Trends in Treatment of Ruptured Abdominal Aortic Aneurysm: Impact of Endovascular Repair and Implications for Future Care

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term Mortality and Reintervention After Repair of Ruptured Abdominal Aortic Aneurysms Using VQI-matched Medicare Claims

OBJECTIVE

The objective of this study was to compare endovascular aortic aneurysm repair (EVAR) versus open aortic repair (OAR) on mortality and reintervention after ruptured infrarenal abdominal aortic aneurysm (rAAA) repair in the Vascular Quality Initiative (VQI).

BACKGROUND

The optimal treatment modality for rAAA remains debated, with little data on long-term comparisons.

METHODS

VQI rAAA repairs (2004-2018) were matched with Medicare claims (VQI-VISION). Primary outcomes were in-hospital and long-term mortality. Secondary outcome was reintervention. Inverse probability weighting was used to adjust for treatment selection, and Cox Proportional Hazards models and negative binomial regressions were used for analysis. Landmark analysis was performed among patients surviving hospital discharge.

RESULTS

Among 1885 VQI/Medicare rAAA patients, 790 underwent OAR, and 1095 underwent EVAR. Median age was 76 years; 73% were male. Inverse probability weighting produced comparable groups. In-hospital mortality was lower after EVAR versus OAR (21% vs 37%, odds ratio: 0.52, 95% CI, 0.4-0.7). One-year mortality rates were lower for EVAR versus OAR [hazard ratio (HR) 0.74, 95% CI, 0.6-0.9], but not statistically different after 1 year (HR: 0.95, 95% CI, 0.8-1.2). This implies additional benefits to EVAR in the short term. Reintervention rates were higher after EVAR than OAR at 2 and 5 years (rate ratio: 1.79 95% CI, 1.2-2.7 and rate ratio:2.03 95% CI, 1.4-3.0), but not within the first year. Reintervention was associated with higher mortality risk for both OAR (HR: 1.66 95% CI, 1.1-2.5) and EVAR (HR: 2.14 95% CI, 1.6-2.9). Long-term mortality was similar between repair types (HR: 0.99, 95% CI, 0.8-1.2).

CONCLUSIONS

Within VQI/Medicare patients undergoing rAAA repair, the perioperative mortality rate favors EVAR but equalizes after 1 year. Reinterventions were more common after EVAR and were associated with higher mortality regardless of treatment.

Infrarenal Abdominal Aortic Aneurysm

Abdominal aortic aneurysms are found in up to 6% of men and 1.7% of women over the age of 65 years and are usually asymptomatic. The natural history of aortic aneurysms is continued dilation leading to rupture, which is associated with an overall 80% mortality. Of the patients with ruptured aneurysms that undergo intervention, half will not survive their hospitalization. Reduction in aneurysm mortality is therefore achieved by prophylactic repair during the asymptomatic period. On a population-based level, this is supported by abdominal aortic aneurysm screening programs. Approximately 60% of abdominal aortic aneurysms are confined to the infrarenal portion of the aorta and are amenable to repair with off-the-shelf endovascular devices. Endovascular techniques have now replaced open surgery as the primary modality for aneurysm repair.

Inter-Hospital Transfer of Patients With Ruptured Abdominal Aortic Aneurysm in Switzerland

OBJECTIVE

To analyse the association between inter-hospital transfer and hospital mortality in patients with ruptured abdominal aortic aneurysms (rAAA) in Switzerland.

METHODS

Secondary data analysis of case related hospital discharge data from the Swiss Federal Statistical Office for the years 2009 - 2018. All cases with rAAA as primary or secondary diagnosis were included. Cases with rAAA as a secondary diagnosis without surgical treatment and cases that had been transferred to another hospital without surgical treatment at the referring hospital were excluded. Logistic regression models for hospital mortality were constructed with age, sex, type of admission, van Walraven comorbidity score, type of treatment, insurance class, hospital level, and year of treatment as independent variables.

RESULTS

A total of 1 798 cases with rAAA were treated either surgically (62.5%) or palliatively (37.5%) in Switzerland from 1 January 2009 to 31 December 2018. Of these cases, 72.9% were treated directly (surgically or palliatively) at the hospital of first presentation, whereas 27.1% of all cases with rAAA were transferred between hospitals. The overall crude hospital mortality was 50.3%; being 23.1% in the surgically treated cohort and 95.7% in the palliatively treated cohort. Inter-hospital transfer was associated with better survival compared with patients who were admitted directly (OR 0.52; 95% CI 0.36 - 0.75; p < .001). Treatment in major hospitals was associated with significantly higher mortality rate compared with university hospitals (OR 1.98; 1.41 - 2.79; p < .001). There was no evidence of an association between open repair and hospital mortality (OR 1.06; 0.77 - 1.48; p = .72) compared with endovascular repair.

CONCLUSION

In a healthcare system such as Switzerland's with a highly specialised rescue chain, transfer of haemodynamically stable patients with rAAA is probably safe. In this setting, centralised medical care might outweigh the potential disadvantages of a short delay due to patient transfer. Further studies are needed to address potential confounding factors such as haemodynamic and anatomical features.

Long-term Survival After Repair of Ruptured Abdominal Aortic Aneurysms Is Improving Over Time: Nationwide Analysis During Twenty-four Years in Sweden (1994-2017)

OBJECTIVE

To investigate long-term survival after ruptured abdominal aortic aneurysms (rAAA) repair in Sweden during twenty-four years (1994-2017).

SUMMARY BACKGROUND DATA

Management of rAAA has seen significant changes in the past decades, with the shifting from open (OAR) to endovascular (EVAR) being the most striking, thereby enabling treatment of elderly patients with multiple comorbidities.

METHODS

A registry-based nationwide cohort study was performed, and three 8-year periods (1994-2001, 2002-2009, 2010-2017) were compared for crude long-term survival with Kaplan-Meier and multivariable Cox proportional hazards analyses. Relative survival compared to matched general population referents was estimated.

RESULTS

Overall, 8928 rAAA repair subjects were identified (1994-2001 N = 3368; 2002-2009 N = 3405; 2010-2017 N = 2155). The proportion of octogenarians (20.6%; 27.5%; 34.0%; P < 0.001), women (14.3%; 18.5%; 20.6%; P < 0.001), and EVAR procedures (1.5%; 14.9%; 35.5%; P < 0.001) increased over time. The crude 5-year survival was 36%; 44%; 43% (P < 0.0001). Multivariable Cox proportional hazard analysis displayed a decreasing mortality hazard ratio (HR) over time (1.00; 0.80; 0.72; P < 0.001). Use of EVAR was associated with reduced hazards of crude long-term mortality (HR = 0.80, P < 0.001). Relative survival for patients surviving the perioperative period (ie, 90 days) was lower than matched general population referents, and was stable over time (relative 5-year survival: 86% vs 88%, vs 86% P < 0.001).

