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Fornasari A, Perini P, Gargiulo M, Silingardi R, Michelagnoli S, Bonardelli S, Bellosta R, Freyrie A. Endograft Thrombosis as indication for Open Conversion after EVAR in a multicenter experience over 25 years. Ann Vasc Surg 2024:S0890-5096(24)00294-2. [PMID: 38944191 DOI: 10.1016/j.avsg.2024.04.018] [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: 02/13/2024] [Revised: 03/26/2024] [Accepted: 04/10/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter experience. METHODS This study retrospectively analyzed cases of OC for AET following EVAR across 12 Italian Vascular Surgery centers from 1997 to September 2022. The endpoints were as follows: 30-days mortality and major postoperative complications. Follow-up data included: survival and aortic-related complications. RESULTS Sixteen patients (mean age: 68.6±8.5 years) were included. Median elapsed time between EVAR to OC was 26.46 months (IQR 13.8-45.9). Proximal aortic cross-clamping site was supraceliac in 8 out of 16 (50%) patients, complete removal of the stentgraft was achieved in 75% of cases (12/16 patients). Reconstructions were: aorto-bi-iliac grafts in 8 cases (50%), 7 aorto-bi-femoral bypass grafts (43.8%), and 1 aorto-aortic tube graft (6.3%). All patients were symptomatic at presentation (68.7% unilateral acute limb ischemia, 25% bilateral acute limb ischemia, 1 patient had chronic severe claudication). Thirty-day mortality was 12.5% (2/16 patients). Overall morbidity rate was 43.8% (7 of 16 patients). No specific risk factors for early mortality were found. The overall estimated survival rate was 80.4% at 1 year, 62.5% at 2 years and 41.7% at 3 years. CONCLUSIONS OC for AET is typically reserved for complex cases that are not amenable to endovascular solutions. The frequent need for suprarenal clamping and complete endograft removal seem to be associated with high short-term mortality.
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Affiliation(s)
- Anna Fornasari
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Paolo Perini
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy; Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Parma, Italy.
| | - Mauro Gargiulo
- Vascular Surgery, University of Bologna, Department of Medical and Surgical Sciences, Bologna, Italy; Bologna Vascular Surgery Unit, IRCCS University Hospital S. Orsola, Bologna, Italy
| | - Roberto Silingardi
- Vascular Surgery, Department of Biomedical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Michelagnoli
- Vascular and Endovascular Surgery, Department of Surgery, USL Toscana Centro, "San Giovanni di Dio" Hospital, Florence, Italy
| | - Stefano Bonardelli
- Vascular Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Raffaello Bellosta
- Vascular Surgery, Department of Surgery, "Poliambulanza" Foundation Hospital, Brescia, Italy
| | - Antonio Freyrie
- Vascular Surgery, Department of Medicine and Surgery, University of Parma, Parma, Italy; Vascular Surgery, Cardio-Thoracic and Vascular Department, University Hospital of Parma, Parma, Italy
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Blecha M, Scali S, Stone D, Mao J, Goodney P, Lemmon G. Duplex Ultrasound Only Surveillance After Endovascular Abdominal Aortic Aneurysm Repair is Associated with Favorable Long-Term Outcomes. Ann Vasc Surg 2024:S0890-5096(24)00286-3. [PMID: 38942366 DOI: 10.1016/j.avsg.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/30/2024]
Abstract
OBJECTIVE Long-term data surrounding the impact of different endovascular abdominal aortic aneurysm repair (EVAR) surveillance strategies is limited. Therefore, the purpose of this study was to characterize postoperative imaging patterns, as well as to evaluate the association of duplex ultrasound surveillance after the first postoperative year with 5-year EVAR outcomes. METHODS EVAR patients (2003-2016), who survived at least 1-year without aneurysm rupture, conversion to open repair, and reintervention in the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) were examined to provide all subjects ≥3-years of follow-up time. Patients were categorized into 6 cohorts after the first postoperative year: No imaging (N=953); CT/MRI-only (N=2,976); Duplex ultrasound-only (DUS; N=1,808); Combined CT/MRI+DUS with >50% being CT/MRI (N=1,937); Combined CT/MRI+DUS with >50% being DUS (N=2,253); and Mixed (CT+DUS+MRI-N=1,272). Abdominal aortic aneurysm (AAA) related re-intervention, rupture, conversion to open repair, and all-cause mortality were estimated using Kaplan-Meier analysis. Multivariable logistic regression models identified variables associated with using DUS-only imaging (vs. CT/MRI only). Cox regression models compared 5-year outcomes between patients receiving DUS-only vs. CT/MRI-only imaging. RESULTS A total of 11,199 EVAR patients were examined (mean age-76±7 years; female-20%; non-elective-10%). DUS-only imaging surveillance after the first postoperative year was more likely to occur after elective repairs, as well as among older, male patients. Smaller (<6cm) preoperative AAA diameter and absence of documented concurrent iliac aneurysm was also associated with DUS-only follow-up. Additionally, no endoleak detection on index EVAR completion imaging, as well as a documented >5mm decrease in AAA sac diameter at 1-year follow-up was more common with DUS-only surveillance protocols. Post-EVAR DUS-only imaging after the first postoperative year had the lowest incidence of re-intervention, conversion to open repair, and rupture (as well as the composite reintervention/open conversion/rupture; log-rank P<.001 for all). Further, patients receiving exclusively DUS after their first postoperative year had better overall survival (log-rank P<.001). These outcome advantages that were associated with DUS-only surveillance compared with CT/MRI-only surveillance after EVAR persisted when controlling for baseline co-variates, preoperative AAA diameter, prior aortic surgery history, sac growth, and presence of endoleak (all P<.01). CONCLUSIONS EVAR patients selected for DUS-only surveillance after the first postoperative year have excellent freedom from AAA-related reintervention, conversion to open repair, rupture and all-cause mortality. These findings remained on multivariable analysis after adjusting for baseline characteristics, endoleak status and sac diameter changes within the first year. This is the first registry-based investigation to document long-term EVAR outcomes for patients entered into a DUS-only monitoring protocol which serves to corroborate the growing evidence base that DUS may be able to supplant CT surveillance in certain subgroups. A prospective randomized multi-center trial comparing DUS versus CT-based imaging after EVAR is needed to validate these findings which may serve to change current practice guidelines, as well as industry and regulatory stakeholder requirements.
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Affiliation(s)
- Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University, Chicago, IL.
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - David Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Philip Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Gary Lemmon
- Division of Vascular Surgery, University of Indiana, Indianapolis, IN
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Mansoor SM, Jørgensen JJ, Hisdal J, Rabben T. Thirty-nine percent of patients with a ruptured abdominal aortic aneurysm (AAA) have an incidentally detected AAA prior to rupture. Ann Vasc Surg 2024:S0890-5096(24)00293-0. [PMID: 38942371 DOI: 10.1016/j.avsg.2024.04.017] [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: 01/31/2024] [Revised: 03/26/2024] [Accepted: 04/07/2024] [Indexed: 06/30/2024]
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA) screening has been offered to 65-year-old men living in Oslo, Norway, since May 2011. A significant number of AAA-related deaths occurred in individuals who are not eligible for screening. The primary aim of this study was to describe the group of patients admitted to Oslo University Hospital with a ruptured AAA after the implementation of the local AAA screening project. The following parameters were investigated: AAA detection prior to rupture, surveillance status, eligibility for screening and comorbidities. We also sought to compare outcomes (repair rates and 30-day mortality) between patients with and without an AAA detected prior to rupture. METHODS This cohort study included patients admitted acutely to Oslo University Hospital due to a symptomatic or ruptured AAA in the period January 2011 to December 2022. Data on demographics, prior AAA detection, surveillance status, treatment and mortality were collected retrospectively through electronic medical records. RESULTS We identified 200 patients with a symptomatic or ruptured AAA, among which 79 (40%) had an AAA detected prior to rupture - one (1%) through screening and 78 (39%) incidentally. Up to 30% of the incidentally detected AAAs were not under any surveillance. Six patients were found eligible for screening: one had attended, three were non-attenders and two had not been invited. Patients with an incidentally detected AAA prior to rupture had a more advanced age and a significantly higher degree of comorbidities than patients without a previously detected AAA, and the repair rates in these groups were 56% and 84% respectively (p < 0.001). Adjusted for comorbidities and risk factors, the odds ratio for repair among patients with incidentally detected AAA was 0.56 (p = 0.292). The 30-day mortality was not significantly different between the two groups (p = 0.097). CONCLUSION Most patients with a ruptured AAA were not eligible for screening, but 39% of the patients had an incidentally detected AAA prior to rupture. Standardized reporting and follow-up of incidentally detected AAAs is thus identified as an additional measure to organized screening in the effort to reduce AAA-related mortality.
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Affiliation(s)
- Saira Mauland Mansoor
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Jørgen Joakim Jørgensen
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Traumatology, Oslo University Hospital, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Toril Rabben
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
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Farres H, Lanka SP, Nussbaum S, Shoukry M, Hanouneh T, Alexander L, Sella D, Jarmi T. Correlation Between Calcium Scoring and Abdominal Aortic Aneurysm Endovascular Repair Outcomes. Vasc Endovascular Surg 2024:15385744241263696. [PMID: 38886243 DOI: 10.1177/15385744241263696] [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: 06/20/2024]
Abstract
OBJECTIVES Endovascular aneurysm repair, though minimally invasive and has the benefit of relatively low perioperative complication rates, it is associated with significant long term reintervention rates related to endoleaks. Several variables have been studied to predict the outcomes of endovascular aneurysm repair, 1 of which is the calcium burden of the vasculature. This prompted us to study the association between calcium burden measured by the standardized Agatston scoring system and the outcomes of Endovascular aneurysm repair. METHODS This is a retrospective study of patients who underwent Endovascular aneurysm repair from 2008 to 2020 at our institution and who had a non-contrast computerized tomography scan preoperatively, accounting for 87 patients. The calcium burden of the vasculature was measured by the Agatston scoring system allowing for better reproducibility, and the outcome variables included mortality and endoleaks. RESULTS Patients with higher median total calcium scores (≥12966.9) had significantly lesser survival (79.8% vs 52.3% (P = .002) at five years compared to patients with lower median total calcium score (<12966.9). Also, patients with type 2 endoleaks had higher calcium scores in above the aneurysm level ((1591.2 vs 688.2), P = .05)) compared to patients with no type 2 endoleaks. CONCLUSION Calcium score assigned using a standardized Agatston scoring system can be used as a predictor of mortality risk assisting in deciding the treatment of choice for patients.
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Affiliation(s)
- Houssam Farres
- Division of Vascular Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Sam Nussbaum
- Division of Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Mira Shoukry
- Mayo ClinicAlix School of Medicine, Scottsdale, AZ, USA
| | - Tareq Hanouneh
- Division of Transplant Nephrology, Mayo Clinic, Jacksonville, FL, USA
| | | | - David Sella
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Tambi Jarmi
- Division of Transplant Nephrology, Mayo Clinic, Jacksonville, FL, USA
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Franco RDL, Iora PH, Massago M, Arruda Beltrame MH, Hatoum US, Giacomin V, Borba IM, Belczak SQ, Staton CA, Dutra ADC, Andrade LD. Geographical disparities in access to surgical treatment and mortality rates from abdominal aortic aneurysms in Brazil: A retrospective longitudinal study. Vasc Med 2024:1358863X241253732. [PMID: 38860442 DOI: 10.1177/1358863x241253732] [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: 06/12/2024]
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA) is a growing public health problem, and not all patients have access to surgery when needed. This study aimed to analyze spatiotemporal variations in AAA mortality and surgical procedures in Brazilian intermediate geographic regions and explore the impact of different surgical techniques on operative mortality. METHODS A retrospective longitudinal study was conducted to evaluate AAA mortality from 2008 to 2020 using space-time cube (STC) analysis and the emerging hot spot analysis tool through the Getis-Ord Gi* method. RESULTS There were 34,255 deaths due to AAA, 13,075 surgeries to repair AAA, and a surgical mortality of 14.92%. STC analysis revealed an increase in AAA mortality rates (trend statistic = +1.7693, p = 0.0769) and a significant reduction in AAA surgery rates (trend statistic = -3.8436, p = 0.0001). Analysis of emerging hotspots revealed high AAA mortality rates in the South, Southeast, and Central-West, with a reduction in procedures in São Paulo and Minas Gerais States (Southeast). In the Northeast, there were extensive areas of increasing mortality rates and decreasing procedure rates (cold spots). CONCLUSION AAA mortality increased in several regions of the country while surgery rates decreased, demonstrating the need for implementing public health policies to increase the availability of surgical procedures, particularly in less developed regions with limited access to services.
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Affiliation(s)
- Rogério do Lago Franco
- Medicine Department, State University of Maringá, Maringá, PR, Brazil
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
| | | | - Miyoko Massago
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
| | | | - Ualid Saleh Hatoum
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
| | - Vinicius Giacomin
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
| | | | | | | | | | - Luciano de Andrade
- Medicine Department, State University of Maringá, Maringá, PR, Brazil
- Postgraduate Master Health Sciences Program, State University of Maringá, Maringá, PR, Brazil
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Zecca F, Faa G, Sanfilippo R, Saba L. How to improve epidemiological trustworthiness concerning abdominal aortic aneurysms. Vascular 2024:17085381241257747. [PMID: 38842081 DOI: 10.1177/17085381241257747] [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: 06/07/2024]
Abstract
BACKGROUND Research on degenerative abdominal aortic aneurysms (AAA) is hampered by complex pathophysiology, sub-optimal pre-clinical models, and lack of effective medical therapies. In addition, trustworthiness of existing epidemiological data is impaired by elements of ambiguity, inaccuracy, and inconsistency. Our aim is to foster debate concerning the trustworthiness of AAA epidemiological data and to discuss potential solutions. METHODS We searched the literature from the last five decades for relevant epidemiological data concerning AAA development, rupture, and repair. We then discussed the main issues burdening existing AAA epidemiological figures and proposed suggestions potentially beneficial to AAA diagnosis, prognostication, and management. RESULTS Recent data suggest a heterogeneous scenario concerning AAA epidemiology with rates markedly varying by country and study cohorts. Overall, AAA prevalence seems to be decreasing worldwide while mortality is apparently increasing regardless of recent improvements in aortic-repair techniques. Prevalence and mortality are decreasing in high-income countries, whereas low-income countries show an increase in both. However, several pieces of information are missing or outdated, thus systematic renewal is necessary. Current AAA definition and surgical criteria do not consider inter-individual variability of baseline aortic size, further decreasing their reliability. CONCLUSIONS Switching from flat aortic-size thresholds to relative aortic indices would improve epidemiological trustworthiness regarding AAAs. Aortometry standardization focusing on simplicity, univocity, and accuracy is crucial. A patient-tailored approach integrating clinical data, multi-adjusted indices, and imaging parameters is desirable. Several novel imaging modalities boast promising profiles for investigating the aortic wall. New contrast agents, computational analyses, and artificial intelligence-powered software could provide further improvements.
