Increasing Incidence of Thoracic Aortic Aneurysm Repair in Germany in the Endovascular Era: Secondary Data Analysis of the Nationwide German DRG Microdata

Development of modified laser Doppler flowmetry device for real-time monitoring of esophageal mucosal blood flow: a preclinical assessment with an animal model

This study aimed to modify a laser Doppler flowmeter designed and assembled at our institute. After measuring sensitivity evaluation in ex vivo experiments, we confirmed the efficacy of this new device for monitoring real-time esophageal mucosal blood flow changes after thoracic stent graft implantation by simulating various clinical situations in an animal model. Thoracic stent graft implantation was performed in a swine model (n = 8). Esophageal mucosal blood flow decreased significantly from baseline (34.1 ± 18.8 ml/min/100 g vs. 16.7 ± 6.6 ml/min/100 g, P < 0.05) in the lower esophagus (Th6-Th8) where the stent graft covered the aorta. In the hemorrhagic shock model (shock index ≥ 1.0), esophageal mucosal blood flow showed a remarkable change from baseline in the upper esophagus (Th1-Th3), where the stent graft did not cover the aorta (20.8 ± 9.8 ml/min/100 g vs. 12.9 ± 8.6 ml/min/100 g, P < 0.01); however, it returned to the baseline value within a 30-min period. Mucosal blood flow remained stable in the esophagus, where the stent graft did not cover the aorta. After elevating the mean blood pressure to > 70 mmHg with continuous intravenous noradrenaline infusion, esophageal mucosal blood flow increased significantly in both regions; however, the reaction was different between the two regions. Our newly developed laser Doppler flowmeter could measure real-time esophageal mucosal blood flow changes in various clinical situations during thoracic stent graft implantation in a swine model. Hence, this device can be applied in many medical fields by downsizing it.

Scoring system to predict mid-term adverse events after elective thoracic endovascular aortic repair

OBJECTIVE

To develop and validate a scoring system to predict mid-term adverse events after elective thoracic endovascular aortic repair (TEVAR).

METHODS

In this multicenter retrospective observational cohort study, 350 patients who underwent elective TEVAR for thoracic aortic disease between January 2008 and December 2021 were analyzed. The primary outcome was the first adverse event occurring within 5 years of the initial TEVAR, which included death during the initial hospitalization, perioperative neurologic complication, stent graft-induced new entry, dissection, rupture, graft infection, and reintervention related to the initial TEVAR. The scoring system was developed using the regression coefficients of the Fine-Gray subdistribution hazard model. Its performance was evaluated using the area under the receiver operating characteristic curve (AUC) for competing risk analysis and internally validated by cross-validation.

RESULTS

Eighty-two patients experienced at least 1 adverse event within 5 years of the initial TEVAR. The 5-year cumulative incidence of adverse events was 26% (95% confidence interval, 21%-31%). Female sex, comorbidity score, use of anticoagulants, preoperative aortic diameter at the diaphragm level, proximal oversizing ratio, aortic coverage length, and hybrid procedure were included in the scoring system. The AUC of the scoring system in the internal validation was 0.748 (standard error, 0.009). When the scoring system was validated in patients with intact thoracic aortic aneurysm only, the AUC was 0.780 (standard error, 0.012).

CONCLUSIONS

Although external validation is needed, our scoring system may be useful for decision making, especially in patients with an intact thoracic aortic aneurysm.

Aortic arch isolation to reduce cerebral embolic risk during replacement of the atherosclerotic aortic arch

OBJECTIVE

To analyze the efficacy of isolating the upper body circulation from the lower body (isolation technique) in reducing the risk of embolic stroke during cardiopulmonary bypass in patients with severe atherosclerosis undergoing aortic arch surgery.

METHODS

Between 2006 and 2019, 156 patients with severe atherosclerosis undergoing total arch replacement were enrolled. Since 2017, the right axillary or innominate artery and ascending aorta were both cannulated before cardiopulmonary bypass in the isolation group (n = 30). The left common carotid artery was clamped and inserted with a 13-Fr balloon perfusion catheter. The innominate artery was clamped in succession and cardiopulmonary bypass was instituted, establishing a parallel noncommunicating circulation for the upper and lower body. Patients without atherosclerosis that were not considered at high risk of embolic complications were excluded. The no-isolation group was drawn from historically matched control patients undergoing total arch replacement.