CONCLUSIONS

Nationwide analysis of long-term outcomes after repair of rAAA in Sweden during 24 years (1994-2017) has revealed that, despite changes in the baseline population characteristics as well as in the treatment strategy, long-term survival improved over time.

Iliac Branch Devices in the Repair of Ruptured Aorto-iliac Aneurysms: A Multicenter Study

PURPOSE

To evaluate the outcomes of preserving the internal iliac artery (IIA) with iliac branched devices (IBDs) during acute endovascular repair of ruptured aortoiliac aneurysms.

MATERIAL AND METHODS

This is a multicenter retrospective review of all consecutive patients undergoing acute endovascular repair of ruptured aortoiliac aneurysm with an IBD at 8 aortic centers between December 2012 and June 2020. A control group was used where the IIA was intentionally occluded from the same study period. The main outcome measures were 30-day mortality, major adverse events, technical success, and clinical success. Secondary outcomes were buttock claudication, primary patency, primary-assisted and secondary patency of the IBD, occurrence of endoleak types I/III, and reintervention. Values are presented as numbers and percentages or interquartile range in parenthesis.

RESULTS

Forty-eight patients were included in the study: 24 with IBD and 24 with IIA occlusion. There was no difference in demographics, cardiovascular risk factors, and aneurysm extent. Twenty (83%) of them were hemodynamically stable during the procedure as opposed to 14 (58%, p=.23) with the IIA occlusion. Technical success was achieved in all cases with a procedure time of 180 (133-254) minutes, 45 (23-65) of which were from IBD. There were 2 (8%) deaths during the first 30 days and 2 (8%) major complications unrelated to the IBD, whereas in the IIA occlusion, the figures were 10 (42%) and 7 (29%), respectively. No patient in the IBD group developed buttock claudication compared to 8 (57%, p<.0001) in the IIA occlusion group; 1 (4%) patient developed bowel ischemia on both groups, with 1 in the IIA occlusion group needing resection. The median follow-up duration was 17 months (interquartile range 2-39) for the IBD group, with a primary patency of 60±14% at 3 years that went up to 92±8% with reinterventions (8 reinterventions in 6 patients). When the first 90 days were disregarded, there were no differences in survival between the groups.

CONCLUSION

IBD is a valid alternative for maintaining the pelvic circulation for endovascular aortic aneurysm repair of ruptured aortoiliac aneurysms. The technical success and midterm outcomes are very satisfactory but require patient selection particularly regarding hemodynamic stability. The reintervention rate is considerable, mandating continuous follow-up.

CLINICAL IMPACT

This multicenter study demonstrates that ruptured aortoiliac aneurysms do not necessarily require mandatory occlusion of hypogastric arteries. Iliac branch devices are shown to be a valid alternative in highly selected cases, with good midterm results, even if reinterventions are required in a significant proportion of patients.

Identification of Risk Factors and Development of Predictive Risk Score Model for Mortality after Open Ruptured Abdominal Aortic Aneurysm Repair

Background and Objectives: Despite the relatively large number of publications concerning the validation of these models, there is currently no solid evidence that they can be used with absolute precision to predict survival. The goal of this study is to identify preoperative factors that influenced 30-day mortality and to create a predictive model after open ruptured abdominal aortic aneurysm (RAAA) repair. Materials and Methods: This was a retrospective single-center cohort study derived from a prospective collected database, between 1 January 2009 and 2016. Multivariate logistic regression analysis was used to identify all significant predictive factors. Variables that were identified in the multivariate analysis were dichotomized at standard levels, and logistic regression was used for the analysis. To ensure that dichotomized variables were not overly simplistic, the C statistic was evaluated for both dichotomized and continuous models. Results: There were 500 patients with complete medical data included in the analysis during the study period. Of them, 37.6% were older than 74 years, and 83.8% were males. Multivariable logistic regression showed five variables that were predictive of mortality: age > 74 years (OR = 4.01, 95%CI 2.43−6.26), loss of consciousness (OR = 2.21, 95%CI 1.11−4.40), previous myocardial infarction (OR = 2.35, 95%CI 1.19−4.63), development of ventricular arrhythmia (OR = 4.54, 95%CI 1.75−11.78), and DAP < 60 mmHg (OR = 2.32, 95%CI 1.17−4.62). Assigning 1 point for each variable, patients were stratified according to the preoperative RAAA mortality risk score (range 0−5). Patients with 1 point suffered 15.3% mortality and 3 points 68.2% mortality, while all patients with 5 points died. Conclusions: This preoperative RAAA score identified risk factors readily assessed at the bedside and provides an accurate prediction of 30-day mortality after open repair of RAAA.

Derivation and Validation of a Risk Score for Abdominal Compartment Syndrome after Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms

BACKGROUND

Abdominal compartment syndrome (ACoS) is a devastating complication after endovascular aneurysm repair for ruptured abdominal aortic aneurysms (rEVAR). This study sought to develop a risk score for ACoS to identify patients who would benefit from early decompressive laparotomy.

METHODS

Model derivation was performed with VQI data for rEVAR from 2013-2020. The primary outcome was evacuation of abdominal hematoma. Multivariable logistic regression was used to create and validate a scoring system to predict ACoS. The model was validated using institutional data for rEVAR from 1998-2019.

RESULTS

The derivation cohort included 2,310 patients with rEVAR. Abdominal hematoma evacuation occurred in 265 patients (11.5%). Factors associated with abdominal hematoma evacuation on multivariable analysis included transfer from an outside hospital, preoperative creatinine ≥1.4 mg/dl, preoperative systolic blood pressure ≤85 mmHg, preoperative altered mental status, ≥3.0 liters intraoperative crystalloid, and ≥4 units of red blood cells transfused intraoperatively. The validation cohort consisted of 67 rEVAR; ACoS occurred in 8 patients (11.9%). The c-statistic was 0.84 in the derivation and 0.87 in the validation cohort, while Hosmer-Lemeshow was p= 0.15 in the derivation and 0.84 in the validation cohorts, suggesting good model discrimination and calibration. Points were applied based on β-coefficients to produce a risk score ranging from -1 to 13. A cutoff of risk score ≥8 resulted in a sensitivity and specificity of 87.5% and 83.1% for detecting patients with ACoS, respectively. ACoS conveyed a significantly higher mortality in both the derivation (ACoS: 49.8% vs No ACoS: 17.8%; p<0.001) and validation cohorts (ACoS: 75.0% vs No ACoS: 15.2%; p<0.001).

CONCLUSION

In patients with equivocal signs/symptoms of ACoS, this scoring system can be used to guide surgeons on when to perform decompressive laparotomy prior to leaving the operating room for rEVAR. Patients with a risk score ≥8 would benefit from decompressive laparotomy at index rEVAR.

