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Patient-tailored approach for diagnostics and treatment of mycotic abdominal aortic aneurysm. Ann Vasc Surg 2022; 84:225-238. [PMID: 35104593 DOI: 10.1016/j.avsg.2022.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/10/2021] [Accepted: 01/04/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The existing literature on mycotic aortic aneurysm is scarce and focuses on treatment. This study evaluates the clinical characteristics, diagnostics, treatment and outcome of patients with a mycotic abdominal aortic aneurysm treated in a tertiary referral center. METHODS A retrospective cohort study was conducted including all patients with a proven mycotic abdominal aortic aneurysm admitted between May 2010 and July 2020. Primary outcome was mortality and secondary outcome included complications such as vascular graft/endograft infection. RESULTS Twenty-four patients with a mycotic abdominal aortic aneurysm were included. Patients had a mean age of 68 ± 9 years and 20 (83%) were male. Thirteen patients (57%) had positive preoperative blood cultures. Streptococcus pneumoniae was most frequently isolated by blood culturing, pus, and vascular or perivascular tissue cultures (17%). In 19 (83%) patients the mycotic abdominal aortic aneurysm was located infrarenally, in three (13%) patients suprarenally, and in one (4%) patient juxtarenally. Median follow-up was 20 (7-42) months. In eight patients (33%) vascular graft and or endograft infection was diagnosed after surgical repair. Ten (42%) patients died during the follow-up period. The main causes of death were vascular graft/endograft infection-related (n=4) and rupture of the mycotic abdominal aortic aneurysm (n=3). No patient characteristics could be identified as predictive for mortality. CONCLUSION This study shows a large variation in presentation, diagnostic approaches, and surgical and antibiotic treatment of mycotic abdominal aortic aneurysm. The detailed information about the diagnostic approaches to this rare disease and its antibiotic/other treatment contributes to existing knowledge of mycotic abdominal aortic aneurysm. Because of the individual variation patients should be discussed in a multidisciplinary team with a vascular surgeon, infectious disease specialist, and clinical microbiologist.
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Gupta AK, Dakour-Aridi H, Locham S, Nejim B, Veith FJ, Malas MB. Real-world evidence of superiority of endovascular repair in treating ruptured abdominal aortic aneurysm. J Vasc Surg 2018; 68:74-81. [DOI: 10.1016/j.jvs.2017.11.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/05/2017] [Indexed: 11/26/2022]
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Amato B, Fugetto F, Compagna R, Zurlo V, Barbetta A, Petrella G, Aprea G, Danzi M, Rocca A, de Franciscis S, Serra R. Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review. MINERVA CHIR 2018; 74:472-480. [PMID: 29806754 DOI: 10.23736/s0026-4733.18.07768-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions. EVIDENCE ACQUISITION A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data. EVIDENCE SYNTHESIS Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts. CONCLUSIONS The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.
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Affiliation(s)
- Bruno Amato
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Francesco Fugetto
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy
| | - Rita Compagna
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Valeria Zurlo
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy
| | - Andrea Barbetta
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | | | - Giovanni Aprea
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Michele Danzi
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Aldo Rocca
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy - .,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
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Stoneham MD, Von Kier S, Harvey L, Murphy M. Effects of a targeted blood management programme on allogeneic blood transfusion in abdominal aortic aneurysm surgery. Transfus Med 2017; 28:290-297. [PMID: 29243334 DOI: 10.1111/tme.12495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To investigate the impact of a dedicated cell salvage practitioner team on blood loss and allogeneic transfusion in abdominal aortic aneurysm (AAA) surgery. BACKGROUND Cell salvage reduces allogeneic transfusion in AAA surgery, but is commonly performed by the anaesthetic nurse. At our hospital, a dedicated patient blood management practitioner is present for all elective open AAA repairs. METHODS/MATERIALS Data were collected on 171 AAA patients operated on at the John Radcliffe Hospital, Oxford over a 3-year period, looking at the Patient Blood Management processes, including: blood loss, cell salvage, near-patient testing (thrombelastography) and transfusion rates of allogeneic blood products. RESULTS Blood loss ranged from 3-108% of estimated blood volume (EBV) (median 25% = 1500 mL). In seven patients who lost 70-110% of their EBV, none reached the thrombelastography intervention threshold for R time (11 min) or MA (48 mm) despite such massive blood loss. Overall, only 7/171 (4%) patients received intra-operative allogeneic blood, all of whom had a mean baseline haemoglobin concentration < 106 g L-1 (median 98, range 95-105 g L-1 ). In terms of other blood products, only 4/171 (2·3%) received one unit of platelets each intra-operatively. None received FFP or cryoprecipitate. CONCLUSIONS Such low levels of allogeneic transfusion have not been reported previously. We hypothesise that this is due to the additional blood management contributions of the specialised cell salvage practitioners and collaboration with the rest of the vascular surgical team. These results support the development of pre-operative anaemia clinics. Overall the service runs at a profit to the trust.
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Affiliation(s)
- M D Stoneham
- Nuffield Division of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - S Von Kier
- Haemostasis and Blood Conservation Service, John Radcliffe Hospital, Oxford, UK
| | - L Harvey
- Nuffield Division of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - M Murphy
- National Health Service (NHS) Blood and Transplant & Oxford National Institute for Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals & University of Oxford, Oxford, UK
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Bos WTGJ, Verhoeven ELG, Zeebregts CJAM, Tielliu IFJ, Prins TR, Oranen BI, van den Dungen JJAM. Emergency Endovascular Stent Grafting for Thoracic Aortic Pathology. Vascular 2016; 15:12-7. [PMID: 17382049 DOI: 10.2310/6670.2007.00002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Our aim was to report single-center results of emergency endovascular treatment for thoracic aortic disease. From March 1998 to January 2006, 30 acute thoracic EVAR procedures were carried out in 29 patients. One patient received two procedures in different settings. Four patients died before treatment could be initiated. The pathology of aortic lesions included atherosclerotic aneurysm ( n = 13), pseudoaneurysm ( n = 6), aortic rupture ( n = 5), type B dissection ( n = 5), aortobronchial or aortoesophageal fistula ( n = 4), and intramural hematoma ( n = 1). The surgical mortality rate was 21%. Three patients died as a result of technical complications, and three patients died after technically successful procedures. The mean follow-up was 31 ± 23 months. The late mortality rate was 40% (8 of 20). Four patients died of causes unrelated to the procedure; two patients died at home without autopsy. Two patients died as a consequence of graft infections. Three late nonfatal complications occurred. Two of these resulted in additional treatment: one patient developed a mycotic aneurysm that was treated with additional stent grafting, and one patient developed a type 3 endoleak after 6 years of follow-up and was successfully treated with a bridging stent graft. Endovascular treatment for acute thoracic disease is feasible and associated with a reasonable outcome. In selected cases, it may be considered as a first option.