RESULTS

The permanent stroke rate in the isolation and no-isolation groups were 3.3% (n = 1) and 15.9% (n = 15.9), respectively. After inverse-probability-of-treatment-weighting adjustment, the early mortality (P = .043), stroke (P = .044), and composite of early mortality or stroke (P = .005) rates were significantly lower in the isolation group. The logistic regression analysis after inverse-probability-of-treatment-weighting risk adjustment showed a significantly reduced composite risk of early death and stroke in the isolation group (odds ratio, 0.09; 95% confidence interval, 0.01-0.70; P = .023).

CONCLUSIONS

The isolation technique was associated with a significant reduction in early postoperative embolic stroke and mortality risks in patients with severe aortic atherosclerosis undergoing total arch replacement.

Hospital Incidence, Sex Disparities, and Perioperative Mortality in Open Surgically Treated Patients with Aneurysms of the Ascending Aorta and Aortic Arch in Switzerland

OBJECTIVE

To analyze the epidemiological shifts in the incidence of ascending and arch aortic aneurysms (AA) treated with open surgery in the context of evolving endovascular options on a national basis.

METHODS

Between 1 January 2009 and 31 December 2018, 4388 cases were admitted to the hospital with either ruptured (r)AA or non-ruptured (nr)AA as the primary or secondary diagnosis. Patients were classified as having AA based on inclusion and exclusion criteria.

RESULTS

The age-standardized hospital incidence rates for treatment of nrAA were 7.8 (95% confidence interval (CI): 6.9 to 8.7) in 100,000 men and 2.9 (2.4 to 3.4) in 100,000 women and were stable over time. The overall raw in-hospital mortality rate was 2.0% and was significantly lower in males compared to women (1.6% vs. 2.8%, p = 0.015). Higher van Walraven scores (OR: 1.08 per point; 95%CI: 1.06 to 1.11; p = 0.001) and higher age (OR 1.05 per year; (95%CI: 1.02 to 1.07, p = 0.045) were significantly associated with hospital mortality.

CONCLUSIONS

Endovascular surgery seems to have no influence on hospital incidence in patients treated with conventional surgery for AA in Switzerland. There was a significant reduction in in-hospital mortality in both men and women, with age and the von Walraven score being independent factors for worse outcomes.

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.

Comparison of surgical and endovascular left subclavian artery revascularization during thoracic aortic endovascular repair: a systematic review and meta-analysis

Objective

The purpose of this systematic review and meta-analysis was to incorporate data from the latest clinical studies and compare the safety and efficacy of surgical left subclavian artery (LSA) revascularization and endovascular LSA revascularization during thoracic endovascular aortic repair (TEVAR).

Methods

This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered with the PROSPERO database on 16 April 2023 (CRD42023414579). The Embase, MEDLINE (PubMed), and the Cochrane Library databases were searched from January 2000 to May 2023.

Results

A total of 14 retrospective cohort studies with a total of 1,695 patients, were included for review. The peri-operative stroke rates of the surgical and endovascular LSA revascularization groups were 3.8% and 2.6%, respectively (P = 0.97). The peri-operative technical success rates for the surgical and endovascular LSA revascularization groups were 95.6% and 93.0%, respectively (P = 0.24). The peri-operative spinal cord ischemia rates were 1.6% (n = 18) and 1.9% (n = 7) in the surgical and endovascular LSA revascularization groups, respectively (P = 0.90). The peri-operative type Ⅰ endoleak rates for the surgical and endovascular LSA revascularization groups were 6.6% and 23.2%, respectively (P = 0.25). The subgroup analysis showed that the incidence of peri-operative type I endoleak in the parallel stent group was significantly higher than that in the surgical LSA revascularization group (P < 0.0001). The peri-operative left upper limb ischemia rates for the surgical and endovascular LSA revascularization groups were 1.2% and 0.6%, respectively (P = 0.96). The peri-operative mortality rates of the surgical and endovascular LSA revascularization groups were 2.0% and 2.0%, respectively (P = 0.88).

Conclusion

There was no significant difference in the terms of short-term outcomes when comparing the two revascularization techniques. The quality of evidence assessed by GRADE scale was low to very-low. Surgical and endovascular LSA revascularization during TEVAR were both safe and effective. Compared with surgical LSA revascularization techniques, parallel stent revascularization of LSA significantly increased the rate of type I endoleak.

