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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: 124] [Impact Index Per Article: 124.0] [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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Latz CA, Boitano LT, Tanious A, Wang LJ, Schwartz SI, Pendleton AA, DeCarlo C, Dua A, Conrad MF. Endovascular Versus Open Repair for Ruptured Complex Abdominal Aortic Aneurysms: A Propensity Weighted Analysis. Ann Vasc Surg 2020; 68:34-43. [DOI: 10.1016/j.avsg.2020.04.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/21/2020] [Accepted: 04/27/2020] [Indexed: 12/31/2022]
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SÁ P, Oliveira-Pinto J, Mansilha A. Abdominal compartment syndrome after r-EVAR: a systematic review with meta-analysis on incidence and mortality. INT ANGIOL 2020; 39:411-421. [PMID: 32519533 DOI: 10.23736/s0392-9590.20.04406-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Endovascular aneurysm repair for ruptured abdominal aortic aneurysms (r-EVAR) sometimes complicates with abdominal compartment syndrome (ACS) due to extensive retroperitoneal hematoma, with significant prognostic implications. This systematic review aimed to analyze the incidence of the syndrome and assess the impact of ACS on mortality. Mortality after decompressive laparotomy was also assessed. EVIDENCE ACQUISITION Two databases were searched: Medline and Web of Science. The search was conducted through October 2019. The titles and abstracts of the retrieved articles were independently reviewed. All studies reporting on the ACS incidence after r-EVAR were initially included. From each study, eligibility was determined and descriptive, methodological, and outcome data was extracted. The incidence was calculated with summary proportion. Odds ratio was used to compare the mortality rate. Meta-analysis was performed with fixed effect model when calculating the ACS incidence in r-EVAR patients and when assessing the impacts of ACS and DL in the mortality rate. EVIDENCE SYNTHESIS A total of 46 studies were included, with a cumulative cohort of 3064 patients. Two hundred and fifty-two (8.2%) patients developed ACS. The ACS pooled incidence was 9% with a 95% confidence interval of [0.08; 0.11]. Among the 46 included studies, 19 studies reported data on the mortality rate, corresponding to 1825 of the 3064 patients. Of these, 169 (9.3%) had developed ACS and 94 (55.6%) of them died by multi organ failure. Among the 1656 patients without ACS, 328 died (19.8%). The mortality odds ratio meta-analysis was 6.25 with a 95% confidence interval of [4.44, 8.80]. Decompressive laparotomy was performed in 41 patients, decreasing mortality in 47%. CONCLUSIONS ACS affects approximately 9% of patients submitted to r-EVAR, and significantly increases perioperative mortality. Close postoperative surveillance to clinical signs of ACS is vital in these patients.
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Yamaguchi T, Nakai M, Sumita Y, Nishimura K, Nagai T, Anzai T, Sakata Y, Ogino H. Impact of Endovascular Repair on the Outcomes of Octogenarians with Ruptured Abdominal Aortic Aneurysms: A Nationwide Japanese Study. Eur J Vasc Endovasc Surg 2020; 59:219-225. [DOI: 10.1016/j.ejvs.2019.07.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/12/2019] [Accepted: 07/14/2019] [Indexed: 10/25/2022]
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Yamaguchi T, Nakai M, Sumita Y, Nishimura K, Tazaki J, Kyuragi R, Kinoshita Y, Miyamoto T, Sakata Y, Nozato T, Ogino H. Editor's Choice – Endovascular Repair Versus Surgical Repair for Japanese Patients With Ruptured Thoracic and Abdominal Aortic Aneurysms: A Nationwide Study. Eur J Vasc Endovasc Surg 2019; 57:779-786. [DOI: 10.1016/j.ejvs.2019.01.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 01/22/2019] [Indexed: 11/24/2022]
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Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 873] [Impact Index Per Article: 174.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Jalalzadeh H, van Leeuwen CF, Indrakusuma R, Balm R, Koelemay MJW. Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2018; 68:900-915. [PMID: 30146037 DOI: 10.1016/j.jvs.2018.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/14/2018] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Hamid Jalalzadeh
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands.
| | - Carlijn F van Leeuwen
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Reza Indrakusuma
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
| | - Mark J W Koelemay
- Department of Surgery and Amsterdam Cardiovascular Sciences, Academic Medical Center, Amsterdam, The Netherlands
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Borger van der Burg BLS, van Dongen TTCF, Morrison JJ, Hedeman Joosten PPA, DuBose JJ, Hörer TM, Hoencamp R. A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination. Eur J Trauma Emerg Surg 2018; 44:535-550. [PMID: 29785654 PMCID: PMC6096615 DOI: 10.1007/s00068-018-0959-y] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 04/18/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome. METHODS Systematic review and meta-analysis (1900-2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords "aortic balloon occlusion", "aortic balloon tamponade", "REBOA", and "Resuscitative Endovascular Balloon Occlusion" in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered. RESULTS A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use. CONCLUSION REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.
