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Rastogi V, Varkevisser RRB, Patel PB, Marcaccio CL, Conroy PD, O'Donnell TFX, Zettervall SL, Patel VI, Verhagen HJM, Schermerhorn ML. Editor's Choice -- Age Stratified Midterm Survival Following Endovascular Versus Open Repair of Juxtarenal Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:408-415. [PMID: 37586459 DOI: 10.1016/j.ejvs.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 06/21/2023] [Accepted: 08/10/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE Age stratified mortality was examined following fenestrated endovascular aneurysm repair (F-EVAR) vs. open repair of juxtarenal abdominal aortic aneurysms (AAAs) METHODS: All patients undergoing first time elective F-EVAR and complex open aneurysm repair (c-OAR) for juxtarenal AAA in the Vascular Quality Initiative between 2014 and 2021 were identified. Open repairs were compared with commercially available fenestrated endovascular aneurysm repair and physician modified endografts (PMEGs). Patients were stratified into three age groups (< 65, 65 - 75, > 75 years). Primary outcomes were peri-operative and five year mortality, and inverse probability weighted risk adjustment was performed to account for baseline differences. RESULTS Overall, 1 961 patients underwent F-EVAR (82% commercial F-EVAR, 18% PMEG) and 3 385 patients underwent c-OAR. Across age groups, the distribution of F-EVAR (vs. c-OAR) was: < 65 years: 23%, 65 - 75 years: 33%, > 75 years: 52%. After adjustment, among patients < 65 years, compared with c-OAR, F-EVAR was associated with similar peri-operative mortality (0.9% vs. 2.1%; hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.07 - 1.44], p = .22), and five year mortality (13% vs. 9.5%; HR 1.44, 95% CI 0.71 - 2.90, p = .31). Among patients aged 65 - 75 years, between juxtarenal AAA repair modalities, compared with c-OAR, F-EVAR was associated with a significantly lower risk of peri-operative mortality (2.2% vs. 5.0%; HR 0.50, 95% CI 0.30 - 0.79, p = .004), and five year mortality (13% vs. 13%; HR 0.94, 95% CI 0.65 - 1.36, p = .74). Similarly, among patients > 75 years, compared with c-OAR, F-EVAR was associated with lower peri-operative mortality (2.2% vs. 6.5%; HR 0.26, 95% CI 0.13 - 0.47, p < .001), but with similar five year mortality (18% vs. 21%; HR 0.83, 95% CI 0.57 - 1.20, p = .31). CONCLUSION Among patients with a juxtarenal AAA, F-EVAR was associated with a lower peri-operative mortality compared with c-OAR in patients ≥ 65 years, but was similar in those < 65 years. At five years, F-EVAR was associated with similar mortality in all age groups, though there was a non-significant trend for a higher mortality rate in younger patients.
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Affiliation(s)
- Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Rens R B Varkevisser
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Priya B Patel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA; Department of General Surgery, Rutgers Robert Wood Johnson University Hospital, New Brunswick NJ, USA
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Patrick D Conroy
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Thomas F X O'Donnell
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA; Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Centre, New York, NY, USA
| | - Sara L Zettervall
- Division of Vascular Surgery, University of Washington, Seattle, WA, USA
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, Columbia University Medical Centre, New York, NY, USA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA.
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
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.
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3
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King B, Rockman C, Han S, Siracuse JJ, Patel VI, Johnson WS, Chang H, Cayne N, Maldonado T, Jacobowitz G, Garg K. Aortobifemoral reconstruction in open abdominal aortic aneurysm repair is associated with increased morbidity and mortality. J Vasc Surg 2023; 78:77-88.e3. [PMID: 36918104 DOI: 10.1016/j.jvs.2023.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/23/2023] [Accepted: 03/05/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVE Much attention has been given to the influence of anatomic and technical factors, such as maximum abdominal aortic aneurysm diameter and proximal clamp position, in open abdominal aortic aneurysm repair (OSR). However, no studies have rigorously examined the correlation between site of distal anastomosis and OSR outcomes despite conventional wisdom that more proximal sites of anastomosis are preferrable when technically feasible. This study aimed to test the association between sites of distal anastomosis and clinical outcomes for patients undergoing primary elective OSR. METHODS Our study included 5683 patients undergoing primary elective OSR at 233 centers from 2014 to 2020. Using a variety of statistical methods to account for potential confounders, including multivariable logistic regression and Cox proportional hazards modeling, as well as subgroup analysis, we examined the association between site of distal anastomosis and clinical outcomes in elective OSR. Primary outcomes were major in-hospital complication rate, 30-day mortality, and long-term survival. RESULTS Patients undergoing elective aortobifemoral reconstruction (n = 672) exhibited significantly increased rates of smoking, chronic obstructive pulmonary disease, and peripheral artery disease in comparison to patients undergoing elective OSR with distal anastomosis to the aorta (n = 2298), common iliac artery (n = 2163), or external iliac artery (n = 550). Patients undergoing aorto-aortic tube grafting were significantly less likely to exhibit iliac aneurysmal disease and significantly more likely to be undergoing elective OSR with a suprarenal or supraceliac proximal clamp position. Using multivariable logistic regression and Cox proportional hazards analysis to control for important confounders, such as age, smoking status, and medical history, we found that distal anastomosis to the common femoral artery was associated with increased odds of major in-hospital complications (adjusted odds ratio, 1.79; 95% confidence interval, 1.46-2.18; P < .001) and reduced long-term survival (adjusted hazard ratio, 1.44; 95% confidence interval, 1.09-1.89; P = .010). We observed no significant differences in 30-day mortality across sites of distal anastomosis in our study population. CONCLUSIONS It is generally accepted that more proximal sites of distal anastomosis should be selected in OSR when technically feasible. Our findings support this hypothesis by demonstrating that distal anastomosis to the common femoral artery is associated with increased perioperative morbidity and reduced long-term survival. Careful diligence regarding optimization of preoperative health status, perioperative care, and long-term follow-up should be applied to mitigate major complications in this patient population.