The impact of circulatory arrest with selective antegrade cerebral perfusion on brain functional connectivity and postoperative cognitive function

Aortic surgery is one of the most challenging types of surgeries, which is possibly related to cognitive sequelae. We aimed to investigate the changes in resting-state functional connectivity (rsFC) associated with intraoperative circulatory arrest (CA) in aortic surgery, exploring the relationship between the altered connectivity and postoperative cognitive functions. Thirty-eight patients participated in this study (14 with CA, 24 without). Functional magnetic resonance imaging was scanned on the fifth day after surgery or after the resolution of delirium if it was developed. We assessed the differences in the development of postoperative cognitive changes and rsFC between patients with and without CA. The occurrence of postoperative delirium and postoperative cognitive dysfunction was not significantly different between the patients with and without the application of CA. However, patients with CA showed increased in posterior cingulate cortex-based connectivity with the right superior temporal gyrus, right precuneus, and right hippocampus, and medial prefrontal cortex-based connectivity with the dorsolateral prefrontal cortex. The application of moderate hypothermic CA with unilateral antegrade cerebral perfusion is unlikely to affect aspects of postoperative cognitive changes, whereas it may lead to increased rsFC of the default mode network at a subclinical level following acute brain insults.

Satralizumab, Novel Interleukine-6 Inhibitor for Preventing Descending Thoracic Aorta Aneurysm Development

BACKGROUND

Descending thoracic aorta aneurysm (dTAA) has increasing incidence and, if left untreated, could lead to death. There is not any study of satralizumab treatment for preventing dTAA formation and progression.

MATERIALS AND METHODS

Forty male 10-week-old Rattus norvegicus were enrolled in the experiment. They were divided into four equal groups: dTAA treated with saline (dTAA-P) and dTAA treated with satralizumab (dTAA-S). One of the control groups was treated with saline (C-P), and the other was treated with satralizumab (C-S). Satralizumab and saline were used once every 2 weeks, subcutaneously 120 mg for 4 weeks. dTA diameter was measured at days 0, 3, 7, 14, 21, and 28.

RESULTS

IL-6 level was measured on the 7th day that showed significantly increased IL-6 serum level in dTAA-P rats compared to C-P. Maximal dTA diameter (%MAD) was obtained at day 14, which was scientifically matched to the aorta aneurysm definition (>50% increase in diameter). From the seventh day, a significant difference in %MAD was observed between dTAA-P and dTAA-S groups. However, the %MAD of these two groups was significantly higher than control groups till the end of the 28th day.

CONCLUSION

Using an IL-6 inhibitor agent to prevent dTAA formation and progression showed promising results. It suggests that using the IL-6 inhibitors in susceptible persons can be considered a lifesaving therapeutic approach.

Postoperative management in patients with complex aortic aneurysms

Patients with complex aortic aneurysms (CAA) are often high risk due to advanced age and widespread atherosclerosis affecting numerous vascular territories. Therefore, a thorough perioperative evaluation is needed prior to performing in any type of aortic repair, regardless of whether an endovascular or open surgical approach is selected. Because these operations are technically demanding and often result in end organ ischemia, it is not surprising that complex aortic repair carries significant risk of morbidity and mortality. Disabling complications such as dialysis, major stroke and paraplegia constitute the main limitation of complex aortic repair. The aim of this article was to review postoperative management to mitigate complications after CAA repair.

Trends in thoracic aortic aneurysm hospital admissions, interventions and mortality in England between 1998 to 2020: An observational study

OBJECTIVE

To assess trends in thoracic aortic aneurysm (TAA) hospital admissions, interventions, and aneurysm-related mortality (ARM) in England and examine the impact of endovascular repair on mortality for the years 1998 to 2020.

METHODS

Hospital admission and operative approach (thoracic endovascular aortic repair, TEVAR or open surgical repair, OSR) using Hospital Episodes Statistics (HES), and ARM data from the Office for National Statistics for England (ONS) standardised to the 2013 European Standard Population were analysed using linear regression and Joinpoint regression analyses. ARM was compared between the pre-endovascular era (1998-2008) and the endovascular era (2009-2019).