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Affiliation(s)
- Wendy T G J Bos
- Department of Surgery, University Medical Center Groningen, 9700 RB Groningen, the Netherlands.
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6
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Patelis N, Moris D, Karaolanis G, Georgopoulos S. Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm. Med Sci Monit Basic Res 2016; 22:34-44. [PMID: 27090791 PMCID: PMC4847558 DOI: 10.12659/msmbr.897601] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Patients presenting with ruptured abdominal aortic aneurysms are most often treated with open repair despite the fact that endovascular aneurysm repair is a less invasive and widely accepted method with clear benefits for elective aortic aneurysm patients. A debate exists regarding the definitive benefit in endovascular repair for patients with a ruptured abdominal aortic aneurysm. The aim of this literature review was to determine if any trends exist in favor of either open or endovascular repair. Material/Methods A literature search was performed using PUBMED, OVID, and Google Scholar databases. The search yielded 64 publications. Results Out of 64 publications, 25 were retrospective studies, 12 were population-based, 21 were prospective, 5 were the results of RCTs, and 1 was a case-series. Sixty-one studies reported on early mortality and provided data comparing endovascular repair (rEVAR) and open repair (rOR) for ruptured abdominal aneurysm groups. Twenty-nine of these studies reported that rEVAR has a lower early mortality rate. Late mortality after rEVAR compared to that of rOR was reported in 21 studies for a period of 3 to 60 months. Results of 61.9% of the studies found no difference in late mortality rates between these 2 groups. Thirty-nine publications reported on the incidence of complications. Approximately half of these publications support that the rEVAR group has a lower complication rate and the other half found no difference between the groups. Length of hospital stay has been reported to be shorter for rEVAR in most studies. Blood loss and need for transfusion of either red cells or fresh frozen plasma was consistently lower in the rEVAR group. Conclusions Differences between the included publications affect the outcomes. Randomized control trials have not been able to provide clear conclusions. rEVAR can now be considered a safe method of treating rAAA, and is at least equal to the well-established rOR method.
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Affiliation(s)
- Nikolaos Patelis
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Demetrios Moris
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Georgios Karaolanis
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Sotiris Georgopoulos
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
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Luebke T, Brunkwall J. Risk-Adjusted Meta-analysis of 30-Day Mortality of Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2015; 29:845-63. [DOI: 10.1016/j.avsg.2014.12.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/19/2014] [Accepted: 12/22/2014] [Indexed: 12/20/2022]
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Raats JW, Flu HC, Ho GH, Veen EJ, Vos LD, Steyerberg EW, van der Laan L. Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age. Clin Interv Aging 2014; 9:1721-32. [PMID: 25342890 PMCID: PMC4206251 DOI: 10.2147/cia.s64718] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA. Methods We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital. Results Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01–1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70–79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008). Conclusion The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.
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Affiliation(s)
- Jelle W Raats
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Hans C Flu
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Eelco J Veen
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Louwerens D Vos
- Department of Radiology, Amphia Hospital, Breda, the Netherlands
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Blaszak M, Juszkat R. Monte Carlo Simulations for Assessment of Organ Radiation Doses and Cancer Risk in Patients Undergoing Abdominal Stent-graft Implantation. Eur J Vasc Endovasc Surg 2014; 48:23-8. [DOI: 10.1016/j.ejvs.2014.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 03/20/2014] [Indexed: 11/24/2022]
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Piffaretti G, Caronno R, Tozzi M, Lomazzi C, Rivolta N, Castelli P. Endovascular versus open repair of ruptured abdominal aortic aneurysms. Expert Rev Cardiovasc Ther 2014; 4:839-52. [PMID: 17173500 DOI: 10.1586/14779072.4.6.839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although major improvement has occurred to make elective repair of abdominal aortic aneurysms a safe procedure, the incidence of ruptured abdominal aortic aneurysms and mortality rates are still disappointing. Endovascular abdominal aortic aneurysm repair has produced quantum changes in aneurysm treatment. The successful application of the endovascular approach for the treatment of abdominal aortic aneurysms in the elective setting has prompted a strong interest regarding its possible use in dealing with the long-standing challenge of a ruptured abdominal aortic aneurysm. Since the first report, several centers have reported results and a wide spectrum of opinion regarding its application, with special consideration to logistical and practical barriers for appropriate utilization. The purpose of this article is to review all the available literature on the endovascular repair of ruptured abdominal aortic aneurysms and to analyze the most recent trends in their management, with special consideration given to comparing results of conventional and endovascular approaches.
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Affiliation(s)
- Gabriele Piffaretti
- University of Insubria, Vascular Surgery-Department of Surgery, Viale Borri 57 21100, Varese, Italy.
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Matsushita M, Ikezawa T, Sugimoto M, Idetsu A. Management of symptomatic abdominal aortic aneurysms following emergency computed tomography. Surg Today 2013; 44:620-5. [DOI: 10.1007/s00595-013-0512-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Accepted: 01/23/2013] [Indexed: 10/27/2022]
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Stokmans R, Teijink J, Cuypers P, Riambau V, van Sambeek M. No Differences in Perioperative Outcome between Symptomatic and Asymptomatic AAAs after EVAR: An Analysis from the ENGAGE Registry. Eur J Vasc Endovasc Surg 2012; 43:667-73. [DOI: 10.1016/j.ejvs.2012.02.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 02/21/2012] [Indexed: 11/29/2022]
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Ten Bosch JA, Willigendael EM, Kruidenier LM, de Loos ER, Prins MH, Teijink JAW. Early and mid-term results of a prospective observational study comparing emergency endovascular aneurysm repair with open surgery in both ruptured and unruptured acute abdominal aortic aneurysms. Vascular 2012; 20:72-80. [DOI: 10.1258/vasc.2011.oa0302] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of the paper is to prospectively describe early and mid-term outcomes for emergency endovascular aneurysm repair (eEVAR) versus open surgery in acute abdominal aortic aneurysms (aAAAs), both unruptured (symptomatic) and ruptured. We enrolled all consecutive patients treated for aAAA at our center between April 2002 and April 2008. The main outcome parameters were 30-day, 6- and 12-month mortality (all-cause and aneurysm-related). Two hundred forty patients were enrolled in the study. In the unruptured aAAA group ( n = 111), 47 (42%) underwent eEVAR. The 30-day, 6- and 12-month mortality rates were 6, 13 and 15% in the eEVAR group versus 11% (NS), 13% (NS) and 16% (NS) in the open group, respectively. In the ruptured aAAA group ( n = 129), 25 (19%) underwent eEVAR (mortality rates: 20, 28 and 36%, respectively) compared with 104 (81%) patients who underwent open surgery (mortality rates: 45% ( P = 0.021), 60% ( P = 0.004) and 63% ( P = 0.014), respectively). In conclusion, the present study showed a reduced 30-day, 6- and 12-month mortality of eEVAR compared with open surgery in all patients with aAAA, mainly due to a lower mortality in the ruptured aAAA group. Late aneurysm-related mortality occurred only in the eEVAR group.