Epidemiology of Abdominal Aortic Aneurysm Repair in Brazil from 2008 to 2019 and Comprehensive Review of Nationwide Statistics Across the World

INTRODUCTION

Studying epidemiology of abdominal aortic aneurysms repairs is essential to prevent related deaths. Although outcomes are influenced by socioeconomic factors, there are no nationwide studies on these statistics in low-and-middle income countries. Therefore, we designed this study to evaluate abdominal aortic aneurysms repair rates, trends, costs, and in-hospital mortality in the Brazilian Public Health System, which exclusively insures over 160 million Brazilians.

MATERIAL AND METHODS

Retrospective cross-sectional population-based analysis of publicly available data referring to all abdominal aortic aneurysm repairs performed between 2008 and 2019 in Brazilian public hospitals.

RESULTS

We observed a total of 13,506 abdominal aortic aneurysm repairs, of which 32% were emergency endovascular repairs, 20% emergency open repairs, 32% elective endovascular repairs and 16% elective open repairs. There has been a downward trend in total abdominal aortic aneurysms repairs and an increasing predominance of endovascular repair. Elective and endovascular repairs were significantly associated with lower in-hospital mortality. For ruptured abdominal aortic aneurysms, we observed mortality rates of 13.8% after endovascular repair and 52.1% after open repair. For intact abdominal aortic aneurysms, we observed mortalities of 3.8% after endovascular repair and 18.6% after open repair. Procedure and mortality rates varied significantly among the Brazilian regions.

CONCLUSIONS

We observed a low and decreasing rate of abdominal aortic aneurysm repair. Most repairs were emergency and endovascular and there was an increasing predominance of endovascular repair. Endovascular and elective repairs were associated with lower mortality.

Helicopter emergency medical service for time critical interfacility transfers of patients with cardiovascular emergencies

Background

The goal of improving quality through centralisation of specialised medical services must be balanced against potential harm caused by delayed access to emergency treatments in rural areas. This study aims to assess the duration of transfers of critically ill patients with cardiovascular emergencies from smaller hospitals to major medical centres by a helicopter emergency medical service (HEMS) in Switzerland.

Methods

This retrospective observational cohort study includes all consecutive emergency interfacility transfers (IFTs) conducted by Switzerland’s largest HEMS provider between July 3rd, 2019, and March 31st, 2021. All patients with acute myocardial infarction, non-traumatic strokes, ruptured aortic aneurysms, and other acute vascular emergencies were included. The duration and distance of each HEMS IFT were compared to calculated distances and duration of travel for the same missions using ground-based transportation (GEMS). The ground-based mission distance beyond which the total mission duration of HEMS is expected to be faster than GEMS was calculated.

Findings

A total of 645 patients were transferred for stroke (n = 364), myocardial infarction (n = 252) and other acute vascular emergencies (n = 29). The median total mission duration from emergency call to landing at the destination was 59.9 (IQR 51.5 to 70.5) minutes. The median road distance for the same missions was 60 (IQR 43 to 72) km. Regression analysis revealed that HEMS is expected to be faster if the road distance is more than 51.3 km.

Interpretation

Centralisation of specialised medical services should be accompanied by a comprehensive and specialised rescue chain. HEMS in Switzerland ensures time-sensitive IFT in medical emergencies, even in topographically challenging terrain.

Graphical Abstract

Outcomes and predictors of mortality in a Belgian population of patients admitted with ruptured abdominal aortic aneurysm and treated by open repair in the contemporary era

BACKGROUND

Abdominal aortic aneurysm (AAA) rupture is a serious condition that results in extremely high mortality rates. Some improvements in outcome have been reported during the last 2 decades. The objective of the present study was to determine the overall and operative (by open repair) mortality related to ruptured AAA in the contemporary era and to identify preoperative, intraoperative, and early postoperative parameters associated with poor outcomes.

METHODS

We performed a retrospective review of all consecutive patients admitted to our single institution with a diagnosis of ruptured AAA between 2004 and 2013. A total of 103 parameters, including demographic characteristics, medical history, clinical and biological parameters, cardiovascular risk factors, emergency level, diagnostic modalities, time from symptoms to diagnosis and treatment, type of operative procedure and postoperative complications, were analyzed. The primary endpoint considered in this study was the cumulative incidence rate of mortality. The secondary endpoint was the identification, by logistic regression methods, of risk factors for overall mortality as well as for operative, and postoperative mortality.

RESULTS

Within our study period, 104 patients were admitted for a ruptured AAA. The majority of patients (84.6%) were male, and the AAA was known in 34.6% of the patients. Rupture occurred for a maximal diameter lower than 55 mm in 25% of the female population, compared to 5.7% of the male population (P = 0.030). The proportions of admitted patients who died before (preoperative mortality), during (intraoperative mortality) or after (postoperative hospital mortality) surgery was 17.3%, 16.3%, and 18.3%, respectively, yielding a cumulative in-hospital mortality of 51.9%. In the multivariate analysis, age ≥ 80 (P = 0.001), myocardial ischemia on the admission ECG (P = 0.046), and management by the physician response unit (P = 0.002) were the only preoperative parameters associated with a higher risk of hospital mortality. Four risk factors were found to be associated with a higher risk of postoperative mortality in the multivariate analysis, and all patients presenting with 3 or more of these risk factors (n = 5) died.

CONCLUSIONS

The overall mortality of ruptured AAA in a contemporary cohort of patients who underwent open repair remains high and does not seem to have decreased during recent decades. Ruptures occur at smaller diameters in women than in men, supporting a lower threshold for intervention in women with known AAA. We developed risk scores to predict the mortality of patients with rAAA at different times of their hospital course. The validity of these scores should be assessed in prospective clinical studies.

The role of surgical and total endovascular techniques in the treatment of ruptured juxtarenal aortic aneurysms

Background: Ruptured juxtarenal aortic aneurysms (RJAAA) represent a special challenge in clinical practice, but the evidence to guide therapeutic decision-making is scarce. The aim of this study was to present two different approaches, open surgical (OAR) and chimney endovascular repair (CHEVAR), for treating patients with RJAAA. Patients and methods: This retrospective two-center study included all patients per center undergoing OAR or CHEVAR for RJAAA between February 2008 and January 2020. Juxtarenal aortic aneurysms were defined as having an infrarenal neck of 2-5 mm, measured after three-dimensional reconstruction of the computed tomography angiography scan. Results: 12 OAR patients (10 male, median age 73 years [58-90 years]) and 6 CHEVAR patients (all male, median age 74 years [59-83 years]) were included. In the OAR group, the proximal aortic clamping was suprarenal in 7 and interrenal in 5 patients. Cold renal perfusion was used in 4 patients, in 2 with suprarenal aortic clamping and in 2 with interrenal aortic clamping. 3 CHEVAR patients received a single renal chimney, the other 3 received double renal chimneys. Technical success was 12/12 in the OAR group 5/6 in the CHEVAR group. In-hospital mortality and 30-day mortality were 3/12 after OAR and 0/6 after CHEVAR. 2 OAR patients required transient dialysis. Median in-hospital stay was 14 (10-63) and 8 (6-21) days and median follow-up (FU) was 20 (3-37) and 30 (7-101) months, respectively. No further deaths occurred during FU. One OAR patient and 4 CHEVAR patients required aortic reinterventions. Conclusions: RJAAAs are rare. Both OAR and CHEVAR can represent adequate treatments for RJAAAs. OAR is the traditional approach, but CHEVAR has - in a high-volume center - promising early results with nonetheless a need for continuous FU to prevent reinterventions. Defining the studied aortic pathology precisely is essential for future research in order to draw valid conclusions.