RESULTS

A rising trend in in-hospital admission incidence was observed, mainly due non-ruptured admissions (4.11 per 100,000 in 1998 [95% CI 3.71 to 4.50 per 100,000] to 12.61 per 100,000 in 2020 [95% CI 12.00 to 13.21 per 100,000] in 2020; r² = 0.98; p < .001). Operative interventions increased mainly due to an increase in TEVAR (2.15 per 100,000 [95% CI 1.91 to 2.41 per 100,000] in 2020 vs 0.26 per 100,000 [95% CI 0.16 to 0.36 per 100,000] in 2006; r² = 0.90; p < .001). Reductions in ARM from TAA were observed for males and females, irrespective of age and rupture status. The greatest reduction in ARM in the endovascular era was observed in females > 80 years, with ruptured disease 15.26 deaths per 100,000 versus 9.50 deaths per 100,000, p < .0001).

CONCLUSION

A significant increase in hospital admissions for non-ruptured TAA was observed in the last 23 years in England, paralleled by a shift towards endovascular repair, and significant declining trends in ARM irrespective of gender and age. The significant reductions in ASDR from ruptured and non-ruptured TAA in the endovascular era, particularly for females >80 years with ruptured disease affirm the positive impact of an endovascular approach to TAA.

Impact of Female Sex on Outcomes of Patients Undergoing Thoracic Endovascular Aortic Aneurysm Repair: A Ten-Year Retrospective Nationwide Study in France

The impact of sex on the outcomes of patients with cardiovascular disease is still incompletely understood. The aim of this nationwide multicenter observational study was to investigate the impact of sex on post-operative outcomes in patients undergoing thoracic endovascular aortic repair (TEVAR) for intact thoracic aortic aneurysm (iTAA). The French National Health Insurance Information System was searched to identify these patients over a ten-year retrospective period. Post-operative outcomes, 30-day and overall mortality were recorded. Among the 7383 patients included (5521 men and 1862 women), females were significantly older than males (66.8 vs. 64.8 years, p < 0.001). They were less frequently diagnosed with cardiovascular comorbidities. Post-operatively, women had less frequently respiratory (10.9 vs. 13.7%, p = 0.002) as well as cardiac complications (34.3 vs. 37.3%, p = 0.023), but they had more frequently arterial complications (52.8 vs. 49.8%, p = 0.024). There was no significant difference on overall mortality for a mean follow-up of 2.2 years (26.9 vs. 27.6%, p = 0.58). In the multivariable regression model, female sex was not associated with 30-day or overall mortality. Although women had a favorable comorbidity profile, the short-term and long-term survival was similar. The significantly higher rate of arterial complications suggests that women may be at higher risk of access-vessel-related complications.

Utility of psoas muscle area in selecting older patients feasible for thoracic endovascular aortic repair

BACKGROUND

The impact of psoas muscle mass index (PMI) on overall survival is unknown in older patients undergoing elective thoracic endovascular aortic repair (TEVAR).

METHODS

We retrospectively reviewed 105 patients 75 years and older who underwent elective TEVAR for descending thoracic aortic aneurysm between January 2010 and December 2019. Psoas muscle area was measured at the L3 level with preoperative computed tomography and adjusted by height² to derive PMI. The patients were stratified into two groups, Sarcopenia and Non-sarcopenia. Sarcopenia was defined as a PMI < 5.40 cm²/m² for male and < 3.56 cm²/m² for female. The overall survival was compared with the age- and sex-matched general population using the one-sample log-rank test. The propensity score adjusted-Cox proportional-hazard model was applied to determine the hazard ratio for all-cause mortality.

RESULTS

Twenty-three patients died during the follow-up period (median, 3.0 years). Thirty-eight (36%) patients were classified as Sarcopenia. The 5-year overall survival rate was 46% (95% confidence interval, 29-73) in Sarcopenia and 84% (95% confidence interval, 74-94) in Non-sarcopenia. The overall survival was significantly lower in Sarcopenia than in its matched general population (P = .004). Whereas, no statistically significant difference in overall survival was found between Non-sarcopenia and its matched general population (P = .417). Sarcopenia was an independent risk factor for all-cause mortality (adjusted hazard ratio, 2.64; 95% confidence interval, 1.02- 6.82; P = .045).

CONCLUSIONS

PMI may be a good predictor of mortality in older patients undergoing elective TEVAR for descending thoracic aortic aneurysm.