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Affiliation(s)
- J A Ten Bosch
- Department of Surgery, Atrium Medical Centre Parkstad, PO Box 4446, 6401 CX, Heerlen
| | - E M Willigendael
- Department of Surgery – Vascular Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven
| | - L M Kruidenier
- Department of Surgery, Atrium Medical Centre Parkstad, PO Box 4446, 6401 CX, Heerlen
| | - E R de Loos
- Department of Surgery, Atrium Medical Centre Parkstad, PO Box 4446, 6401 CX, Heerlen
| | - M H Prins
- Department of Epidemiology, Caphri Research School, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
| | - J A W Teijink
- Department of Surgery – Vascular Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven
- Department of Epidemiology, Caphri Research School, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands
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Ten Bosch J, Cuypers P, van Sambeek M, Teijink J. Current insights in endovascular repair of ruptured abdominal aortic aneurysms. EUROINTERVENTION 2011; 7:852-8. [DOI: 10.4244/eijv7i7a133] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Carrafiello G, Piffaretti G, Laganà D, Fontana F, Mangini M, Ierardi AM, Piacentino F, Canì A, Mariscalco G, Di Massa A, Cuffari S, Castelli P, Fugazzola C. Endovascular treatment of ruptured abdominal aortic aneurysms: aorto-uni-iliac or bifurcated endograft? LA RADIOLOGIA MEDICA 2011; 117:410-25. [PMID: 21892717 DOI: 10.1007/s11547-011-0717-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 02/21/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE This study evaluated the safety and technical and clinical success rates of positioning endovascular endografts (EG) in ruptured abdominal aneurysms. MATERIALS AND METHODS Patients with a ruptured abdominal aortic aneurysm confirmed by contrast-enhanced computed tomography angiography (CTA) were eligible for the analysis. Of 67 patients, 42 (62.7%) were treated with EG. Thirteen patients (30.9%) received an aorto-uni-iliac EG (group A) and 29 a bifurcated EG (group B). Patients were divided for comparative analysis according to the configuration of the EG implanted. RESULTS The primary technical success rate was 100%; the primary clinical success rate was 95% (40/42). There were two intraoperative deaths (4.7%) related to intractable shock. No patient required conversion to open repair. Overall, 12 patients (28.5%) died within 30 days. The in-hospital death rate was 30.9% (13/42). Hospital mortality rate was statistically higher in group A; the type of EG and intensive care unit admission were the only independent predictors of hospital mortality. CONCLUSIONS In our experience, a higher mortality rate was observed for the aorto-uni-iliac configuration; shock at admission was confirmed as the most important factor for postoperative survival.
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Affiliation(s)
- G Carrafiello
- Interventional Radiology, Department of Radiology, University of Insubria, Viale Borri 57, 21100, Varese, Italy.
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Moll FL, Powell JT, Fraedrich G, Verzini F, Haulon S, Waltham M, van Herwaarden JA, Holt PJE, van Keulen JW, Rantner B, Schlösser FJV, Setacci F, Ricco JB. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 Suppl 1:S1-S58. [PMID: 21215940 DOI: 10.1016/j.ejvs.2010.09.011] [Citation(s) in RCA: 996] [Impact Index Per Article: 76.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Accepted: 09/12/2010] [Indexed: 12/11/2022]
Affiliation(s)
- F L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, The Netherlands.
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Perrott S, Puckridge P, Foreman R, Russell D, Spark J. Anatomical Suitability For Endovascular AAA Repair May Affect Outcomes following Rupture. Eur J Vasc Endovasc Surg 2010; 40:186-90. [DOI: 10.1016/j.ejvs.2010.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 04/04/2010] [Indexed: 10/19/2022]
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Endovascular aneurysm repair is superior to open surgery for ruptured abdominal aortic aneurysms in EVAR-suitable patients. J Vasc Surg 2010; 52:13-8. [DOI: 10.1016/j.jvs.2010.02.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 12/16/2009] [Accepted: 02/06/2010] [Indexed: 11/19/2022]
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Soong CV, Dasari BVM, Loan W, Hannon R, Lee B, Lau L, Thompson M. Setting the Standards for Reporting Ruptured Abdominal Aortic Aneurysm. Vasc Endovascular Surg 2010; 44:449-53. [DOI: 10.1177/1538574410373667] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Reported mortality rates for endovascular repair (EVR) of ruptured abdominal aortic aneurysm (rAAA) vary from 0% to 50%. Selection bias, inaccurate reporting, and lack of uniform reporting standards are responsible for this significant discrepancy. Material and Methods: Existing literature about the classification/reporting systems of rAAA is reviewed. A standard way of reporting rAAA based on the physiological, radiological, and operative findings is proposed. Conclusion: The proposed system attempts to provide a universal language of communicating the severity of rupture, address the reporting bias, and allow comparing the outcomes of rAAA.