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Affiliation(s)
| | - Thijs T. C. F. van Dongen
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
| | - J. J. Morrison
- R. Adam Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | | | - J. J. DuBose
- Division of Vascular Surgery, David Grant Medical Center, Travis AFB, California, USA
| | - T. M. Hörer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - R. Hoencamp
- Department of Surgery, Alrijne Hospital, Simon Smitweg 1, 2353 GA Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
- Division of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Amato B, Fugetto F, Compagna R, Zurlo V, Barbetta A, Petrella G, Aprea G, Danzi M, Rocca A, de Franciscis S, Serra R. Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review. MINERVA CHIR 2018; 74:472-480. [PMID: 29806754 DOI: 10.23736/s0026-4733.18.07768-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Bruno Amato
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Francesco Fugetto
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy
| | - Rita Compagna
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Valeria Zurlo
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy
| | - Andrea Barbetta
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | | | - Giovanni Aprea
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Michele Danzi
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Aldo Rocca
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy - .,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
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Siracuse JJ, Krafcik BM, Farber A, Kalish JA, McChesney A, Rybin D, Doros G, Eslami MH. Contemporary open repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2017; 65:1023-1028. [DOI: 10.1016/j.jvs.2016.08.115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 08/28/2016] [Indexed: 10/20/2022]
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11
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Spanos K, Saleptsis V, Karathanos C, Makris D, Stamoulis K, Giannoukas AD. Transition from Open Surgery to Endovascular Treatment of Abdominal Aortic Aneurysm Rupture. Ann Vasc Surg 2016; 36:85-91. [PMID: 27421198 DOI: 10.1016/j.avsg.2016.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/08/2016] [Accepted: 03/06/2016] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Vasileios Saleptsis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christos Karathanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimosthenis Makris
- Department of Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Stamoulis
- Department of Anesthesiology, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Baderkhan H, Gonçalves FMB, Oliveira NG, Verhagen HJM, Wanhainen A, Björck M, Mani K. Challenging Anatomy Predicts Mortality and Complications After Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm. J Endovasc Ther 2016; 23:919-927. [DOI: 10.1177/1526602816658494] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To analyze the effects of aortic anatomy and endovascular aneurysm repair (EVAR) inside and outside the instructions for use (IFU) on outcomes in patients treated for ruptured abdominal aortic aneurysms (rAAA). Methods: All 112 patients (mean age 73 years; 102 men) treated with standard EVAR for rAAA between 2000 and 2012 in 3 European centers were included in the retrospective analysis. Patients were grouped based on aortic anatomy and whether EVAR was performed inside or outside the IFU. Data on complications, secondary interventions, and mortality were extracted from the patient records. Cox regression analysis was performed to assess predictors of mortality and complications; results are presented as the hazard ratio (HR) with 95% confidence interval (CI). Survival was analyzed using the Kaplan-Meier method. Results: Of the 112 patients examined, 61 (54%) were treated inside the IFU, 43 (38%) outside the IFU, and 8 patients lacked adequate preoperative computed tomography scans for determination. Median follow-up of those surviving 30 days was 2.5 years. Mortality at 30 days was 15% (95% CI 6% to 24%) inside the IFU vs 30% (95% CI 16% to 45%) outside (p=0.087). Three-year mortality estimates were 33.8% (95% CI 20.0% to 47.5%) inside the IFU vs 56% (95% CI 39.7% to 72.2%) outside (p=0.016). At 5 years, mortality was 48% (95% CI 30% to 66%) inside the IFU vs 74% (95% CI 54% to 93%) outside (p=0.015). Graft-related complications occurred in 6% (95% CI 0% to 13%) inside the IFU and 30% (95% CI 14% to 42%) outside (p=0.015). The rate of graft-related secondary interventions was 14% (95% CI 4% to 22%) inside the IFU vs 35% (95% CI 14% to 42%) outside (p=0.072). In the multivariate analysis, neck length <15 mm (HR 8.1, 95% CI 3.0 to 21.9, p<0.001) and angulation >60° (HR 3.1, 95% CI 1.0 to 9.3, p=0.045) were independent predictors of late graft-related complications. Aneurysm neck diameter >29 mm (HR 2.5, 95% CI 1.1 to 5.9, p=0.035) was an independent predictor of overall mortality. Conclusion: Long-term mortality and complications after rEVAR are associated with aneurysm anatomy. The role of adjunct endovascular techniques and the outcome of open repair in cases with challenging anatomy warrant further study.