Early and Mid-Term Outcomes of Open versus Endovascular Left Subclavian Artery Debranching for Thoracic Aortic Diseases

Purpose: To compare open versus endovascular left subclavian artery debranching for thoracic endovascular aortic repair of thoracic aortic pathologies.

Methods: This is a retrospective study of patients receiving left subclavian artery debranching in our institution from October 2009 to January 2020. The primary outcome was freedom from aortic reintervention. Secondary outcomes were type I endoleaks, left subclavian artery (LSA) debranching failure, stroke, technical or clinical success, procedure-related reintervention, as well as 30-day or overall all-cause and aorta-related mortality.

Results: Forty-eight patients received parallel graft-based (n = 24, ENDO; median age 75 years [70–80 years]) or open (n = 24, OPEN; median age 71 years [59–75 years]) debranching for type B aortic dissection (n = 25), degenerative aneurysm (n = 12), type IA endoleak (n = 6), suture-associated (n = 3) or ostial LSA aneurysm (n = 1), or penetrating aortic ulcer (n = 1). The median follow-up was 36 months (13–61 months). After 16 months, aortic reintervention-free survival in groups OPEN and ENDO was 91% (95% confidence interval [CI]: 79 to 100%) and 86% (73 to 100%) (p = 0.71), respectively. After 36 months, all-cause survival in groups OPEN and ENDO was 74% (95% CI: 55 to 99%) and 79% (95% CI: 64 to 97%) (p = 0.74), respectively; freedom from aorta-related mortality was 81% (95% CI: 62 to 100%) and 91% (95% CI: 80 to 100%) (p = 0.78), respectively. Group OPEN presented less type I endoleaks (OPEN/ENDO = 3/19, p <0.001) and higher technical (OPEN/ENDO = 81/36%, p = 0.003) and clinical success rates (OPEN/ENDO = 67/36%, p = 0.047). No statistical differences were found for other outcomes.

Conclusion: Both strategies achieved comparable reintervention and mortality rates, but open debranching should be preferred due to its higher technical and clinical success and less type I endoleaks.

Endovascular repair for thoracoabdominal aortic aneurysms: current status and future challenges

Open surgical repair has been the gold standard for treatment of thoracoabdominal aortic aneurysms (TAAA). Currently, open surgical repair has been reserved mostly for young and fit patients with connective tissue disorders, using separate branch vessel reconstructions instead of 'island' patches, and distal perfusion instead of a 'clamp and go' technique. Endovascular repair has gained widespread acceptance because of its potential to significantly decrease morbidity and mortality. Several large aortic centers have developed dedicated clinical programs to advance techniques of fenestrated-branched endovascular aortic repair (FB-EVAR) using patient-specific and off-the-shelf devices, which offers a less-invasive alternative to open repair. Although FB-EVAR was initially considered an option for older and frail patients, many centers have expanded its indications to any patient with suitable anatomy and no evidence of connective tissue disorders, independent of their clinical risk. In this article, we review current techniques and outcomes of endovascular TAAA repair.

Long-term results of total endovascular repair of arch-involving aortic pathologies using parallel grafts for supra-aortic debranching

OBJECTIVE

We evaluated the long-term morphologic and clinical outcomes after thoracic endovascular aortic repair combined with parallel grafts (PG-TEVAR) for arch-involving aortic pathologies.

METHODS

We performed a retrospective analysis of perioperative and follow-up data of patients who had undergone PG-TEVAR at a single vascular surgery center from November 2010 to April 2018. Patients with prior or simultaneous open chest or cervical debranching procedures or arch repair were excluded. The primary endpoint was freedom from overall PG-TEVAR-related reintervention. The secondary endpoints were parallel graft sealing zone failure (presence of gutter-related type I or Ic endoleak), PG failure (occlusion or reintervention), stroke, and 30-day and overall PG-TEVAR-related and all-cause mortality. Kaplan-Meier curves were used to estimate the freedom from reintervention and survival. Receiver operating characteristics curves were used to find the optimal cutoff to prevent type Ia endoleak-related reintervention.