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Affiliation(s)
- Benjamin King
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Sukgu Han
- Comprehensive Aortic Center, Division of Vascular and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Hospital/Columbia University Irving Medical Center/Columbia University College of Physicians and Surgeons, New York, NY
| | - William S Johnson
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Heepeel Chang
- Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Neal Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Thomas Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Glenn Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Grossman School of Medicine, New York, NY.
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Natour AK, Kabbani L, Rteil A, Nypaver T, Weaver M, Lee A, Mohammad F, Shepard A, Omar Z. Cross-clamp location and perioperative outcomes after open infrarenal abdominal aortic aneurysm repair: A Vascular Quality Initiative ® review. Vascular 2023; 31:199-210. [PMID: 35435780 DOI: 10.1177/17085381211067616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES By analyzing national Vascular Quality Initiative (VQI) data for patients undergoing open infrarenal abdominal aortic aneurysms (AAA) repair, we sought to better characterize the effects of different suprarenal clamping positions on postoperative outcomes. METHODS We performed a retrospective analysis of a prospectively collected national VQI database for all open infrarenal AAA repairs performed between 2003 and 2017. Patients were initially divided into proximal (above 1 renal, above 2 renals, and supraceliac) and infrarenal clamp groups. Patients were then subdivided into those who underwent surgery between 2003-2010 and those who had surgery between 2011-2017. Univariate followed by multivariate analyses were done to compare the baseline characteristics, preoperative, intraoperative, and postoperative outcomes between the two groups. RESULTS During the study period, 9068 open AAA repairs were recorded in the VQI; of these, 5043 met the inclusion criteria. Aortic clamp level was infrarenal in 59% (N = 2975), above 1 renal in 15% (N = 735), above both renals in 21% (N = 1053), and supraceliac in 5% (N = 280). The average age was 69 years, and males comprised 73% (N = 3701) of the cohort. The overall 30-day mortality for the entire study group was 2.7%. On univariate analysis, patients who underwent proximal clamping had significantly higher 30-day mortality than those undergoing infrarenal clamping (3.7 vs 2.0%, p < 0.001). After adjusting for preoperative and intraoperative variables, this difference became nonsignificant. On multivariate analysis, clamping above both renals or the celiac artery was associated with an increased occurrence of postoperative myocardial infarction (odds ratio = 1.44, p = 0.037 and odds ratio = 1.78, p = 0.023, respectively). All proximal clamp positions were associated with a significant increase in the incidence of AKI and renal failure requiring dialysis. There was no significant difference when looking at overall survival times comparing the suprarenal and infrarenal clamp position groups (p = 0.1). Patients who underwent surgery in the latter half of the study period had longer intraoperative renal ischemia time, increased in estimated blood loss, and longer total procedure time. CONCLUSIONS Suprarenal clamping, at any level, was associated with an increased risk of AKI and renal replacement therapy. Clamping above both renal and celiac arteries was associated with increased cardiac morbidity. Perioperative and long-term mortality was unaffected by clamp level. Patients operating in the latter half of the study had increased estimated blood loss, renal ischemia time, and operative time, which may reflect decreased training in open AAA repair. During open AAA repair, the proximal clamp site should be chosen based on anatomic considerations and not a perceived perioperative mortality benefit. Proximal aortic clamping should always be performed at the safest, distal-most level to reduce cardiac morbidity and the risk of postoperative dialysis.
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Affiliation(s)
- Abdul Kader Natour
- Division of Vascular Surgery, ringgoldid:2971Henry Ford Hospital, Detroit, MI, USA
| | - Loay Kabbani
- Division of Vascular Surgery, ringgoldid:2971Henry Ford Hospital, Detroit, MI, USA
| | - Ali Rteil
- Division of Vascular Surgery, ringgoldid:2971Henry Ford Hospital, Detroit, MI, USA
| | - Timothy Nypaver
- Division of Vascular Surgery, ringgoldid:2971Henry Ford Hospital, Detroit, MI, USA
| | - Mitchell Weaver
- Division of Vascular Surgery, ringgoldid:2971Henry Ford Hospital, Detroit, MI, USA
| | - Alice Lee
- Division of Vascular Surgery, ringgoldid:2971Henry Ford Hospital, Detroit, MI, USA
| | - Farah Mohammad
- Division of Vascular Surgery, ringgoldid:2971Henry Ford Hospital, Detroit, MI, USA
| | - Alexander Shepard
- Division of Vascular Surgery, ringgoldid:2971Henry Ford Hospital, Detroit, MI, USA
| | - Ziad Omar
- Division of Vascular Surgery, ringgoldid:2971Henry Ford Hospital, Detroit, MI, USA
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Hossack M, Simpson G, Shaw P, Fisher R, Torella F, Brennan J, Smout J. Open Retroperitoneal Repair for Complex Abdominal Aortic Aneurysms. AORTA (STAMFORD, CONN.) 2022; 10:114-121. [PMID: 36318932 PMCID: PMC9626034 DOI: 10.1055/s-0042-1748959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background
Open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) can be challenging. We frequently utilize the retroperitoneal (RP) approach for such cases. We audited our outcomes with the aim of establishing the utility and safety of this approach.