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Affiliation(s)
- Chee V. Soong
- Department of Vascular Surgery, Belfast City Hospital, Belfast, UK
| | | | - William Loan
- Department of Vascular Surgery, Belfast City Hospital, Belfast, UK
| | - Ray Hannon
- Department of Vascular Surgery, Belfast City Hospital, Belfast, UK
| | - Bernard Lee
- Department of Vascular Surgery, Belfast City Hospital, Belfast, UK
| | - Louis Lau
- Department of Vascular Surgery, Belfast City Hospital, Belfast, UK
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Paraskevas KI, Tsiantoula P, Mikhailidis DP, Giannoukas AD. eComment: Endovascular repair of ruptured abdominal aortic aneurysms: identifying issues which may be difficult to achieve. Interact Cardiovasc Thorac Surg 2010; 10:619. [PMID: 20335396 DOI: 10.1510/icvts.2009.228866a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Red Cross Hospital, 24 Al Papagou Street, 14122 Athens, Greece
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Ricotta JJ, Malgor RD, Oderich GS. Ruptured Endovascular Abdominal Aortic Aneurysm Repair: Part II. Ann Vasc Surg 2010; 24:269-77. [DOI: 10.1016/j.avsg.2009.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Accepted: 08/21/2009] [Indexed: 12/11/2022]
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22
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Collected World and Single Center Experience With Endovascular Treatment of Ruptured Abdominal Aortic Aneurysms. Ann Surg 2009; 250:818-24. [PMID: 19809296 DOI: 10.1097/sla.0b013e3181bdd7f5] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Eliason JL, Upchurch GR. Endovascular treatment of aortic aneurysms: State of the art. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2009; 11:136-45. [DOI: 10.1007/s11936-009-0014-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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24
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10 Years of Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortoiliac Aneurysms: Lessons Learned. Ann Surg 2009; 249:510-5. [DOI: 10.1097/sla.0b013e31819a8b65] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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An Emergency EVAR Service Reduces Mortality in Ruptured Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2009; 37:189-93. [DOI: 10.1016/j.ejvs.2008.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Accepted: 11/03/2008] [Indexed: 10/21/2022]
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26
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Bos WTGJ, Cohen T, Vourliotakis G, Sambeek MRHMV, Verhoeven ELG. Open Treatment Versus Endovascular Repair for Aortic Abdominal Aneurysm-Keeping the Balance. Ann Vasc Dis 2009. [DOI: 10.3400/avd.sa09001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bos W, Cohen T, Vourliotakis G, van Sambeek M, Verhoeven E. Open treatment versus endovascular repair for aortic abdominal aneurysm-keeping the balance. Ann Vasc Dis 2009; 2:95-9. [PMID: 23555366 DOI: 10.3400/avd.avdsa09001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2009] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wtgj Bos
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Verhoeven EL, Kapma MR, Groen H, Tielliu IF, Zeebregts CJ, Bekkema F, van den Dungen JJ. Mortality of ruptured abdominal aortic aneurysm treated with open or endovascular repair. J Vasc Surg 2008; 48:1396-400. [DOI: 10.1016/j.jvs.2008.07.054] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 07/12/2008] [Accepted: 07/15/2008] [Indexed: 02/06/2023]
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A Systematic Review and Meta-analysis of Endovascular Repair (EVAR) for Ruptured Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2008; 36:536-44. [DOI: 10.1016/j.ejvs.2008.08.008] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 08/06/2008] [Indexed: 11/17/2022]
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30
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Sadat U, Boyle JR, Walsh SR, Tang T, Varty K, Hayes PD. Endovascular vs open repair of acute abdominal aortic aneurysms—A systematic review and meta-analysis. J Vasc Surg 2008; 48:227-36. [DOI: 10.1016/j.jvs.2007.11.028] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Revised: 11/07/2007] [Accepted: 11/11/2007] [Indexed: 01/25/2023]
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31
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Monge M, Eskandari MK. Strategies for Ruptured Abdominal Aortic Aneurysms. J Vasc Interv Radiol 2008; 19:S44-50. [DOI: 10.1016/j.jvir.2008.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 02/11/2008] [Accepted: 02/11/2008] [Indexed: 11/16/2022] Open
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32
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Renewed endovascular repair for recurrent acute abdominal aortic aneurysm. Emerg Radiol 2008; 16:239-42. [PMID: 18481125 DOI: 10.1007/s10140-008-0721-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2008] [Accepted: 03/14/2008] [Indexed: 10/22/2022]
Abstract
The aim of the study was to describe the successful endovascular management of a patient who was admitted urgently with a second episode of acute abdominal aortic aneurysm (AAA) 30 months after emergency endovascular abdominal aortic aneurysm repair (eEVAR) for a ruptured AAA. The patient, an 84 year-old male physician, presented with severe acute abdominal and back pain. Contrast-enhanced computer tomography scanning showed type III endoleak owing to complete disconnection of both graft limbs and the prosthetic main body. Treatment consisted of acute stent-grafting with two bridging stent-grafts to seal the endoleak and reline the graft. The patient is alive and well 6 months postoperatively. This case indicates the need for follow-up after eEVAR, but also that complications can be managed endovascularly.
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Mastracci TM, Garrido-Olivares L, Cinà CS, Clase CM. Endovascular repair of ruptured abdominal aortic aneurysms: A systematic review and meta-analysis. J Vasc Surg 2008; 47:214-221. [DOI: 10.1016/j.jvs.2007.07.052] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Revised: 07/26/2007] [Accepted: 07/28/2007] [Indexed: 02/07/2023]
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Harkin DW, Dillon M, Blair PH, Ellis PK, Kee F. Endovascular Ruptured Abdominal Aortic Aneurysm Repair (EVRAR): A Systematic Review. Eur J Vasc Endovasc Surg 2007; 34:673-81. [PMID: 17719809 DOI: 10.1016/j.ejvs.2007.06.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Accepted: 06/03/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND To review evidence supporting the use of endovascular ruptured aneurysm repair (EVRAR) for treatment of ruptured abdominal aortic aneurysm (RAAA). METHODS A systematic review of the medical literature was performed for relevant studies. We searched a number of electronic databases and hand-searched relevant journals until November 2006 to identify studies for inclusion. We considered studies in which patients with a confirmed ruptured abdominal aortic aneurysm were treated with EVRAR, which reported endpoints of mortality and major complications. RESULTS There was 1 randomised controlled trial (RCT), 33 non-randomised case series (24 retrospective and 9 prospective) reports were identified comparing EVRAR (n=891) with conventional open surgical repair for the treatment of RAAA. Whilst no benefit in the primary outcome of mortality was noted in the only RCT, evidence from non-randomised studies suggest that EVRAR is feasible in selected patients, where it may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, early complications, and mortality. CONCLUSIONS For the treatment of symptomatic or ruptured abdominal aortic aneurysm, emergency endovascular repair (EVRAR) is feasible in selected patients, with early outcomes comparable to best conventional open surgical repair for the treatment of RAAA.
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Affiliation(s)
- D W Harkin
- Regional Vascular Surgery Unit, Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland, UK.
