Decrease in total aneurysm-related deaths in the era of endovascular aneurysm repair

The rise of endovascular repair for abdominal, thoracoabdominal, and thoracic aortic aneurysms

BACKGROUND

Given changes in intervention guidelines and the growing popularity of endovascular treatment for aortic aneurysms, we examined the trends in admissions and repairs of abdominal aortic aneurysms (AAAs), thoracoabdominal aortic aneurysms (TAAAs), and thoracic aortic aneurysms (TAAs).

METHODS

We identified all patients admitted with ruptured aortic aneurysms and intact aortic aneurysms repaired in the Nationwide Inpatient Sample between 2004 and 2019. We then examined the use of open, endovascular, and complex endovascular repair (OAR, EVAR, and cEVAR) for each aortic aneurysm location (AAA, TAAA, and TAA), alongside their resulting in-hospital mortality, over time. cEVAR included branched, fenestrated, and physician-modified endografts.

RESULTS

715,570 patients were identified with AAA (87% intact repairs and 13% rupture admissions). Both intact AAA repairs and ruptured AAA admissions decreased significantly between 2004 and 2019 (intact 41,060-34,215, P < .01; ruptured 7175-4625, P = .02). Of all AAA repairs performed in a given year, the use of EVAR increased (2004-2019: intact 45%-66%, P < .01; ruptured 10%-55%, P < .01) as well as cEVAR (2010-2019: intact 0%-23%, P < .01; ruptured 0%-14%, P < .01). Mortality after EVAR of intact AAAs decreased significantly by 29% (2004-2019, 0.73%-0.52%, P < .01), whereas mortality after OAR increased significantly by 16% (2004-2019, 4.4%-5.1%, P < .01). In the study, 27,443 patients were identified with TAAA (80% intact and 20% ruptured). In the same period, intact TAAA repairs trended upward (2004-2019, 1435-1640, P = .055), and cEVAR became the most common approach (2004-2019, 3.8%-72%, P = .055). A total of 141,651 patients were identified with ascending, arch, or descending TAAs (90% intact and 10% ruptured). Intact TAA repairs increased significantly (2004-2019, 4380-10,855, P < .01). From 2017 to 2019, the mortality after OAR of descending TAAs increased and mortality after thoracic endovascular aneurysm repair decreased (2017-2019, OAR 1.6%-3.1%; thoracic endovascular aneurysm repair 5.2%-3.8%).

CONCLUSIONS

Both intact AAA repairs and ruptured AAA admissions significantly decreased between 2004 and 2019. The use of endovascular techniques for the repair of all aortic aneurysm locations, both intact and ruptured, increased over the past two decades. Most recently in 2019, 89% of intact AAA repairs, infrarenal through suprarenal, were endovascular (EVAR or cEVAR, respectively). cEVAR alone increased to 23% of intact AAA repairs in 2019, from 0% a decade earlier. In this period of innovation, with many new options to repair aortic aneurysms while maintaining arterial branches, endovascular repair is now used for the majority of all intact aortic aneurysm repairs. Long-term data are needed to evaluate the durability of these procedures.

Imaging in Interventional Radiology: Applications of Contrast-Enhanced Ultrasound

This review explores the applications of contrast-enhanced ultrasound (CEUS) in interventional radiology, focusing on its role in endoleak detection after endovascular abdominal aortic aneurysm repair (EVAR), periprocedural thermal ablation guidance, and transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). CEUS offers a dynamic assessment for the detection of endoleak following EVAR, facilitating accurate diagnosis and classification. In periprocedural thermal ablation, CEUS enhances target lesion delineation with the visualization of real-time perfusion changes, optimizing treatment strategies and reducing residual tumor rates. Finally, CEUS has demonstrated efficacy in intraprocedural evaluation and postprocedural follow-up in TACE for HCC, offering early detection of residual tumor enhancement and providing an alternative for patients with contraindications to contrast-enhanced computed tomography or magnetic resonance imaging. Overall, CEUS is a versatile and valuable tool with many applications to offer interventional radiologists enhanced diagnostic capabilities and improved patient management.

Incidence and Outcomes of Bloodstream Infection After Arterial Aneurysm Repair: Findings From a Population-Based Study

Background

Limited research has focused on bloodstream infection (BSI) in patients with arterial grafts. This study aims to describe the incidence and outcomes of BSI after arterial aneurysm repair in a population-based cohort.

Methods

The expanded Rochester Epidemiology Project (e-REP) was used to analyze aneurysm repairs in adults (aged ≥18 years) residing in 8 counties in southern Minnesota from January 2010 to December 2020. Electronic records were reviewed for the first episode of BSI following aneurysm repair. BSI patients were assessed for vascular graft infection (VGI) and followed for all-cause mortality.