Methods
Retrospective analysis was performed of all patients undergoing OSR of an unruptured CAAA via a RP approach in our center over a 7-year period. Data on repairs via a transperitoneal (TP) approach were collected to provide context. Demographic, operative, radiological, and biochemical data were collected. The primary outcome measure was 30-day/inpatient mortality. Secondary outcomes included the need for reoperation, incidence of postoperative chest infection, acute kidney injury (AKI) and length of stay (LOS). All patients received aortic clamping above at least one main renal artery.
Results
One hundred and three patients underwent OSR of an unruptured CAAA; 55 via a RP approach, 48 TP. The RP group demonstrated a more advanced pattern of disease with a larger median maximum diameter (65 vs. 61 mm,
p
= 0.013) and a more proximal extent. Consequently, the rate of supravisceral clamping was higher in RP repair (66 vs. 15%,
p
< 0.001). Despite this there were no differences in the observed early mortality (9.1 vs. 10%, NS); incidence of reoperation (10.9 vs. 12.5%, NS), chest infection (32.7 vs. 25%, NS), and AKI (52.7 vs. 45.8%, NS); or median LOS (10 vs. 12 days, NS) following RP and TP repair.
Conclusion
OSR of CAAAs carries significant 30-day mortality. In patients unsuitable for fenestrated endovascular aortic repair or those desiring a durable long-term solution, OSR can be performed through the RP or TP approach. This study has demonstrated that in our unit RP repair facilitates treatment of more advanced AAA utilizing complex proximal clamp zones with similar perioperative morbidity and mortality compared with TP cases utilizing more distal clamping.
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Affiliation(s)
- Martin Hossack
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom,Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool, United Kingdom,Address for correspondence Martin Hossack, MBChB, BSc Liverpool Vascular and Endovascular ServiceLink 8C, Royal Liverpool University Hospital, Prescot Street, Liverpool, United Kingdom L7 8XP
| | - Gregory Simpson
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Penelope Shaw
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Robert Fisher
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Francesco Torella
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom,Liverpool Centre for Cardiovascular Sciences, University of Liverpool, Liverpool, United Kingdom
| | - John Brennan
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | - Jonathan Smout
- Liverpool Vascular and Endovascular Service, Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
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Titarenko V, Beer A, Schonefeld-Siepmann E, Muschal F, Beyer JK. Giant Symptomatic Unruptured Juxtarenal Abdominal Aortic Aneurysm. Vasc Specialist Int 2022; 38:23. [PMID: 36097707 PMCID: PMC9468660 DOI: 10.5758/vsi.220019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/30/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022] Open
Abstract
Herein, we present the case of an 84-year-old male with a 13-cm, symptomatic, unruptured juxtarenal abdominal aortic aneurysm. This aneurysm was successfully treated with open surgical repair, which was deemed satisfactory at the 3-year follow-up. Despite a paradigm shift towards endovascular techniques in aortic repair, postgraduate training with a focused exposure to open aortic surgery at high-volume centers is essential for future vascular surgeons to safely perform complex aortic repairs with acceptable mortality and morbidity rates.
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Affiliation(s)
- Valentin Titarenko
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Anita Beer
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Eva Schonefeld-Siepmann
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Felix Muschal
- Departments of Interventional, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
| | - Jochen Karsten Beyer
- Departments of Vascular Surgery, Diagnostik Radiology and Nuclear Medicine, Augusta-Kranken-Anstalt Bochum-Mitte, Bochum, Germany
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Li B, Eisenberg N, Witheford M, Lindsay TF, Forbes TL, Roche-Nagle G. Sex Differences in Outcomes Following Ruptured Abdominal Aortic Aneurysm Repair. JAMA Netw Open 2022; 5:e2211336. [PMID: 35536576 PMCID: PMC9092206 DOI: 10.1001/jamanetworkopen.2022.11336] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Sex differences in aortic surgery outcomes are commonly reported. However, data on ruptured abdominal aortic aneurysm (rAAA) repair outcomes in women vs men are limited. OBJECTIVE To assess differences in perioperative and long-term mortality following rAAA repair in women vs men. DESIGN, SETTING, AND PARTICIPANTS A multicenter, retrospective cohort study was conducted using the Vascular Quality Initiative database, which prospectively captures information on patients who undergo vascular surgery across 796 academic and community hospitals in North America. All patients who underwent endovascular or open rAAA repair between January 1, 2003, and December 31, 2019, were included. Outcomes were assessed up to January 1, 2020. EXPOSURES Patient sex. MAIN OUTCOMES AND MEASURES Demographic, clinical, and procedural characteristics were recorded, and differences between women vs men were assessed using independent t test and χ2 test. The primary outcomes were in-hospital and 8-year mortality. Associations between sex and outcomes were analyzed using univariable and multivariable logistic regression and Cox proportional hazards regression analysis. RESULTS A total of 1160 (21.9%) women and 4148 (78.1%) men underwent rAAA repair during the study period. There was a similar proportion of endovascular repairs in women and men (654 [56.4%] vs 2386 [57.5%]). Women were older (mean [SD] age, 75.8 [9.3] vs 71.7 [9.6] years), more likely to have chronic kidney disease (718 [61.9%] vs 2184 [52.7%]), and presented with ruptured aneurysms of smaller diameters (mean [SD] 68 [18.2] vs 78 [30.2] mm). In-hospital mortality was higher in women (34.4% vs 26.6%; odds ratio, 1.44; 95% CI, 1.25-1.66), which persisted after adjusting for demographic, clinical, and procedural characteristics (adjusted odds ratio, 1.36; 95% CI, 1.12-1.66; P = .002). Eight-year survival was lower in women (36.7% vs 49.5%; hazard ratio, 1.25; 95% CI, 1.04-1.50; P = .02), which persisted when stratified by endovascular and open repair. This survival difference existed in both the US and Canada. Variables associated with long-term mortality in women included older age and chronic kidney disease. CONCLUSIONS AND RELEVANCE Women who underwent rAAA repair had higher perioperative and 8-year mortality rates following both endovascular and open repair compared with men. Older age and higher rates of chronic kidney disease in women were associated with higher mortality rates. These findings suggest that future studies should assess the reasons for these disparities and whether opportunities exist to improve AAA care for women.