RESULTS

A total of 33 patients, including 8 women, with a median age of 74 years (interquartile range, 67-79 years) had undergone PG-TEVAR (chimney, periscope, and sandwich in 20, 15, and 13 patients, respectively) with proximal landing in Ishimaru zone 0, 1, or 2 in 4, 5, and 24 patients, respectively. The aortic pathologies included type B aortic dissection (acute and chronic, eight and six, respectively), degenerative aneurysm (n = 10), type Ia endoleak (n = 3), para-anastomotic/patch aneurysm (n = 4), left subclavian artery aneurysm (n = 1), and traumatic rupture (n = 1). The perioperative stroke rate and 30-day mortality was 6% and 9%, respectively. Direct postoperative computed tomography revealed 28 endoleaks (gutter-related type Ia, 12; gutter-related type Ib, 9; type Ia, 2; type Ic, 2; type III, 1; undetermined, 2) in 27 patients. The technical and clinical success rate was 37% and 30%, respectively. The mean follow-up for survival was 48 ± 31 months. The latest radiologic follow-up demonstrated 12 remaining and 1 new endoleak. The early and overall PG sealing zone failure and PG failure was 73% and 36% and 9% and 18%, respectively. The overall PG-TEVAR-related reintervention rate was 33% (n = 11). The estimated freedom from overall PG-TEVAR-related reintervention was 68% at 60 months. The main graft oversizing and length oversizing rates were not significantly associated statistically with the type Ia endoleak-related reintervention rate. The PG-TEVAR-related and all-cause mortality were 18% and 34%, respectively.

CONCLUSIONS

PG-TEVAR for total endovascular repair of arch-involving aortic pathologies resulted in a high rate of type I endoleaks and the need for long-term reintervention. Gutter-related endoleaks might be more frequent than reported and should not be underestimated because they can lead to sac enlargement and reintervention. Frequent radiologic surveillance is mandatory. Further studies comparing PG-TEVAR to other total endovascular alternatives are required to confirm these findings.

Effectiveness of endovascular versus open surgical repair for thoracic aortic aneurysm: a systematic review and meta-analysis

INTRODUCTION

Since the approval, the TEVAR is widely used for the repair of thoracic aortic aneurysm. However, the long-term mortality and re-intervention rates compared to OSR are unclear. We aimed to compare the effectiveness of the thoracic endovascular aortic repair (TEVAR) with open surgical repair (OSR) specifically for thoracic aortic aneurysms.

EVIDENCE ACQUISITION

We conducted a comprehensive search in MEDLINE, PubMed, EMBASE, CINAHL, PROSPERO, Centre for Reviews and Dissemination, and the Cochrane Library up to November 2020. The main outcomes were early mortality, mid-to-long-term survival, and re-intervention. The quality of the evidence was assessed using the GRADE methodology. All analyses were performed using RevMan with the random effect model and Comprehensive Meta-Analysis software.

EVIDENCE SYNTHESIS

One systematic review and 15 individual studies were included. Pooled analysis showed that 30-day mortality, stroke, renal failure, and pulmonary complications were significantly lower in TEVAR vs. open surgery. The pooled rate of re-intervention significantly favored the OSR. The long-term survival and mortality favored TEVAR and OSR in one and two studies, respectively, but was non-significant in 7 analyzes.

CONCLUSIONS

Early clinical outcomes including the 30-day mortality, stroke, renal failure, and pulmonary complications significantly favored the TEVAR. However, the mid-to-long-term re-intervention rate favored the OSR and long-term survival was inconsistent among the studies. The quality of evidence was very low. More studies with longer follow-ups are needed. The use of TEVAR should be decided by taking into account other factors including patient characteristics and preferences, cost, and surgeon expertise.

Mid-Term Survival and Risk Factors Associated With Myocardial Injury After Fenestrated and/or Branched Endovascular Aortic Aneurysm Repair

OBJECTIVE

Myocardial injury after non-cardiac surgery (MINS) is an independent predictor of post-operative mortality in non-cardiac surgery patients and may increase health costs. Few data are available for MINS in vascular surgery patients, in general, and those undergoing fenestrated/branched endovascular aortic repairs (F/BEVAR), in particular. The incidence of MINS after F/BEVAR, the associated risk factors, and prognosis have not been determined. The aim of the present study was to help fill these knowledge gaps.

METHODS

A single centre, retrospective study was carried out at a high volume F/BEVAR centre in a university hospital. Adult patients who underwent F/BEVAR between October 2010 and December 2018 were included. A high sensitivity troponin T (HsTnT) assay was performed daily in the first few post-operative days. MINS was defined as a HsTnT level ≥ 14 ng/L (MINS₁₄) or ≥ 20 ng/L (MINS₂₀). After assessment of the incidence of MINS, survival up to two years was estimated in a Kaplan-Meier analysis and the groups were compared according to MINS status. A secondary aim was to identify predictors of MINS.