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Affiliation(s)
- Fabio Zecca
- Department of Radiology, University Hospital "D. Casula", Cagliari, Italy
| | - Gavino Faa
- Department of Pathology, University Hospital "D. Casula", Cagliari, Italy
| | - Roberto Sanfilippo
- Department of Vascular Surgery, University Hospital "D. Casula", Cagliari, Italy
| | - Luca Saba
- Department of Radiology, University Hospital "D. Casula", Cagliari, Italy
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Li J, Weng C, Zhao J. Impact of distal anchor-zone roundness on iliac-branch adverse events in endovascular aneurysm repair. Asian J Surg 2024; 47:2710-2713. [PMID: 38521749 DOI: 10.1016/j.asjsur.2024.03.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/06/2024] [Indexed: 03/25/2024] Open
Affiliation(s)
- Jiacheng Li
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China; West China School of Medicine, Sichuan University, Chengdu, 610041, China
| | - Chengxin Weng
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jichun Zhao
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Kang G, Bae M, Chung SW, Lee CW, Huh U, Kim J, Jeong H. Changes in the Remaining Iliac Artery According to Retrograde Flow after Aorto-Femoral Bypass in Abdominal Aortic Aneurysms. Ann Vasc Surg 2024; 106:289-296. [PMID: 38830448 DOI: 10.1016/j.avsg.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/08/2024] [Accepted: 03/12/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Considering a patient's anatomy and vascular conditions, aorto-femoral bypass is a treatment approach for the open repair of abdominal aortic aneurysms. This study aimed at evaluating changes in the remnant iliac artery and their correlation with the preservation state of retrograde flow from femoral anastomosis. METHODS Of 221 patients who underwent abdominal aortic aneurysm surgery between 2007 and 2022 in Pusan National University Hospital, 29 patients who underwent aorto-femoral bypass were included in this retrospective cohort study. Of these patients, 21 underwent aortobifemoral bypass and 8 underwent aortoiliac-and-femoral bypass. The change in size of the iliac artery from preoperative to postoperative and whether this difference in size depended on the status of postoperative retrograde flow were investigated. Additionally, factors affecting overall mortality and ischemic complications were identified. RESULTS The median duration from operation to the last follow-up was 2069.5 days (about 5.7 years). The average age of the patients was 78.1 years, and the proportion of males was 75.9%. In cases of disappearance of postoperative retrograde flow from the femoral anastomosis, the postoperative iliac artery size was significantly reduced compared to its preoperative size (18.4 ± 18.9 mm vs. 13.2 ± 7.9 mm, respectively; P = 0.04). The group with maintained retrograde flow had significantly larger residual common iliac artery size than the group with disappearance of flow. (20.0 ± 28.0 mm vs. 14.6 ± 8.5 mm, respectively; P = 0.02). Disappearance of retrograde flow was a significant factor in the iliac artery size reduction after surgery (odds ratio, 2.5; 95% confidence interval, 1.9-5.3; P = 0.02). Three patients with maintained retrograde flow (18.8%) required intervention owing to an increase in the size of the iliac artery. The factors that significantly influenced overall death as analyzed by Cox proportional hazard regression were chronic obstructive pulmonary disease (hazard ratio, 36.8; 95% confidence interval, 1.6-870.0; P = 0.03), peripheral arterial occlusive disease (hazard ratio, 12.7; 95% confidence interval, 1.4-115.8; P = 0.02), and disappearance of retrograde flow (hazard ratio, 8.7; 95% confidence interval, 1.2-63.9; P = 0.03). CONCLUSIONS Among the open repair methods for abdominal aortic aneurysms, if retrograde flow was not maintained through femoral anastomosis when aorto-femoral bypass was performed, the size of the remaining iliac artery decreased. However, loss of retrograde flow increased long-term mortality. When aorto-femoral bypass is performed, regular imaging follow-up is necessary at appropriate intervals to check the remnant iliac artery and retrograde flow.
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Affiliation(s)
- Gayeon Kang
- Biomedical Research Institute, Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea
| | - Miju Bae
- Biomedical Research Institute, Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea.
| | - Sung Woon Chung
- Biomedical Research Institute, Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Chung Won Lee
- Biomedical Research Institute, Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Up Huh
- Biomedical Research Institute, Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea; Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Yangsan-si, Gyeongsangnam-do, Republic of Korea
| | - Jongwon Kim
- Biomedical Research Institute, Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea
| | - Hyuncheol Jeong
- Biomedical Research Institute, Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Busan, Republic of Korea
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Long C, Katsargyris A, Milner R, Verhoeven E. Five-Year Results for Abdominal Aortic Aneurysm Repair with the GORE® EXCLUDER® Device: Insights from the Gore Global Registry for Endovascular Aortic Treatment (GREAT). Ann Vasc Surg 2024; 106:247-254. [PMID: 38815908 DOI: 10.1016/j.avsg.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND The early postoperative benefits of endovascular aneurysm repair (EVAR) have been well established but questions remain regarding its durability at mid-term and long-term time points. Long-term results in real-world use of EVAR outside of randomized trial data are limited. This study used the Global Registry for Endovascular Aortic Treatment registry to explore the 5-year outcomes with the GORE EXCLUDER device in real-world clinical circumstances. METHODS All patients within the Global Registry for Endovascular Aortic Treatment registry who underwent an infrarenal abdominal aortic aneurysm repair with the GORE EXCLUDER device were included in this study. Baseline characteristics and demographic information of the cohort were collected. End points included mortality (all-cause and aneurysm-related), serious endoleaks, aneurysm sac diameter, endograft integrity (fracture, compression, migration), post-EVAR aortic rupture, device-related reintervention, conversion to open repair, graft explantation, and major adverse cardiovascular events. RESULTS A total of 3,216 patients were included in this analysis. The cohort reflected a significantly comorbid population with 46% of patients reaching a Charlson Comorbidity Index score of ≥5. Follow-up at 5 years was 60% of eligible participants. The freedom from aortic-related mortality was at 98.8% and overall survival was 71.2%. Postoperative major adverse cardiovascular events occurred in 49 (1.5%) patients. Device-related intervention through 5 years was 7.2% and the overall serious endoleak rate was 6.8%. Less than 1% of patients required an open conversion/revision and aortic rupture following device placement occurred in 15 (0.5%) patients. Aneurysm sac regression was achieved in 58.1% of patients at 5 years, and stability/absence of growth was observed in 83.6% at 5 years. CONCLUSIONS This study supports the durability of the GORE EXCLUDER device through 5 years with negligible incidence of graft integrity compromise and low aortic/device-related reintervention rates. Furthermore, the efficacy of the device is highlighted with low aortic-related mortality and high sac regression/stability diameter through 5 years.
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Affiliation(s)
- Chandler Long
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC.
| | - Athanasios Katsargyris
- Division of Vascular and Endovascular Surgery, General Hospital & Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Ross Milner
- Division of Vascular Surgery, University of Chicago Medical Center, Chicago, IL
| | - Eric Verhoeven
- Division of Vascular and Endovascular Surgery, General Hospital & Paracelsus Medical University Nuremberg, Nuremberg, Germany
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Rabia B, Thanigaimani S, Golledge J. The potential involvement of glycocalyx disruption in abdominal aortic aneurysm pathogenesis. Cardiovasc Pathol 2024; 70:107629. [PMID: 38461960 DOI: 10.1016/j.carpath.2024.107629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Abdominal aortic aneurysm is a weakening and expansion of the abdominal aorta. Currently, there is no drug treatment to limit abdominal aortic aneurysm growth. The glycocalyx is the outermost layer of the cell surface, mainly composed of glycosaminoglycans and proteoglycans. OBJECTIVE The aim of this review was to identify a potential relationship between glycocalyx disruption and abdominal aortic aneurysm pathogenesis. METHODS A narrative review of relevant published research was conducted. RESULTS Glycocalyx disruption has been reported to enhance vascular permeability, impair immune responses, dysregulate endothelial function, promote extracellular matrix remodeling and modulate mechanotransduction. All these effects are implicated in abdominal aortic aneurysm pathogenesis. Glycocalyx disruption promotes inflammation through exposure of adhesion molecules and release of proinflammatory mediators. Glycocalyx disruption affects how the endothelium responds to shear stress by reducing nitric oxide availabilty and adversely affecting the storage and release of several antioxidants, growth factors, and antithromotic proteins. These changes exacerbate oxidative stress, stimulate vascular smooth muscle cell dysfunction, and promote thrombosis, all effects implicated in abdominal aortic aneurysm pathogenesis. Deficiency of key component of the glycocalyx, such as syndecan-4, were reported to promote aneurysm formation and rupture in the angiotensin-II and calcium chloride induced mouse models of abdominal aortic aneurysm. CONCLUSION This review provides a summary of past research which suggests that glycocalyx disruption may play a role in abdominal aortic aneurysm pathogenesis. Further research is needed to establish a causal link between glycocalyx disruption and abdominal aortic aneurysm development.
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Affiliation(s)
- Bibi Rabia
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland 4811, Australia; Department of Pharmacy, Hazara University, Mansehra 21300, Pakistan
| | - Shivshankar Thanigaimani
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland 4811, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland 4811, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland 4811, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland 4811, Australia; The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland 4810, Australia.
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Nana P, Spanos K, Apostolidis G, Haulon S, Kölbel T. Systematic review and meta-analysis of fenestrated or branched devices after previous open surgical aortic aneurysm repair. J Vasc Surg 2024; 79:1251-1261.e4. [PMID: 37757916 DOI: 10.1016/j.jvs.2023.09.026] [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: 06/16/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Despite open surgical repair (OSR) of abdominal aortic aneurysms being considered as a durable solution, disease progression and para-anastomotic aneurysms may require further repair, and fenestrated and branched endovascular aneurysm repair (F/BEVAR) may be applied to address these pathologies. The aim of this systematic review was to assess technical success, mortality, and morbidity (acute kidney injury, spinal cord ischemia) at 30 days, and mortality and reintervention rates during the available follow-up, in patients managed with F/BEVAR after previous OSR. METHODS The PRISMA statement was followed, and the study was pre-registered to the PROSPERO (CRD42022363214). The English literature was searched, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, through November 30, 2022. Observational studies and case series with ≥5 patients (2000-2022), reporting on F/BEVAR outcomes after OSR, were considered eligible. The Newcastle-Ottawa Scale and GRADE were used to assess the risk of bias and quality of evidence. The primary outcome was technical success, mortality, and morbidity at 30 days. Data on the outcomes of interest were synthesized using proportional meta-analysis. RESULTS The initial search yielded 1694 articles. Eight retrospective studies (476 patients) were considered eligible. In 78.3% of cases, disease progression set the indication for reintervention. Technical success was estimated at 96% (95% confidence interval [CI], 89%-98%; I2 = 0%; 95% prediction interval [PI], 79%-99%). Thirty-day mortality was 2% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-28%). The estimated spinal cord ischemia and acute kidney injury rates were 3% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-30%) and 6% (95% CI, 2%-15%; I2 = 0%; 95% PI, 1%-40%), respectively. During follow-up, overall mortality was 5% (95% CI, 2%-12%; I2 = 34%; 95% PI, 0%-45%) and aorta-related mortality was 1% (95% CI, 0%-2%; I2 = 0%; 95% PI, 0%-3%). The rate of reinterventions was 16% (95% CI, 9%-26%; I2 = 22%; 95% PI, 3%-50%). CONCLUSIONS According to the available literature, F/BEVAR after OSR may be performed with high technical success and low mortality and morbidity during the perioperative period. Follow-up aortic-related mortality was 1%, whereas the reintervention rates were within the standard range following F/BEVAR.
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Affiliation(s)
- Petroula Nana
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.
| | - Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany; Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - George Apostolidis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
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12
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Png CYM, Pendleton AA, Altreuther M, Budtz-Lilly JW, Gunnarsson K, Kan CD, Khashram M, Laine MT, Mani K, Pederson CC, Srivastava SD, Eagleton MJ. Effect of EVAR on International Ruptured AAA Mortality-Sex and Geographic Disparities. J Clin Med 2024; 13:2464. [PMID: 38730993 PMCID: PMC11084331 DOI: 10.3390/jcm13092464] [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: 02/02/2024] [Revised: 04/04/2024] [Accepted: 04/12/2024] [Indexed: 05/13/2024] Open
Abstract
Background: We sought to investigate the differential impact of EVAR (endovascular aneurysm repair) vis-à-vis OSR (open surgical repair) on ruptured AAA (abdominal aortic aneurysm) mortality by sex and geographically. Methods: We performed a retrospective study of administrative data on EVAR from state statistical agencies, vascular registries, and academic publications, as well as ruptured AAA mortality rates from the World Health Organization for 14 14 states across Australasia, East Asia, Europe, and North America. Results: Between 2011-2016, the proportion of treatment of ruptured AAAs by EVAR increased from 26.1 to 43.8 percent among females, and from 25.7 to 41.2 percent among males, and age-adjusted ruptured AAA mortality rates fell from 12.62 to 9.50 per million among females, and from 34.14 to 26.54 per million among males. The association of EVAR with reduced mortality was more than three times larger (2.2 vis-à-vis 0.6 percent of prevalence per 10 percentage point increase in EVAR) among females than males. The association of EVAR with reduced mortality was substantially larger (1.7 vis-à-vis 1.1 percent of prevalence per 10 percentage point increase in EVAR) among East Asian states than European+ states. Conclusions: The increasing adoption of EVAR coincided with a decrease in ruptured AAA mortality. The relationship between EVAR and mortality was more pronounced among females than males, and in East Asian than European+ states. Sex and ethnic heterogeneity should be further investigated.
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Affiliation(s)
- C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - A Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Martin Altreuther
- Department of Vascular Surgery, St. Olavs Hospital, 7030 Trondheim, Norway
| | - Jacob W Budtz-Lilly
- Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Skejby, 8200 Aarhus, Denmark
| | - Kim Gunnarsson
- Department of Surgical Sciences, Uppsala University, 75237 Uppsala, Sweden
| | - Chung-Dann Kan
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 701, Taiwan
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland 1010, New Zealand
| | - Matti T Laine
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, 75237 Uppsala, Sweden
| | - Christian C Pederson
- Department of Vascular Surgery, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
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13
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Yu J, Khamzina Y, Kennedy J, Liang NL, Hall DE, Arya S, Tzeng E, Reitz KM. The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair. J Vasc Surg 2024:S0741-5214(24)00983-2. [PMID: 38614142 DOI: 10.1016/j.jvs.2024.04.021] [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: 02/06/2024] [Revised: 03/28/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs). METHODS Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation. RESULTS We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients. CONCLUSIONS Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.