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Affiliation(s)
- Hassan Baderkhan
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Frederico M. Bastos Gonçalves
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Nelson Gomes Oliveira
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Angiology and Vascular Surgery, Hospital do Divino Espírito Santo-Ponta Delgada, Azores, Portugal
| | - Hence J. M. Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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Patelis N, Moris D, Karaolanis G, Georgopoulos S. Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm. Med Sci Monit Basic Res 2016; 22:34-44. [PMID: 27090791 PMCID: PMC4847558 DOI: 10.12659/msmbr.897601] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Nikolaos Patelis
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Demetrios Moris
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Georgios Karaolanis
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Sotiris Georgopoulos
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
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Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm repair. J Vasc Surg 2015; 63:39-47. [PMID: 26506941 DOI: 10.1016/j.jvs.2015.08.050] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 08/02/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm (AAA) repair. Emergency AAA repair carries a high risk of morbidity and mortality. This study seeks to examine morbidity and mortality trends from the National Surgical Quality Improvement Program (NSQIP) database, and identify potential risk factors. METHODS All emergency AAA repairs were identified using the NSQIP database from 2005 to 2011. Univariate analysis (using the Student t, χ(2), and Fisher's exact tests) and multivariate logistic regression was performed to examine trends in mortality and morbidity. RESULTS Out of 2761 patients who underwent emergency AAA repair, 321 (11.6%) died within 24 hours of surgery. Of the remaining 2440 patients, 1133 (46.4%) experienced major complications and 459 (18.8%) died during the postoperative period. From 2005 to 2011, there was a significant decrease in patient mortality, particularly in patients who survived the perioperative period (P = .002). Total complications increased overall (P < .0001); however, major complications decreased from 58.7% in 2005 to 42.6% in 2011 (P < .0001) among patients who survived beyond 24 hours. The use of endovascular aortic repair (EVAR) increased over the study period (P < .0001). On multivariate analysis of patients who survived past the initial 24-hour period, advancing age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.1), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.7-4.1), dependent functional status (OR, 2.0; 95% CI, 1.2-3.2), and presence of a major complication (OR, 3.1; 95% CI, 2.0-5.0) were significantly associated with death, whereas presence of a senior resident (OR, 0.4; 95% CI, 0.3-0.6) or fellow (OR 0.3; 95% CI, 0.2-0.6) was inversely associated with death. EVAR was not associated with death, but was associated with 30-day complications (OR, 0.5; 95% CI, 0.3-0.6). CONCLUSIONS Patient survival has increased from 2005 to 2011 after emergency AAA repair, with a significant improvement particularly in patients who survive past the first 24 hours. EVAR was not associated with mortality, but was protective of 30-day complications. Although the total number of complications increased, the number of major complications decreased over the study period, suggesting that newer techniques and patient care protocols may be improving outcomes.
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Open surgery (OS) versus endovascular aneurysm repair (EVAR) for hemodynamically stable and unstable ruptured abdominal aortic aneurysm (rAAA). Heart Vessels 2015; 31:1291-302. [DOI: 10.1007/s00380-015-0736-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 08/21/2015] [Indexed: 10/23/2022]
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The Impact of Aortic Occlusion Balloon on Mortality After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Meta-analysis and Meta-regression Analysis. Cardiovasc Intervent Radiol 2015; 38:1425-37. [DOI: 10.1007/s00270-015-1132-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/15/2015] [Indexed: 12/11/2022]
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Luebke T, Brunkwall J. Risk-Adjusted Meta-analysis of 30-Day Mortality of Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2015; 29:845-63. [DOI: 10.1016/j.avsg.2014.12.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/19/2014] [Accepted: 12/22/2014] [Indexed: 12/20/2022]
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Endovascular Repair of Ruptured and Symptomatic Abdominal Aortic Aneurysms Using a Structured Protocol in a Community Teaching Hospital. Ann Vasc Surg 2015; 29:76-83. [DOI: 10.1016/j.avsg.2014.07.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 07/14/2014] [Accepted: 07/27/2014] [Indexed: 02/02/2023]
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Raats JW, Flu HC, Ho GH, Veen EJ, Vos LD, Steyerberg EW, van der Laan L. Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age. Clin Interv Aging 2014; 9:1721-32. [PMID: 25342890 PMCID: PMC4206251 DOI: 10.2147/cia.s64718] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA. Methods We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital. Results Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01–1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70–79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008). Conclusion The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.