Survival and Living Situation After Ruptured Abdominal Aneurysm Repair in Octogenarians

OBJECTIVE

To determine the 30 day and one year mortality and post-operative living situation in octogenarians treated for ruptured abdominal aortic aneurysm (rAAA).

METHODS

A retrospective study was performed at four centres in the Netherlands. All consecutive patients aged ≥80 years, presenting with a rAAA between January 2013 and October 2018, were included. The primary outcomes were post-operative living situation and one year mortality.

RESULTS

In total, 157 patients were included. Forty-seven received palliative care and 110 patients had surgery. After endovascular or open repair, the one year mortality rate was 50.0%. The 30 day mortality rate was 40.8% (95% confidence interval [CI] 27-55) and 31.7% (95% CI 20-44), for endovascular and open repair, respectively (p = .32). Sixty-five per cent of survivors were discharged home, while 34.8% went to a nursing home for rehabilitation. Of the surviving patients, 82.6% went back to living in their pre-rupture home situation. Of the investigated variables, only a high body mass index proved a significant predictor of death at 30 days and one year. Compared with operated patients, patients turned down for surgery were older (mean age 87.5 ± 3.8 vs. 84.0 ± 3.5; p < .001), lived significantly more often in a nursing home (odds ratio 1.02, 95% CI 1.00-1.03; p < .001), were more often dependent (odds ratio 3.69, 95% CI 2.31-5.88; p < .001) and had a lower Glasgow Coma Scale score on arrival (odds ratio 0.42, 95% CI 0.25-0.69; p = .002). All palliative patients died within three days.

CONCLUSION

Overall treatment outcomes showed that octogenarians should not be denied surgery based on age alone, as half of the octogenarians that undergo surgical treatment are still alive one year after rAAA repair. In addition, > 80% returned to their own home after rehabilitation.

Acute Renal Failure/Acute Kidney Injury (AKI) Associated with Endovascular Procedures

AKI is one of the most common yet underdiagnosed postoperative complications that can occur after any type of surgery. Contrast-induced nephropathy (CIN) is still poorly defined and due to a wide range of confounding individual variables, its risk is difficult to determine. CIN mainly affects patients with underlying chronic kidney disease, diabetes, sepsis, heart failure, acute coronary syndrome and cardiogenic shock. Further research is necessary to better understand pathophysiology of contrast-induced AKI and consequent implementation of effective prevention and therapeutic strategies. Although many therapies have been tested to avoid CIN, the only potent preventative strategy involves aggressive fluid administration and reduction of contrast volume. Regardless of surgical technique—open or endovascular—perioperative AKI is associated with significant morbidity, mortality and cost. Endovascular procedures always require administration of a contrast media, which may cause acute tubular necrosis or renal vascular embolization leading to renal ischemia and as a consequence, contribute to increased number of post-operative AKIs.

Meta-analysis of phase-specific survival after elective endovascular versus surgical repair of abdominal aortic aneurysm from randomized controlled trials and propensity score-matched studies

OBJECTIVE

Although endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) significantly decreases perioperative mortality compared with open surgical repair (OSR), we have not concluded superiority between EVAR and OSR beyond the perioperative period. The aim of this study was to compare phase-specific survival after EVAR vs OSR.

METHODS

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Embase and MEDLINE were searched up to November 2019 to identify randomized controlled trials and propensity score-matched studies that investigated ≥2-year all-cause mortality (primary outcome) after EVAR vs OSR for intact infrarenal AAA. For each study, the hazard ratio (HR) with 95% confidence interval (CI) of mortality for EVAR vs OSR was calculated using survival curves for the following specific phases: early term (0-2 years after repair), midterm (2-6 years after repair), long term (6-10 years after repair), and very long term (≥10 years after repair). The risk ratio (RR) in the perioperative (in-hospital or 30-day) period was also extracted. Phase-specific HRs or RRs were separately pooled using the random effects model. Sensitivity analyses were performed by removing one study at a time to confirm that our findings were not derived from any single study. Funnel plot asymmetry was also examined using the linear regression test.

RESULTS

Our search identified four randomized controlled trials and seven propensity score-matched studies enrolling a total of 106,243 AAA patients assigned to EVAR (n = 53,123) or OSR (n = 53,120). The mortality after EVAR compared with OSR was significantly lower in the perioperative period (RR, 0.39; 95% CI, 0.29-0.51; P < .00001) and similar in the early-term period (HR, 0.93; 95% CI, 0.84-1.03; P = .16). Notably, significantly higher mortality was observed in the EVAR group compared with the OSR group in the midterm period (HR, 1.15; 95% CI, 1.03-1.29; P = .01). However, similar mortality was observed between the EVAR group and the OSR group in the long-term (HR, 1.06; 95% CI, 0.96-1.17; P = .27) and very-long-term (HR, 1.17; 95% CI, 0.93-1.47; P = .19) periods. In sensitivity analyses, the significant benefit of EVAR in the perioperative period and that of OSR in the midterm period were not changed. No funnel plot asymmetry was identified in all analyses.

CONCLUSIONS

Compared with OSR, EVAR was associated with lower perioperative mortality and higher mortality in the midterm period for intact infrarenal AAA. The superiority of EVAR was absent in the early-term period, and the inferiority of EVAR in the midterm period disappeared in the long-term and very-long-term periods.

Improved outcomes from endovascular aortic repair in younger patients: Towards improved risk stratification

Objectives

Abdominal aortic aneurysms are conventionally treated by open repair surgery. While endovascular aortic repair improves survival in high-risk patients, younger patients (40–65 years) potentially at lower risk with asymptomatic abdominal aortic aneurysms undergoing endovascular aortic repair usually have poorer post-operative outcomes and require longer term follow-up. In this study, clinical data on younger patients were analyzed to investigate whether endovascular aortic repair leads to poorer short- and long-term outcomes.