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Affiliation(s)
- Ben Li
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Miranda Witheford
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F. Lindsay
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L. Forbes
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- University Health Network, Peter Munk Cardiac Centre, Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
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8
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Mehta A, O'Donnell TFX, Schutzer R, Trestman E, Garg K, Mohebali J, Siracuse JJ, Schermerhorn M, Clouse WD, Patel VI. Evaluating Proximal Clamp Site and Intraoperative Ischemia Time Among Open Repair of Juxtarenal Aneurysms. J Vasc Surg 2022; 76:411-418. [PMID: 35149161 DOI: 10.1016/j.jvs.2022.01.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 01/21/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The proportion of open aneurysm repairs requiring at least a suprarenal clamp has increased in the past few decades, partly due to preferred endovascular approaches for most patients with infrarenal aneurysms, suggesting that the management of aortic clamp placement has become even more relevant. This study evaluated the association between proximal clamp site and intraoperative ischemia times with postoperative renal dysfunction and mortality. METHODS We used the Vascular Quality Initiative to identify all patients undergoing open repairs of elective or symptomatic juxtarenal AAAs from 2004-2018 and compared outcomes by clamp site: above one renal artery, above both renal arteries (supra-renal), or above the celiac trunk (supra-celiac). Outcomes evaluated included acute kidney injury (AKI), new-onset renal failure requiring renal replacement therapy (RRT), 30-day mortality, and one-year mortality. We used multilevel logistic regressions and cox-proportional hazards models, clustered at the hospital level, to adjust for confounding. RESULTS We identified 3976 patients (median age 71 years, 70% male, 8.2% non-Caucasian), with a median aneurysm diameter of 5.9cm (IQR 5.4-6.8cm). Proximal clamp sites were: above one renal artery (31%), supra-renal (52%), and supra-celiac (17%). Rates of unadjusted outcomes were 20.5% for AKI, 4.1% for new-onset RRT, 4.9% for 30-day mortality, and 8.3% for one-year mortality. On adjusted analyses, independent of ischemia time, supra-renal clamping relative to clamping above a single renal artery had higher odds of postoperative AKI (aOR 1.50 [95%-CI 1.28-1.75]) but similar odds for new-onset RRT (aOR 1.27 [0.79-2.06]) and 30-day mortality (aOR 1.12 [0.79-1.58]) and hazards for one-year mortality (aHR 1.12 [0.86-1.45]). However, every ten minutes of prolonged intraoperative ischemia time was associated with an increase in odds or hazards ratio of postoperative AKI by +7% (IQR 3-11%), new-onset RRT by +11% (IQR 4-17%), 30-day mortality by +11% (IQR 6-17%), and one-year mortality by +7% (IQR 2-13%). Patients with greater than 40 minutes of ischemia time had notably higher rates of all four outcomes. DISCUSSION Supra-renal clamping relative to clamping above a single renal artery was associated with AKI but not new-onset RRT or 30-day mortality. However, intraoperative renal ischemia time was independently associated with all four postoperative outcomes. While further studies are warranted, our findings suggest that an expeditious proximal anastomosis creation is more important than trying to maintain clamp position below one renal artery, suggesting that suprarenal clamping may be the best strategy for open AAA repair when needed to efficiently perform the proximal anastomosis.
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Affiliation(s)
- Ambar Mehta
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center/Columbia University College of Physicians and Surgeons, New York, NY
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Richard Schutzer
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center/Columbia University College of Physicians and Surgeons, New York, NY
| | - Eric Trestman
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center/Columbia University College of Physicians and Surgeons, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, NYU Langone Medical Center, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, MA
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - William D Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center/Columbia University College of Physicians and Surgeons, New York, NY.