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35
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Kapma MR, Groen H, Oranen BI, van der Hilst CS, Tielliu IF, Zeebregts CJ, Prins TR, van den Dungen JJ, Verhoeven EL. Emergency Abdominal Aortic Aneurysm Repair With a Preferential Endovascular Strategy:Mortality and Cost-Effectiveness Analysis. J Endovasc Ther 2007; 14:777-84. [DOI: 10.1583/07-2182.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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36
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Visser JJ, van Sambeek MRHM, Hamza TH, Hunink MGM, Bosch JL. Ruptured Abdominal Aortic Aneurysms: Endovascular Repair versus Open Surgery—Systematic Review. Radiology 2007; 245:122-9. [PMID: 17885185 DOI: 10.1148/radiol.2451061204] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To perform a systematic review of studies in which endovascular repair was compared with open surgery in the treatment of patients with a ruptured abdominal aortic aneurysm (AAA). MATERIALS AND METHODS A search of the English-language literature from January 1994 until March 2006 was performed. Inclusion criteria for studies were that they were about a comparison between patients who underwent endovascular repair and patients who underwent open surgery, that each treatment group included at least five patients, that information about patients' hemodynamic condition at presentation was reported, and that 30-day mortality was reported for each treatment group. Two reviewers independently extracted the data, and discrepancies were resolved by an arbiter. Random-effects models and meta-regression analysis were used to calculate crude and adjusted odds ratios (ORs) for endovascular repair versus open surgery. RESULTS Ten studies, in which the results of 478 procedures (n=148 for endovascular repair, n=330 for open surgery) were reported, met the inclusion criteria. All studies were observational; no randomized controlled trials were found. The pooled 30-day mortality was 22% (95% confidence interval [CI]: 16%, 29%) for endovascular repair and 38% (95% CI: 32%, 45%) for open surgery. The pooled rate for total systemic complications was 28% (95% CI: 17%, 48%) for endovascular repair and 56% (95% CI: 37%, 85%) for open surgery. The crude OR for 30-day mortality for endovascular repair compared with open surgery was 0.45 (95% CI: 0.28, 0.72). After adjustment for patients' hemodynamic condition, the OR was 0.67 (95% CI: 0.31, 1.44). CONCLUSION In this systematic review, after adjustment for patients' hemodynamic condition at presentation, a benefit in 30-day mortality for endovascular repair compared with open surgery for patients with a ruptured AAA was observed, but it was not statistically significant.
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Affiliation(s)
- Jacob J Visser
- Department of Epidemiology and Biostatistics, Erasmus MC, Dr Molewaterplein 40, Room Ee21-40B, 3015 GD Rotterdam, the Netherlands
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37
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Hoornweg LL, Wisselink W, Vahl A, Balm R. The Amsterdam Acute Aneurysm Trial: Suitability and Application Rate for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2007; 33:679-83. [PMID: 17276096 DOI: 10.1016/j.ejvs.2006.12.011] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Accepted: 12/06/2006] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate anatomical suitability and application rate for endovascular repair of patients with a ruptured abdominal aortic aneurysm (RAAA). METHODS The Amsterdam Acute Aneurysm trial is a multicenter randomised trial comparing open with endovascular treatment in patients with a RAAA (International Standard Randomized Controlled Trial Number (ISRCTN) 66212637). Between April 2004 and January 2006, all consecutive patients with clinical suspicion of a RAAA at presentation were assessed prospectively. Anatomical suitability for endovascular repair was based on use of an aorto-uni-iliac endovascular graft and assessed in patients with a proven aortic rupture on CT angiography (CTA). RESULTS In 128/256 patients, presenting with clinical suspicion of a ruptured aneurysm, RAAA was diagnosed. 105 patients were brought to a trial center and CTA confirmed RAAA in 83 patients. In 38 of 83 patients (45.8%) with positive CTA, the anatomy of the aorta and iliac arteries was considered suitable for endovascular repair. Exclusion from endovascular repair was due to unsuitable infrarenal neck or iliac anatomy (37 and 8 patients respectively). Overall, endovascular treatment was applicable in 38/128 patients (29.7%) with a RAAA in the Amsterdam region and in 38 out of 105 patients (35.5%) admitted to the trial centers. CONCLUSION In this prospective cohort of all patients with a RAAA in the Amsterdam Acute Aneurysm Trial region, the suitability for endovascular repair in patients with a RAAA confirmed on CTA is 45.8%, but the application rate was lower.
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Affiliation(s)
- L L Hoornweg
- Department of Vascular Surgery, Academic Medical Center, Amsterdam, The Netherlands
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38
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Mastracci TM, Cinà CS. Screening for abdominal aortic aneurysm in Canada: Review and position statement of the Canadian Society for Vascular Surgery. J Vasc Surg 2007; 45:1268-1276. [PMID: 17543696 DOI: 10.1016/j.jvs.2007.02.041] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 02/10/2007] [Indexed: 11/19/2022]
Affiliation(s)
- Tara M Mastracci
- Department of Surgery, Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
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Haveman JW, Karliczek A, Verhoeven ELG, Tielliu IFJ, de Vos R, Zwaveling JH, van den Dungen JJAM, Zeebregts CJ, Nijsten MWN. Results of streamlined regional ambulance transport and subsequent treatment of acute abdominal aortic aneurysms. Emerg Med J 2007; 23:807-10. [PMID: 16988317 PMCID: PMC2579610 DOI: 10.1136/emj.2006.037879] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To describe the triage of patients operated for non-ruptured and ruptured abdominal aortic aneurysms (AAAs) before the endovascular era. DESIGN Retrospective single-centre cohort study. METHODS All patients treated for an acute AAA between 1998 and 2001 and admitted to our hospital were evaluated in the emergency department for urgent AAA surgery. All time intervals, from the telephone call from the patient to the ambulance department, to the arrival of the patient in the operating theatre, were analysed. Intraoperative, hospital and 1-year survival were determined. RESULTS 160 patients with an acute AAA were transported to our hospital. Mean (SD) age was 71 (8) years, and 138 (86%) were men. 34 (21%) of these patients had symptomatic, non-ruptured AAA (sAAA) and 126 patients had ruptured AAA (rAAA). All patients with sAAA and 98% of patients with rAAA were operated upon. For the patients with rAAA, median time from telephone call to arrival at the hospital was 43 min (interquartile range 33-53 min) and median time from arrival at the hospital to arrival at the operating room was 25 min (interquartile range 11-50 min). Intraoperative mortality was 0% for sAAA and 11% for rAAA (p = 0.042), and hospital mortality was 12% and 33%, respectively (p = 0.014). CONCLUSIONS A multidisciplinary unified strategy resulted in a rapid throughput of patients with acute AAA. Rapid transport, diagnosis and surgery resulted in favourable hospital mortality. Despite the fact that nearly all the patients were operated upon, survival was favourable compared with published data.
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Affiliation(s)
- J W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen Hanzeplein 1, PO Box 30.001, 9700 RB Groningen, The Netherlands.