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Affiliation(s)
- Jelle W Raats
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Hans C Flu
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Eelco J Veen
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Louwerens D Vos
- Department of Radiology, Amphia Hospital, Breda, the Netherlands
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Pini R, Faggioli G, Longhi M, Mauro R, Freyrie A, Gargiulo M, Gallitto E, Mascoli C, Stella A. The Influence of Study Design on the Evaluation of Ruptured Abdominal Aortic Aneurysm Treatment. Ann Vasc Surg 2014; 28:1568-80. [DOI: 10.1016/j.avsg.2014.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 02/19/2014] [Accepted: 03/23/2014] [Indexed: 12/20/2022]
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Speicher PJ, Barbas AS, Mureebe L. Open versus Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2014; 28:1249-57. [DOI: 10.1016/j.avsg.2013.12.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/14/2013] [Accepted: 12/16/2013] [Indexed: 11/28/2022]
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Karkos CD, Menexes GC, Patelis N, Kalogirou TE, Giagtzidis IT, Harkin DW. A systematic review and meta-analysis of abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2014; 59:829-42. [DOI: 10.1016/j.jvs.2013.11.085] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 10/19/2013] [Accepted: 11/23/2013] [Indexed: 12/20/2022]
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Ho MF, Chan YC, Cheung GC, Cheng SW. Multicenter audit of emergency endovascular repair of infrarenal aortic aneurysms. Ann Vasc Surg 2013; 28:560-7. [PMID: 24090827 DOI: 10.1016/j.avsg.2012.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Revised: 10/25/2012] [Accepted: 11/08/2012] [Indexed: 10/25/2022]
Abstract
BACKGROUND Emergency endovascular aneurysm repair (eEVAR) for infrarenal abdominal aortic aneurysm has become widely accepted as an alternative to open repair, if the aortic anatomy is favorable and endovascular expertise is readily available. The aim of this study is to report the outcome of eEVAR in Hong Kong. METHODS This was a retrospective review of prospectively collected data from Hong Kong Hospital Authority Clinical Data Analysis and Reporting System (CDARS), Clinical Management System (CMS), and departmental prospective computerized databases. Patient demographics, clinical and biochemical parameters, perioperative complications, and outcomes were recorded and analyzed. The independent sample t-test was used for continuous variables and the Fisher's exact test was used for nonparametric variables. Kaplan-Meier analysis was performed for overall survival and survival of subgroups. Binary logistic regression was performed for factors predicting perioperative mortality. SPSS software (version 15.0; SPSS Inc., Chicago, IL) was used for all statistical analyses. RESULTS A total of 40 patients (36 men with a mean age of 74.9 ± 1.53 years [range: 52-89 years]) underwent emergency eEVAR between January 2006 and September 2011 in 6 Hospital Authority Hospitals in Hong Kong. All patients were treated using commercially available aortoiliac endografts (including 26 bifurcated and 14 aorto-uniiliac grafts). There was 1 conversion from eEVAR to open repair. Blood loss, operating time, duration of stay in intensive care, and duration of stay in the hospital were 948 ± 495.5 mL, 194 ± 12.7 min, 4.7 ± 1.26 days, and 14.5 ± 2.19 days, respectively. The 7-day, 30-day, and 12-month mortality rates were 15%, 17.5%, and 35%, respectively. Six patients required reintervention on follow-up, and 8 patients died during hospitalization. Cox regression analysis of survival found that hypotension (P = 0.001) and being >76 years of age (P = 0.002) were associated with reduced overall survival. Binary logistic regression found that hypotension is associated with increased 30-day mortality (P = 0.026). CONCLUSIONS This audit shows that the results of eEVAR in Hong Kong are comparable to international standards. In the endovascular era, this may be an attractive alternative to emergency open aneurysm repair.
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Affiliation(s)
- Man-Fung Ho
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong
| | - Yiu-Che Chan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong.
| | - Grace C Cheung
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong
| | - Stephen W Cheng
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Hong Kong
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Antoniou GA, Georgiadis GS, Antoniou SA, Pavlidis P, Maras D, Sfyroeras GS, Georgakarakos EI, Lazarides MK. Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair. J Vasc Surg 2013; 58:1091-105. [DOI: 10.1016/j.jvs.2013.07.109] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/16/2013] [Accepted: 07/26/2013] [Indexed: 01/08/2023]
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The use of rapid endovascular balloon occlusion in unstable patients with ruptured abdominal aortic aneurysm. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013; 4:74-9. [PMID: 22436987 DOI: 10.1097/imi.0b013e3181a00bc9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE : To present our results and demonstrate advantages of rapid endovascular balloon occlusion (REBO) of the juxtarenal aorta in unstable patients with ruptured abdominal aortic aneurysm (rAAA). METHODS : Since 2006, all unstable patients with rAAA are immediately transferred to the operating room (OR). No computed tomography scan is performed once diagnosis is made on ultrasound examination. Instability is defined as systolic blood pressure less than 60 mm Hg, unconsciousness, cardiac ischemia, or intubation. Once arrived in the OR, a Reliant aortic balloon is introduced and inflated at the level of the renal arteries. Subsequently, an angiogram is made through the contralateral femoral artery in order to decide between open or endovascular repair (EVAR). RESULTS : Twelve patients with rAAA were defined as unstable. REBO was installed within 10 minutes after arrival in the OR. Aortic occlusion resulted in immediate hemodynamic stability. Five patients were suitable for EVAR. Seven patients had open repair. For these abdominal dissection was more careful since no instability was encountered. All patients survived the procedure except one. Mean stay on intensive care unit was 19.7 days for open group and 8.4 for EVAR. CONCLUSIONS : REBO of the juxtarenal abdominal aorta by pc technique in unstable patients with rAAA resulted in a 17% 30-day mortality and a 100% 1-year event-free follow-up for survivors. With this technique, EVAR exclusion is still a valuable treatment. Exposure and decision making for the open group is easier to perform with less risk for additional damaging to neighboring structures during dissection since urgent cross-clamping is not necessary.