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9
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Pomy BJ, Devlin J, Lala S, Amdur RL, Ricotta JJ, Sidawy AN, Nguyen BN, Macsata RA. Comparison of contemporary and historical outcomes of elective and ruptured open abdominal aortic aneurysm repair. J Vasc Surg 2021; 75:543-551. [PMID: 34555478 DOI: 10.1016/j.jvs.2021.08.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Recently, open abdominal aortic aneurysm (AAA) repair (OSR) has become less common and will often be reserved for patients with more complex aortic anatomy. Despite improvements in patient management, the reduced surgical volume has raised concerns for potentially worsened outcomes in the contemporary era (2014-2019) compared with an earlier era in which OSR was more widely practiced (2005-2010). In the present study, we compared the 30-day outcomes of open AAA repair between these two eras. METHODS The American College of Surgeons National Quality Improvement Program general database was queried for open AAA repair using the Current Procedural Terminology and International Classification of Diseases, 9th and 10th, codes. The cases were stratified into two groups by operation year: 2005 to 2010 (early) and 2014 to 2019 (contemporary). In each era, the cases were further divided into elective and ruptured groups. The 30-day outcomes, including mortality, major morbidity, postoperative sepsis, and unplanned reoperation, were compared between the contemporary and early eras in the elective and ruptured groups. Preoperative variables with a P value <.25 were adjusted for in the multivariate analysis. RESULTS In the contemporary and early eras, 3749 and 3798 patients had undergone elective OSR and 1148 and 907 had undergone ruptured OSR, respectively. These samples were of similar sizes owing to the National Quality Improvement Program sampling process and our relatively strict inclusion criteria. In the contemporary era, fewer patients were elderly and fewer were smokers or had hypertension or dyspnea in the elective and rupture cohorts. More patients had had American Society of Anesthesiologists class >3 in the elective contemporary era (39% vs 24%; P < .0001). The contemporary elective repair group demonstrated increased 30-day mortality (3.7% vs 3.2%; adjusted odds ratio [aOR], 1.36; P = .006), major adverse cardiac events (5.7% vs 3.4%; aOR, 1.87; P < .0001), and bleeding requiring transfusion (58.5% vs 13.7%; aOR, 8.96; P < .0001). The incidence of pulmonary complications (12.1% vs 15.2%; aOR, 0.80; P = .02) and sepsis (3.7% vs 8.4%; aOR, 0.47; P < .0001) had decreased in the contemporary era, with a similar rate of unplanned reoperations (8.4% vs 7.7%; aOR, 1.16; P = .09). The incidence of renal complications in the contemporary era had increased, with a statistically significant difference. However, the absolute increase of <0.5% was likely not clinically relevant (5.5% vs 5.1%; aOR, 1.23; P = .049). In the ruptured cohort, contemporary repair was associated with increased 30-day mortality (41.4% vs 40%; aOR, 1.53; P < .0001), major adverse cardiac events (25.8% vs 12.8%; aOR, 2.49; P < .0001), and bleeding requiring transfusion (88.2% vs 27%; aOR, 23.03; P < .0001). The incidence of pulmonary complications (36.9% vs 48.1%; aOR, 0.67; P < .0001), sepsis (14.6% vs 23%; aOR, 0.75; P = .03), and unplanned reoperations (18.1% vs 22.7%; aOR, 0.74; P = .008) had decreased in the contemporary OSR group. No differences were detected in the incidence of renal complications. CONCLUSIONS The 30-day mortality has worsened after open AAA repair in the elective and rupture settings despite the improvements in perioperative management over the years. These complications likely stem from increased bleeding events and major cardiac events, which were increased in the contemporary era.
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Affiliation(s)
- Benjamin J Pomy
- Department of Surgery, The George Washington University, Washington, D.C..
| | - Joseph Devlin
- Department of Surgery, The George Washington University, Washington, D.C
| | - Salim Lala
- Department of Surgery, The George Washington University, Washington, D.C
| | - Richard L Amdur
- Department of Surgery, The George Washington University, Washington, D.C
| | - John J Ricotta
- Department of Surgery, The George Washington University, Washington, D.C
| | - Anton N Sidawy
- Department of Surgery, The George Washington University, Washington, D.C
| | - Bao-Ngoc Nguyen
- Department of Surgery, The George Washington University, Washington, D.C
| | - Robyn A Macsata
- Department of Surgery, The George Washington University, Washington, D.C
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10
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Bashir M, Munir W, Davies H, Bailey DM, Williams IM. The retroperitoneal approach for contemporary open abdominal aortic aneurysm surgery: The anatomical reasoning. Asian Cardiovasc Thorac Ann 2021; 29:654-660. [PMID: 34409877 DOI: 10.1177/02184923211039799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In current practice, the place of open surgery in managing abdominal aortic aneurysm is a contentious issue. The principal reason being greater applications of endovascular techniques treating increasingly complicated aortic disease. Development of branched and fenestrated devices enabled this, with numbers increasing annually. This meant a good risk patient with a long infrarenal aortic neck and normal diameter non-tortuous iliac arteries may be suitable for both endovascular and open techniques. However, indications for open surgery are becoming increasingly unclear nowadays due to short-term gains in morbidity and mortality. Exact aortic anatomical morphologies optimum for open or endovascular techniques remains unclear. As graft technology evolves, possibilities for endovascular options are expanding. Currently, establishing optimum treatment plans for complicated abdominal aortic aneurysm (little or no infrarenal neck) is difficult without considering general fitness of the patient. Hence, two sets of possible postoperative complications and follow-up protocols must be explained to patients before either approach. Complicating matters is the optimum surgical approach used for any open repair. The standard approach for open abdominal aortic aneurysm surgery has been transperitoneal as this provides excellent access to the infrarenal aorta and iliac arteries. However, although less commonly used, the retroperitoneal approach has advantages particularly when location of proximal aortic disease indicates suprarenal clamp might be optimum. This paper scrutinises benefits of the retroperitoneal approach performed purely for anatomical reasons where stent graft may be considered complicated. Also, long-term outcomes are examined in terms of endo-leak and subsequent development of true and false aneurysm following both endovascular and open repair.