Methods

This was a systematic review and meta-analysis of articles comparing clinical outcomes in patients aged 40–65 years undergoing open repair or endovascular aortic repair and published between 2000 and 2017. In-hospital mortality, long-term mortality, and post-operative complication data were retrieved from eligible studies and clinical outcomes were compared. Twenty-one retrospective cohort analyses were included, accounting for 250,837 patients (149,051 endovascular aortic repair; 101,786 open repair). Risk ratios were pooled using the DerSimonian and Laird random effects model. All statistical analyses were performed in Review Manager 5.3.

Results

Younger patients with asymptomatic abdominal aortic aneurysms undergoing endovascular aortic repair had a significantly reduced 30-day mortality (odds ratio (OR) = 0.40, 95% confidence intervals (CI) 0.28–0.57; p  < 0.00001), long-term mortality (OR = 0.37, 95% CI 0.17–0.82; p  = 0.01), incidence of reintervention (OR = 0.47, 95% CI 0.34–0.66; p  < 0.0001), and incidence of renal failure (OR = 1.58, 95% CI 1.37–1.82; p  < 0.00001).

Conclusions

Endovascular aortic repair may improve short- and long-term survival and reduce post-operative complications in younger patients with asymptomatic abdominal aortic aneurysms.

Comparison of Outcomes in Elective Endovascular Aortic Repair vs Open Surgical Repair of Abdominal Aortic Aneurysms

IMPORTANCE

Knowledge regarding the long-term outcomes of elective treatment of abdominal aortic aneurysm (AAA) using endovascular aortic repair (EVAR) is increasing. However, data with greater than 10 years' follow-up remain sparse and are lacking from population-based studies.

OBJECTIVE

To determine the long-term outcomes of EVAR compared with open surgical repair (OSR) for elective treatment of AAA.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based cohort study used linked administrative health data from Ontario, Canada, to identify all patients 40 years and older who underwent elective EVAR or OSR for AAA repair from April 1, 2003, to March 31, 2016, with follow-up terminating on March 31, 2017. A total of 17 683 patients were identified using validated procedure and billing codes and were propensity score matched. Analysis was conducted from June 26, 2018, to January 16, 2019.

EXPOSURES

Elective EVAR or OSR for AAA.

MAIN OUTCOMES AND MEASURES

The primary outcome was overall survival. Secondary outcomes were major adverse cardiovascular event-free survival, defined as being free of death, myocardial infarction, or stroke; reintervention; and secondary rupture.

RESULTS

Among 17 683 patients who received elective AAA repairs (mean [SD] age, 72.6 [7.8] years; 14 286 [80.8%] men), 6100 (34.5%) underwent EVAR and 11 583 (65.5%) underwent OSR. From these patients, 4010 well-balanced propensity score-matched pairs of patients were defined, with a mean (SD) age of 73.0 (7.6) years and 6583 (82.1%) men. In the matched cohort, the mean (SD) follow-up was 4.4 (2.7) years, and maximum follow-up was 13.8 years. The overall median survival was 8.9 years. Compared with OSR, EVAR was associated with a higher survival rate up to 1 year after repair (91.0% [95% CI, 90.1%-91.9%] vs 94.0% [95% CI, 93.3%-94.7%]) and a higher major adverse cardiovascular event-free survival rate up to 4 years after repair (69.9% [95% CI, 68.3%-71.3%] vs 72.9% [95% CI, 71.4%-74.4%]). Cumulative incidence of reintervention was higher among patients who underwent EVAR compared with those who underwent OSR at the 7-year follow-up (45.9% [95% CI, 44.1%-47.8%] vs 42.2% [95% CI, 40.4%-44.0%]). Survival analyses demonstrated no statistically significant differences in long-term survival, reintervention, and secondary rupture for patients who underwent EVAR compared with those who underwent OSR. Kaplan-Meier analysis suggested superior long-term major adverse cardiovascular event-free survival among patients who underwent EVAR compared with those who underwent OSR (32.6% [95% CI, 26.9%-38.4%] vs 14.1% [95% CI, 4.0%-30.4%]; stratified log-rank P < .001) during a maximum follow-up of 13.8 years.

CONCLUSIONS AND RELEVANCE

Endovascular aortic repair was not associated with a difference in long-term survival during more than 13 years' maximum follow-up. The reasons for these findings will require studies to consider specific graft makes and models, adherence to instructions for use, and types and reasons for reintervention.

The impact of randomized trial results on abdominal aortic aneurysm repair rates from 2003 to 2016: A population-based time-series analysis

Objectives

The uptake of endovascular aortic repair for elective and ruptured abdominal aortic aneurysm repair is not well studied. We aimed to examine the trends in open surgical repair and endovascular aortic repair of eAAA and rAAA and to examine the effects of randomized trial publications on elective open surgical repair and endovascular aortic repair rates.

Methods

We conducted a population-based time-series analysis of eAAA and rAAA repairs in Ontario, Canada from 2003 to 2016. We examined changes in overall and approach-specific rates of eAAA and rAAA repair using exponential smoothing models. Interventional autoregressive integrated moving average models were fit to the eAAA rates to examine the impact of randomized trial results on these rates.

Results

We identified 19,489 eAAA (12,232 open (63%) and 7257 endovascular (37%)) and 2732 rAAA (2466 open (90%) and 266 endovascular (10%)) repairs from 2003 to 2016. The rate of eAAA repair declined from 6.39/100,000 in 2003 to 5.59/100,000 in 2016 (13% decrease, p = 0.17). The rate of elective open surgical repair decreased nearly three-fold from 6.07/100,000 to 2.12/100,000 ( p < 0.0001), while elective endovascular aortic repair increased approximately 10-fold (0.32/100,000 to 3.47/100,000, p < 0.0001). The rate of ruptured open surgical repair decreased from 1.62/100,000 to 0.37/100,000 ( p < 0.44), while ruptured endovascular aortic repair uptake increased (0.00/100,000 to 0.12/100,000, p < 0.25). The mid-term results of the DREAM and EVAR-1 trials were associated with a decrease in the rate of elective open surgical repair decline after 2010 ( p = 0.01).

Conclusions

While elective open surgical repair use has significantly decreased from 2003 to 2016, elective endovascular aortic repair use has significantly increased. The DREAM and EVAR-1 results significantly impacted the observed rates of elective open surgical repair only. The reasons for these trends require further characterization.

Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair

OBJECTIVE

Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR).

METHODS

This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis.

RESULTS

A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias.

CONCLUSIONS

The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.