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Affiliation(s)
- Jia Yu
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Jason Kennedy
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Surgery Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, PA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
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14
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Hawkins A, Jin R, Clouse WD, Tracci M, Weaver ML, Farivar BS. Center-level outcomes following elective fenestrated endovascular aortic aneurysm repair in the Vascular Quality Initiative database. J Vasc Surg 2024:S0741-5214(24)00954-6. [PMID: 38604317 DOI: 10.1016/j.jvs.2024.03.453] [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: 12/27/2023] [Revised: 03/25/2024] [Accepted: 03/31/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Hospital volume is associated with mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair (B-FEVAR) has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms, but evidence of a center-volume relationship is limited. We aimed to measure the association of center volume with in-hospital mortality, postoperative outcomes, and 1-year survival following B-FEVAR. METHODS Patients undergoing elective endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2014-2021) listed within the national Vascular Quality Initiative Thoracic Endovascular Aortic Repair/Complex EVAR database were analyzed. Centers were grouped into quartiles by mean annual procedure volume. Multivariable regression was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation, log rank test, and mixed effects Cox regression were used to evaluate 1-year survival. RESULTS A total of 4302 adult elective F-BEVAR procedures were identified at a total of 163 centers. In-hospital mortality did not differ by hospital volume (quartile [Q]1 = 35/1059 [3.3%]; Q2 = 30/1063 [2.8%]; Q3 = 33/1120 [2.9%]; and Q4 = 44/1060 [4.2%]; P = .308). The high volume group had a higher rate of major complication (Q1 = 14.9%; Q2 = 12.8%; Q3 = 13.3%; and Q4 = 20.1%; adjusted P < .001). Physician-modified grafts were more frequently employed in high-volume centers (Q1 = 4.5%; Q2 = 18.7%; Q3 = 11.3%; and Q4 = 19.2%; P < .001), with a decreased incidence of any endoleak noted at the end of the procedure (Q1 = 34.9%; Q2 = 32.8%; Q3 = 30.0%; and Q4 = 29.0%; P = .003). In the multivariable analysis, in-hospital mortality was not associated with center volume, comparing very low volume to medium- and high-volume centers (odds ratio [95% confidence interval] vs Q4: Q1 = 1.1 [0.6-1.9], Q2 = 0.6 [0.4-1.1], and Q3 = 0.9 [0.5-1.5]; all P > .05). No significant difference was found in 1-year survival between center volume groups. CONCLUSIONS In-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, complication rates and endoleak may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.
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Affiliation(s)
- Andrew Hawkins
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Ruyun Jin
- Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret Tracci
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Behzad S Farivar
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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Obrand J, Jones M, Mirakhur A, Rommens K, Moore R. A hybrid approach to complex bilateral common iliac artery and internal iliac artery aneurysm repair. J Vasc Surg Cases Innov Tech 2024; 10:101410. [PMID: 38379612 PMCID: PMC10877432 DOI: 10.1016/j.jvscit.2023.101410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/14/2023] [Indexed: 02/22/2024] Open
Abstract
A case of a young patient with incidental bilateral internal iliac artery aneurysms and common iliac artery aneurysms is described. A staged hybrid surgical approach was performed to preserve pelvic perfusion, with bilateral stent grafts deployed into an ipsilateral anterior division branch and contralateral posterior division branch of the internal iliac arteries. One week later, an open infrarenal aorto-bi-iliac graft was performed with distal anastomoses to the previously deployed stent grafts. The findings from the present case add to the growing number of reported cases of hybrid repair of bilateral internal iliac and common iliac artery aneurysms with preservation of pelvic perfusion.
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Affiliation(s)
- Jeremy Obrand
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Melissa Jones
- Division of Vascular Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anirudh Mirakhur
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kenton Rommens
- Division of Vascular Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Randy Moore
- Division of Vascular Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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16
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Shirasu T, Akai A, Motoki M, Kato M. Midterm outcomes of side branch embolization and endovascular abdominal aortic aneurysm repair. J Vasc Surg 2024; 79:784-792.e2. [PMID: 38070786 DOI: 10.1016/j.jvs.2023.12.004] [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: 08/17/2023] [Revised: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE To analyze the effects of total side branch embolization at endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms on the incidences of persistent type 2 endoleak (pT2EL), changes in sac diameter, and reintervention. METHODS Between 2013 and 2021, all patients who underwent primary EVAR with a few exceptions were included. Side branch embolization was considered during EVAR for inferior mesenteric artery (IMA) or IMA plus lumbar artery (LA) when feasible for contrast agent use. Outcomes measured were pT2EL, sac diameters, reintervention, ruptures, and aneurysm-related mortality. Radiation exposure and safety outcomes were also reported. RESULTS Among 732 patients who underwent EVAR, 616 (84.2%) were included. Of the 616 patients, 223 (36.2%) did not undergo side branch embolization (NO-E), whereas 228 (37.0%) underwent IMA only (IMA-E) and 165 (26.8%) underwent IMA+LA including median sacral artery (IMA+LA-E). The technical success rate of IMA and LA embolization was 97.0% and 74.7%, respectively. Crude incidences of pT2EL were significantly different from 6 months through 3 years (NO-E, 27.8%; IMA-E, 31.7%; IMA+LA-E, 9.4% at 3 years; P = .007). In the multivariate analysis adjusted for background differences, the incidences of pT2EL were significantly higher in the NO-E (odds ratio [OR], 3.21; 95% confidence intervals [CIs], 1.08-9.57; P = .004) and IMA-E (OR, 4.86; 95% CIs, 1.68-14.11; P = .004) compared with the IMA+LA-E group. Similarly, any reintervention until 3 years was significantly frequent in the NO-E (OR, 5.26; 95% CIs, 1.76-15.70; P = .003) and IMA-E group (OR, 4.19; 95% CIs, 1.38-12.67; P = .01). Surgical conversion and secondary rupture were seen only in 1 patient without any aneurysm-related mortality. Percent sac shrinkage from the baseline was significantly promoted in the IMA+LA group (NO-E, 12.1% ± 16.6%; IMA-E, 11.4% ± 16.7%; IMA+LA-E, 18.0% ± 18.8%; P = .047). Fluoroscopy time was significantly longer in the IMA+LA-E group (NO-E, 60.2 ± 47.4 minutes; IMA-E, 59.3 ± 39.5 minutes; IMA+LA-E, 75.5 ± 42.8 minutes; P < .0001), and so do the dose-area product (NO-E, 424.6 ± 333.4 Gy cm2; IMA-E, 477.7 ± 342.4 Gy cm2; IMA+LA-E, 631.8 ± 449.1 Gy cm2; P < .0001). No embolization-related complications or radiation-related adverse events were recorded. CONCLUSIONS Pre-emptive embolization of IMA, LAs, and median sacral artery at the time of EVAR reduced the incidences of pT2EL and any reintervention and promoted sac shrinkage during the follow-up period of 3 years.
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Affiliation(s)
- Takuro Shirasu
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan; Division of Vascular Surgery, Department of Surgery, University of Tokyo, Tokyo, Japan.
| | - Atsushi Akai
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
| | - Manabu Motoki
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital, Osaka, Japan
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Geraedts AC, Zuidema R, Schuurmann RC, Kwant AN, Mulay S, Balm R, de Vries JPP. Shortest Apposition Length at the First Postoperative Computed Tomography Angiography Identifies Patients at Risk for Developing a Late Type Ia Endoleak After Endovascular Aneurysm Repair. J Endovasc Ther 2024; 31:274-281. [PMID: 36113063 PMCID: PMC10938489 DOI: 10.1177/15266028221120514] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
PURPOSE Imaging surveillance following endovascular aneurysm repair (EVAR) is strictly recommended. This study investigates the value of endograft apposition and position relative to the aortic neck on the first postoperative computed tomography angiography (CTA) in determining patients at risk for a late type Ia endoleak (T1aEL). MATERIALS AND METHODS Patients with a T1aEL after the first postoperative CTA were selected from a consecutive database and matched with uncomplicated controls. Endograft apposition and position, including the shortest apposition length (SAL), were determined on the first postoperative CTA. The SAL is the shortest distance between the proximal endograft fabric and the first slice where circumferential apposition with the aortic wall is lost. Differences in endograft apposition at the first postoperative CTA were compared between groups. Logistic regression analysis identified independent predictors for late T1aEL. RESULTS A total of 32 patients with a late T1aEL were included and matched with 32 uncomplicated controls. Median follow-up after primary EVAR was 62.0 (interquartile range [IQR]: 36.8, 83.5) months in the T1aEL group compared with 47.5 (IQR: 34.0, 79.3) months in the control group; p=0.265. Median preoperative neck diameter was significantly larger in the T1aEL group than in the control group (26.6 [IQR: 24.9, 29.6] mm versus 23.4 [IQR: 22.5, 25.3] mm); p<0.001. Patients in the T1aEL group had a median SAL of 11.6 (IQR: 4.3, 20.5) mm compared with 20.7 (IQR: 13.1, 24.9) mm in the control group; p=0.002. SAL <10mm on the first postoperative CTA (odds ratio [OR]: 9.63, 95% confidence interval [CI]: 1.60-57.99) and larger neck diameter (OR: 1.80, 95% CI: 1.26-2.57) were independent predictors for developing a late T1aEL. CONCLUSION Preoperative neck diameter and SAL on the first postoperative CTA following EVAR are important predictors for the development of a late T1aEL. Patients with a SAL of <10mm had a significantly higher risk of developing a late T1aEL. Future research should determine whether these patients would benefit from reintervention before an actual T1aEL is present. CLINICAL IMPACT Understanding the mechanisms of endovascular aneurysm repair failure is essential to further enhance clinical outcomes. Adequate proximal sealing is necessary to foster freedom from type 1a endoleak. This study demonstrates that the shortest apposition length (SAL) at the first postoperative computed tomography angiography (CTA) is able to identify patients at risk for a late type 1a endoleak. Especially patients with a SAL <10mm are at high risk. Currently, the guidelines advice repeated imaging with CTA in patients with a seal <10mm. Future research should determine whether these patients would benefit from re-intervention before an actual type 1a endoleak is present.
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Affiliation(s)
- Anna C.M. Geraedts
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Roy Zuidema
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Richte C.L. Schuurmann
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Ayla N. Kwant
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Sana Mulay
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jean-Paul P.M. de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
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18
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Kyrou IE, Antonopoulos CN, Antoniou GA. Time Dependent Correlation Between Sac Behaviour and Re-intervention after Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:612-619. [PMID: 37992984 DOI: 10.1016/j.ejvs.2023.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 10/14/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE This study aimed to investigate the correlation between aneurysm sac behaviour and time to re-intervention after endovascular aneurysm repair (EVAR). METHODS A retrospective observational cohort study of patients who underwent EVAR at a single centre between January 2008 and November 2011 and who were followed up for a mean of 6.6 ± 2.9 years was conducted. Based on sac appearances on pre-operative imaging and imaging at the end of follow up, patients were stratified into two groups: (1) sac regression; and (2) no sac regression. The no sac regression group was further subdivided into stable sac group and sac expansion group. Sac regression and expansion throughout follow up were defined as a decrease or increase in the abdominal aortic aneurysm sac diameter of ≥ 5 mm compared with the pre-operative size. A Cox proportional hazards model using multiple failure per subject data was used to identify sac behaviour as a predictor of re-intervention free time. RESULTS Patients with sac regression had a higher probability of freedom from re-intervention compared with those with a stable or expanding aneurysm sac (94%, 57%, and 16% at 12 years, respectively; log rank, p < .001). Mean time to re-intervention was 11.3 years for the sac regression group, 8.8 years for the stable sac group, and 5.0 years for the sac expansion group (p < .001). In the stable sac group, the risk of re-intervention increased sharply six years after EVAR, whereas in the sac expansion group a sharp rise in re-intervention was noted 3.5 years after EVAR, reaching a plateau after year 6. CONCLUSION A time dependent correlation between aneurysm sac behaviour and re-intervention was found. Such findings have implications for surveillance strategies.
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Affiliation(s)
- Ioanna E Kyrou
- Department of Vascular and Endovascular Surgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Constantine N Antonopoulos
- Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
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19
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Tinelli G, D'Oria M, Sica S, Mani K, Rancic Z, Resch TA, Beccia F, Azizzadeh A, Da Volta Ferreira MM, Gargiulo M, Lepidi S, Tshomba Y, Oderich GS, Haulon S. The sac evolution imaging follow-up after endovascular aortic repair: An international expert opinion-based Delphi consensus study. J Vasc Surg 2024:S0741-5214(24)00424-5. [PMID: 38462062 DOI: 10.1016/j.jvs.2024.03.007] [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: 12/05/2023] [Revised: 02/29/2024] [Accepted: 03/01/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE Management of follow-up protocols after endovascular aortic repair (EVAR) varies significantly between centers and is not standardized according to sac regression. By designing an international expert-based Delphi consensus, the study aimed to create recommendations on follow-up after EVAR according to sac evolution. METHODS Eight facilitators created appropriate statements regarding the study topic that were voted, using a 4-point Likert scale, by a selected panel of international experts using a three-round modified Delphi consensus process. Based on the experts' responses, only those statements reaching a grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement <5%) were included in the final document. RESULTS One-hundred and seventy-four participants were included in the final analysis, and each voted the initial 29 statements related to the definition of sac regression (Q1-Q9), EVAR follow-up (Q10-Q14), and the assessment and role of sac regression during follow-up (Q15-Q29). At the end of the process, 2 statements (6.9%) were rejected, 9 statements (31%) received a grade B consensus strength, and 18 (62.1%) reached a grade A consensus strength. Of 27 final statements, 15 (55.6%) were classified as grade I, whereas 12 (44.4%) were classified as grade II. Experts agreed that sac regression should be considered an important indicator of EVAR success and always be assessed during follow-up after EVAR. CONCLUSIONS Based on the elevated strength and high consistency of this international expert-based Delphi consensus, most of the statements might guide the current clinical management of follow-up after EVAR according to the sac regression. Future studies are needed to clarify debated issues.