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Affiliation(s)
- Mohamad Bashir
- Vascular and Endovascular, Health education and Improvement Wales, UK
| | - Wahaj Munir
- 105711Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Huw Davies
- Vascular Surgery, 97609University Hospital of Wales, UK
| | - Damian M Bailey
- Neurovascular Research Laboratory, 102493Faculty of Life Sciences and Education, University of South Wales, UK
| | - Ian M Williams
- Vascular Surgery, 97609University Hospital of Wales, UK.,Neurovascular Research Laboratory, 102493Faculty of Life Sciences and Education, University of South Wales, UK
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11
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Keschenau PR, Beropoulis E, Gombert A, Jacobs MJ, Torsello G, Austermann M, Kotelis D, Donas KP. The role of surgical and total endovascular techniques in the treatment of ruptured juxtarenal aortic aneurysms. VASA 2021; 50:356-362. [PMID: 34006132 DOI: 10.1024/0301-1526/a000955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Ruptured juxtarenal aortic aneurysms (RJAAA) represent a special challenge in clinical practice, but the evidence to guide therapeutic decision-making is scarce. The aim of this study was to present two different approaches, open surgical (OAR) and chimney endovascular repair (CHEVAR), for treating patients with RJAAA. Patients and methods: This retrospective two-center study included all patients per center undergoing OAR or CHEVAR for RJAAA between February 2008 and January 2020. Juxtarenal aortic aneurysms were defined as having an infrarenal neck of 2-5 mm, measured after three-dimensional reconstruction of the computed tomography angiography scan. Results: 12 OAR patients (10 male, median age 73 years [58-90 years]) and 6 CHEVAR patients (all male, median age 74 years [59-83 years]) were included. In the OAR group, the proximal aortic clamping was suprarenal in 7 and interrenal in 5 patients. Cold renal perfusion was used in 4 patients, in 2 with suprarenal aortic clamping and in 2 with interrenal aortic clamping. 3 CHEVAR patients received a single renal chimney, the other 3 received double renal chimneys. Technical success was 12/12 in the OAR group 5/6 in the CHEVAR group. In-hospital mortality and 30-day mortality were 3/12 after OAR and 0/6 after CHEVAR. 2 OAR patients required transient dialysis. Median in-hospital stay was 14 (10-63) and 8 (6-21) days and median follow-up (FU) was 20 (3-37) and 30 (7-101) months, respectively. No further deaths occurred during FU. One OAR patient and 4 CHEVAR patients required aortic reinterventions. Conclusions: RJAAAs are rare. Both OAR and CHEVAR can represent adequate treatments for RJAAAs. OAR is the traditional approach, but CHEVAR has - in a high-volume center - promising early results with nonetheless a need for continuous FU to prevent reinterventions. Defining the studied aortic pathology precisely is essential for future research in order to draw valid conclusions.
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Affiliation(s)
- Paula R Keschenau
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Efthymios Beropoulis
- Department of Vascular Surgery and Institute for Vascular Research, St. Franziskus Hospital Münster, Münster, Germany
| | - Alexander Gombert
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Michael J Jacobs
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Giovanni Torsello
- Department of Vascular Surgery and Institute for Vascular Research, St. Franziskus Hospital Münster, Münster, Germany
| | - Martin Austermann
- Department of Vascular Surgery and Institute for Vascular Research, St. Franziskus Hospital Münster, Münster, Germany
| | - Drosos Kotelis
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Konstantinos P Donas
- Department of Vascular Surgery and Research Vascular Centre, Asklepios Clinic Langen, University of Frankfurt, Langen, Germany
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12
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Pomy BJ, Rosenfeld ES, Lala S, Lee KB, Sparks AD, Amdur RL, Ricotta JJ, Sidawy AN, Macsata RA, Nguyen BN. Fenestrated Endovascular Aneurysm Repair Affords Fewer Renal Complications than Open Surgical Repair for Juxtarenal Abdominal Aortic Aneurysms in Patients with Chronic Renal Insufficiency. Ann Vasc Surg 2021; 75:349-357. [PMID: 33831525 DOI: 10.1016/j.avsg.2021.03.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/12/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Although fenestrated endovascular aneurysm repair (FEVAR) has been associated with lower morbidity and mortality than open surgical repair (OSR) in juxtarenal aneurysms (JAAA), there is a paucity of data in the literature comparing outcomes of the approaches specifically in patients with chronic renal insufficiency (CRI). We hypothesized that benefits of FEVAR over OSR observed in the general patient population may be diminished in CRI patients due to their heightened vulnerability to renal dysfunction stemming from contrast-induced nephropathy. This study compares 30-day outcomes between FEVAR and OSR for JAAA in patients with non-dialysis dependent CRI. METHODS All adults with estimated glomerular filtration rate (eGFR) < 60 mL/min (but not requiring dialysis) undergoing elective, non-ruptured JAAA repairs were identified in the American College of Surgeons - National Surgical Quality Improvement (ACS-NSQIP) Targeted EVAR and AAA databases from 2012-2018. JAAA were identified by recorded proximal aneurysm extent. FEVAR patients were identified in the Targeted EVAR database as those receiving the "Cook Zenith Fenestrated" endograft. OSR cases were defined as those that required proximal clamp