Meta-analysis of Outcomes Following Aneurysm Repair in Patients with Synchronous Intra-abdominal Malignancy

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of abdominal aortic aneurysm on long-term survival in lung cancer patients

The major causes of death in patients with abdominal aortic aneurysm (AAA) are cardiovascular disease and cancer. The purpose of this study was to evaluate the effect of AAA on long-term survival in lung cancer patients. All patient data with degenerative type AAA and lung cancer over 50 years of age during the period 2009 to 2018 was collected retrospectively from a National Health Insurance Service (NHIS) administrative database and matched to lung cancer patients without AAA by age, sex, metastasis, and other comorbidities. Mortality rate was compared between the groups. A total of 956 AAA patients who could be matched with patients without AAA were included, and 3824 patients in the matched group were used for comparison. Patients with AAA showed higher risk of death compared with the matched cohort (adjusted hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.06-1.23, p < 0.001). When compared to a matched group of untreated AAA patients, patients with of history of AAA exhibited a significantly increased risk of overall mortality [HR (95%CI) 1.219 (1.113-1.335), p < .001, adjusted HR (95% CI) 1.177 (1.073-1.291), p = .001]. By contrast, mortality risk of AAA patients treated either by endovascular abdominal aortic repair or open surgical repair was not significantly different from that of the matched group (p = 0.079 and p = 0.625, respectively). The mortality risk was significantly higher when AAA was present in lung cancer patients, especially in patients with unrepaired AAA, suggesting the need for continuous cardiovascular risk management.

Abdominal Aortic Aneurysm Repair in Patients with Concomitant Cancer: A Literature Review

OBJECTIVES

Abdominal aortic aneurysmal (AAA) repair in patients with concomitant cancer is controversial due to increased comorbidity and reduced life expectancy in this specific patient group. This literature review aims to investigate the evidence supporting one treatment modality over another (endovascular aortic repair (EVAR) or open repair (OR)), as well as treatment strategy (staged AAA-, cancer first or simultaneous procedures) in patients with AAA and concomitant cancer.

METHODS

Literature review, including studies published from 2000 to 2021 on surgical treatment in patients with AAA and concomitant cancer and related outcomes (30-day morbidity/complications as well as 30-day and 3-year mortality).

RESULTS

24 studies comprising 560 patients undergoing surgical treatment of AAA and concomitant cancer were included. Of these, 220 cases were treated with EVAR and 340 with OR. Simultaneous procedures were performed in 190 cases, 370 received staged procedures. The 30-day mortality for EVAR versus OR was 1% and 8%, corresponding to a relative risk (RR) of 0.11 (95% CI: 0.03-0.46, p = 0.002). No difference in mortality was observed between staged versus simultaneous procedure nor between AAA-first versus cancer-first strategy, RR 0.59 (95% CI: 0.29-1.1, p = 0.13) and 0.88 (95% CI 0.34-2.31, p = 0.80), respectively. Overall, 3-year mortality was 21% for EVAR and 39% for OR from 2000-2021, while the mortality up to 3 years after EVAR within recent years (2015-2021) was 16%.

CONCLUSION

This review supports EVAR treatment as first choice if suitable. No consensus was established on treating either the aneurysm or the cancer first or simultaneously. Long-term mortality after EVAR was comparable to non-cancer patients within recent years.

Stage II Pancreatic Adenocarcinoma after Endovascular Repair of Abdominal Aortic Aneurysm: A Case Report and Literature Review

BACKGROUNDS

Concomitant abdominal aortic aneurysms (AAA) and gastrointestinal malignancies are uncommon. Endovascular repair (EVAR) is widely used to treat AAA. However, no consensus exists on the optimal strategy for treating AAA when associated with pancreatic adenocarcinoma. In addition, only few reports of pancreaticoduodenectomy (PD) after EVAR exist.

PRESENTATION OF CASE

A pancreatic tumor was detected during follow-up after EVAR for AAA in an 83-year-old female patient. The diagnosis was high-grade intraepithelial neoplasia. Modified pylorus-preserving pancreaticoduodenectomy was safely performed. The patient recovered moderately and was discharged two weeks after surgery. The pathological diagnosis was middle-grade pancreatic ductal adenocarcinoma. The patient survived for 24 months with no recurrence or cardiovascular complications.