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Dillon M, Cardwell C, Blair PH, Ellis P, Kee F, Harkin DW. Endovascular treatment for ruptured abdominal aortic aneurysm. Cochrane Database Syst Rev 2007:CD005261. [PMID: 17253551 DOI: 10.1002/14651858.cd005261.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND An abdominal aortic aneurysm (AAA) (the pathological enlargement of the aorta) can develop in both men and women as they grow older. It is most commonly seen in men over the age of 65 years. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, a fatal event unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. A newer minimally invasive technique, endovascular repair, has been shown to reduce early morbidity and mortality, as compared to conventional open surgery, for planned AAA repair. Emergency endovascular repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in selected patients. However, it is not yet known if eEVAR will lead to significant improvements in outcomes for these patients or indeed if it can replace conventional open repair as the preferred treatment for this lethal condition. OBJECTIVES To compare the advantages and disadvantages of eEVAR in comparison with conventional open surgical repair for the treatment of RAAA. SEARCH STRATEGY The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched October 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) database (last searched Issue 4, 2006). We searched a number of electronic databases and handsearched relevant journals until March 2006 to identify studies for inclusion. SELECTION CRITERIA Randomised controlled trials in which patients with a confirmed ruptured abdominal aortic aneurysm were randomly allocated to eEVAR, or conventional open surgical repair. DATA COLLECTION AND ANALYSIS Studies identified for potential inclusion were independently assessed for eligibility by at least two reviewers, with excluded studies further checked by the agreed arbitrators. As no randomised controlled trials were identified at present no tests of heterogeneity or sensitivity analysis were performed. MAIN RESULTS There were no randomised controlled trials identified at present comparing eEVAR with conventional open surgical repair for the treatment of RAAA. AUTHORS' CONCLUSIONS There is no high quality evidence to support the use of eEVAR in the treatment of RAAA. However, evidence from prospective controlled studies without randomisation, prospective studies, and retrospective case series suggest that eEVAR is feasible in selected patients, with outcomes comparable to best conventional open surgical repair for the treatment of RAAA . Furthermore, endovascular repair in selected patients may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, and mortality.
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Affiliation(s)
- M Dillon
- Royal Victoria Hospital, Vascular Surgery Unit, Grosvenor Road, Belfast, Northern Ireland, UK.
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Visser JJ, Bosch JL, Hunink MGM, van Dijk LC, Hendriks JM, Poldermans D, van Sambeek MRHM. Endovascular repair versus open surgery in patients with ruptured abdominal aortic aneurysms: clinical outcomes with 1-year follow-up. J Vasc Surg 2007; 44:1148-55. [PMID: 17145414 DOI: 10.1016/j.jvs.2006.08.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 08/11/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare the clinical outcomes of treatment after endovascular repair and open surgery in patients with ruptured infrarenal abdominal aortic aneurysms (AAAs), including 1-year follow-up. METHODS All consecutive conscious patients with ruptured infrarenal AAAs who presented to our tertiary care teaching hospital between January 1, 2001, and December 31, 2005, were included in this study (n = 55). Twenty-six patients underwent endovascular repair, and 29 patients underwent open surgery. Patients who were hemodynamically too unstable to undergo a computed tomography angiography scan were excluded. Outcomes evaluated were intraoperative mortality, 30-day mortality, systemic complications, complications necessitating surgical intervention, and mortality and complications during 1-year follow-up. The statistical tests we used were the Student t test, chi2 test, Fisher exact test, and Mann-Whitney U test (two sided; alpha = .05). RESULTS Thirty-day mortality was 8 (31%) of 26 patients who underwent endovascular repair and 9 (31%) of 29 patients who underwent open surgery (P = .98). Systemic complications and complications necessitating surgical intervention during the initial hospital stay were similar in both treatment groups (8/26 [31%] and 5/26 [19%] for endovascular repair, respectively, and 9/29 [31%] and 8/29 [28%] for open surgery, respectively; P > .40). During 1-year follow-up, two patients initially treated with endovascular repair died as a result of non-aneurysm-related causes; no death occurred in the open surgery group. Complications during 1-year follow-up were 1 (5%) of 20 for endovascular repair and 4 (16%) of 25 for open surgery (P = .36). CONCLUSIONS On the basis of our study with a highly selected population, the mortality and complication rates after endovascular repair may be similar compared with those after open surgery in patients treated for ruptured infrarenal AAAs.
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Affiliation(s)
- Jacob J Visser
- Department of Epidemiology and Biostatistics, Erasmus MC, Rotterdam, The Netherlands
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42
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Analysis of Early and Distant Results Following Endovascular Repair of the Descending and Abdominal Aorta. POLISH JOURNAL OF SURGERY 2007. [DOI: 10.2478/v10035-007-0031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Coppi G, Silingardi R, Gennai S, Saitta G, Ciardullo AV. A single-center experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms. J Vasc Surg 2006; 44:1140-7. [PMID: 17145413 DOI: 10.1016/j.jvs.2006.08.070] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Accepted: 08/26/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To retrospectively compare a single center's immediate and mid-term outcomes of ruptured abdominal aortic aneurysm open and endovascular repair (EVAR) for two patient groups-hemodynamically stable and unstable patients-in the same time period. METHODS Patients presenting at our center with confirmed rupture of an abdominal aortic aneurysm between December 1999 and April 2006 were considered according to an intention-to-treat model with EVAR. Patients with symptomatic or acute (but not ruptured) AAAs were not included in this study. Thirty-three patients underwent EVAR, and 91 underwent open repair. Seventy-two patients (EVAR, 45%; open, 63%) were classified as hemodynamically unstable at arrival, and 52 were classified as stable (EVAR, 55%; open, 37%). Ninety-seven percent of EVAR procedures commenced under local anesthesia, and 100% of open repairs occurred with general anesthesia. Overall successful graft deployment, 30-day mortality, overall reintervention rate, and complications were the study primary end points. RESULTS Overall successful graft deployment for EVAR was 91%; for open repair, it was 96%. Overall 30-day mortality for EVAR was 30% (unstable, 53%; stable, 11%), and the rate was 46% for open repair (unstable, 61%; stable, 21%). The EVAR postoperative reintervention rate (within 30 days) was 15% (unstable, 20%; stable, 11%), and for open repair it was 10% (unstable, 9%; stable, 15%). We recorded a 27% severe complication rate for EVAR patients (unstable, 40%; stable, 17%), and for patients treated with open repair, it was 33% (unstable, 35%; stable, 29%). Our overall EVAR eligibility rate was 52%, and our overall EVAR treatment rate was 27%. CONCLUSIONS Our study's overall results for EVAR remain encouraging when compared with those of conventional repair, but large randomized trials are required to confirm the efficacy of the procedure.
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Affiliation(s)
- Gioacchino Coppi
- Department of Vascular Surgery, Policlinico Hospital of Modena and University of Studies of Modena and Reggio Emilia, Modena, Italy.