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Affiliation(s)
- Giovanni Tinelli
- Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Simona Sica
- Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Zoran Rancic
- Department of Vascular Surgery, University of Zurich, Zurich, Switzerland
| | - Timothy Andrew Resch
- Department of Vascular Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Flavia Beccia
- Section of Hygiene and Public Health, Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ali Azizzadeh
- Division of Vascular Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Mauro Gargiulo
- Vascular Surgery University of Bologna, Vascular Surgery Unit IRCCS University Hospital Policlinico S. Orsola, Bologna, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Trieste, Italy
| | - Yamume Tshomba
- Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Stéphan Haulon
- Hôpital Marie Lannelongue, GHPSJ, Université Paris Saclay, Paris, France
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20
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Mikami T, Numaguchi R, Shiiku C. Outcomes of Late Partial Conversion With Graft Replacement for Sac Enlargement After Endovascular Abdominal Aortic Aneurysm Repair. J Endovasc Ther 2024:15266028241232517. [PMID: 38454608 DOI: 10.1177/15266028241232517] [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: 03/09/2024]
Abstract
PURPOSE Outcomes of late open conversion with graft replacement for enlargement after endovascular aortic repair remain unclear. Here, we report the outcomes of graft replacement after endovascular aortic repair. MATERIALS AND METHODS Fourteen patients who underwent graft replacement after endovascular aneurysm repair between November 2016 and October 2022 were included. Graft replacement was indicated in cases of rupture and enlargement of the aneurysm sac and when reintervention with endovascular therapy could not be performed. RESULTS The mean age at graft replacement was 80 ± 7 years. The follow-up period from endovascular aortic repair to graft replacement was 73 ± 41 months. The endoleaks that caused enlargement of the aneurysm sac were type I in 8 patients and type II in 6 patients. Ruptures were observed in 5 patients. One patient had paraplegia as a postoperative complication, and 2 patients died within 30 days. Morbidity and mortality were observed in cases of rupture, and no morbidity or mortality was observed in any elective surgery cases. CONCLUSION Late open conversion with graft replacement after endovascular aortic repair is a feasible elective surgery. However, morbidity and mortality have been observed in cases of rupture. CLINICAL IMPACT In elective surgery, postoperative outcomes are good for late open conversion with graft replacement after endovascular aortic repair. On the other hand, morbidity and mortality were observed in case of rupture. Therefore, it is important to perform elective surgical reintervention at the appropriate time.
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Affiliation(s)
- Takuma Mikami
- Department of Cardiovascular Surgery, Obihiro Hospital, National Hospital Organization, Hokkaido, Japan
| | - Ryosuke Numaguchi
- Department of Cardiovascular Surgery, Obihiro Hospital, National Hospital Organization, Hokkaido, Japan
| | - Chikara Shiiku
- Department of Cardiovascular Surgery, Obihiro Hospital, National Hospital Organization, Hokkaido, Japan
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21
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Herrlett K, Epple J, Lingwal N, Schmitz-Rixen T, Böckler D, Grundmann RT. [Inpatient rehabilitation for patients 65 years and older with abdominal aortic aneurysm repair: Indications and long-term outcome]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2024; 184:71-79. [PMID: 38142201 DOI: 10.1016/j.zefq.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/15/2023] [Accepted: 10/25/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND In Germany, there is no data available on the frequency of inpatient rehabilitation (IR) after elective endovascular (EVAR) and open (OAR) abdominal aortic aneurysm (AAA) repair. OBJECTIVE To report for the first time on the outcome of patients 65 years and older and thus of retirement age with and without IR after AAA repair in a retrospective analysis of routine data from all eleven regional companies of the AOK health insurance fund (AOK-Gesundheit). METHODS Anonymized data of 16,358 patients 65 years and older with intact abdominal aortic aneurysm treated with EVAR (n = 12,960) or OAR (n = 3,398) between 01/01/2010 and 12/31/2016 were analyzed. Patients with postoperative IR (n = 1,531) were compared to those without postoperative IR (n = 14,827) with respect to general patient characteristics, comorbidities, perioperative and postoperative outcomes, and survival. The average follow-up of patients with postoperative and without postoperative IR was 49.9 months and 51.8 months, respectively. RESULTS 5.4% of EVAR patients, but 24.6% of OAR patients were referred to IR (p < 0.001). Patients with IR were sicker than those without IR. Parameters significantly influencing the use of IR included OAR vs EVAR (Odds Ratio [OR] 6.03), condition after cerebral infarction (OR 1.53), and women vs men (OR 1.49). Perioperative influencing parameters were cerebral infarction (OR 2.40), blood transfusions (OR 2.21) and complex critical care (OR 2.15). After nine years, the Kaplan-Meier estimated survival was 41.9% for patients with vs 43.4% for those without IR in the EVAR group (p = 0.178). For OAR, it was 50.2% for patients with IR vs 49.8% for patients without IR (p = 0.006). In multivariate regression analysis, postoperative IR had a significant effect on long-term survival in OAR but not in EVAR patients. CONCLUSION There are no generally binding guidelines for the indication of IR after AAA repair. It should therefore be a requirement for the future that the fitness of each patient with elective AAA repair be determined with a score before and after the procedure in order to make indications for AHB more comparable. The score should be documented in the hospital discharge letter.
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Affiliation(s)
- Katrin Herrlett
- Klinik für Gefäß- und Endovaskularchirurgie, Klinikum der Goethe-Universität, Frankfurt am Main, Deutschland
| | - Jasmin Epple
- Klinik für Gefäß- und Endovaskularchirurgie, Klinikum der Goethe-Universität, Frankfurt am Main, Deutschland
| | - Neelam Lingwal
- Institut für Biostatistik und mathematische Modellierung, Goethe-Universität, Frankfurt am Main, Deutschland
| | | | - Dittmar Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Reinhart T Grundmann
- Klinik und Poliklinik für Gefäßmedizin, Universitäres Herzzentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.
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22
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Li HL, Kwan KJS, Chan YC, Cheng SW. Contemporary Outcomes of Endovascular and Open Surgical Repair for Mycotic Aortic Aneurysms: A Systematic Review. Ann Vasc Surg 2024; 100:172-183. [PMID: 37898457 DOI: 10.1016/j.avsg.2023.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND To perform a systematic review on contemporary outcomes of endovascular repair and open surgical repair (OSR) for the treatment of mycotic aortic aneurysm (MAA). METHODS A comprehensive literature search on the management of MAAs with endovascular repair or OSR was performed between January 1998 and January 2023. Patient demographics, early and late outcomes were analyzed with respect to treatment modality and MAA location. RESULTS Forty-eight articles were included, encompassing a total of 1,358 patients (75.8% male; mean age 66.9 years; 1,372 aneurysms) treated by open (49.8%) or endovascular (50.2%) repair. Salmonella spp., and Staphylococcus spp. were the most prevalent pathogens in Asian and European countries respectively. An increasing number of descending thoracic MAAs were managed by endovascular repair (27.9% vs. 12.8%). Early mortality rates for supra- and infra-renal MAAs managed by endovascular repair were lower than OSR (suprarenal 5.4% vs. 43.2%; infrarenal 1.8% vs. 16.7%). Overall, endovascular repair demonstrated lower intraoperative (1.0% vs. 1.8%) and early mortality (6.5% vs. 15.9) rates than OSR. However, endovascular repair was associated with higher late sepsis rate (5.7% vs. 0.9%) and reintervention rate (17.6% vs. 7.3%). Pooled survival rates at 1- and 5-year were similar between the 2 groups. CONCLUSIONS Current literature suggest that endovascular repair is an effective and safe alternative to OSR for descending thoracic, suprarenal, and infrarenal MAAs. However, endovascular repair is associated with higher risk of infection-related complications and reintervention during follow-up.
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Affiliation(s)
- Hai-Lei Li
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Kristine J S Kwan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China; Shanghai Medical College, Fudan University, Shanghai, China
| | - Yiu Che Chan
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China; Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
| | - Stephen W Cheng
- Division of Vascular Surgery, Department of Surgery, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China; Division of Vascular & Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China
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23
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Berchiolli R, Troisi N, Bertagna G, D’Oria M, Mezzetto L, Malquori V, Artini V, Motta D, Grosso L, Grando B, Badalamenti G, Calvagna C, Mastrorilli D, Veraldi GF, Adami D, Lepidi S. Intraoperative Predictors and Proposal for a Novel Prognostic Risk Score for In-Hospital Mortality after Open Repair of Ruptured Abdominal Aortic Aneurysms (SPARTAN Score). J Clin Med 2024; 13:1384. [PMID: 38592197 PMCID: PMC10934212 DOI: 10.3390/jcm13051384] [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: 12/18/2023] [Revised: 01/30/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Several mortality risk scores have been developed to predict mortality in ruptured abdominal aortic aneurysms (rAAAs), but none focused on intraoperative factors. The aim of this study is to identify intraoperative variables affecting in-hospital mortality after open repair and develop a novel prognostic risk score. (2) Methods: The analysis of a retrospectively maintained dataset identified patients who underwent open repair for rAAA from January 2007 to October 2023 in three Italian tertiary referral centers. Multinomial logistic regression was used to calculate the association between intraoperative variables and perioperative mortality. Independent intraoperative factors were used to create a prognostic score. (3) Results: In total, 316 patients with a mean age of 77.3 (SD ± 8.5) were included. In-hospital mortality rate was 30.7%. Hemoperitoneum (p < 0.001), suprarenal clamping (p = 0.001), and operation times of >240 min (p = 0.008) were negative predictors of perioperative mortality, while the patency of at least one hypogastric artery had a protective role (p = 0.008). Numerical values were assigned to each variable based on the respective odds ratio to create a risk stratification for in-hospital mortality. (4) Conclusions: rAAA represents a major cause of mortality. Intraoperative variables are essential to estimate patients' risk in surgically treated patients. A prognostic risk score based on these factors alone may be useful to predict in-hospital mortality after open repair.
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Affiliation(s)
- Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Mario D’Oria
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Department of Cardio-Thoraco-Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, 37134 Verona, Italy; (L.M.); (L.G.); (D.M.); (G.F.V.)
| | - Vittorio Malquori
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Valerio Artini
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Duilio Motta
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Lorenzo Grosso
- Unit of Vascular Surgery, Department of Cardio-Thoraco-Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, 37134 Verona, Italy; (L.M.); (L.G.); (D.M.); (G.F.V.)
| | - Beatrice Grando
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
| | - Giovanni Badalamenti
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
| | - Cristiano Calvagna
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Department of Cardio-Thoraco-Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, 37134 Verona, Italy; (L.M.); (L.G.); (D.M.); (G.F.V.)
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Department of Cardio-Thoraco-Vascular Surgery, University Hospital and Trust of Verona, University of Verona School of Medicine, 37134 Verona, Italy; (L.M.); (L.G.); (D.M.); (G.F.V.)
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (N.T.); (G.B.); (V.M.); (V.A.); (D.M.); (D.A.)
| | - Sandro Lepidi
- Vascular and Endovascular Surgery Unit, Cardio-Thoraco-Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy; (B.G.); (G.B.); (C.C.); (S.L.)
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24
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Wilkat M, Lommen J, Rana M, Kübler N, Wienemann T, Braß SM, Ziegler RT, Mazrekaj A, Knapsis A, Schelzig H, Wagenhäuser MU, Arnautovic A. Accuracy and Sterilizability of In-House Printed Patient-Specific Aortic Model for Surgeon-Modified Stent Grafts-A Workflow Description for Emergency Aortic Endovascular Procedures. J Clin Med 2024; 13:1309. [PMID: 38592134 PMCID: PMC10931993 DOI: 10.3390/jcm13051309] [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: 01/23/2024] [Revised: 02/17/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Introduction: The use of 3D-printed aortic models for the creation of surgeon-modified endoprostheses represents a promising avenue in aortic surgery. By focusing on the potential impact of sterilization on model integrity and geometry, this report sheds light on the suitability of these models for creating customized endoprostheses. The study presented here aimed to investigate the safety and viability of 3D-printed aortic models in the context of sterilization processes and subsequent remodeling. Methods: The study involved the fabrication of 3D-printed aortic models using patient-specific imaging data and established additive manufacturing techniques. Five identical aortic models of the same patient were printed. Two models were subjected to sterilization and two to disinfection using commonly employed methods, and one model remained untreated. The models were checked by in-house quality control for deformation (heat map analyses) after the sterilization and disinfection processes. Three models (sterilized, disinfected, and untreated) were sent for ex-house (Lufthansa Technik, AG, Materials Technologies and Central Laboratory Services, Hamburg, Germany) evaluation and subsequent quantification of possible structural changes using advanced imaging and measurement technologies (macroscopic and SEM/EDX examinations). After sterilization and disinfection, each aortic model underwent sterility checks. Results: Based on macroscopic and SEM/EDX examinations, distinct evidence of material alterations attributed to a treatment process, such as a cleaning procedure, was not identified on the three implants. Comparative material analyses conducted via the EDX technique yield consistent results for all three implants. Disinfected and sterilized models tested negative for common pathogens. Conclusions: The evaluation of 3D-printed aortic models' safety after sterilization as well as their suitability for surgeon-modified endoprostheses is a critical step toward their clinical integration. By comprehensively assessing changes in model integrity and geometry after sterilization, this research has contributed to the broader understanding of the use of 3D-printed models for tailor-made endovascular solutions. As medical technologies continue to evolve, research endeavors such as this one can serve as a foundation for harnessing the full potential of 3D printing to advance patient-centered care in aortic surgery.
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Affiliation(s)
- Max Wilkat
- Department for Oral & Maxillofacial Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Julian Lommen
- Department for Oral & Maxillofacial Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Majeed Rana
- Department for Oral & Maxillofacial Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Norbert Kübler
- Department for Oral & Maxillofacial Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Tobias Wienemann
- Institute of Medical Microbiology and Hospital Hygiene, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Sönke Maximilian Braß
- Department for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Reinhold Thomas Ziegler
- Department for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Agnesa Mazrekaj
- Department for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Artis Knapsis
- Department for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Hubert Schelzig
- Department for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Markus Udo Wagenhäuser
- Department for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
| | - Amir Arnautovic
- Department for Vascular and Endovascular Surgery, Medical Faculty and University Hospital Düsseldorf, 40225 Düsseldorf, Germany
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25
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Villa F, Mozzetta G, Esposito D, Stefano LD, Pratesi G, Pulli R, Angiletta D, Piffaretti G. Results of the Italian Collaborators for Evar Registry on Acute Kidney Injury After Elective Endovascular Aortic Repair of Infrarenal Abdominal Aortic Aneurysm. J Endovasc Ther 2024:15266028241234277. [PMID: 38409775 DOI: 10.1177/15266028241234277] [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: 02/28/2024]
Abstract
OBJECTIVES To analyze the incidence and predictive factors of postoperative acute kidney injury (AKI) after elective standard endovascular aortic repair (EVAR) in a large recent, multicenter cohort. MATERIALS AND METHODS This is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study. Between January 2018 and March 2021, only patients treated with elective standard EVAR for infrarenal non-infected abdominal aortic aneurysm were analyzed. Patients already on hemodialysis (HD) were excluded. AKI was defined as an increase in serum creatinine (sCr) ≥0.3 mg/dL within 48 hours or an increase in sCr to ≥1.5 times baseline known or presumed to have occurred within 7 days, or a urine volume of <0.5 mL/kg/h for 6 hours. Primary outcomes of interest were AKI incidence at 30 days and freedom from HD at 1-year follow-up. Secondary outcomes were freedom from severe postoperative complication, and freedom from aorta-related mortality (ARM) at 1 year. RESULTS The final cohort analyzed 526 (29.8%). There were 489 (93%) males and 37 (7%) females: the median age was 76 years (interquartile range [IQR], 71-81). Chronic kidney disease (CKD) was present in 86 (16.3%) patients. Early mortality was observed in 8 (1.5%) patients, none was aorta-related. Complication rate was 17.1% (n=89). AKI was observed in 17 (3.2%). Renal replacement therapy was needed in 4 (0.8%). HD was transitory in 2 cases and definitive in 1. Binary logistic regression analysis identified CKD (odds ratio [OR]: 4.68, 95% confidence interval [CI]: 2.10-10.45, p<0.001), and the presence of renal artery stenosis (OR: 3.80, 95% CI: 1.35-10.66, p=0.011) to be associated with an increased risk of postoperative AKI. Estimated freedom from ARM was 94.9% at 1 year. Estimated freedom from HD rate at 1 year was 94%: This was significantly different between patients with preoperative CKD and those who did not have preoperative CKD (log-rank, p=0.042). CONCLUSION AKI after elective standard EVAR still occurs but with an acceptably low incidence rate. Preoperative CKD is the most important predictor for postoperative AKI, which was not associated with the need for HD at 1-year follow-up but with a higher propensity of mortality. CLINICAL IMPACT This "real world" experience confirm that EVAR performed with standard contrats agent protocol remains safe for acute kidney injury development. Therefore, only patients presenting with preoperative borderline or ascertained chronic kidney disease will take the most advantage from the use of carbon dioxide contrast.