CONCLUSIONS

Conducting periodic follow-ups after AAA surgery is helpful for the early discovery of gastrointestinal tumors. EVAR surgery is safe and feasible and thus recommended for AAA patients with pancreatic cancer, although it may increase the risk of cancer. The stage of malignancy and post-EVAR medical history can be valuable in evaluating the benefits of pancreatic surgery for such cases.

Management of Concomitant Abdominal Aortic Aneurysm and Intra-abdominal, Retroperitoneal Malignancy

BACKGROUND/AIM

As the population ages, there are increasing findings of coincidental diseases such as abdominal aortic aneurysm (AAA) and intra-abdominal, retroperitoneal malignancy. The aim of this study was to propose an optimal treatment procedure for these patients.

PATIENTS AND METHODS

Over a twenty-year-period, surgery was performed on a total of 1,098 patients with AAA and 32 (2.9%) patients with AAA and intra-abdominal, retroperitoneal malignancy: 18 renal, 6 colorectal carcinomas, 3 carcinomas of the small intestine, 3 primary liver tumours, 1 stomach carcinoma and 1 teratoma. The median age of patients was 72.5 years, there were 20 men (62.5%) and 12 women (37.5%). A one-stage procedure was performed on 19 patients (59.4%), and a two-stage procedure on 13 (40.6%) patients.

RESULTS

The average time of hospitalization was 12.4±6.9 days (median=11.0 days) for one-stage procedure, for a two-stage procedure 21.3±9.3 days (median=20.0 days), p=0.0045. Seven patients (21.9%) died within 30 days after the operation. All the deaths were in the group of one-stage procedures (p=0.0252). The 1-, 3- and 5-year overall survival for patients following one-stage and twostage procedures was 61.0/56.3/51.5% and 89.0/79.9/53.0% respectively (p=0.1199).

CONCLUSION

Symptomatic disease must be resolved first. Two-stage procedures are the method of choice and offer better short-term results compared to one-stage procedures.

A systematic review and meta-analysis on the management of concomitant abdominal aortic aneurysms and renal tumours

OBJECTIVES

The treatment of concomitant abdominal aortic aneurysms and renal tumours is controversial. The aim of this study was to ascertain which of the following three strategies, one-stage open aneurysm repair and nephrectomy, two-stage open aneurysm repair and nephrectomy or two-stage endovascular aneurysm repair and nephrectomy, is the best approach.

METHODS

systematic review and meta-analysis of articles published between January 1992 and April 2021 describing the treatment of concomitant abdominal aortic aneurysms and renal tumours.

RESULTS

A total of 1168 records were identified. After the selection process, 12 studies with data on 89 patients were included. Sixty-two patients underwent one-stage open procedures, 18 patients underwent two-stage open procedures and nine underwent two-stage endovascular procedures. The overall postoperative mortality was 0.82% (95% CI, 0.00-4.61). The postoperative mortality for one-stage open procedures was 3.09% (95% CI, 0.00-10.11). No deaths occurred in the postoperative period open two-stage procedures or two-stage endovascular procedures. The weighted postoperative morbidity for all procedures was 23.86% (95% CI, 12.64-35.08) and for open one-stage procedures was 37.40% (95% CI, 14.33-60.47). Data concerning postoperative complications of two-stage open procedures were extractable from only one patient in whom no complications were reported. Two postoperative complications were reported after two-stage endovascular procedures from a total of six patients with extractable postoperative data. We were unable to perform meta-analysis on long-term outcomes as the data were reported non-uniformly.

CONCLUSION

There is currently no evidence to suggest that any procedure is associated with better outcomes. However, a one-stage open approach was the most commonly used option, favoured as it avoids delaying treatment of either of the conditions. Two-stage open procedures were preferred in cases where the surgical risk of a one-stage procedure was higher than the potential benefit. For such cases, two-stage endovascular repair is becoming more popular as a less invasive approach.

Prevalence of Renal Masses Suspected of Malignancy and Adrenal Incidentalomas in Patients With Abdominal Aortic Aneurysm

OBJECTIVE

The aim of our study was to assess the prevalence of renal masses suspected of malignancy and adrenal incidentalomas in patients with abdominal aortic aneurysm based on the computed tomography angiography (CTA).

METHODS

In the retrospective cross-sectional study, the CTA scans of patients with abdominal aortic aneurysms and thoraco-abdominal aortic aneurysms type II-IV were assessed. Patients with thoraco-abdominal aortic aneurysms type I and V and history of abdominal aortic surgery were excluded from the study.