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44
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Oranen BI, Bos WTGJ, Verhoeven ELG, Tielliu IFJ, Zeebregts CJ, Prins TR, van den Dungen JJAM. Is emergency endovascular aneurysm repair associated with higher secondary intervention risk at mid-term follow-up? J Vasc Surg 2006; 44:1156-1161. [PMID: 17055694 DOI: 10.1016/j.jvs.2006.07.048] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 07/26/2006] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The study assessed mid-term outcome of emergency endovascular repair for acute infrarenal abdominal aortic aneurysms, with special attention to secondary interventions. METHODS Between May 1998 and August 2005, 56 patients underwent emergent endovascular repair for a ruptured abdominal aortic aneurysm (n = 34) or an acute nonruptured abdominal aortic aneurysm (n = 22). During the same period, 322 consecutive patients underwent elective endovascular aneurysm repair and were used as control group. Five types of stent grafts were used: Vanguard, Talent, Excluder, Zenith, and Quantum. Follow-up included abdominal radiograph, duplex ultrasound scanning, and computed tomographic angiography. Outcome measures included all-cause and aneurysm-related mortality, complications, and secondary interventions. RESULTS Mortality at 30 days was 18%, 5%, and 1% in the ruptured, acute nonruptured, and elective aneurysm groups, respectively. Overall mean follow-up was 38 +/- 26 months. In the ruptured aneurysm group, survival was 67.8% +/- 8.6% at 1 year and 62.1% +/- 9.5% at 2 and 3 years. Seven secondary interventions (4 early and 3 late) were required in five patients (15%), with a cumulative risk of 9.2% +/- 5.1% at 1 year and 16.2% +/- 8.2% at 2 and 3 years. In the acute nonruptured aneurysm group, survival was 90.9% +/- 6.1% at 1 year, 84.8% +/- 8.2% at 2 years, and 76.4% +/- 10.9% at 3 years. Four secondary interventions (1 early and 3 late) were required in four patients (18%), with a cumulative risk of 9.6% +/- 6.5% at 1 and 2 years and 20.9% +/- 12.0% at 3 years. In the elective aneurysm (control) group, survival was 95.2% +/- 1.2% at 1 year, 89.9% +/- 1.8% at 2 years, and 86.2% +/- 2.1% at 3 years. A total of 51 secondary interventions (4 early, 47 late) were required in 38 patients (12%), with a cumulative risk of 4.2% +/- 1.1% at 1 year, 7.6% +/- 1.6% at 2 years, and 12.9% +/- 2.2% at 3 years. CONCLUSIONS To our surprise, emergency endovascular aneurysm repair did not present with higher secondary intervention rate at mid-term follow-up.
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Affiliation(s)
- Björn I Oranen
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands.
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Arya N, Makar RR, Lau LL, Loan W, Lee B, Hannon RJ, Soong CV. An intention-to-treat by endovascular repair policy may reduce overall mortality in ruptured abdominal aortic aneurysm. J Vasc Surg 2006; 44:467-71. [PMID: 16950418 DOI: 10.1016/j.jvs.2006.05.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2006] [Accepted: 05/07/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) has been restricted to a small number of specialized units on a selected group of patients. The aim of this study is to assess if the overall mortality in these patients with ruptured AAA may be reduced in a unit where all patients with ruptured AAA are considered first for EVAR. METHODS During a 24-month period beginning in July 2002, 51 patients admitted with ruptured AAA were considered for EVAR as the treatment of choice and comprised the study group. EVAR was performed in 17 patients. Open repair was performed in 34 patients: 13 patients had hemodynamic instability and 16 patients had an unsuitable aortic neck anatomy. The study group was compared with a historical control group of 41 patients with ruptured AAA who were treated by open repair from July 2000 to June 2002. RESULTS Mortality rate was 39% in the study group compared with 59% in the control group (P = .065). The duration of stay in the intensive care unit was significantly lower in the study group than in the control group (P = .01), although the total in-hospital stay was similar (17 days vs 14 days, P = .83). Within the study group, EVAR patients had a mortality rate of 24% compared with 47% in the open group (P = .14). CONCLUSION Although the number of patients was small, offering EVAR to as many patients as possible with ruptured AAA has resulted in a 20% reduction in mortality, albeit statistically insignificant. However, it is in the unstable patients that EVAR will need to improve survival before it may be hailed to supersede the conventional approach.
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Affiliation(s)
- Nityanand Arya
- Vascular & Endovascular Unit, Belfast City Hospital, Belfast, United Kingdom.
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Dalainas I, Nano G, Bianchi P, Stegher S, Casana R, Malacrida G, Tealdi DG. Endovascular Techniques for the Treatment of Ruptured Abdominal Aortic Aneurysms: 7-year Intention-to-treat Results. World J Surg 2006; 30:1809-14; discussion 1815-6. [PMID: 16847714 DOI: 10.1007/s00268-005-0667-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The purpose of this single-institution study was to describe our 7-year intention-to-treat results, obtained with the use of endovascular techniques for the treatment of ruptured abdominal aortic aneurysms (rAAA). PATIENTS AND METHODS From October 1998 until March 2005, a total of 28 patients were admitted or transferred to our department with an rAAA. They were all treated according to a management protocol of intention-to-treat with endovascular techniques. Twenty of the patients received endovascular treatment and the remaining 8 underwent an open surgery procedure. RESULTS The mortality rate of the endovascularly treated patients was 40% (8 in 20), whereas of the 8 surgical patients 3 survived (mortality = 62.5%). The overall mortality rate of the 28 patients admitted with an rAAA was 46.4% (13 of 28 patients). CONCLUSIONS In our experience the intension-to-treat protocol for rAAA offered acceptable results in terms of mortality rates. Multi-center studies are necessary to establish the role of endovascular treatment in patients with rAAA.
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Affiliation(s)
- Ilias Dalainas
- 1st Unit of Vascular Surgery, Istituto Policlinico San Donato-School of Vascular Surgery, University of Milan, Milan, Italy.
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Grey BR, Butterfield JS, Nasim A. Successful endovascular repair of a ruptured abdominal aortic aneurysm in a patient with unfavorable anatomy. J Vasc Surg 2006; 43:831-3. [PMID: 16616244 DOI: 10.1016/j.jvs.2005.12.055] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Accepted: 12/25/2005] [Indexed: 10/24/2022]
Abstract
Endovascular repair of an abdominal aortic aneurysm (AAA) offers hope of improved outcomes in patients presenting with acute rupture. However, a high proportion of such patients have unfavorable proximal neck anatomy and are not suitable for treatment with conventional endografts. Fenestrated endografts overcome the problem of a short proximal neck, but at present their deployment is time consuming and therefore not easily applicable to a ruptured AAA. In this case report, the authors describe a hybrid device (a composite thoracic and infrarenal stent graft) that was able to overcome the problem of a short wide proximal neck in a patient with a ruptured AAA.
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Affiliation(s)
- Benjamin R Grey
- Department of Vascular Surgery & Interventional Radiology, South Manchester University Hospitals Trust, United Kingdom.