RESULTS

Of the 387 included patients, 240 (62.0%) had MINS₁₄ and 166 (42.9%) had MINS₂₀. In multivariable Cox models, both conditions were significantly associated with poor two year survival (MINS14: adjusted hazard ratio [aHR] 2.15, 95% confidence interval [CI] 1.10 - 4.19; MINS₂₀: aHR 2.43, 95% CI 1.36 - 4.34). In a multivariable logistic regression, age, revised cardiac risk index, duration of surgery, pre-operative estimated glomerular filtration rate (eGFR), and haemoglobin level were independent predictors of MINS.

CONCLUSION

After F/BEVAR surgery, the incidence of MINS was particularly high, regardless of the definition considered (MINS₁₄ or MINS₂₀). MINS was significantly associated with poor two year survival. The modifiable predictors identified were duration of surgery, eGFR, and haemoglobin level.

Incidence and Prevalence of Thoracic Aortic Aneurysms: A Systematic Review and Meta-analysis of Population-Based Studies

Thoracic aortic aneurysms (TAA) may grow asymptomatically until they rupture, with a mortality over 90%. The true incidence and prevalence of this condition is uncertain and epidemiologic data is scarce, understudied and dispersed. Therefore, we aimed to conduct a systematic review and meta-analysis of the incidence and prevalence of TAAs in population-based studies. We searched MEDLINE, EMBASE and CENTRAL from inception to October 2020 for all population-based studies reporting on incidence and/or prevalence of TAAs. Data were pooled using a random effects model. The main outcome was the overall available worldwide incidence and prevalence of TAAs. The secondary outcomes were to evaluate the incidence of ruptured TAAs, differences in the location of these aneurysms (either ascending, arch or descending aorta) and differences in prevalence/incidence across different study designs. Twenty-two studies were included in the review and meta-analysis. The pooled incidence and prevalence of TAAs was 5.3 per 100,000 individuals/year (95% confidence interval [CI]: 3.0; 8.3) and 0.16% (95% CI: 0.12; 0.20), respectively. The pooled incidence of ruptured aneurysms was 1.6 per 100,000 individuals/year (95% CI: 1.3; 2.1). We found a significant difference of the prevalence in autopsy-only studies, which was 0.76% (95% CI: 0.47; 1.13) and the prevalence of TAAs dropped down to 0.07% (95% CI: 0.05;0.11) when these studies were excluded from the overall analysis. The current epidemiologic information provided serve as a base for future public-health decisions. The lack of well-design population-base studies and the limitations encountered serve as calling for future research in this field.

Hospital Incidence and In-Hospital Mortality of Surgically and Interventionally Treated Aortic Dissections: Secondary Data Analysis of the Nationwide German Diagnosis-Related Group Statistics From 2006 to 2014

Background

Population‐based data about the incidence and mortality of patients with aortic dissections (ADs) are sparse. Therefore, the hospital incidence and in‐hospital mortality of patients undergoing open or endovascular surgery for type A ADs (TAADs) and type B ADs (TBADs) in Germany were analyzed on a nationwide basis between 2006 and 2014.

Methods and Results

A secondary data analysis of the nationwide diagnosis‐related group statistics, compiled by the German Federal Statistical Office, was performed for patients who were surgically/interventionally treated for AD (International Classification of Diseases, Tenth Revision, German Modification [ICD‐10‐GM] codes I71.00‐I71.07; n=20 533). By using specific procedure codes, a distinction between TAAD (n=14 911/72.6%) and TBAD (n=5622/27.4%) could be made. The standardized hospital incidence of surgically/interventionally treated AD was 2.7/100 000 per year, comprising 2.0/100 000 per year for TAAD and 0.7/100 000 per year for TBAD. The in‐hospital mortality of TAAD was 19.5%; and of TBAD, 9.3%. Both the incidence and in‐hospital mortality increased over the 9‐year period. The share of endovascularly treated TBAD increased steadily during the same time interval. A multilevel multivariable analysis revealed that, for TAAD, age and comorbidity were significantly associated with a higher mortality risk.

The latter was also true for TBAD. Sex was not significantly associated with mortality. A significant association between higher annual center volume and mortality was found for TAAD, but not for TBAD.