RESULTS

Study group comprised 937 patients with a median age of 73.0 years, 83.8% of whom were male. CTA revealed renal tumors in 11 patients (1.2% of the study population) with a median size of 26 mm (interquartile range 20-50). Adrenal incidentalomas were found in 61 patients (6.5% of the study population). In 20 patients (2.1%) adrenal lesions were found bilaterally.

CONCLUSION

In the described cohort, the renal and adrenal tumors were relatively common findings among patients with abdominal aortic aneurysm and thoraco-abdominal aortic aneurysms type II-IV. Both anaesthesiologists and surgeons should be vigilant about the possibility of such coexistence in order to provide the patients with the best possible perioperative care and an optimal surgical modality.

Endovascular Repair for Abdominal Aortic Rupture Caused by Periaortic Mantle Cell Lymphoma

A 72-year-old man was referred to our hospital for the suspicion of ruptured abdominal aortic aneurysm. Before admission, he was suspected of having a malignant lymphoma and underwent excisional biopsy in his right groin. A contrast enhanced computed tomography scan revealed a massive retroperitoneal hematoma with an extravasation arising from the infrarenal abdominal aorta coexisting with an extensive retroperitoneal mass surrounding the aorta. An emergency endovascular aneurysm repair was performed and the postoperative course was uneventful. After the treatment, histological examination of the previous biopsy confirmed the diagnosis of mantle cell lymphoma.

Synchronous sigmoid cancer and abdominal aortic aneurysm treated by laparoscopic colectomy followed by endovascular aneurysm repair

INTRODUCTION

The occurrence of synchronous abdominal aorta aneurysms and colorectal cancer represents a real management challenge. Up till now, there is no evidence-based consensus recommendation in the surgical management of such patients. Herein we reported the clinical management challenge of synchronous abdominal aorta aneurysms (AAA) and colorectal cancer (CRC).

PRESENTATION OF CASE

78-year-old man was admitted in our structure for acute abdominal pain, vomiting and constipation. His past medical history included type 2 diabetes, arterial hypertension and a stable infra-renal aortic aneurysm documented 2 years ago. Physical examination found a stable patient with blood pressure and heart rate within normal range, pulsatile mass along with abdominal distension with vital signs within normal limits. Abdominal CT scan and subsequent CT angiogram confirmed an 88 × 75 mm infra-renal aortic aneurysm concomitant with considerable lumen reduction due to asymmetric wall thickening of the sigmoid. Colonoscopy combined with biopsy examination confirmed structuring irregular sigmoid adenocarcinoma Therefore we report a case of a large AAA and concomitant sigmoid adenocarcinoma tumor causing stricture.

DISCUSSION

In such situation, the main controversy is the necessity of treating the diseases simultaneouslor in two stages favoring the AAA management first. To our best knowledge, we report the first case published in literature in which the patient was treated for colorectal cancer first by laparoscopic surgery followed by AAA management with EVAR.

CONCLUSION

In this case report, we highlight some tricks required in performing laparoscopic sigmoid colectomy for patient with large AAA to prevent per-operative pitfalls. Evidence-based consensus is required to determine the optimal surgical treatment.

Outcomes of Endovascular Aneurysm Repair Using the Anaconda Stent-Graft

Purpose: To report outcomes of elective endovascular aneurysm repair (EVAR) using the Anaconda stent-graft in a tertiary vascular center. Materials and Methods: A retrospective study was conducted of 271 patients (mean age 71.5 years; 260 men) who underwent elective EVAR for abdominal aortic aneurysm using the Anaconda stent-graft from January 2006 to January 2017. Median aneurysm diameter was 58 mm (range 50-90). All patients were anatomically suitable for EVAR according to the 2003 version of the instructions for use. Follow-up included computed tomography angiography at 1, 6, and 12 months and yearly thereafter for the first 4 years and then every 2 years. Primary outcomes included technical success and 30-day aneurysm-related mortality and complications; secondary outcomes were overall and aneurysm-related mortality and aneurysm-related morbidity in follow-up. Results: The Anaconda stent-graft was implanted successfully in all patients. Primary and secondary technical success rates were 99.6% and 100%, respectively. Three patients (1.1%) died within 30 days of causes unrelated to the aneurysm, while 15 patients (5.5%) suffered perioperative complications. Median follow-up was 72 months (range 14-141). The overall type I endoleak rate was 4.7% (11 proximal, 2 distal). Late aneurysm-related complications were observed in 48 patients (17.3%); aneurysm-related mortality was 1.4% (n=4). Non-aneurysm-related mortality was 21.0% (n=57). Freedom from reintervention was 95.2% at 1 year, 98% at 2 years, and 90% at 6 years. There was no significant difference in the overall limb graft occlusion rate between the second- and third-generation devices. Conclusion: Results in our cohort study demonstrate that the Anaconda stent-graft has satisfactory early and late results with low aneurysm-related mortality.