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Mohan PP, Hamblin MH. Comparison of endovascular and open repair of ruptured abdominal aortic aneurysm in the United States in the past decade. Cardiovasc Intervent Radiol 2013; 37:337-42. [PMID: 23756880 DOI: 10.1007/s00270-013-0665-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 05/16/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this study is national-level comparison of the endovascular (EVAR) and open repair (OAR) of ruptured abdominal aortic aneurysm (AAA) in the United States from 2001 to 2010. METHODS The data were obtained from nationwide inpatient sample from the Department of Health and Human Services. Ruptured AAA treated by OAR or EVAR were selected using combination ICD-9 codes. RESULTS There were 42,126 cases of ruptured AAA of which 8,140 (19.3%) were repaired by EVAR. EVAR patients were older (74.1 vs. 72.8 years, p < 0.001) and had higher incidence of comorbidities compared with OAR group. EVAR patients had lower in-hospital mortality (25.9 vs. 39.1%, p < 0.001) and shorter hospital stay (10.4 vs. 13.7 days, p < 0.001). More patients were discharged home following EVAR (36.8 vs. 21.5%, p < 0.001). There was reduced need for institutional rehabilitation following EVAR (26.3 vs. 29.1%, p < 0.001). Females had significantly higher mortality compared with males after both EVAR (32.2 vs. 24.1%, p < 0.001) and OAR (46.2 vs. 36.9%, p < 0.001). The hospital mortality (41.3-25.8%, p < 0.001) and mean length of stay (11.8-9.7 days, p < 0.01) of EVAR steadily improved over the study period. CONCLUSIONS National level comparison of data from the past decade shows that in suitable cases, EVAR for ruptured AAA is associated with reduced hospital mortality, shorter hospital stay, and reduced need for rehabilitation. EVAR outcomes showed consistent improvement with time. Regardless of the type of repair, women had higher mortality compared with men.
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Affiliation(s)
- Prasoon P Mohan
- Diagnostic and Interventional Radiology, St. Francis Hospital, 355 Ridge Avenue, Evanston, IL, 60202, USA,
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De Rango P, Lenti M, Cieri E, Simonte G, Cao P, Richards T, Manzone A. Association between sex and perioperative mortality following endovascular repair for ruptured abdominal aortic aneurysms. J Vasc Surg 2013; 57:1684-92. [DOI: 10.1016/j.jvs.2013.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 03/18/2013] [Accepted: 03/20/2013] [Indexed: 02/07/2023]
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Mehta M, Paty PS, Byrne J, Roddy SP, Taggert JB, Sternbach Y, Ozsvath KJ, Darling RC. The impact of hemodynamic status on outcomes of endovascular abdominal aortic aneurysm repair for rupture. J Vasc Surg 2013; 57:1255-60. [DOI: 10.1016/j.jvs.2012.11.042] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 11/05/2012] [Accepted: 11/06/2012] [Indexed: 12/17/2022]
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Mohan PP, Rozenfeld M, Kane RA, Calandra JD, Hamblin MH. Nationwide trends in abdominal aortic aneurysm repair and use of endovascular repair in the emergency setting. J Vasc Interv Radiol 2012; 23:338-44. [PMID: 22365291 DOI: 10.1016/j.jvir.2011.11.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 10/29/2011] [Accepted: 11/06/2011] [Indexed: 10/28/2022] Open
Abstract
PURPOSE To analyze nationwide trends in abdominal aortic aneurysm (AAA) repair and the use of endovascular abdominal aortic aneurysm repair (EVAR) in the emergency setting. MATERIALS AND METHODS Data were obtained from the Nationwide Inpatient Sample (NIS) using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes for open and endovascular repairs from 2001-2009. Trends in outcome parameters and hospital charges were compared. RESULTS The number of emergency EVAR procedures increased from 382 in 2001 to 1,247 in 2009 (P < .001). During the study period, length of hospital stay associated with total number of EVAR procedures decreased from 3.8 days to 3.4 days (P < .05), and the in-hospital mortality decreased from 2.4% to 2% (P = .32). From 2001-2009, mean hospital charges associated with EVAR increased from $50,630 to $91,401 (74% increase), whereas charges associated with open repairs increased from $54,578 to $128,925 (136% increase). The proportion of patients needing rehabilitation or nursing home placement after EVAR increased from 5.8% to 7.7% (P < .01), and need for home health increased from 6.9% to 10.5% (P < .01). CONCLUSIONS There was a significant increase in the number of emergency EVAR procedures during the study period; however, the overall in-hospital mortality associated with EVAR remained unchanged, and the length of hospital stay showed a decreasing trend. The total hospital charges for EVAR were lower than the charges for open abdominal aneurysm repair throughout the study period; the difference in charges between the procedures showed a significant increasing trend with time.
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Affiliation(s)
- Prasoon P Mohan
- Department of Diagnostic and Interventional Radiology, St Francis Hospital, Evanston, IL 60202, USA.