positions "above one renal" or "between SMA & renals." Infra-renal or supra-celiac proximal clamp placement, or cases involving concomitant renal/visceral revascularization were excluded. Thirty-day outcomes including mortality, major adverse cardiovascular events (MACE), pulmonary, and renal complications were compared between FEVAR and OSR groups. RESULTS There were 284 patients with CRI who underwent elective repair of JAAA (FEVAR: 89; OSR: 195). FEVAR patients were significantly older than those undergoing OSR (77.3±7.2 vs. 74.2±7.7, P=0.001) and less likely to be smokers (25.8% vs 42.1%; P = 0.009). Other baseline demographic and pre-operative parameters were comparable between the two groups.Multivariable analysis revealed no significant difference between FEVAR and OSR in 30-day mortality (4.5% vs 4.6%; OR=1.22; 95% CI=0.35 - 4.22; P=0.753) or unplanned re-operation (4.5% vs 5.1%; OR=0.78; 95% CI=0.22 - 2.70; P=0.693). Patients undergoing FEVAR had significantly fewer pulmonary complications (3.4% vs 18.5%; OR=0.12; 95% CI=0.03 - 0.42; P<0.001) and renal dysfunction (3.4% vs 11.8%; OR 0.24 95% CI=0.07 - 0.86; P=0.029) compared to OSR. FEVAR was also associated with significantly shorter ICU and hospital lengths of stay (ICU stay: 0 days vs 3 days, P<0.0001; hospital stay: 3 days vs 8 days, P<0.0001). CONCLUSION For patients with chronic renal insufficiency, FEVAR offered improved perioperative renal morbidity compared to OSR without a corresponding mortality benefit. Future studies will be required to determine long term outcomes of this procedure in this vulnerable population.
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Affiliation(s)
- Benjamin J Pomy
- The George Washington University Department of Surgery, Washington, District of Columbia.
| | - Ethan S Rosenfeld
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Salim Lala
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - K Benjamin Lee
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Andrew D Sparks
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Richard L Amdur
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - John J Ricotta
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Anton N Sidawy
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Robyn A Macsata
- The George Washington University Department of Surgery, Washington, District of Columbia
| | - Bao-Ngoc Nguyen
- The George Washington University Department of Surgery, Washington, District of Columbia
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13
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Kakkos SK, Apostolopoulou PG, Ntouvas I, Dimitrakopoulou K, Kalogeropoulou C, Zampakis P. Evacuation Technique of Left-Sided Inferior Vena Cava for a Successful Open Repair of a Large Juxtarenal Aortic Aneurysm. Vasc Specialist Int 2021; 37:41-45. [PMID: 33795553 PMCID: PMC8021493 DOI: 10.5758/vsi.200073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/03/2021] [Accepted: 02/19/2021] [Indexed: 11/24/2022] Open
Abstract
We report a case of successful open repair of a 7.5-cm juxtarenal abdominal aortic aneurysm (AAA) in the presence of a left-sided inferior vena cava (LS-IVC) crossing the aorta at the level of the renal arteries in a 72-year-old man. The orifice of the right renal artery was slightly caudal to that of the left renal artery and concomitant occlusive diseases of both iliac arteries were present. Based on the imaging and intraoperative findings, repair of the juxtarenal AAA was performed with mobilization of the LS-IVC, which was encircled twice with soft silicone rubber vessel loops on both sides of operating field and the blood content of the LS-IVC was temporarily evacuated. This procedure allowed proximal control with inter-renal clamping of the aorta and placement of an aortobifemoral polytetrafluoroethylene graft.
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Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, School of Medicine of University of Patras, Patras, Greece
| | | | - Ioannis Ntouvas
- Department of Vascular Surgery, School of Medicine of University of Patras, Patras, Greece
| | - Kalliopi Dimitrakopoulou
- Department of Anesthesiology and Intensive Care, School of Medicine of University of Patras, Patras, Greece
| | | | - Peter Zampakis
- Department of Radiology, School of Medicine of University of Patras, Patras, Greece
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14
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Blackstock CD, Jackson BM. Open Surgical Repair of Abdominal Aortic Aneurysms Maintains a Pivotal Role in the Endovascular Era. Semin Intervent Radiol 2020; 37:346-355. [PMID: 33041480 DOI: 10.1055/s-0040-1715881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Since the advent of endovascular aortic repair (EVAR) nearly three decades ago, there has been a paradigm shift in the treatment of the abdominal aortic aneurysm (AAA) to favor EVAR due to its reduced operative mortality, less invasive nature, and faster recovery times. However, more recently there has been an accumulation of data from large meta-analyses and randomized clinical trials revealing that EVAR has no survival benefit after approximately 2 years and is associated with substantially higher rates of reintervention and aneurysm rupture in the long term. These findings call into question the durability of EVAR compared with open aortic repair and emphasize the need for surgeons to remain competent with open aortic surgery in the modern era. This article will provide comprehensive review of a large body of literature comparing endovascular repair to open aortic surgery for the management of AAAs, and it will offer an overview of the open surgical repair technique for AAAs.