Outcomes after aortic aneurysm repair in patients with history of cancer: a nationwide dataset analysis

Background

Synchronous cancer in patients with abdominal aortic aneurysm (AAA) increases morbidity and mortality after AAA repair. However, little is known about the impact of the history of cancer on mortality after AAA repair.

Methods

Patients with intact AAA who were treated with endovascular aneurysm repair or open surgical repair were selected from the Health Insurance and Review Assessment data in South Korea between 2007 and 2016. Primary endpoints included the 30- and 90-day mortality and long-term mortality after AAA repair. The Cox proportional hazards models were constructed to evaluate independent predictors of mortality.

Results

A total of 1999 patients (17.0%, 1999/11785) were diagnosed with cancer prior to the AAA repair. History of cancer generally had no effect in short-term mortality at 30 and 90 days. However, short-term mortality rate of patients with a history of lung cancer was more than twice that of patients without it (3.07% vs. 1.06%, P = 0.0038, 6.14% vs. 2.69%, P = 0.0016). Furthermore, the mortality rate at the end of the study period was significantly higher in AAA patients with a history of cancer than in those without a history of cancer (21.21% vs. 17.08%, P < .0001, HR, 1.31, 95% CI, 1.17–1.46).

Conclusions

The history of cancer in AAA patients increases long-term mortality but does not affect short-term mortality after AAA repair. However, AAA repair could increase both short- and long-term mortality in patients with lung cancer history, and those cases should be more carefully selected.

Endovascular Exclusion of Abdominal Aortic Aneurysms and Simultaneous Resection of Colorectal Cancer

BACKGROUND

No consensus exists on the optimal strategy for treatment of abdominal aortic aneurysm (AAA) associated with colorectal cancer (CRC). The purpose of this study was to evaluate the results of endovascular treatment of AAA with simultaneous resection of CRC.

METHODS

Twenty-two consecutive patients presenting with AAA associated with a CRC were treated by endovascular AAA exclusion and simultaneous CRC resection. Median diameter of the aneurysm was 6.5 cm (range, 4.8-8 cm). Two patients (9%) had grade I cancer, 5 patients (23%) grade II, 13 patients (59%) grade III, and 2 patients (9%) grade IV. The 2 surgical procedures were performed under the same general anesthesia. Aneurysm exclusion was achieved using an infrarenal aorto-bi-iliac endoprosthesis (13 patients) and using an aorto-bi-iliac endoprosthesis with suprarenal fixation (9 patients), with 1 patient receiving bilateral renal chimney stent implantation. In all cases, vascularization of the hypogastric arteries was preserved. After AAA exclusion, colic resection was carried out by laparotomy with right colectomy (7 patients) and anterior rectocolic resection (15 patients). In all patients, AAA exclusion was controlled by a computed tomographic angioscan (CTA) at 1 month and duplex ultrasound every 6 months, and at some later stage, it was through inclusion of CTA as part of oncology surveillance. The mean duration of follow-up was 42 months (10-120 months). The primary endpoint was composite and regrouped any death occurring during the first 30 days after procedures, any type I endoleak, any aortic reintervention, and any AAA-related mortality.

RESULTS

No patient died during the first 30 postoperative days, and no patient was lost to follow-up. No aortic endoprosthesis infection and no type I endoleak were observed. Five endoleaks arising from the lumbar arteries (n = 4) or from the inferior mesenteric artery (n = 1) were identified. As they were not associated with an increase of the AAA diameter >5 mm, they were not treated. 1 colic anastomotic leak and 2 incisional abscesses were successfully cured by local care only. Nine patients (41%) died of cancer evolution during the follow-up period.

CONCLUSIONS

In this series, treatment of AAA and CRC during the same operative session yields results comparable to those observed when surgery is performed in 2 distinct operative sessions. Synchronous treatment reduced waiting time of colic resection. It may also shorten total hospitalization duration, although this last hypothesis is not supported by comparison with a control group.