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Affiliation(s)
- Federico Villa
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Gaddiel Mozzetta
- Vascular Surgery, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa School of Medicine, Genoa, Italy
| | - Davide Esposito
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Florence School of Medicine, Florence, Italy
| | - Lucia Di Stefano
- Vascular Surgery, Department of Emergency and Organ Transplantation, University of Bari School of Medicine, Bari, Italy
| | - Giovanni Pratesi
- Vascular Surgery, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa School of Medicine, Genoa, Italy
| | - Raffaele Pulli
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Florence School of Medicine, Florence, Italy
| | - Domenico Angiletta
- Vascular Surgery, Department of Emergency and Organ Transplantation, University of Bari School of Medicine, Bari, Italy
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
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Pherwani AD, Johal AS, Cromwell DA, Boyle JR, Szeberin Z, Venermo M, Beiles B, Khashram M, Lattmann T, Altreuther ME, Laxdal E, Behrendt CA, Mani K, Budtz-Lilly J. Outcomes Following Intact and Ruptured Aneurysm Repair across Nations: Analysis of International Registry Data from the VASCUNET Collaboration 2014 - 2019. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00178-3. [PMID: 38382695 DOI: 10.1016/j.ejvs.2024.02.019] [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: 11/27/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To determine the peri-operative mortality rate for intact and ruptured abdominal aortic aneurysm (AAA) repair in 10 countries and to compare practice and outcomes over a six year period by age, sex, and geographic location. METHODS This VASCUNET study used prospectively collected data from vascular registries in 10 countries on primary repair of intact and ruptured AAAs undertaken between January 2014 and December 2019. The primary outcome was peri-operative death (30 day or in hospital). Logistic regression models were used to estimate the association between peri-operative death, patient characteristics, and type of procedure. Factors associated with the use of endovascular aortic aneurysm repair (EVAR) were also evaluated. RESULTS The analysis included 50 642 intact and 9 453 ruptured AAA repairs. The proportion of EVARs for intact repairs increased from 63.4% in 2014 to 67.3% in 2016 before falling to 62.3% in 2019 (p < .001), but practice varied between countries. EVAR procedures were more common among older patients (p < .001) and men (p < .001). Overall peri-operative mortality after intact AAA repair was 1.4% (95% confidence interval [CI] 1.3 - 1.5%) and did not change over time. Mortality rates were stable within countries. Among ruptured AAA repairs, the proportion of EVARs increased from 23.7% in 2014 to 35.2% in 2019 (p < .001). The average aortic diameter was 7.8 cm for men and 7.0 cm for women (p < .001). The overall peri-operative mortality rate was 31.3% (95% CI 30.4 - 32.2%); the rates were 36.0% (95% CI 34.9 - 37.2%) for open repair and 19.7% (95% CI 18.2 - 21.3%) for EVAR. This difference and shift to EVAR reduced peri-operative mortality from 32.6% (in 2014) to 28.7% (in 2019). CONCLUSION The international practice of intact AAA repair was associated with low mortality rates in registry reported data. There remains variation in the use of EVAR for intact AAAs across countries. Overall peri-operative mortality remains high after ruptured AAA, but an increased use of EVAR has reduced rates over time.
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Affiliation(s)
- Arun D Pherwani
- Keele University School of Medicine, Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK.
| | - Amundeep S Johal
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK. http://www.twitter.com/vsqip
| | | | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust and Department of Surgery, University of Cambridge, Cambridge, UK. http://www.twitter.com/Jonnyboyle1
| | - Zoltan Szeberin
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. http://www.twitter.com/VenerMa
| | - Barry Beiles
- Australasian Vascular Audit, Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - Manar Khashram
- University of Auckland, Waikato Hospital, Hamilton, New Zealand. http://www.twitter.com/ManarKhashram
| | - Thomas Lattmann
- Swissvasc Registry, Clinic for Interventional Radiology and Vascular Surgery, Kantonsspital Winterthur, Winterthur, Switzerland. http://www.twitter.com/LattmannThomas
| | - Martin E Altreuther
- Section of Vascular Surgery, Department of Surgery, St Olavs Hospital, and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elin Laxdal
- Department of Vascular Surgery, Landspitalinn University Hospital, Reykjavik, Iceland
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany. http://www.twitter.com/VASCevidence
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden. http://www.twitter.com/KevinMani7
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, Aarhus, Denmark
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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: 49] [Impact Index Per Article: 49.0] [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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Ramirez JL, Sung E, Jaramillo E, Gasper WJ, Conte MS, Boitano L, Iannuzzi JC. Development and Validation of a Novel Preoperative Risk Score to Identify Patients at Risk for Nonhome Discharge after Elective Endovascular Aortic Aneurysm Repair (EVAR). Ann Vasc Surg 2024; 99:341-348. [PMID: 37852368 DOI: 10.1016/j.avsg.2023.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after elective endovascular aortic repair (EVAR) is uncommon. However, NHD after surgery has an important impact on patient quality of life and postdischarge outcomes. Understanding factors that put patients undergoing EVAR at high risk for NHD is essential to providing adequate preoperative counseling and shared decision making. This study aimed to identify independent predictors of NHD following elective EVAR and to create a clinically useful preoperative risk score. METHODS Elective EVAR cases were queried from the Society for Vascular Surgery Vascular Quality Initiative 2014-2018. A risk score was created by splitting the data set into two-thirds for development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. The score was then validated, and model performance assessed. RESULTS Overall, 24,426 patients were included and 932 (3.8%) required NHD. Multivariable analysis in the development group identified independent predictors of NHD, which were used to create a 20-point risk score. Patients were stratified into 3 groups based upon their risk score: low risk (0-7 points; n = 16,699) with an NHD rate of 1.8%, moderate risk (8-13 points; n = 7,315) with an NHD rate of 7.3%, and high risk (≥14 points; n = 412) with an NHD rate of 21.8%. The risk score had good predictive ability with c-statistic = 0.75 for model development and c-statistic = 0.73 in the validation dataset. CONCLUSIONS This novel risk score can predict NHD following EVAR using characteristics that can be identified preoperatively. Utilization of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA; Chan Zuckerberg Biohub, San Francisco, CA
| | - Eric Sung
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Emanual Jaramillo
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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't Mannetje YW, Reijnen MMPJ, Zeebregts CJ. Upside-Down Gore Excluder as an Endoprosthesis for Aortoiliac Aneurysm Exclusion: A Retrospective Multicenter Study. J Endovasc Ther 2024:15266028231224257. [PMID: 38193446 DOI: 10.1177/15266028231224257] [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: 01/10/2024]
Abstract
OBJECTIVE The upside-down configuration of a Gore Excluder contralateral leg endoprosthesis has been used to overcome diameter differences in the endovascular treatment of aortoiliac aneurysms. Our goal was not to describe the technique but to study the applicability and safety. MATERIAL AND METHODS Patients were retrospectively enrolled. The indication and details of the procedure were at the discretion of the treating physicians. A case report form was completed including baseline characteristics, indication for treatment, procedural data, and outcomes during follow-up. RESULTS A total of 31 subjects were enrolled with a range of indications, including 3 patients treated in the emergency setting (9.7%). In 64.5% (n=20), it was a primary intervention for a common iliac aneurysm (n=10), internal iliac aneurysm (n=4), or abdominal aortic aneurysm (n=6). In 11 subjects (35.5%), treatment was performed after previous aortoiliac interventions, including anastomotic iliac artery aneurysm (n=5), type III endoleak (n=3), and endograft thrombus (n=3). Median follow-up was 13 months (range=1-142 months). During follow-up, 2 patients required an upside-down contralateral leg-related secondary intervention, one for an occlusion and another for a type Ia endoleak. There was no type Ib or III endoleak, and no migration, kinking/stenosis, or conversion to open repair was observed. The aneurysm-related mortality was 3.3% (n=1). CONCLUSION An upside-down contralateral leg is a valuable technique that can be used to achieve adequate aneurysm exclusion or resolve complications. It is associated with a limited number of complications. CLINICAL IMPACT This article studies the use of an upside-down iliac endograft. We describe a wide range of indications in which this previously published technique has been applied. In elective and acute settings and as primary and revision intervention an upside-down iliac endograft was performed successfully. Furthermore, follow-up data is presented showing the effectiveness of the technique. Knowledge of this procedure is a valuable addition to the skillset of every interventionalist.
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Affiliation(s)
| | - Michel M P J Reijnen
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, The Netherlands
- Multi-Modality Medical Imaging Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Simonte G, Isernia G, Pecoraro F, Antonello M, Guzzardi G, Dinoto E, Feriani G, Migliara B. Rotational Mechanical Thrombectomy to Treat Iliac Limb Occlusion after Endovascular Aortic Aneurysm Repair: The Rotational Mechanical Thrombectomy Italian Study. J Vasc Interv Radiol 2024; 35:25-31. [PMID: 37776993 DOI: 10.1016/j.jvir.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/23/2023] [Accepted: 09/21/2023] [Indexed: 10/02/2023] Open
Abstract
PURPOSE To assess the safety and effectiveness of a rotational mechanical atherothrombectomy device in patients with symptomatic iliac limb occlusion after abdominal endovascular aneurysm repair (EVAR). MATERIALS AND METHODS A retrospective analysis was conducted on patients who underwent rotational mechanical thrombectomy using the Rotarex S device for symptomatic acute, subacute, or chronic graft limb thrombosis at 5 vascular centers between 2017 and 2021. This study comprised 23 male patients with a mean age of 74.5 years (SD ± 7.2) at the time of the procedure. The clinical presentation of the patients varied, with 1 patient experiencing acute limb ischemia and 11 patients (47.8%) experiencing disabling intermittent claudication. The remaining patients developed chronic limb-threatening ischemia after iliac limb occlusion. Early outcomes included technical success, postprocedural complications, and periprocedural mortality. Follow-up evaluations encompassed primary patency, patient survival, freedom from reintervention, and the need for surgical conversion. RESULTS Technical success was achieved in all cases, with no occurrences of distal embolization during or after the procedure, and no periprocedural deaths were reported. Endograft relining was performed in 82.6% of patients to establish a new, nonthrombogenic surface within the graft. Over a median follow-up period of 8 months (interquartile range, 3-16 months), 2 patients experienced iliac limb reocclusion. No deaths or other reinterventions occurred during the observational follow-up period. CONCLUSIONS Rotational mechanical thrombectomy for iliac limb occlusion after EVAR appears to be both safe and effective. This technique may uncover intraluminal defects contributing to graft occlusion and enable their resolution within the same procedure.
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Affiliation(s)
- Gioele Simonte
- Vascular and Endovascular Surgery Unit, S. Maria Della Misericordia University Hospital, Perugia, Italy.
| | - Giacomo Isernia
- Vascular and Endovascular Surgery Unit, S. Maria Della Misericordia University Hospital, Perugia, Italy
| | - Felice Pecoraro
- Department of Surgical Oncological and Oral Sciences, University of Palermo, Palermo, Italy; Vascular Surgery Unit, Azienda Ospedaliera Universitaria Policlinico 'P. Giaccone, Palermo, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Unit, University of Padua, Padova, Italy
| | - Giuseppe Guzzardi
- Interventional Radiology Unit, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Ettore Dinoto
- Vascular Surgery Unit, Azienda Ospedaliera Universitaria Policlinico 'P. Giaccone, Palermo, Italy
| | - Giovanni Feriani
- Vascular and Endovascular Surgery Unit, Pederzoli Hospital, Peschiera del Garda (VR), Italy
| | - Bruno Migliara
- Vascular and Endovascular Surgery Unit, Pederzoli Hospital, Peschiera del Garda (VR), Italy
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Borgen L, Aasekjær K, Skoe ØW. Exploiting endovascular aortic repair as a minimally invasive method - Nine years of experience in a non-university hospital. Eur J Radiol Open 2023; 11:100522. [PMID: 37701925 PMCID: PMC10493885 DOI: 10.1016/j.ejro.2023.100522] [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: 02/02/2023] [Revised: 08/22/2023] [Accepted: 09/02/2023] [Indexed: 09/14/2023] Open
Abstract
Background At the introduction of endovascular aortic repair (EVAR) in 2013 in our non-university hospital, we established a quality registry to monitor our EVAR activity. Purpose To observe if we over time were able to exploit EVAR as a minimally invasive method in an elective as well as emergency setting, and to monitor our treatment quality in terms of complications, secondary interventions and mortality. Material and methods From November 2013 to March 2022, we treated 207 patients with EVAR, including six patients with rupture. Follow-up regimen was partly based on contrast-enhanced computer tomography, and partly on contrast-enhanced ultrasound in combination with plain radiography. Results During the observation period, the method of anesthesia changed from general, via spinal, to local anesthesia. The groin access changed from surgical cut down to percutaneous and the median length of postoperative stay decreased from 3 days to 1 day. EVAR on ruptured aneurysm was done for the first time in 2019. Endoleak was detected in 85 patients (42%) and 37 patients (18%) had one or more secondary interventions, of which 85% were endovascular. Estimated five-year survival was 72% in patients below 80 years of age and 45% in patients 80 years or older. Conclusion Nine years of experience enabled us to exploit EVAR's advantages as a minimally invasive method in an elective as well as emergency setting. Complications, secondary interventions and survival rates in our low volume non-university hospital matches results from larger vascular centers.
