aortic coverage was 48 ± 2 mm with no differences among JAAAs (52 ± 1 mm), PAAAs (42 ± 2 mm), and type IV-TAAAs (50 ± 2 mm) (P.09). Technical success, defined as correct endograft deployment, with TVV patency, absence of type I-III endoleaks, iliac leg stenosis/occlusions, open surgical conversion, and 24-hour mortality, was achieved in 98% of cases. Failures occurred for 1 type-III endoleak (type-IV TAAA) and 2 renal artery losses (PAAA and type IV-TAAA). The only case of SCI (0.7%) occurred in a type-IV TAAA where the proximal healthy aortic coverage was 80 mm. One BI was caused by acute thrombosis of the bridging stent graft for the superior mesenteric artery at 24 hours in 1 type IV-TAAA (0.7%). Thirty-five patients (24%) suffered postoperative RFW and required hemodialysis in 1 (0.7%) JAAA with severe preoperative chronic renal failure. There was no difference of proximal additional aortic coverage between patients with (49 ± 29 mm) and without (48 ± 23 mm) RFW (P.2). The 30-day mortality was 1.4%. The mean follow-up was 37 ± 2 months with no cases of aneurysm-related late mortality. Survival was 94%, 89%, and 75% at 1, 2, and 5 years, respectively. TVV patency was 97%, 97%, and 93% at 1, 2, and 5 years, respectively. FFR was 98%, 95%, and 87% at 1, 2, and 5 years, respectively. CONCLUSIONS Custom-made FEVAR requires a mean proximal additional aortic coverage of 48 ± 2 mm above the level of hypothetical aortic cross-clamping in case of open repair. This aspect should be considered for CM-FEVAR indication in JAAAs, PAAAs, and type-IV TAAAs; nevertheless, it does not appear to be associated with negative early and follow-up clinical sequelae.
Collapse
|