Conclusions

This is the first report on hospital incidence and mortality for surgically/interventionally treated AD on a nationwide basis. Overall, in Germany, hospital incidence and mortality of TAAD and TBAD increased over time. In addition, TAAD is performed more safely in high‐volume centers.

See Editorial Svensson

Natural history of descending thoracic and thoracoabdominal aortic aneurysms

OBJECTIVES

Elucidating critical aortic diameters at which natural complications (rupture, dissection, and death) occur is of paramount importance to guide timely surgical intervention. Natural history knowledge for descending thoracic and thoracoabdominal aortic aneurysms is sparse. Our small early studies recommended repairing descending thoracic and thoracoabdominal aortic aneurysms before a critical diameter of 7.0 cm. We focus exclusively on a large number of descending thoracic and thoracoabdominal aortic aneurysms followed over time, enabling a more detailed analysis with greater granularity across aortic sizes.

METHODS

Aortic diameters and long-term complications of 907 patients with descending thoracic and thoracoabdominal aortic aneurysms were reviewed. Growth rates (instrumental variables approach), yearly complication rates, 5-year event-free survival (Kaplan-Meier), and risk of complications as a function of aortic height index (aortic diameter [centimeters]/height [meters]) (competing-risks regression) were calculated.

RESULTS

Estimated mean growth rate of descending thoracic and thoracoabdominal aortic aneurysms was 0.19 cm/year, increasing with increasing aortic size. Median size at acute type B dissection was 4.1 cm. Some 80% of dissections occurred below 5 cm, whereas 93% of ruptures occurred above 5 cm. Descending thoracic and thoracoabdominal aortic aneurysm diameter 6 cm or greater was associated with a 19% yearly rate of rupture, dissection, or death. Five-year complication-free survival progressively decreased with increasing aortic height index. Hazard of complications showed a 6-fold increase at an aortic height index of 4.2 or greater compared with an aortic height index of 3.0 to 3.5 (P < .05). The probability of fatal complications (aortic rupture or death) increased sharply at 2 hinge points: 6.0 and 6.5 cm.

CONCLUSIONS

Acute type B dissections occur frequently at small aortic sizes; thus, prophylactic size-based surgery may not afford a means for dissection protection. However, fatal complications increase dramatically at 6.0 cm, suggesting that preemptive intervention before that criterion can save lives.

Predictors of bleeding or anemia requiring transfusion in complex endovascular aortic repair and its impact on outcomes in health insurance claims

OBJECTIVE

This study aimed to determine predictors and outcomes associated with bleeding or anemia requiring transfusion (BAT) after fenestrated or branched endovascular aneurysm repair (FB-EVAR).

METHODS

Health insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate BAT in elective FB-EVAR performed between 2008 and 2017. International Classification of Diseases and German Operations and Procedure Key codes were used.

RESULTS

A total of 959 patients (24.8% with BAT) matching the inclusion criteria were identified during the study period. Compared with patients without BAT, patients with BAT were older (74.4 vs 73.0 years; P = .015) and suffered more frequently from congestive heart failure (18.5% vs 9.4%), cardiac arrhythmias (26.9% vs 14.7%), and hereditary or acquired coagulopathy (31.9% vs 6.2%; all P < .001). Coagulopathy (odds ratio [OR], 3.65; 95% confidence interval [CI], 2.29-5.84), female sex (OR, 2.67; 95% CI, 1.78-4.00), and multiple comorbidities (OR, 1.10; 95% CI, 1.07-1.14) were independent predictors of BAT (all P < .001). BAT was associated with higher in-hospital (11.3% vs 2.6%), 30-day (12.2% vs 3.1%), and 90-day (18.5% vs 4.4%) mortality (all P < .001). Furthermore, myocardial infarction (23.9% vs 2.8%) and paraplegia (9.7% vs 0.7%) were more frequent in the BAT group (all P < .001). In multivariable analyses, BAT was associated with worse short-term (OR, 3.19; 95% CI, 1.63-6.33; P = .001) and long-term survival (hazard ratio, 1.62; 95% CI, 1.24-2.11; P < .001).

CONCLUSIONS

Patients with hereditary or acquired coagulopathy, patients with multiple comorbidities, and women are at higher risk for development of BAT after FB-EVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of patient blood management in FB-EVAR.