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Affiliation(s)
- Lars Borgen
- Department of Radiology, Drammen Hospital, Vestre Viken Health Trust, Dronning gaten 28, 3004 Drammen, Norway
| | - Kjartan Aasekjær
- Department of Radiology, Drammen Hospital, Vestre Viken Health Trust, Dronning gaten 28, 3004 Drammen, Norway
| | - Øyvind Werpen Skoe
- Department of Surgery, Drammen Hospital, Vestre Viken Health Trust, Dronning gaten 28, 3004 Drammen, Norway
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Kontopodis N, Galanakis N, Ioannou CV, Antoniou GA. Systematic Review and Meta-Analysis of the Effect of Anticoagulation on Outcomes After Endovascular Aneurysm Repair. J Endovasc Ther 2023:15266028231214761. [PMID: 38031419 DOI: 10.1177/15266028231214761] [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: 12/01/2023]
Abstract
PURPOSE Our objective was to investigate whether patients who receive anticoagulation therapy have different outcomes after endovascular aneurysm repair (EVAR) from those who do not. MATERIALS AND METHODS We conducted a systematic review of studies that compared outcomes of EVAR in patients who were on therapeutic anticoagulation vs those who were not. We developed and reported the review in accordance with the PRISMA guidelines with a registered protocol (CRD42022375894). The Ovid interface was used to search Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), and Cochrane Central Register of Controlled Trials (CENTRAL) up to November 2022. The quality of studies was assessed with the Newcastle-Ottawa Scale (NOS) (maximum score=9), and the evidence was appraised with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. The hazard ratio (HR) and 95% confidence interval (CI) was the effect estimate in time-to-event meta-analyses, calculated using the inverse-variance statistical method and random-effects models. RESULTS Sixteen studies qualified for inclusion reporting a total of 35 739 individuals. Anticoagulated patients had a statistically significantly higher hazard of death (HR=1.93, 95% CI=1.03-3.63), endoleak (HR=2.13, 95% CI=1.55-2.93), reintervention (HR=1.79, 95% CI=1.27-2.52), and aneurysm sac expansion (HR=2.72, 95% CI=1.57-4.72) than patients not receiving anticoagulation therapy. The median score on the NOS was 7 (range=4-9). The certainty of evidence was very low for mortality and reintervention and low for endoleak and sac expansion. CONCLUSIONS Anticoagulation is a poor prognostic factor after standard EVAR and should be considered in decision-making, consent processes, and surveillance strategies. CLINICAL IMPACT The number of individuals who take anticoagulation treatment has been rapidly increasing over the recent years. We aimed to investigate the effect of such treatment on outcomes after endovascular aneurysm repair (EVAR). Anticoagulated patients were found to have increased mortality, endoleak, and reintervention rates after EVAR compared to their non-anticoagulated counterparts. Anticoagulation therapy has a prognostic role in EVAR and should be considered in decision making and EVAR surveillance. Anticoagulated patients need to be informed of the higher failure rates of EVAR, and intensified surveillance strategies may need to be implemented in this patient cohort.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - Nikolaos Galanakis
- Interventional Radiology Unit, Department of Medical Imaging, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - George A Antoniou
- Manchester Vascular Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
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Han SM, DiBartolomeo AD, Chavez M, Meltzer AJ. Techniques and Limitations of Gore Thoracoabdominal Multibranch Endoprosthesis (TAMBE) for Type 1A Endoleak After Failed Endovascular Aortic Repairs. J Endovasc Ther 2023:15266028231214211. [PMID: 38008999 DOI: 10.1177/15266028231214211] [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: 11/28/2023]
Abstract
PURPOSE Endovascular aortic aneurysm repair (EVAR) is the dominant treatment modality over open repair for abdominal aortic aneurysms. However, a higher rate of reinterventions remains the Achilles heel of EVAR. Although type 1A endoleak from proximal seal zone failure of EVAR remains one of the leading causes for reintervention, fenestrated branched devices suitable for proximal extension of failed EVAR are not widely available in the United States. Gore Thoracoabdominal Multibranch Endoprosthesis (TAMBE) is an off-the-shelf investigational device that provides supraceliac seal by incorporating 4 visceral and renal arteries via preloaded inner branches. CASE REPORT In this article, we describe 2 cases of type 1A endoleak from previous EVAR devices repaired using TAMBE. Both cases were performed under the Food and Drug Administration (FDA) compassionate use exemption. Considerations on the case planning and implantation techniques of TAMBE specific to previous EVAR devices are reviewed. CONCLUSIONS Gore TAMBE can be utilized to repair a type 1A endoleak of a previous infrarenal EVAR device. Greater supraceliac coverage necessary for TAMBE relative to the minimal seal zone should be considered when applying this device for a type 1A endoleak. CLINICAL IMPACT This report demonstrates the feasibility of applying off-the-shelf TAMBE device to treat one of the most common failure modes of EVAR, type1A endoleak.
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Affiliation(s)
- Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Alexander D DiBartolomeo
- Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center of University of Southern California, Los Angeles, CA, USA
| | - Marin Chavez
- Division of Vascular Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Andrew J Meltzer
- Division of Vascular Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Lopez Espada C, Behrendt CA, Mani K, D'Oria M, Lattman T, Khashram M, Altreuther M, Cohnert TU, Pherwani A, Budtz-Lilly J. Editor's Choice - The VASCUNExplanT Project: An International Study Assessing Open Surgical Conversion of Failed Non-Infected Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2023; 66:653-660. [PMID: 37490979 DOI: 10.1016/j.ejvs.2023.07.029] [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: 02/23/2023] [Revised: 07/09/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE The need for open surgical conversion (OSC) after failed endovascular aortic aneurysm repair (EVAR) persists, despite expanding endovascular options for secondary intervention. The VASCUNExplanT project collected international data to identify risk factors for failed EVAR, as well as OSC outcomes. This retrospective cross sectional study analysed data after OSC for failed EVAR from the VASCUNET international collaboration. METHODS VASCUNET queried registries from its 28 member countries, and 17 collaborated with data from patients who underwent OSC (2005 - 2020). Any OSC for infection was excluded. Data included demographics, EVAR, and OSC procedural details, as well as post-operative mortality and complication rates. RESULTS There were 348 OSC patients from 17 centres, of whom 33 (9.4%) were women. There were 130 (37.4%) devices originally deployed outside of instructions for use. The most common indication for OSC was endoleak (n = 143, 41.1%); ruptures accounted for 17.2% of cases. The median time from EVAR to OSC was 48.6 months [IQR 29.7, 71.6]; median abdominal aortic aneurysm diameter at OSC was 70.5 mm [IQR 61, 82]. A total of 160 (45.6%) patients underwent one or more re-interventions prior to OSC, while 63 patients (18.1%) underwent more than one re-intervention (range 1 - 5). Overall, the 30 day mortality rate post-OSC was 11.8% (n = 41), 11.1% for men and 18.2% for women (p = .23). The 30 day mortality rate was 6.1% for elective cases, and 28.3% for ruptures (p < .0001). The predicted 90 day survival for the entire cohort was 88.3% (95% CI 84.3 - 91.3). Multivariable analysis revealed rupture (OR 4.23; 95% CI 2.05 - 8.75; p < .0001) and total graft explantation (OR 2.10; 95% CI 1.02 - 4.34; p = .04) as the only statistically significant predictive factors for 30 day death. CONCLUSION This multicentre analysis of patients who underwent OSC shows that, despite varying case mix and operative techniques, OSC is feasible but associated with significant morbidity and mortality rates, particularly when performed for rupture.
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Affiliation(s)
- Cristina Lopez Espada
- Vascular Surgery Unit, University Hospital Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain.
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Thomas Lattman
- Kantonsspital Winterthur, Swissvasc Registry, Zurich, Switzerland
| | - Manar Khashram
- Waikato Hospital, University of Auckland, Auckland, New Zealand
| | - Martin Altreuther
- Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway
| | - Tina U Cohnert
- Department of Vascular Surgery, Graz Medical University, Graz, Austria
| | - Arun Pherwani
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, Aarhus, Denmark
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Kim H, Kwon TW, Cho YP, Gwon JG, Han Y, Lee SA, Kim YJ, Kim S. Treatment Outcomes of Patients With Ruptured Abdominal Aortic Aneurysms. J Korean Med Sci 2023; 38:e321. [PMID: 37821088 PMCID: PMC10562185 DOI: 10.3346/jkms.2023.38.e321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/26/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Ruptured abdominal aortic aneurysm (rAAA) is a serious complication of abdominal aortic aneurysm associated with high operative mortality and morbidity rates. The present study evaluated the perioperative and long-term outcomes of Korean patients with rAAA based on national health insurance claims data. METHODS The National Health Insurance Service (NHIS) database was searched retrospectively to identify patients with rAAA who underwent endovascular aneurysm repair (EVAR) and open surgical repair (OSR) from 2009 to 2018. Perioperative (≤ 30 days), early postoperative (≤ 3 month), and long-term (> 3 month) survival, reinterventions, and complications were assessed. RESULTS The search identified 1,034 patients with rAAA, including 594 who underwent EVAR and 440 who underwent OSR. When the study period was divided into two, the total numbers of patients with rAAA, patients who underwent EVAR, and octogenarians were higher during the second half. The perioperative mortality rate was 29.8% in the EVAR and 35.0% in the OSR group (P = 0.028). Hartmann's procedure for bowel infarction was performed more frequently in the OSR than in the EVAR group (adjusted odds ratio, 6.28; 95% confidence interval [CI], 2.33-21.84; P = 0.001), but other complication rates did not differ significantly. All-cause mortality during the entire observation period did not differ significantly in the EVAR and OSR groups (adjusted hazard ratio, 1.17; 95% CI, 0.98-1.41; P = 0.087). Abdominal aortic aneurysm-related reintervention rate was significantly lower in the OSR group (adjusted hazard ratio, 0.31; 95% CI, 0.14-0.70; P = 0.005). CONCLUSION Although EVAR showed somewhat superior perioperative outcomes for rAAA, the long-term outcomes of EVAR after excluding initial 3 months were significantly worse than OSR. When anatomically feasible for both treatments, the perioperative mortality risk and reasonable prospects of long-term survival should be considered in rAAA.
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Affiliation(s)
- Hyangkyoung Kim
- Department of Surgery, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Tae-Won Kwon
- Division of Vascular Surgery, Department of Surgery, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea.
| | - Yong-Pil Cho
- Division of Vascular Surgery, Department of Surgery, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Jun Gyo Gwon
- Division of Vascular Surgery, Department of Surgery, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Youngjin Han
- Division of Vascular Surgery, Department of Surgery, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Sang Ah Lee
- Division of Vascular Surgery, Department of Surgery, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seonok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abdelhalim MA, Tenorio ER, Oderich GS, Haulon S, Warren G, Adam D, Claridge M, Butt T, Abisi S, Dias NV, Kölbel T, Gallitto E, Gargiulo M, Gkoutzios P, Panuccio G, Kuzniar M, Mani K, Mees BM, Schurink GW, Sonesson B, Spath P, Wanhainen A, Schanzer A, Beck AW, Schneider DB, Timaran CH, Eagleton M, Farber MA, Modarai B. Multicenter trans-Atlantic experience with fenestrated-branched endovascular aortic repair of chronic post-dissection thoracoabdominal aortic aneurysms. J Vasc Surg 2023; 78:854-862.e1. [PMID: 37321524 DOI: 10.1016/j.jvs.2023.05.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE This multicenter international study aimed to describe outcomes of fenestrated-branched endovascular aortic repairs (FB-EVAR) in a cohort of patients treated for chronic post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs). METHODS We reviewed the clinical data of all consecutive patients treated by FB-EVAR for repair of extent I to III PD-TAAAs in 16 centers from the United States and Europe (2008-2021). Data were extracted from institutional prospectively maintained databases and electronic patient records. All patients received off-the-shelf or patient-specific manufactured fenestrated-branched stent grafts. Endpoints were any cause mortality and major adverse events at 30 days, technical success, target artery (TA) patency, freedom from TA instability, minor (endovascular with <12 Fr sheath) and major (open or ≥12 Fr sheath) secondary interventions, patient survival, and freedom from aortic-related mortality (ARM). RESULTS A total of 246 patients (76% male; median age, 67 years [interquartile range, 61-73 years]) were treated for extent I (7%), extent II (55%), and extent III (35%) PD-TAAAs by FB-EVAR. The median aneurysm diameter was 65 mm (interquartile range, 59-73 mm). Eighteen patients (7%) were octogenarians, 212 (86%) were American Society of Anesthesiologists class ≥3, and 21 (9%) presented with contained ruptured or symptomatic aneurysms. There were 917 renal-mesenteric vessels targeted by 581 fenestrations (63%) and 336 directional branches (37%), with a mean of 3.7 vessels per patient. Technical success was 96%. Mortality and rate of major adverse events at 30 days was 3% and 28%, including disabling complications such as new onset dialysis in 1%, major stroke in 1%, and permanent paraplegia in 2%. Mean follow-up was 24 months. Kaplan-Meier (KM) estimated patient survival at 3 and 5 years was 79% ± 6% and 65% ± 10%. KM estimated freedom from ARM was 95% ± 3% and 93% ± 5% at the same intervals. Unplanned secondary interventions were needed in 94 patients (38%), including minor procedures in 64 (25%) and major procedures in 30 (12%). There was one conversion to open surgical repair (<1%). KM estimated freedom from any secondary intervention was 44% ± 9% at 5 years. KM estimated primary and secondary TA patency were 93% ± 2% and 96% ± 1% at 5 years, respectively. CONCLUSIONS FB-EVAR for chronic PD-TAAAs was associated with high technical success and a low rate of mortality (3%) and disabling complications at 30 days. Although the procedure is effective in the prevention of ARM, patient survival was low at 5 years (65%), likely due to the significant comorbidities in this cohort of patients. Freedom from secondary interventions at 5 years was 44%, although most procedures were minor. The significant rate of reinterventions highlights the need for continued patient surveillance.
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Affiliation(s)
- Mohamed A Abdelhalim
- Academic Department of Vascular Surgery, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, British Heart Foundation Centre of Research Excellence, London, United Kingdom
| | - Emanuel R Tenorio
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Gustavo S Oderich
- Department of Cardiothoracic and Vascular Surgery, Advanced Aortic Research Program, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX
| | - Stephan Haulon
- Department of Cardiac and Vascular Surgery, Hôpital Marie Lannelongue, GHPSJ, Université Paris Saclay, Paris, France
| | - Gasper Warren
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Donald Adam
- Birmingham Vascular Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Martin Claridge
- Birmingham Vascular Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Talha Butt
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Said Abisi
- Department of Vascular Surgery, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Nuno V Dias
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Eppendorf, Hamburg, Germany
| | - Enrico Gallitto
- Metropolitan Unit of Vascular Surgery, IRCCS S. Orsola Hospital, Bologna, Italy
| | - Mauro Gargiulo
- Metropolitan Unit of Vascular Surgery, IRCCS S. Orsola Hospital, Bologna, Italy
| | - Panos Gkoutzios
- Department of Interventional Radiology, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center Hamburg, University Medical Center Eppendorf, Hamburg, Germany
| | - Marek Kuzniar
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Barend M Mees
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Geert W Schurink
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Björn Sonesson
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Paolo Spath
- Metropolitan Unit of Vascular Surgery, IRCCS S. Orsola Hospital, Bologna, Italy
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts, Worcester, MA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Carlos H Timaran
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, TX
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Bijan Modarai
- Academic Department of Vascular Surgery, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, British Heart Foundation Centre of Research Excellence, London, United Kingdom.