Controlled hypotension versus normotensive resuscitation strategy for people with ruptured abdominal aortic aneurysm

BACKGROUND

An abdominal aortic aneurysm (AAA) is the pathological enlargement of the aorta and can develop in both men and women. Progressive aneurysm enlargement can lead to rupture. The rupture of an AAA is frequently fatal and accounts for the death from haemorrhagic shock of at least 45 people per 100,000 population. The outcome of people with ruptured AAA varies among countries and healthcare systems, with mortality ranging from 53% to 90%. Definitive treatment for ruptured AAA includes open surgery or endovascular repair. The management of haemorrhagic shock is crucial for the person's outcome and aims to restore organ perfusion and systolic blood pressure above 100 mmHg through immediate and aggressive fluid replacement. This rapid fluid replacement is known as the normotensive resuscitation strategy. However, evidence suggests that infusing large volumes of cold fluid causes dilutional and hypothermic coagulopathy. The association of these factors may exacerbate bleeding, resulting in a 'lethal triad' of hypothermia, acidaemia, and coagulopathy. An alternative to the normotensive resuscitation strategy is the controlled (permissive) hypotension resuscitation strategy, with a target systolic blood pressure of 50 mmHg to 100 mmHg. The principle of controlled or hypotensive resuscitation has been used in some management protocols for endovascular repair of ruptured AAA. It may be beneficial in preventing blood loss by avoiding the clot disruption caused by the rapid increase in systolic blood pressure; avoiding dilution of clotting factors, platelets and fibrinogen; and by avoiding the temperature decrease that inhibits enzyme activity involved in platelet and clotting factor function. This is an update of a review first published in 2016.

OBJECTIVES

To compare the effects of controlled (permissive) hypotension resuscitation and normotensive resuscitation strategies for people with ruptured AAA.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Specialised Register (August 2017), the Cochrane Register of Studies (CENTRAL (2017, Issue 7)) and EMBASE (August 2017). The Cochrane Vascular Information Specialist also searched clinical trials databases (August 2017) for details of ongoing or unpublished studies.

SELECTION CRITERIA

We sought all published and unpublished randomised controlled trial (RCTs) that compared controlled hypotension and normotensive resuscitation strategies for the management of shock in patients with ruptured abdominal aortic aneurysms.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions.

MAIN RESULTS

We identified no RCTs that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs that compared controlled hypotension and normotensive resuscitation strategies in the management of haemorrhagic shock in patients with ruptured abdominal aortic aneurysm that assessed mortality, presence of coagulopathy, intensive care unit length of stay, and the presence of myocardial infarct and renal failure. High quality studies that evaluate the best strategy for managing haemorrhagic shock in ruptured abdominal aortic aneurysms are required.

Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review

INTRODUCTION

Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions.

EVIDENCE ACQUISITION

A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data.

EVIDENCE SYNTHESIS

Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts.

CONCLUSIONS

The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.

Surgical Versus Endovascular Aortic Aneurysm Repair: Evidence to Guide the Optimal Approach for the Individual Patient

The choice between an open surgical and an endovascular approach for abdominal aortic aneurysm (AAA) repair remains an individualized clinical decision. As the technology and applications of endovascular aortic aneurysm repair (EVAR) continue to evolve, so does the literature investigating its outcomes. Multiple high-quality, randomized controlled trials comparing EVAR to open surgical repair (OSR) have now been published with long-term follow-up. Experience with ruptured aneurysms and the use of complex endografts is growing as well. This review is an up-to-date compilation of pertinent clinical trials for practitioners placed in the context of individual patient considerations to guide the choice of an optimal approach to the management of AAAs.

Outcomes of endovascular and open surgical repair of ruptured abdominal aortic aneurysms in elderly patients

BACKGROUND

Endovascular aneurysm repair (EVAR) is becoming the preferred treatment modality for patients with a ruptured abdominal aortic aneurysm (rAAA). Although the survival advantage of EVAR over open aortic repair (OAR) has been shown in some studies, it is unclear whether this benefit extends to elderly patients. We sought to evaluate the outcomes of rAAA repair in octogenarians.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set (2005-2014) to identify patients older than 80 years who were treated with EVAR and OAR for rAAA. Procedural trends were evaluated during the course of the study period. Perioperative outcomes including mortality, morbidity, and hospital length of stay (LOS) were compared. Multivariable regression models were used to identify predictors of perioperative mortality and morbidity.

RESULTS

Among 1048 elderly patients who underwent rAAA repair, 450 (43%) and 598 (57%) were treated with EVAR and OAR, respectively. The use of EVAR to treat rAAA had increased significantly in this population of patients (0% in 2005 vs 56% in 2014; P < .001). The overall 30-day mortality rate among octogenarians was 41%. The mortality rate was significantly higher among those treated with OAR compared with EVAR (47% vs 33%; P < .001). Pneumonia (21% vs 10%; P < .001), reintubation (14% vs 9%; P < .001), and >48-hour ventilator dependence (43% vs 21%; P < .001) were significantly higher in patients undergoing OAR. Hospital LOS (13 vs 10 days; P < .001) was also longer in the OAR cohort. Compared with EVAR, OAR was independently predictive of 30-day mortality (adjusted odds ratio [AOR], 1.7; 95% confidence interval [CI], 1.3-2.2; P < .001), pneumonia (AOR, 2.4; 95% CI, 1.7-3.6; P < .001), >48-hour ventilator dependence (AOR, 2.5; 95% CI, 1.8-3.3; P < .001), and longer LOS (adjusted mean ratio, 1.4; 95% CI, 1.2-1.6; P < .001).

CONCLUSIONS

Elderly patients have significant but acceptable perioperative mortality and morbidity after rAAA repair. Use of endovascular repair in the elderly population has increased and is associated with better perioperative survival and 30-day outcomes compared with traditional open repair in this study.

The impact of endovascular repair on management and outcome of ruptured thoracic aortic aneurysms

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has become an alternative to open repair for the treatment of ruptured thoracic aortic aneurysms (rTAAs). The aim of this study was to assess national trends in the use of TEVAR for the treatment of rTAA and to determine its impact on perioperative outcomes.

METHODS

Patients admitted with an rTAA between 1993 and 2012 were identified from the National Inpatient Sample. Patients were grouped in accordance with their treatment: TEVAR, open repair, or nonoperative treatment. The primary outcomes were treatment trends over time and in-hospital death. Secondary outcomes included perioperative complications and length of stay. Trend analyses were performed using the Cochran-Armitage test for trend, and adjusted mortality risks were established using multivariable logistic regression analysis.

RESULTS

A total of 12,399 patients were included, with 1622 (13%) undergoing TEVAR, 2808 (23%) undergoing open repair, and 7969 (64%) not undergoing surgical treatment. TEVAR has been increasingly used from 2% of total admissions in 2003-2004 to 43% in 2011-2012 (P < .001). Concurrently, there was a decline in the proportion of patients undergoing open repair (29% to 12%; P < .001) and nonoperative treatment (69% to 45%; P < .001). The proportion of patients undergoing surgical repair has increased for all age groups since 1993-1994 (P < .001 for all) but was most pronounced among those aged 80 years with a 7.5-fold increase. After TEVAR was introduced, procedural mortality decreased from 36% in 2003-2004 to 27% in 2011-2012 (P < .001); mortality among those undergoing nonoperative treatment remained stable between 63% and 60% (P = .167). Overall mortality after rTAA admission decreased from 55% to 42% (P < .001). Since 2005, mortality for open repair was 33% and 22% for TEVAR (P < .001). In adjusted analysis, open repair was associated with a twofold higher mortality than TEVAR (odds ratio, 2.0; 95% confidence interval, 1.7-2.5).