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Saqib N, Park SC, Park T, Rhee RY, Chaer RA, Makaroun MS, Cho JS. Endovascular repair of ruptured abdominal aortic aneurysm does not confer survival benefits over open repair. J Vasc Surg 2012; 56:614-9. [PMID: 22572008 DOI: 10.1016/j.jvs.2012.01.081] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 12/29/2011] [Accepted: 01/03/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Endovascular repair of ruptured abdominal aortic aneurysm (rAAA) is being increasingly performed despite lack of good evidence for its superiority. Other reported studies suffer from patient selection and publication bias with limited follow-up. This study is a single-center propensity score comparing early and midterm outcomes between open surgical repair (OSR) and endovascular repair of rAAA (REVAR). METHODS A retrospective review from January 2001 to November 2010 identified 312 patients who underwent rAAA repairs. Thirty-one patients with antecedent AAA repair and three with incomplete records were excluded, leaving 37 REVARs and 241 OSRs. Propensity score-based matching for sex, age, preoperative hemodynamic status, surgeon's annual AAA volume, and preoperative cardiopulmonary resuscitation was performed in a 1:3 ratio to compare outcomes. Thirty-seven REVARs were matched with 111 OSRs. Late survival was estimated by Kaplan-Meier methods. RESULTS Operative time and blood replacement were higher with OSR. Overall complication rates were similar (54% REVAR vs 66% OSR; P = .23), except for higher incidences of tracheostomies (21% vs 3%; P = .015), myocardial infarction (38% vs 18%; P = .036), and acute tubular necrosis (47% vs 21%; P = .009) with OSR. Operative mortality rates were similar (22% REVAR vs 32% OSR), with an odds ratio of 0.63 for REVAR (95% confidence interval = [0.24, 1.48]; P = .40). No differences in the incidences for secondary interventions for aneurysm- or graft-related complications were noted (22% REVAR vs 22% OSR; P = .99). Kaplan-Meier estimates of 1-, 2-, and 3-year survival rates were also similar (50%, 50%, 42% REVAR vs 54%, 52%, 47% OSR; P = .66). CONCLUSIONS REVAR for rAAA does not seem to conclusively confer either acute or late survival advantages. Routine use of REVAR should be deferred until prospective, randomized trial data become available.
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Affiliation(s)
- Naveed Saqib
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa 15213, USA
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Mid-term Outcomes following Emergency Endovascular Aortic Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2012; 43:382-5. [DOI: 10.1016/j.ejvs.2011.12.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 12/20/2011] [Indexed: 11/17/2022]
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Ten Bosch J, Cuypers P, van Sambeek M, Teijink J. Current insights in endovascular repair of ruptured abdominal aortic aneurysms. EUROINTERVENTION 2011; 7:852-8. [DOI: 10.4244/eijv7i7a133] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Karkos CD, Sutton AJ, Bown MJ, Sayers RD. A meta-analysis and metaregression analysis of factors influencing mortality after endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2011; 42:775-86. [PMID: 21908210 DOI: 10.1016/j.ejvs.2011.07.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 07/19/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine factors that may influence the perioperative mortality after endovascular repair of ruptured abdominal aortic aneurysms (RAAAs) using metaregression analysis. METHODS A meta-analysis of all English-language literature with information on mortality rates after endovascular repair of RAAAs was conducted. A metaregression was subsequently performed to determine the impact on mortality of the following 8 factors: patient age; mid-time study point; anaesthesia; endograft configuration; haemodynamic instability; use of aortic balloon; conversion to open repair; and abdominal compartment syndrome. RESULTS The pooled perioperative mortality across the 46 studies (1397 patients) was 24.3% (95% CI: 20.7-28.3%). Of the 8 variables, only bifurcated approach was significantly associated with reduced mortality (p = 0.005). A moderate negative correlation was observed between bifurcated approach and haemodynamic instability (-0.35). There was still a strong association between bifurcated approach and mortality after simultaneously adjusting for haemodynamic instability, indicating that the latter was not a major factor in explaining the observed association. CONCLUSIONS Endovascular repair of RAAAs is associated with acceptable mortality rates. Patients having a bifurcated endograft were less likely to die. This may be due to some surgeons opting for a bifurcated approach in patients with better haemodynamic condition. Further studies will be needed to clarify this.
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Affiliation(s)
- C D Karkos
- The 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocratio Hospital, Greece.
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Mehta M, Kreienberg PB, Roddy SP, Paty PSK, Taggert JB, Sternbach Y, Hnath J, Ozsvath KJ, Chang BB, Shah DM, Darling RC. Ruptured abdominal aortic aneurysm: endovascular program development and results. Semin Vasc Surg 2011; 23:206-14. [PMID: 21194637 DOI: 10.1053/j.semvascsurg.2010.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality when compared to the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help ones ability to deal with not just the technical aspects of these procedures, but also address some of the challenges including: the availability of preoperative CT, the choice of anesthesia, percutaneous vs. femoral cut-down approach, use of aortic occlusion balloons, need for bifurcated vs. aorto-uniiliac stentgrafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.