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Wang X, Ayakulangara Panickan V, Cai T, Xiong X, Cho K, Cai T, Bourgeois FT. Endovascular Aneurysm Repair Devices as a Use Case for Postmarketing Surveillance of Medical Devices. JAMA Intern Med 2023; 183:1090-1097. [PMID: 37603326 PMCID: PMC10442779 DOI: 10.1001/jamainternmed.2023.3562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023]
Abstract
Importance The US Food and Drug Administration (FDA) is building a national postmarketing surveillance system for medical devices, moving to a "total product life cycle" approach whereby more limited premarketing data are balanced with postmarketing surveillance to capture rare adverse events and long-term safety issues. Objective To assess the methodological requirements and feasibility of postmarketing device surveillance using endovascular aneurysm repair devices (EVARs), which have been the subject of safety concerns, using clinical data from a large health care system. Design, Setting, and Participants This retrospective cohort study included patients with electronic health record (EHR) data in the Veterans Affairs Corporate Data Warehouse. Exposure Implantation of an AFX Endovascular AAA System (AFX) device (any of 3 iterations) or a non-AFX comparator EVAR device from January 1, 2011, to December 21, 2021. Main Outcomes and Measures The primary outcomes were rates of type III endoleaks and all-cause mortality; and rates of these outcomes associated with AFX devices compared with non-AFX devices, assessed using Cox proportional hazards regression models and doubly robust causal modeling. Information on type III endoleaks was available only as free-text mentions in clinical notes, while all-cause mortality data could be extracted using structured data. Device-specific information required by the FDA is ascertained using unique device identifiers (UDIs), which include factors such as model numbers, catalog numbers, and manufacturer-specific product codes. The availability of UDIs in EHRs was assessed. Results In total, 13 941 patients (mean [SD] age, 71.8 [7.4] years) received 1 of the devices of interest (AFX with Strata [AFX-S]: 718 patients [5.2%]; AFX with Duraply [AFX-D]: 404 patients [2.9%]; or AFX2: 682 patients [4.9%]), and 12 137 (87.1%) received non-AFX devices. The UDIs were not recorded in the EHR for any patient with an AFX device, and partial UDIs were available for 19 patients (0.1%) with a non-AFX device. This necessitated the development of advanced natural language processing tools to define the cohort of patients for analysis. The study identified a significantly higher risk of type III endoleaks at 5 years among patients receiving any of the AFX device iterations, including the most recent version, AFX2 (11.6%; 95% CI, 8.1%-15.1%) compared with that among patients with non-AFX devices (5.7%; 95% CI, 2.2%-9.2%; absolute risk difference, 5.9%; 95% CI, 2.3%-9.4%). However, there was no significantly higher all-cause mortality for any of the AFX device iterations, including for AFX2 (19.0%; 95% CI, 16.0%-22.0%) compared with non-AFX devices (18.0%; 95% CI, 15.0%-21.0%; absolute risk difference, 1.0%; 95% CI, -2.1% to 4.1%). Conclusions and Relevance The findings of this cohort study suggest that clinical data can be used for the postmarketing device surveillance required by the FDA. The study also highlights ongoing challenges to performing larger-scale surveillance, including lack of consistent use of UDIs and insufficient relevant structured data to efficiently capture certain outcomes of interest.
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Affiliation(s)
- Xuan Wang
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | | | - Tianrun Cai
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Xin Xiong
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kelly Cho
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Population Health and Data Sciences, Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston
| | - Tianxi Cai
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Division of Population Health and Data Sciences, Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston
| | - Florence T. Bourgeois
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Chait J, Gilkey GD, Mendes BC, Ramakrishna H. Complex Endovascular Aortic Reconstruction: An Update. J Cardiothorac Vasc Anesth 2023; 37:2125-2132. [PMID: 37344248 DOI: 10.1053/j.jvca.2023.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Jesse Chait
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - George D Gilkey
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Nocun W, Muscogliati R, Al-Tawil M, Jubouri M, Alsmadi AS, Surkhi AO, Bailey DM, Williams IM, Bashir M. Impact of patient demographics and intraoperative characteristics on abdominal aortic aneurysm sac following endovascular repair. Asian Cardiovasc Thorac Ann 2023; 31:633-643. [PMID: 37264635 DOI: 10.1177/02184923231178704] [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] [Indexed: 06/03/2023]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has become the preferred treatment for abdominal aortic aneurysm (AAA). Its main aim is to seal the perfusion of the aneurysmal sac and, thus, induce sac regression and subsequent aortic remodelling. Aneurysmal sac regression has been linked to the short- and long-term clinical outcomes post-EVAR. It has also been shown to be influenced by endograft device choice, with several of these available commercially. This review summarises and discusses current evidence on the influence of pre- and intraoperative factors on sac regression. Additionally, this review aims to highlight the device-specific variations in sac regression to provide an overall holistic approach to treating AAAs with EVAR. METHODS A comprehensive literature search was conducted using multiple electronic databases to identify and extract relevant data. RESULTS Female sex, >70 mm original sac diameters, higher pre-procedural fibrinogen levels, smoking and low intra-aneurysmal pressure were found to positively impact sac regression. Whereas renal impairment, ischemic heart disease, high intra-aneurysmal pressure and aneurysm neck thrombus negatively influenced sac regression. Patent lumbar arteries, age, statins and hypercholesterolaemia displayed conflicting evidence regarding sac regression. Regarding the EVAR endografts compared, newer generation devices such as the Anaconda mainly showed the most optimal results. CONCLUSION Sac regression following EVAR in AAA is an important prognostic factor for morbidity and mortality. Nevertheless, several pre- and intraoperative factors can have an influence on sac regression. Therefore, it is necessary to take them into account when assessing AAA patients for EVAR to optimise outcomes. The choice of EVAR stent-graft can also affect sac regression, with evidence suggesting that the Fenestrated Anaconda is associated with the most favourable results.
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Affiliation(s)
- Weronika Nocun
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Ayah S Alsmadi
- Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan
| | | | - Damian M Bailey
- Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales, Cardiff, UK
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Takei Y, Tezuka M, Saito S, Ogasawara T, Seki M, Kato T, Kanno Y, Hirota S, Shibasaki I, Fukuda H. A protocol-based treatment for ruptured abdominal aortic aneurysm contributed to improving aorta-related mortality: a retrospective cohort study. BMC Cardiovasc Disord 2023; 23:436. [PMID: 37658328 PMCID: PMC10474727 DOI: 10.1186/s12872-023-03473-8] [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: 05/17/2023] [Accepted: 08/25/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Recent guidelines state that improving the survival rate of patients with ruptured abdominal aortic aneurysm (rAAA) requires a protocol or algorithm for the emergency management of these patients. We aimed to investigate whether introducing a protocol treatment for rAAA improves clinical outcomes compared with the pre-protocol strategy. METHODS At our institution, 92 patients treated for rAAA between June 2008 and August 2022 were retrospectively analyzed. In 2014, the protocol-based treatment was introduced comprising a transfer algorithm to shorten the time to proximal control, use of an endovascular occlusion balloon, strict indications for endovascular aortic aneurysm repair (EVAR) or open surgical repair, and perioperative care, including for abdominal compartment syndrome (ACS). Clinical outcomes were compared between the protocol and pre-protocol group, including operative status, all-cause mortality, and rAAA-related death at 30-day, in-hospital, and 1-year postoperative follow-ups. RESULTS Overall, 52 and 40 patients received the protocol-based and pre-protocol treatments, respectively. EVAR was more frequently performed in the protocol group. The rate of achieving time to proximal control was significantly faster, and the transfusion volume was lower in the protocol group. ACS occurred more frequently in the protocol group with a higher EVAR. No difference was found in all-cause mortality between the two groups. The protocol group exhibited fewer rAAA-related deaths than the pre-protocol group during the following time points: 30 days (9.6% vs. 22.5%), during the hospital stay (11.5% vs. 30.0%), and 1 year (14.5% vs. 31.5%). CONCLUSIONS The protocol-based treatment improved the survival rate of patients with rAAA.
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Affiliation(s)
- Yusuke Takei
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan.
| | - Masahiro Tezuka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Shunsuke Saito
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Takeshi Ogasawara
- Mathematics and Statistics Section, Department of Fundamental Education, Dokkyo Medical University, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Masahiro Seki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Takashi Kato
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Yasuyuki Kanno
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Shotaro Hirota
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Ikuko Shibasaki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Hirotsugu Fukuda
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
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Spinella G, Boschetti GA, Bauckneht M, Raffa S, Marini C, Finotello A, Pane B, Pratesi G, Palombo D, Sambuceti G. Endovascular aortic repair impact on myocardial contractility: A prospective study. Eur J Clin Invest 2023; 53:e14011. [PMID: 37099603 DOI: 10.1111/eci.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/07/2023] [Accepted: 04/24/2023] [Indexed: 04/27/2023]
Abstract
BACKGROUND This study aimed to estimate if the altered sphygmic wave transmission may affect the left ventricular (LV) contractile function in patients undergoing endovascular aortic repair (EVAR). METHODS A prospective single-centre study was carried out on consecutive patients undergoing EVAR for abdominal aortic aneurysm. A preoperative and 6-month single photon emission computed tomography (SPECT) with arterial stiffness measurement were performed to evaluate variations in pressure wave curve and myocardial perfusion parameters. RESULTS From 2018 to 2020 a total of 16 patients were included in the study. Among the parameters evaluated, we found a measurable reduction of the reflected wave transit time from pre- to postoperative period, for both stress (115.13 ± 7.2 ms-111.1 ± 7.0 ms, p = .08) and rest SPECT acquisitions (115.3 ± 6.2 ms-112.2 ± 5.6 ms, p = .1). Unidirectional increase of both LV end-systolic volume (34 ± 9 mL-39 ± 8 mL, p = .02) and end-diastolic volume (85 ± 34 mL-89 ± 29 mL, p = .6) was also observed. Lastly, the ratio between the end-systolic pressure and the end-systolic volume (maximal systolic myocardial stiffness) decreased from 3.6 ± 1.5 mmHg/mL to 2.66 ± .74 mmHg/mL (p = .03). CONCLUSIONS Our data showed that EVAR induced an altered transmission of the sphygmic wave associated with an early LV contractile impairment.
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Affiliation(s)
- Giovanni Spinella
- Vascular and Endovascular Surgery Clinic, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Gian Antonio Boschetti
- Vascular and Endovascular Surgery Clinic, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Matteo Bauckneht
- Nuclear Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Stefano Raffa
- Nuclear Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Cecilia Marini
- Nuclear Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- CNR Institute of Molecular Bioimaging and Physiology (IBFM), Segrate, Italy
| | - Alice Finotello
- Vascular and Endovascular Surgery Clinic, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Bianca Pane
- Vascular and Endovascular Surgery Clinic, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Giovanni Pratesi
- Vascular and Endovascular Surgery Clinic, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Domenico Palombo
- Vascular and Endovascular Surgery Clinic, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Gianmario Sambuceti
- Nuclear Medicine, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Health Sciences, University of Genoa, Genoa, Italy
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Troisi N, Pulli R, Donato GD, Adami D, Bertagna G, Michelagnoli S, Berchiolli R. Early and Midterm Outcomes of Endovascular Aneurysm Repair With Zenith Alpha Abdominal Stent-Graft: Results From a Multicenter Retrospective Tuscany Registry. J Endovasc Ther 2023:15266028231197151. [PMID: 37646124 DOI: 10.1177/15266028231197151] [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: 09/01/2023]
Abstract
PURPOSE Zenith Alpha Abdominal (Cook Medical, Bloomington, IN, USA) is one of the new-generation low-profile stent-grafts with demonstrated satisfactory early and midterm clinical outcomes for endovascular treatment of abdominal aortic aneurysms (AAAs). The aim was to evaluate early and midterm results of this device in the framework of a multicenter regional retrospective registry, with the analysis of morphological factors affecting outcomes, including different limb configurations. MATERIALS AND METHODS Between January 2016 and November 2021, 202 patients with AAA underwent elective endovascular aneurysm repair (EVAR) with implantation of a Zenith Alpha Abdominal in 7 centers. Early (30 day) outcomes in terms of technical and clinical success were assessed. Estimated 5 year outcomes were evaluated in terms of survival, freedom from type I/III endoleak, freedom from surgical conversion, freedom from limb graft occlusion, freedom from any device-related reintervention, and graft infection evaluation by life-table analysis (Kaplan-Meier test). A comparative analysis between different limb configurations (Zenith Spiral Z AAA iliac legs, codes ZISL vs ZSLE) was performed in terms of limb graft occlusion. RESULTS The 30 day technical and clinical success rates were 97.5% and 99.5%, respectively. Median follow-up period was 25.5 months (interquartile range [IQR]: 12-43.25). The 5 year survival rate was 73.6%. The estimated 5 year outcomes in terms of freedom from type I/III endoleak, freedom from surgical conversion, freedom from limb graft occlusion, freedom from any device-related reintervention, and freedom from graft infection were 88.6% (95% CI [confidence interval]: 83.4%-93.1%), 95.8% (95% CI: 92.7%-97.1%), 93.6% (95% CI: 90.2%-96.8%), 87% (95% CI: 83.3%-91.6%), and 97.7% (95% CI: 95.1%-98.9%), respectively. About limb configuration, no differences were found in terms of 5 year freedom from limb graft occlusion (ZSLE 93.4% [95% CI: 89.8%-95.5%] vs ZISL 94.3% [95% CI: 90.1%-95.9%], p=0.342; log-rank 0.903). CONCLUSION Zenith Alpha Abdominal in elective EVAR offered satisfactory early and 5 year outcomes with low complication rates. Limb graft occlusion continued to be an issue. Limb configuration did not affect outcomes. CLINICAL IMPACT The authors describe satisfactory early and 5 year outcomes of Zenith Alpha Abdominal in elective endovascular aortic repair in the framework of a multicenter regional retrospective registry. At 5 years freedom from type I endoleak was 88.6%, and rate of endograft infections and conversions to open repair were very low. in the present study. Hot topic about about Zenith stent-graft still remains the limb graft occlusion with a 30-day overall rate of 2%, and estimated 5-year freedom from limb graft occlusion of 93.6%. Limb graft configuration did not affect limb graft occlusion rate. A standardized protocol including iliac stenting should be adopted to reduce kimb graft occlusion.