CONCLUSIONS

TEVAR has replaced open repair as primary surgical treatment for rTAA. The introduction of endovascular treatment appears to have broadened the eligibility of patients for surgical treatment, particularly among the elderly. Mortality after rTAA admission has declined since the introduction of TEVAR, which is the result of improved operative mortality as well as the increased proportion of patients undergoing surgical repair.

Repair of a bowel-containing, scrotal hernia with incarceration contributed by femorofemoral bypass graft

The rising use of endovascular techniques utilizing femoral artery access may increase the frequency with which surgeons face the challenge of hernia repair in reoperative groins—which may or may not include a vascular graft. We present a case where a vascular graft contributed to an acute presentation and complicated dissection, and review the literature. A 67-year-old man who had undergone prior endovascular aneurysm repair via open bilateral femoral artery access and concomitant prosthetic femorofemoral bypass, presented with an incarcerated, scrotal inguinal hernia. The graft with its associated fibrosis contributed to the incarceration by compressing the inguinal ring. Repair was undertaken via an open, anterior approach with tension-free, Lichtenstein herniorraphy after releasing graft-associated fibrosis. Repair of groin hernias in this complex setting requires careful surgical planning, preparation for potential vascular reconstruction and meticulous technique to avoid bowel injury in the face of a vascular conduit and mesh.

Transition from Open Surgery to Endovascular Treatment of Abdominal Aortic Aneurysm Rupture

BACKGROUND

To review the outcome before and after the implementation of protocol-based strategy for endovascular repair (EVAR) of abdominal aortic aneurysm rupture (rAAA).

METHODS

A retrospective analysis of prospectively collected data from a tertiary center during the period 2006-2011. Demographics, comorbidities, blood examinations, perioperative patients' status, and mortality rates were recorded. Univariate and multivariate analyses were used to assess the association of the type of the procedure with various factors.

RESULTS

A total of 58 (46 open surgical repair [OSR] and 12 EVAR) patients with mean age of 74 ± 17 years (91% males) were treated for rAAA. However, 39 (11 EVAR and 28 OSR) were operated with protocol-based strategy available. Total mortality rate was 52.6% (10 of 19) initially and 38.5% (15 of 39) after the implementation of a protocol-based strategy. During protocol-based treatment, the survival rate did not differ between the 2 procedures (7 of 11 EVAR and 17 of 28 OSR; P, ns). A 30-day mortality rate was associated with preoperative number of platelets (unadjusted P values, P = 0.013), age (odds ratio [OR] 0.796; 95% confidence interval [CI], 0.685-0.925; P = 0.003), and diastolic blood pressure (OR, 1.053; 95% CI, 1.016-1.093; P = 0.005). After mean follow-up of 48 ± 11 months, EVAR patients presented better outcome regarding mortality rate (36% OSR vs. 0% EVAR; P = 0.0464).

CONCLUSIONS

After the adoption of an available rEVAR protocol-based strategy, EVAR and OSR were equally effective during postoperative 30 days. The role of hypotension and age is important on poor outcomes during this period. However, after midterm follow-up, EVAR demonstrates better survival rates than OSR.

A 15-Year Single-Center Experience of Endovascular Repair for Elective and Ruptured Abdominal Aortic Aneurysms

Purpose: To evaluate the differences in technical outcomes and secondary interventions between elective endovascular aneurysm repair (el-EVAR) procedures and those for ruptured aneurysms (r-EVAR). Methods: Of the 906 patients treated with primary EVAR from September 1998 until July 2012, 43 cases were excluded owing to the use of first-generation stent-grafts. Among the remaining 863 patients, 773 (89.6%) patients (mean age 72 years; 697 men) with asymptomatic or symptomatic abdominal aortic aneurysms (AAAs) were assigned to the el-EVAR group; 90 (10.4%) patients (mean age 73 years; 73 men) were assigned to the r-EVAR group based on blood outside the aortic wall on preoperative imaging. The primary study outcome was technical success; secondary endpoints, including freedom from secondary interventions and late survival, were examined with Kaplan-Meier analyses. Results: At baseline, r-EVAR patients had larger aneurysms on average (p<0.001) compared to el-EVAR patients. Technical success was comparable (p=0.052), but there were more type Ia endoleaks at completion angiography in the r-EVAR group (p=0.038). As anticipated, more patients died in the first month in the r-EVAR group (18.9% vs 2.2% el-EVAR, p<0.001). At 5 years, there was an overall survival of 65.1% for the el-EVAR patients vs 48.1% in the r-EVAR group (p<0.001). The freedom from AAA-related mortality was 95.7% for el-EVAR and 71.0% for r-EVAR (p<0.001). Five-year freedom from type I/III endoleaks was significantly lower in the r-EVAR group (78.7% vs 90.0%, p=0.003). Five-year freedom from secondary intervention estimates were not significantly different (el-EVAR 84.2% vs r-EVAR 78.2%, p=0.064). Conclusion: Within our cohort of primary EVAR patients, r-EVAR cases showed comparable stent-graft–related technical outcome. Although there was a higher incidence of type Ia endoleaks on completion angiography in the r-EVAR group, the overall secondary intervention rate was comparable to el-EVAR.

Controlled hypotension versus normotensive resuscitation strategy for people with ruptured abdominal aortic aneurysm

BACKGROUND

An abdominal aortic aneurysm (AAA) is the pathological enlargement of the aorta and can develop in both men and women. Progressive aneurysm enlargement can lead to rupture. The rupture of an AAA is frequently fatal and accounts for the death from haemorrhagic shock of at least 45 people per 100,000 population. The outcome of people with ruptured AAA varies among countries and healthcare systems, with mortality ranging from 53% to 90%. Definitive treatment for ruptured AAA includes open surgery or endovascular repair. The management of haemorrhagic shock is crucial for the person's outcome and aims to restore organ perfusion and systolic blood pressure above 100 mm Hg through immediate and aggressive fluid replacement. This rapid fluid replacement is known as the normotensive resuscitation strategy. However, evidence suggests that infusing large volumes of cold fluid causes dilutional and hypothermic coagulopathy. The association of these factors may exacerbate bleeding, resulting in a 'lethal triad' of hypothermia, acidaemia, and coagulopathy. An alternative to the normotensive resuscitation strategy is the controlled (permissive) hypotension resuscitation strategy, with a target systolic blood pressure of 50 to 100 mm Hg. The principle of controlled or hypotensive resuscitation has been used in some management protocols for endovascular repair of ruptured AAA. It may be beneficial in preventing blood loss by avoiding the clot disruption caused by the rapid increase in systolic blood pressure; avoiding dilution of clotting factors, platelets and fibrinogen; and by avoiding the temperature decrease that inhibits enzyme activity involved in platelet and clotting factor function.