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Greco G, Egorova N, Anderson PL, Gelijns A, Moskowitz A, Nowygrod R, Arons R, McKinsey J, Morrissey NJ, Kent KC. Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms. J Vasc Surg 2006; 43:453-459. [PMID: 16520154 DOI: 10.1016/j.jvs.2005.11.024] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Accepted: 11/06/2005] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The successful application of endovascular techniques for the elective repair of abdominal aortic aneurysms (AAAs) has stimulated a strong interest in their possible use in dealing with a long-standing surgical challenge: the ruptured abdominal aortic aneurysm (RAAA). The use of a conventional open procedure to repair ruptured aneurysms is associated with a high operative mortality of 45% to 50%. In this study, we evaluated the current frequency of endovascular repair of RAAAs in four large states and the impact of this technique on patient outcome. METHODS We examined discharge data sets from 2000 through 2003 from the four states of California, Florida, New Jersey, and New York, whose combined population represents almost a third of the United States population. Proportions and trends were analyzed by chi2 analysis and continuous variables by the Student's t test. RESULTS We found that since the year 2000, endovascular repair has begun to emerge as a viable treatment option for RAAAs, accounting for the repair of 6.2% of cases in 2003. During the same period, the use of open procedures for RAAAs declined. The overall mortality rate for the 4-year period was significantly lower for endovascular vs open repair (39.3% vs. 47.7%, P = .005). Moreover, compared with open repair, endovascular repair resulted in a significantly lower rate of pulmonary, renal, and bleeding complications. Survival after endovascular repair correlated with hospital experience, as assessed by the overall volume of elective and nonelective endovascular procedures. For endovascular repairs, mortality ranged from 45.9% for small volume hospitals to 26% for large volume hospitals (P = .0011). Volume was also a determinant of mortality for open repairs, albeit to a much lesser extent (51.5% for small volume hospitals, 44.3% for large volume hospitals; P < .0001). CONCLUSION We observed a benefit to using endovascular procedures for RAAAs in institutions with significant endovascular experience; however, the analysis of administrative data cannot rule out selection bias as an explanation of better outcomes. These data strongly endorse the need for prospective studies to clarify to what extent the improved survival in RAAA patients is to be attributed to the endovascular approach rather than the selection of low-risk patients.
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Affiliation(s)
- Giampaolo Greco
- International Center for Health Outcomes and Innovation Research (inCHOIR), Columbia University, New York, NY 10032, USA.
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Gerassimidis TS, Papazoglou KO, Kamparoudis AG, Konstantinidis K, Karkos CD, Karamanos D, Sfyroeras G. Endovascular management of ruptured abdominal aortic aneurysms: 6-year experience from a Greek center. J Vasc Surg 2005; 42:615-23; discussion 623. [PMID: 16242541 DOI: 10.1016/j.jvs.2005.05.061] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2005] [Accepted: 05/15/2005] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To report our early experience with endovascular treatment of patients with ruptured abdominal aortic aneurysms (RAAAs). METHODS Between March 1998 and October 2004, 40 consecutive patients with an RAAA presented to our unit; 38 underwent assessment by computed tomography, whereas 2 died on arrival before any assessment and treatment was possible. Twenty-three patients (61%) were suitable for stent grafting, and all proceeded to endovascular repair. Of these, 17 underwent operation with local anesthesia, 1 did so under general anesthesia, and a further 5 procedures were commenced under local anesthesia and converted to general anesthesia. A total of 14 bifurcated and 10 aortouni-iliac stent grafts were implanted; in 1 patient, the bifurcated graft was converted to an aortouni-iliac repair during surgery because of technical difficulties. RESULTS Stent-graft deployment in the intended location without a type I or III endoleak was technically successful in 22 of the 23 patients. There were no conversions to open surgery. The 30-day mortality was 39%. Six patients died immediately or soon after the procedure because of severe hypovolemic shock, and three died within 30 days from cardiac causes. After surgery, 13 complications were encountered in 10 patients (3 cardiac, 4 respiratory, 5 renal, and 1 implant related). Two patients required reintervention--one for a type I endoleak and one for limb occlusion. There were 14 survivors. During a median follow-up of 410 days (range, 90-1650 days), 2 more patients died from myocardial infarction, and 9 remain well; 3 patients were lost to follow-up. There were three secondary interventions (two for type I endoleak and one for stent-graft thrombosis). CONCLUSIONS Endovascular treatment of RAAAs is feasible, and the early experience is promising. More experience and evidence from randomized trials are needed to determine whether such an approach is superior to open surgery.
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Affiliation(s)
- Thomas S Gerassimidis
- Fifth Surgical Clinic, Medical School, Aristotle University of Thessaloniki, Ippokratio Hospital, Greece
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Verhoeven ELG, Cinà CS, Tielliu IFJ, Zeebregts CJ, Prins TR, Eindhoven GB, Span MM, Kapma MR, van den Dungen JJAM. Local anesthesia for endovascular abdominal aortic aneurysm repair. J Vasc Surg 2005; 42:402-9. [PMID: 16171579 DOI: 10.1016/j.jvs.2005.05.047] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Accepted: 05/29/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study reports the results of a prospective continuous cohort of patients treated for endovascular aneurysm repair (EVAR) with a unified anesthetic strategy based on the use of local anesthesia (LA) in all patients, while reserving regional (RA) or general anesthesia (GA) only for those with predefined individually or surgically specific indications. METHODS All patients treated by EVAR for an elective aortic abdominal aneurysm (AAA) between April 1998 and December 2003 were included. The strategy of treatment generated three cohorts of patients (LA, RA, or GA). Primary outcome included all-cause mortality, nonfatal cardiac morbidity, respiratory complications, and renal failure. Secondary outcome measures included conversion to general anesthesia, use of analgesics, and time-related outcomes (operating time, length of stay in intensive care unit and hospital, time required to resume oral intake, and time to ambulation). RESULTS A total of 239 patients underwent EVAR: 170 LA, 31 RA, and 38 GA. Overall mortality was one patient (0.4%). LA was associated with a lower incidence of complications compared with GA (P < .001). In the LA group, two patients had to be converted to GA, one because of a dissection and one because of anxiety. In 13% of the patients in the LA group, additional intravenous sedation or analgesia was required. Operating time and length of stay in intensive care was shorter in the LA and RA groups than in the GA group (P < .001). Length of stay in hospital and time to ambulation and regular diet was shorter in the LA group compared with the RA and GA groups (P < .001). CONCLUSIONS A strategy based on the preferential use of LA for EVAR restricting RA or GA only to those with predefined contraindications is feasible and appears to be well tolerated.
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Affiliation(s)
- E L G Verhoeven
- Department of Surgery, University Medical Center, McMaster University.
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