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Affiliation(s)
- Manish Mehta
- The Vascular Group, PLLC, 43 New Scotland Avenue, Albany, NY 12208, USA.
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Ricotta JJ, Malgor RD, Oderich GS. Ruptured Endovascular Abdominal Aortic Aneurysm Repair: Part II. Ann Vasc Surg 2010; 24:269-77. [DOI: 10.1016/j.avsg.2009.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Accepted: 08/21/2009] [Indexed: 12/11/2022]
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Davenport DL, O'Keeffe SD, Minion DJ, Sorial EE, Endean ED, Xenos ES. Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2010; 51:305-9.e1. [DOI: 10.1016/j.jvs.2009.08.086] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 08/26/2009] [Accepted: 08/26/2009] [Indexed: 11/25/2022]
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Giles KA, Hamdan AD, Pomposelli FB, Wyers MC, Dahlberg SE, Schermerhorn ML. Population-based outcomes following endovascular and open repair of ruptured abdominal aortic aneurysms. J Endovasc Ther 2010; 16:554-64. [PMID: 19842719 DOI: 10.1583/09-2743.1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate national outcomes after endovascular and open surgical repair of ruptured abdominal aortic aneurysms (rAAA). METHODS The Nationwide Inpatient Sample was interrogated to identify all repairs between 2000 and 2005 for rAAA based on ICD-9 codes. In the study period, 2323 patients (1794 men; median age 75 years, range 45-98) with rAAAs had endovascular repair, while 26,106 patients (20,311 men; median age 73 years, range 22-99) had an open procedure. Outcomes included in-hospital mortality, length of stay (LOS), complications, and hospitalization charge. A secondary analysis was performed to compare outcomes from low-, medium-, and high-volume institutions based on annual rAAA repair volume. RESULTS Patients in the endovascular group were significantly older (p<0.05). Mortality was 41% overall: 33% and 41% for endovascular versus open repair, respectively (p<0.001). Mortality after endovascular repair was lower than open surgery for patients >or=70 years (36% versus 47%, p<0.001), but not for those <70 years (24% versus 30%, p = 0.15). LOS was shorter after endovascular repair (7 versus 9 days, p<0.001). Respiratory complications (8% versus 4%, p<0.05) and acute renal failure were more common following open repair (30% versus 23%, p<0.01). Costs were similar (endo $73,590 versus open $67,287, p = 0.15). Mortality decreased as hospital surgical volume increased (low 44%, medium 39%, high 38%; p<0.001). Over time, endovascular repair utilization increased more rapidly at high-volume centers, and a lower mortality was seen with endovascular repair at high-volume compared to low-volume hospitals (22% versus 44%, p<0.001). Multivariate predictors of mortality were age, female gender, lower hospital surgical volume, open repair, and year of surgery. CONCLUSION This population-based study found that mortality associated with rAAAs may be improved by the performance of endovascular repair, especially in older patients. Mortality after rAAA for both endovascular and open repairs was also lower at high-volume institutions.
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Affiliation(s)
- Kristina A Giles
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Huddle MG, Schlösser FJ, Dewan MC, Indes J, Muhs BE. Can Laboratory Tests Predict the Prognosis of Patients after Endovascular Aneurysm Repair? Current Status and Future Directions. Vascular 2009; 17:129-37. [DOI: 10.2310/6670.2009.00011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The purpose of this study was to determine what laboratory values predict the prognosis of patients after endovascular aneurysm repair (EVAR). MEDLINE and Cochrane Library databases were searched. This resulted in 13 relevant articles. Data were pooled, and meta-analyses were performed. A meta-analysis including 5,655 patients showed that preoperative serum creatinine > 1.5 mg/dL was a significant risk indicator for increased 30-day mortality (relative risk 3.0, 95% confidence interval 2.3–4.1, p < .0001). Four other studies showed that other cutoff values of creatinine or glomerular filtration rate can predict mortality and complications following EVAR. One study suggested that reduced preoperative hemoglobin is a risk indicator for reduced long-term survival. Increased serum creatinine, reduced glomerular filtration rate, and reduced hemoglobin are significant and strong predictors of mortality and complications after EVAR. Current evidence remains limited, and further research is needed to determine conclusively additional laboratory values that may predict the outcome of patients following EVAR.