OBJECTIVES

To compare the effects of controlled (permissive) hypotension resuscitation and normotensive resuscitation strategies for people with ruptured AAA.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Specialised Register (April 2016) and the Cochrane Register of Studies (CENTRAL (2016, Issue 3)). Clinical trials databases were searched (April 2016) for details of ongoing or unpublished studies.

SELECTION CRITERIA

We sought all published and unpublished randomised controlled trial (RCTs) that compared controlled hypotension and normotensive resuscitation strategies for the management of shock in patients with ruptured abdominal aortic aneurysms.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions.

MAIN RESULTS

We identified no RCTs that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no RCTs that compared controlled hypotension and normotensive resuscitation strategies in the management of haemorrhagic shock in patients with ruptured abdominal aortic aneurysm that assessed mortality, presence of coagulopathy, intensive care unit length of stay, and the presence of myocardial infarct and renal failure. High quality studies that evaluate the best strategy for managing haemorrhagic shock in ruptured abdominal aortic aneurysms are required.

Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm

Background

Patients presenting with ruptured abdominal aortic aneurysms are most often treated with open repair despite the fact that endovascular aneurysm repair is a less invasive and widely accepted method with clear benefits for elective aortic aneurysm patients. A debate exists regarding the definitive benefit in endovascular repair for patients with a ruptured abdominal aortic aneurysm. The aim of this literature review was to determine if any trends exist in favor of either open or endovascular repair.

Material/Methods

A literature search was performed using PUBMED, OVID, and Google Scholar databases. The search yielded 64 publications.

Results

Out of 64 publications, 25 were retrospective studies, 12 were population-based, 21 were prospective, 5 were the results of RCTs, and 1 was a case-series. Sixty-one studies reported on early mortality and provided data comparing endovascular repair (rEVAR) and open repair (rOR) for ruptured abdominal aneurysm groups. Twenty-nine of these studies reported that rEVAR has a lower early mortality rate. Late mortality after rEVAR compared to that of rOR was reported in 21 studies for a period of 3 to 60 months. Results of 61.9% of the studies found no difference in late mortality rates between these 2 groups. Thirty-nine publications reported on the incidence of complications. Approximately half of these publications support that the rEVAR group has a lower complication rate and the other half found no difference between the groups. Length of hospital stay has been reported to be shorter for rEVAR in most studies. Blood loss and need for transfusion of either red cells or fresh frozen plasma was consistently lower in the rEVAR group.

Conclusions

Differences between the included publications affect the outcomes. Randomized control trials have not been able to provide clear conclusions. rEVAR can now be considered a safe method of treating rAAA, and is at least equal to the well-established rOR method.

Volume-outcome relationship for peripheral endovascular interventions: a review of existing literature

The incidence and prevalence of peripheral vascular disease has been increasing. When coexistent with coronary artery disease (CAD), it has shown to predict higher mortality along with poorer quality-of-life consequently leading to a marked increase in healthcare costs. Broadly, there has been an increase in utilization of endovascular techniques in the management of peripheral vascular diseases. An inverse relation between volume and outcomes has been noted in these procedures. Additionally, improved resource utilization has also been noted with higher hospital and operator volumes. This has led to proposals to regionalize these procedures to high volume hospitals. There have also been calls to introduce the idea of having a set threshold of procedures for providers. This review presents an overview of published literature on the volume-outcome relationship affecting the outcomes of peripheral endovascular procedures.

Comparison of long-term mortality after ruptured abdominal aortic aneurysm in England and Sweden

BACKGROUND

Concern has been raised regarding international discrepancies in perioperative mortality after repair of ruptured abdominal aortic aneurysm (rAAA). The variation in in-hospital mortality is difficult to interpret, owing to international differences in discharge strategies. This study compared 90-day and 5-year mortality in patients who had a rAAA in England and Sweden.

METHODS

Patients undergoing rAAA repair were identified from English Hospital Episode Statistics and the Swedish Vascular Registry (Swedvasc) between 2003 and 2012. Ninety-day and 5-year mortality were compared after matching for age and sex. Within-country analyses examined the impact of co-morbidity, teaching hospital status or hospital annual caseload, adjusted with causal inference techniques.

RESULTS

Some 12 467 patients underwent rAAA repair in England, of whom 83.2 per cent were men; the median (i.q.r.) age was 75 (70-80) years. A total of 2829 Swedish patients underwent rAAA repair, of whom 81.3 per cent were men; their median (i.q.r.) age was 75 (69-80) years. The 90-day mortality rate was worse in England (44.0 per cent versus 33.4 per cent in Sweden; P < 0.001), as was 5-year mortality (freedom from mortality 38.6 versus 46.3 per cent respectively; P < 0.001). In England, lower mortality was seen in teaching hospitals with larger bed capacity, higher annual caseloads and greater use of endovascular aneurysm repair (EVAR). In Sweden, lower mortality was associated with EVAR, high annual caseload, or surgery on weekdays compared with weekends.

CONCLUSION

Short- and long-term mortality after rAAA repair was higher in England. In both countries, mortality was lowest in centres performing greater numbers of AAA repairs per annum, and more EVAR procedures.

Utility of simultaneous interventional radiology and operative surgery in a dedicated suite for seriously injured patients

PURPOSE OF REVIEW

In recent years, combined interventional radiology and operative suites have been proposed and are now becoming operational in select trauma centres. Given the infancy of this technology, this review aims to review the rationale, benefits and challenges of hybrid suites in the management of seriously injured patients.

RECENT FINDINGS

No specific studies exist that investigate outcomes within hybrid trauma suites. Endovascular and interventional radiology techniques have been successfully employed in thoracic, abdominal, pelvic and extremity trauma. Although the association between delayed haemorrhage control and poorer patient outcomes is intuitive, most supporting scientific data are outdated. The hybrid suite model offers the potential to expedite haemorrhage control through synergistic operative, interventional radiology and resuscitative platforms. Maximizing the utility of these suites requires trained multidisciplinary teams, ergonomic and workplace considerations, as well as a fundamental paradigm shift of trauma care. This often translates into a more damage-control orientated philosophy.

SUMMARY

Hybrid suites offer tremendous potential to expedite haemorrhage control in trauma patients. Outcome evaluations from trauma units that currently have operational hybrid suites are required to establish clearer guidelines and criteria for patient management.