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Affiliation(s)
- Christopher D Blackstock
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Jackson
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Rosenfeld ES, Macsata RA, Nguyen BN, Lala S, Ricotta JJ, Pomy BJ, Lee KB, Sparks AD, Amdur RL, Sidawy AN. Thirty-day outcomes of open abdominal aortic aneurysm repair by proximal clamp level in patients with normal and impaired renal function. J Vasc Surg 2020; 73:1234-1244.e1. [PMID: 32890718 DOI: 10.1016/j.jvs.2020.08.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/04/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) has often been reserved in contemporary practice for complex aneurysms requiring a suprarenal or supraceliac proximal clamp level. The present study investigated the associated 30-day outcomes of different proximal clamp levels in OSR of complex infrarenal/juxtarenal AAA in patients with normal renal function and those with chronic renal insufficiency (CRI). METHODS All patients undergoing elective OSR of infrarenal and juxtarenal AAA were identified in the American College of Surgeons National Surgical Quality Improvement Program-targeted AAA database from 2012 to 2018. The patients were stratified into two cohorts (normal renal function [estimated glomerular filtration rate, ≥60 mL/min] and CRI [estimated glomerular filtration rate, <60 mL/min and no dialysis]) before further substratification into groups by the proximal clamp level (infrarenal, inter-renal, suprarenal, and supraceliac). The 30-day outcomes, including mortality, renal and pulmonary complications, and major adverse cardiovascular event rates, were compared within each renal function cohort between proximal clamp level groups using the infrarenal clamp group as the reference. Supraceliac clamping was also compared with suprarenal clamping. RESULTS A total of 1284 patients with normal renal function and 524 with CRI were included in the present study. The proximal clamp levels for the 1808 patients were infrarenal for 1080 (59.7%), inter-renal for 337 (18.6%), suprarenal for 279 (15.4%), and supraceliac for 112 (6.2%). In the normal renal function cohort, no difference was found in 30-day mortality with any clamp level. Increased 30-day acute renal failure was only observed in the supraceliac vs infrarenal clamp level comparison (5.9% vs 1.5%; adjusted odds ratio [aOR], 3.97; 95% confidence interval [CI], 1.04-5.18; P = .044). In the CRI cohort, supraceliac clamping was associated with an increased rate of renal composite complications (22.7% vs 5.6%; aOR, 8.81; 95% CI, 3.17-24.46; P < .001) and ischemic colitis (13.6% vs 3.0%; aOR, 4.78; 95% CI, 1.38-16.62; P = .014) compared with infrarenal clamping and greater 30-day mortality (13.6% vs 2.4%; aOR, 6.00; 95% CI, 1.14-31.55; P = .034) and renal composite complications (22.7% vs 10.8%; aOR, 2.87; 95% CI, 1.02-8.13; P = .047) compared with suprarenal clamping. Suprarenal clamping was associated with greater renal dysfunction (10.8% vs 5.6%; aOR, 2.77; 95% CI, 1.08-7.13; P = .035) compared with infrarenal clamping, with no differences in mortality. No differences were found in 30-day mortality or morbidity for inter-renal clamping compared with infrarenal clamping in either cohort. No differences were found in major adverse cardiovascular events with higher clamp levels in either cohort. CONCLUSIONS In elective OSR of infrarenal and juxtarenal AAAs for patients with CRI, this study found a heightened mortality risk with supraceliac clamping and increased renal morbidity with suprarenal clamping, though these effects were not present for patients with normal renal function. Every effort should be made to keep the proximal clamp level as low as possible, especially in patients with CRI.
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Affiliation(s)
- Ethan S Rosenfeld
- Department of Surgery, The George Washington University, Washington, D.C..
| | - Robyn A Macsata
- Department of Surgery, The George Washington University, Washington, D.C
| | - Bao-Ngoc Nguyen
- Department of Surgery, The George Washington University, Washington, D.C
| | - Salim Lala
- Department of Surgery, The George Washington University, Washington, D.C
| | - John J Ricotta
- Department of Surgery, The George Washington University, Washington, D.C
| | - Benjamin J Pomy
- Department of Surgery, The George Washington University, Washington, D.C
| | - K Benjamin Lee
- Department of Surgery, The George Washington University, Washington, D.C
| | - Andrew D Sparks
- Department of Surgery, The George Washington University, Washington, D.C
| | - Richard L Amdur
- Department of Surgery, The George Washington University, Washington, D.C
| | - Anton N Sidawy
- Department of Surgery, The George Washington University, Washington, D.C
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16
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Kakkos SK, Zampakis P, Verhoeven ELG. Re Editor's Choice - Durability of Open Repair of Juxtarenal Abdominal Aortic Aneurysms: A Multicentre Retrospective Study in Five French Academic Centres. Eur J Vasc Endovasc Surg 2020; 60:150. [PMID: 32376216 DOI: 10.1016/j.ejvs.2020.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/25/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece.
| | - Peter Zampakis
- Department of Radiology, University of Patras Medical School, Patras, Greece
| | - Eric L G Verhoeven
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
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17
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Clamp Site Matters. Eur J Vasc Endovasc Surg 2020; 59:419. [DOI: 10.1016/j.ejvs.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 10/28/2019] [Accepted: 11/04/2019] [Indexed: 11/21/2022]
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