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Affiliation(s)
- Matthew G. Huddle
- *Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT; †Department of Chemistry, Illinois Wesleyan University, Bloomington, IL
| | - Felix J.V. Schlösser
- *Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT; †Department of Chemistry, Illinois Wesleyan University, Bloomington, IL
| | - Michael C. Dewan
- *Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT; †Department of Chemistry, Illinois Wesleyan University, Bloomington, IL
| | - Jeffrey Indes
- *Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT; †Department of Chemistry, Illinois Wesleyan University, Bloomington, IL
| | - Bart E. Muhs
- *Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT; †Department of Chemistry, Illinois Wesleyan University, Bloomington, IL
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Philipsen TE, Hendriks JM, Lauwers P, Voormolen M, d'Archambeau O, Schwagten V, Fias L, Van Schil PE. The Use of Rapid Endovascular Balloon Occlusion in Unstable Patients with Ruptured Abdominal Aortic Aneurysm. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009. [DOI: 10.1177/155698450900400204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Tine E. Philipsen
- Departments of Thoracic and Vascular Surgery, University Hospital Antwerp, Edegem, Belgium
| | - Jeroen M. Hendriks
- Departments of Thoracic and Vascular Surgery, University Hospital Antwerp, Edegem, Belgium
| | - Patrick Lauwers
- Departments of Thoracic and Vascular Surgery, University Hospital Antwerp, Edegem, Belgium
| | - Maurits Voormolen
- Departments of Radiology, and University Hospital Antwerp, Edegem, Belgium
| | | | - Veerle Schwagten
- Departments of Emergency Medicine, University Hospital Antwerp, Edegem, Belgium
| | - Lore Fias
- Departments of Thoracic and Vascular Surgery, University Hospital Antwerp, Edegem, Belgium
| | - Paul E. Van Schil
- Departments of Thoracic and Vascular Surgery, University Hospital Antwerp, Edegem, Belgium
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Coppi G, Gennai S, Saitta G, Silingardi R, Tasselli S. Treatment of ruptured abdominal aortic aneurysm after endovascular abdominal aortic repair: A comparison with patients without prior treatment. J Vasc Surg 2009; 49:582-8. [DOI: 10.1016/j.jvs.2008.10.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Revised: 10/07/2008] [Accepted: 10/11/2008] [Indexed: 10/21/2022]
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Giles KA, Pomposelli F, Hamdan A, Wyers M, Jhaveri A, Schermerhorn ML. Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair. J Vasc Surg 2009; 49:543-50; discussion 550-1. [PMID: 19135843 DOI: 10.1016/j.jvs.2008.09.067] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Revised: 09/03/2008] [Accepted: 09/06/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE With the expansion of elective abdominal aortic aneurysm (AAA) repair after the introduction of endovascular aneurysm repair (EVAR), there is a concern that even with a lower operative mortality there could be an increasing number of aneurysm-related deaths. To evaluate this, we looked at national trends in AAA repair volume as well as mortality rates after intact and ruptured AAA repair encompassing the introduction of EVAR. METHODS Patients with intact or ruptured AAA undergoing open repair or EVAR and all those with a diagnosis of ruptured AAA were identified within the 1993 to 2005 Nationwide Inpatient Sample database using International Classification of Diseases, 9th Revision, diagnosis and procedure codes. The number of repairs, number of rupture diagnoses without repair, number of deaths, and associated mortality rates were measured for each year of the database. Outcomes (mean annual volumes) were compared from the pre-EVAR era (1993 to 1998) with the post-EVAR era (2001 to 2005). RESULTS Since its introduction, EVAR increased steadily and accounted for 56% of repairs yet only 27% of the deaths for intact repairs in 2005. The mean annual number of intact repairs increased from 36,122 in the pre-EVAR era to 38,901 in the post-EVAR era, whereas the mean annual number of deaths related to intact AAA repair decreased from 1693 pre-EVAR to 1207 post-EVAR (P < .0001). Mortality for all intact AAA repair decreased from 4.0% to 3.1% (P < .0001) pre-EVAR and post-EVAR, but open repair mortality was unchanged (open repair, 4.7% to 4.5%, P = .31; EVAR, 1.3%). During the same time, the mean annual number of ruptured repairs decreased from 2804 to 1846, and deaths from ruptured AAA repairs decreased from 2804 to 1846 (P < .0001). Mortality for ruptured AAA repair decreased from 44.3% to 39.9% (P < .0001) pre-EVAR and post-EVAR (open repair, 44.3% to 39.9%, P < .001; EVAR, 32.4%). The overall mean annual number of ruptured AAA diagnoses (9979 to 7773, P < .0001) and overall mean annual deaths from a ruptured AAA decreased post-EVAR (5338 to 3901, P < .0001). CONCLUSION Since the introduction of EVAR, the annual number of deaths from intact and ruptured AAA has significantly decreased. This coincided with an increase in intact AAA repair after the introduction of EVAR and a decrease in ruptured AAA diagnosis and repair volume.
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Slater BJ, Harris EJ, Lee JT. Anatomic Suitability of Ruptured Abdominal Aortic Aneurysms for Endovascular Repair. Ann Vasc Surg 2008; 22:716-22. [DOI: 10.1016/j.avsg.2008.06.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Revised: 04/29/2008] [Accepted: 06/10/2008] [Indexed: 11/26/2022]
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Rafii BY, Abilez OJ, Benharash P, Zarins CK. Lateral Movement of Endografts Within the Aneurysm Sac Is an Indicator of Stent-Graft Instability. J Endovasc Ther 2008; 15:335-43. [DOI: 10.1583/08-2422.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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