Management of abdominal aortic aneurysm and concomitant malignant disease

INTRODUCTION

Concomitant malignant disease and abdominal aortic aneurysms (AAA) represent a challenging issue in terms of treatment priority, timing and perspectives. This systematic review provides an overview of the available literature about AAA and concomitant malignant disease.

EVIDENCE ACQUISITION

We conducted a literature search of all the English-language medical literature in Medline (through PubMed), Embase, Clinical Trial databases and the Cochrane Library up to December 31st, 2018.

EVIDENCE SYNTHESIS

The literature about AAA and concomitant malignant disease is mostly based on retrospective small case series. Two recently published meta-analyses focusing on the management of AAA and concomitant abdominal neoplasms came to the same conclusion "treat what is most threatening or symptomatic first." The threshold to treat asymptomatic AAA should not be altered in patients with AAA and concomitant cancer including cases under chemotherapy. An asymptomatic AAA of at least 55 mm anatomically suitable for EVAR, should only be treated first in patients with at least a life expectancy of two years followed by staged cancer surgery two weeks later.

CONCLUSIONS

Decisions about management of AAA and concomitant malignant disease should be based on clinical judgment applied individually in a multidisciplinary setting ("treat first what kills first"). The indication for treatment is not different than in patients with AAA without cancer. A staged approach is preferable and ideally the AAA should be excluded by endovascular means if anatomically suitable. An international registry should be initiated to gather more evidence about the management and outcomes of patients with AAA and concomitant carcinoma.

Synchronous Gastrointestinal Tumor and Abdominal Aortic Aneurysm or Dissection Treated with Endovascular Aneurysm Repair Followed by Tumor Resection

Objective

To evaluate the strategy in the management of patients with synchronous gastrointestinal tumor and abdominal aortic aneurysm (AAA) or abdominal aortic dissection (AAD) undergoing endovascular repair followed by tumor resection.

Materials and Methods

Five patients with synchronous gastrointestinal tumor and AAA or AAD were treated by endovascular repair followed by tumor resection. Clinical data were retrospectively analyzed with respect to the management strategy, safety, and outcome.

Results

Endovascular repair was technically successful in all patients. All the stents were well positioned and well patent, and the AAA (n = 3) or AAD (n = 2) were correctly excluded without endoleaks. After endovascular repair, all patients underwent resection of gastrointestinal tumor. No late mortality or major complications related to the two procedures were observed in the subsequent follow-up.

Conclusion

Our results demonstrate that EVAR could significantly shorten the delay between AAA and gastrointestinal procedure with an excellent postoperative outcome. If the anatomical criteria are satisfied, EVAR followed by tumor resection might be an effective treatment for concomitant AAA and gastrointestinal tumor.

Late-Onset Malignant Neoplasms and Their Prognostic Factors after Abdominal Aortic Aneurysm Repair

BACKGROUND

Little is known about late-onset primary malignant neoplasms after repair of abdominal aortic aneurysms (AAAs) despite malignancy being one of the primary causes of late death. We investigated the incidence and prognostic factors related to the occurrence of malignancy after AAA repair.

METHODS

We performed a retrospective analysis of 589 patients who underwent AAA repair, including 264 endovascular AAA repairs and 325 open surgical repairs; 482 patients had no history of previous malignancy or concomitant malignancy, 72 had previous malignancy, and 35 had concomitant malignancy in remission at the time of AAA repair. The cumulative incidence rates of late-onset malignancy occurrence and cancer death were estimated using the cumulative incidence function in the presence of competing risks, that is, noncancer death, and prognostic factors were investigated using the Fine-Gray hazard model.

RESULTS

After hospital discharge, 128 malignancies occurred in 116 patients. Overall cumulative incidence rates of late-onset malignancy occurrence at 1, 3, 5, and 10 years were 4.0%, 11.7%, 18.2%, and 38.1%, respectively. Multivariate analysis revealed that significant prognostic factors for late-onset malignancy included history of previous malignancy, current smoker, higher intraoperative blood loss, absence of allogeneic blood transfusion, lower C-reactive protein levels, and lower serum high-density lipoprotein-cholesterol levels. The type of surgical procedures for AAA repair did not affect the occurrence of malignancy. In addition, current smoker and higher intraoperative blood loss significantly increased the risk of cancer death.

CONCLUSIONS

Current smoker and higher intraoperative blood loss were independent risk factors for late-onset malignancy after AAA repair. Late-onset malignancy after AAA repair should be monitored among patients at high risk and requires aggressive management to improve long-term survival.