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Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Raffaele Pulli
- CardioThoracic and Vascular Surgery, Vascular Surgery, Careggi University Teaching Hospital, University of Florence School of Medicine, Florence, Italy
| | - Gianmarco de Donato
- Department of Medicine, Surgery, and Neuroscience, Vascular Surgery Unit, University of Siena, Siena, Italy
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Stefano Michelagnoli
- Vascular and Endovascular Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | - Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Chen GX, Liu D, Weng C, Chen C, Wan J, Zhao J, Yuan D, Huang B, Wang T. Patent iliolumbar artery increase no risk of type II endoleaks after endovascular abdominal aortic aneurysm: a case-control study. Front Cardiovasc Med 2023; 10:1210248. [PMID: 37636305 PMCID: PMC10455956 DOI: 10.3389/fcvm.2023.1210248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023] Open
Abstract
Objective The aims of the present study were to explore the risk factors for type 2 endoleaks (T2ELs) after endovascular aneurysm repair (EVAR) and the association between T2ELs and the iliolumbar artery. Materials and methods A single-center, retrospective case-control study in West China Hospital was conducted among patients with infrarenal abdominal aortic aneurysm (AAA) who underwent EVAR between June 2010 and June 2019. The associations of patient characteristics, anatomical factors, internal iliac artery embolization, and ILA with the primary outcome were analyzed. The secondary objective was to analyze survival and reintervention between the T2EL group and the non-T2EL group. Kaplan-Meier survival, propensity matching analysis and multivariate logistic regression analysis were used. Results A total of 603 patients were included. The median follow-up was 51 months (range 5.0-106.0). There was a significant difference in the diameter of the lumbar artery (LA), middle sacral artery (MSA) and inferior mesentery artery (IMA), proportion of thrombus and LA numbers. The univariate analysis showed that T2ELs were more likely to develop more thrombus in aneurysm cavity (OR = 0.294, p = 0.012), larger MSA (OR = 1.284, p = 0.04), LA (OR = 1.520, p = 0.015), IMA (OR = 1.056, p < 0.001) and more LAs (OR = 1.390, p = 0.019). The multivariate analysis showed that the number of LAs (HR: 1.349, 95% CI: 1.140-1.595, p < .001) and the diameter of the IMA (HR: 1.328, 95% CI: 1.078-1.636, p = 0.008) were significantly associated with T2ELs. There were no new findings from the propensity score matching. The reintervention-free survival rates were significantly different between the two groups (p = 0.048). Overall survival and AAA-related death rates were not different between the two group. This was consistent with the PSM analysis. Conclusion The iliolumbar artery and the different internal iliac artery interventions may not increase the incidence of T2ELs. But the numbers of LAs and IMA diameter were independent risk factors for T2Els. T2ELs was associated with the reintervention but did not affect long-term survival or increase aneurysm-related mortality after EVAR.
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Affiliation(s)
- Guo Xin Chen
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Dan Liu
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
| | - Chengxin Weng
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chuwen Chen
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jianghong Wan
- Department of Outpatient, West China Hospital, Sichuan University, Chengdu, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tiehao Wang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
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Mansoor SM, Rabben T, Hisdal J, Jørgensen JJ. Eleven-Year Outcomes of a Screening Project for Abdominal Aortic Aneurysm (AAA) in 65-Year-Old Men. Vasc Health Risk Manag 2023; 19:459-467. [PMID: 37485231 PMCID: PMC10361273 DOI: 10.2147/vhrm.s412954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/13/2023] [Indexed: 07/25/2023] Open
Abstract
Objective Since 2011, the Department of Vascular Surgery at Oslo University Hospital has offered screening for abdominal aortic aneurysm (AAA) to 65-year-old men living in Oslo, Norway. The aim of this study was to evaluate the effect of the screening project on AAA-related mortality and rupture and repair rates in the screened population. Methods This cohort study included men that participated in AAA screening at the Department of Vascular Surgery at Oslo University Hospital in the period May 2011 to September 2019. All men with screen-detected AAA (aortic diameter ≥30 mm) and subaneurysmal aortic dilatation (aortic diameter 25-29 mm) were included. A stratified (1:1 with the subaneurysm group), randomized selection of men with normal aortic diameter (<25 mm) upon screening was also included. The follow-up data on events (ruptures, repairs, and deaths) after screening were collected retrospectively from patient electronic medical records at Oslo University Hospital, the National Population Register and the Norwegian Cause of Death Registry (CoDR). Results In total, 2048 men were included, with a median follow-up time of 7.1 years (IQR 3.8). Among men with screen-detected AAA, 0.6% died of AAA-related causes (0.9 AAA-related deaths per 1000 person-years). The rupture rate was 0.3% among men with screen-detected AAA or subaneurysmal aortic dilatation, giving an incidence of 0.5 ruptures per 1000 person-years. The overall repair rate in the AAA group was 20.6% (36.1 repairs per 1000 person-years) and 0.6% (0.9 repairs per 1000 person-years) in the subaneurysm group. Conclusion In a population screened for AAA, the incidence of rupture and the AAA-related mortality was very low. Almost one-fifth of the participants with screen-detected AAA underwent elective repair, representing a group that might have presented with rupture if untreated. These results indicate that screening is valuable in preventing AAA rupture and AAA-related mortality.
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Affiliation(s)
- Saira Mauland Mansoor
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Toril Rabben
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jørgen Joakim Jørgensen
- Department of Vascular Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Traumatology, Oslo University Hospital, Oslo, Norway
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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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Mesnard T, Dubosq M, Pruvot L, Azzaoui R, Patterson BO, Sobocinski J. Benefits of Prehabilitation before Complex Aortic Surgery. J Clin Med 2023; 12:jcm12113691. [PMID: 37297886 DOI: 10.3390/jcm12113691] [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: 03/26/2023] [Revised: 05/14/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
The purpose of this narrative review was to detail and discuss the underlying principles and benefits of preoperative interventions addressing risk factors for perioperative adverse events in open aortic surgery (OAS). The term "complex aortic disease" encompasses juxta/pararenal aortic and thoraco-abdominal aneurysms, chronic aortic dissection and occlusive aorto-iliac pathology. Although endovascular surgery has been increasingly favored, OAS remains a durable option, but by necessity involves extensive surgical approaches and aortic cross-clamping and requires a trained multidisciplinary team. The physiological stress of OAS in a fragile and comorbid patient group mandates thoughtful preoperative risk assessment and the implementation of measures dedicated to improving outcomes. Cardiac and pulmonary complications are one of the most frequent adverse events following major OAS and their incidences are correlated to the patient's functional status and previous comorbidities. Prehabilitation should be considered in patients with risk factors for pulmonary complications including advanced age, previous chronic obstructive pulmonary disease, and congestive heart failure with the aid of pulmonary function tests. It should also be combined with other measures to improve postoperative course and be included in the more general concept of enhanced recovery after surgery (ERAS). Although the current level of evidence regarding the effectiveness of ERAS in the setting of OAS remains low, an increasing body of literature has promoted its implementation in other specialties. Consequently, vascular teams should commit to improving the current evidence through studies to make ERAS the standard of care for OAS.
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Affiliation(s)
- Thomas Mesnard
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
- Univ. Lille, INSERM U1008-Advanced Drug Delivery Systems and Biomaterials, 59000 Lille, France
| | - Maxime Dubosq
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Louis Pruvot
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Richard Azzaoui
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Benjamin O Patterson
- Department of Vascular Surgery, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Jonathan Sobocinski
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
- Univ. Lille, INSERM U1008-Advanced Drug Delivery Systems and Biomaterials, 59000 Lille, France
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Veličković VM, Carradice D, Boyle JR, Hamady M, Cleveland T, Neequaye S, Ignjatović A, Bogdanović D, Savovic J, Siebert U. Umbrella review and meta-analysis of reconstructed individual patient data of mortality following conventional endovascular and open surgical repair of infrarenal abdominal aortic aneurysm. Expert Rev Cardiovasc Ther 2023; 21:347-356. [PMID: 37128666 DOI: 10.1080/14779072.2023.2207009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES This umbrella review aims to quality assess published meta-analyses, conduct a de-novo meta-analysis of the available randomized control trials (RCTs), and test the hypothesis that there is a long-term difference in mortality between OSR and EVAR. METHODS A systematic search was conducted in MEDLINE and EMBASE's bibliographic databases (June 2022). Data were extracted using standardized extraction forms. The methodological quality of publications was assessed using the ROBIS tool. Data were analyzed with 'one-stage' and 'two-stage' approaches. RESULTS According to two-stage analysis, EVAR has significantly favorable mortality for up to four years (increasing evidence). Subsequently, until the longest available time period, there is no difference between EVAR and OSR; all the results are statistically non-significant.In one stage analysis, the Cox model demonstrated a non-significant (weak evidence) hazard ratio of 1.03 (95% confidence interval [CI]: 0.94-1.12) in favor of OSR. The best-fitting parametric model (generalized gamma), leads to an hazard ratio of 0.97 (95% CI: 0.93-1.01) in favor of EVAR, with the results approaching significance (weak evidence). CONCLUSION The results of this umbrella systematic review and meta-analysis failed to demonstrate any difference in long-term mortality following planned EVAR, compared with OSR of infrarenal AAA.
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Affiliation(s)
- Vladica M Veličković
- Evidence Synthesis Department, Biomath Models, London, UK
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL, University for Health Sciences and Technology, Hall i.T, Austria
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School & Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, UK
| | - Mohamad Hamady
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Trevor Cleveland
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Neequaye
- Department of Interventional Radiology, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Aleksandra Ignjatović
- Evidence Synthesis Department, Biomath Models, London, UK
- Faculty of Medicine, University of Niš, Niš, Serbia
| | | | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- and Weston NHS Foundation Trust, NIHR Applied Research Collaboration West (ARC West) at University Hospitals Bristol, Bristol, UK
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL, University for Health Sciences and Technology, Hall i.T, Austria
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
- Center for Health Decision Science, Departments of Epidemiology and Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Gennai S, Leone N, Andreoli F, Migliari M, Silingardi R. Anatomical Feasibility of an Off-the-shelf Single-Renal Scalloped Stent-Graft for Hostile Neck Abdominal Aortic Aneurysm: A Preclinical Study. J Endovasc Ther 2023:15266028231169164. [PMID: 37096777 DOI: 10.1177/15266028231169164] [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: 04/26/2023]
Abstract
OBJECTIVES To evaluate the feasibility of a standardized single-renal scallop stent-graft. DESIGN Preclinical, single-center, real-world, all-comers, retrospective cohort study. METHODS A total of 1347 abdominal aortic aneurysm (AAA) repairs (endovascular and open) performed between 2010 and 2020 were screened for elective treatment and retrievable preoperative high-quality computed tomography angiography (CTA) performed <6 months of the surgical procedure. Six hundred of the included CTAs involved prespecified measurements and a morphological assessment protocol (NCT05150873). The proximal sealing zones suitable for standard stent-graft implantations were further analyzed (N=547). The primary outcome assessed the feasibility of 2 single-renal scallop designs (10×10 mm and 15×10 mm, height × width). The feasibility was the inter-renal length ≥10 mm and ≥15 mm for prototypes #10 and #15, respectively. The secondary outcome quantified hypothetical length and surface improvements comparing those suitable for investigational devices implantation (study group) versus those not (control group). RESULTS Of the total, 24.7% (n=135) was feasible with prototype #10. The study versus control group sealing zones were shorter (p=0.008), with a smaller surface (p=0.009) and a higher alpha angle (p=0.039). The length and surface area increased by about 25% and 23%, respectively, (both p<0.001) within the study group and became significantly better versus the control group (standard stent-graft; both p<0.001). Of the total, 7.1% (n=39) was suitable for prototype #15. The study versus control group sealing zones were shorter (p=0.148), with a smaller surface (p=0.077) and a higher alpha angle (p=0.027). The length and surface area increased by about 34% and 31%, respectively, (both p<0.001) within the study group and became significantly higher versus the control group (standard stent-graft; both p<0.001). CONCLUSIONS The use of single-renal scalloped stent-graft might be feasible in a considerable number of AAA patients. The breakthrough stands in treating hostile AAAs presenting in mismatched renal arteries, keeping the complexity of the repair as similar as possible to standard endovascular repair with a remarkable improvement in sealing. CLINICAL IMPACT The anatomic feasibility of a single renal stent graft for the treatment of "hostile" abdominal aortic aneurysm (AAA) with mismatched renal arteries was evaluated. The experimental device could be feasible in a considerable number of patients with AAA, approaching 25%, and demonstrate significant improvements in sealing. As far as we know, this is the first paper to report the prevalence of mismatched renal arteries in a large cohort of AAA patients in the real world, while proposing a dedicated device. The breakthrough is to keep the complexity of the repair as close as possible to standard endovascular repair.
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Affiliation(s)
- Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Andreoli
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Mattia Migliari
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Garland SK, Falster MO, Beiles CB, Freeman AJ, Jorm LR, Sedrakyan A, Sotade O, Varcoe RL. Long-Term Outcomes Following Elective Repair of Intact Abdominal Aortic Aneurysms: A Comparison Between Open Surgical and Endovascular Repair Using Linked Administrative and Clinical Registry Data. Ann Surg 2023; 277:e955-e962. [PMID: 35129507 DOI: 10.1097/sla.0000000000005259] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Compare long-term mortality, secondary intervention and secondary rupture following elective endovascular aneurysm repair (EVAR) and open surgical repair (OSR). BACKGROUND EVAR has surpassed OSR as the most common procedure used to repair abdominal aortic aneurysm (AAA), but evidence regarding long-term outcomes is inconclusive. METHODS We included patients in linked clinical registry and administrative data undergoing EVAR or OSR for intact AAA between January 2010 and June 2019. We used an inverse probability of treatment-weighted survival analysis to compare all-cause mortality, cause-specific mortality, secondary interventions and secondary rupture, and evaluate the impact of secondary interventions and secondary rupture on all-cause mortality. RESULTS The study included 3460 EVAR and 427 OSR patients. Compared to OSR, the EVAR all-cause mortality rate was lower in the first 30 days [adjusted hazard ratio (HR) = 0.22, 95% confidence interval (CI) 0.140.33], but higher between 1 and 4 years (HR = 1.29, 95% CI 1.12-1.48) and after 4years (HR = 1.41, 95% CI 1.23-1.63). Secondary intervention rates were higher over the first 30 days (HR = 2.26, 95% CI 1.11-4.59), but lower between 1 and 4years (HR = 0.59, 95% CI 0.48-0.74). Secondary aortic intervention rates were higher across the entire follow-up period (HR = 2.52, 95% CI 2.06-3.07). Secondary rupture rates did not differ significantly (HR = 1.06, 95% CI 0.73-1.55). All-cause mortality beyond 1 year remained significantly higher for EVAR after adjusting for any secondary interventions, or secendary rupture. CONCLUSIONS EVAR has an early survival benefit compared to OSR. However, elevated long-term mortality and higher rates of secondary aortic interventions and subsequent aneurysm repair suggest that EVAR may be a less durable method of aortic aneurysm exclusion.
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Affiliation(s)
- Sarah K Garland
- Center for Big Data Research in Health, UNSW Sydney, Australia
- Biostatistics Training Program, NSW Ministry of Health, Sydney, Australia
| | | | | | | | - Louisa R Jorm
- Center for Big Data Research in Health, UNSW Sydney, Australia
| | - Art Sedrakyan
- Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | | | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital
- Faculty of Medicine, University of New South Wales
- The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
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