Results

During the study, 643 patients had 706 aneurysm repairs: 416 endovascular repairs (EVARs) and 290 open surgical repairs (OSRs). Forty-two patients developed BSI during follow-up. The 5-year cumulative incidence of BSI was 4.7% (95% confidence interval [CI], 3.0%-6.4%), with rates of 4.0% (95% CI, 1.8%-6.2%) in the EVAR group and 5.8% (95% CI, 2.9%-8.6%) in the OSR group (P = .052). Thirty-nine (92.9%) BSI cases were monomicrobial, 33 of which were evaluated for VGI. VGI was diagnosed in 30.3% (10/33), accounting for 50.0% (8/16) of gram-positive BSI cases compared to 11.8% (2/17) of gram-negative BSI cases (P = .017). The 1-, 3-, and 5-year cumulative post-BSI all-cause mortality rates were 22.2% (95% CI, 8.3%-34.0%), 55.8% (95% CI, 32.1%-71.2%), and 76.8% (95% CI, 44.3%-90.3%), respectively.

Conclusions

The incidence of BSI following aneurysm repair was overall low. VGI was more common with gram-positive compared to gram-negative BSI. All-cause mortality following BSI was high, which may be attributed to advanced age and significant comorbidities in our cohort.

Vascular Graft Infection After Aneurysm Repair: A Population-Based Study

OBJECTIVE

To describe the incidence, epidemiology, and outcomes of vascular graft infection (VGI) in a population-based study in southern Minnesota.

PATIENTS AND METHODS

Retrospective review of all adult patients from 8 counties who underwent arterial aneurysm repair between January 1, 2010, and December 31, 2020. Patients were identified through the expanded Rochester Epidemiology Project. The Management of Aortic Graft Infection Collaboration criteria were used to define VGI.

RESULTS

A total of 643 patients underwent 708 aneurysm repairs: 417 endovascular (EVAR) and 291 open surgical (OSR) repairs. Of these patients, 15 developed a VGI during median follow-up of 4.1 years (interquartile range, 1.9-6.8 years), corresponding to a 5-year cumulative incidence of 1.6% (95% CI, 0.6% to 2.7%). The cumulative incidence of VGI 5 years after EVAR was 1.4% (95% CI, 0.2% to 2.6%) compared with 2.0% (95% CI, 0.3% to 3.7%) after OSR (P=.843). Of the 15 patients with VGI, 12 were managed conservatively without explantation of the infected graft/stent. Ten died during median follow-up from VGI diagnosis of 6.0 years (interquartile range, 5.5-8.0 years), including 8 of the 12 patients treated conservatively.

CONCLUSION

The VGI incidence in this study was overall low. There was no statistically significant difference in VGI incidence after OSR and EVAR. The all-cause mortality rate after VGI was high and reflected an older cohort with multiple comorbid conditions.

The Impact of Endovascular Repair of Abdominal Aortic Aneurysms on Vascular Surgery Training in Open Aneurysm Repair

BACKGROUND

Since the introduction of endovascular aneurysm repair (EVAR) in 1992, the number of open AAA repair (OAR) cases continue to decline. The consequence of reduced OAR cases raises valid concerns related to patient safety and the future training of vascular surgeons that need to be appropriately addressed. Our objective is to analyze trends in OAR and EVAR cases and to assess their implications on the quality of vascular surgery training.

METHODS

We analyzed the Accreditation Council for Graduate Medical Education (ACGME) case log database for total clinical experience in OAR and EVAR for graduating vascular surgery fellows (VSFs) finishing 5 + 2 programs between 2002 and 2019 and vascular surgery integrated residents (VSRs) between 2013 and 2019. VSF case totals were calculated by combining average total cases of open and endovascular supra- and infrarenal AAA repair during fellowship years combined with total cases performed during their general surgery residency. VSR case totals included only the cases performed during the 5-year residency period. Isolated Iliac and thoracic aortic aneurysms were excluded from our analysis.

RESULTS

The average number of OAR cases per trainee has decreased by 60% (from 36.9 to 14.7) with a rate of 1.4 cases per year (P < 0.001) for VSF. Meanwhile, EVAR average cases have increased by 102% (from 22 to 44.4). However, there were 2 different trends exhibited with EVAR over the study period. Between 2002 and 2007, EVAR cases tended to increase by 5.9 cases per year (P < 0.001). Whereas, between 2007 and 2019, there was a slightly decreased trend in EVAR cases by 0.3 cases per year (P = 0.01). For VSR, while no significant trend was observed in the mean number of OAR cases (Coef. -0.3, P = 0.2) due to the limited time frame, the proportion of open cases was significantly lower compared to endovascular cases. Additionally, there were 2 different trends exhibited with EVAR over the study period. Between 2013 and 2015, EVAR cases tended to increase by 1.7 cases per year (P = 0.1). Whereas, between 2015 and 2019, there was a slightly decreased trend in EVAR cases by 0.2 cases per year (P = 0.007).

CONCLUSIONS

A significant reduction in average OAR cases and an increase in EVAR cases were observed over the study period. Vascular surgery training programs may need to introduce further training programs in open surgical repair to ensure vascular surgery trainees have the required technical skills and expertize to perform such a high-risk procedure safely and independently.

Increased aortic repair in Germany correlates with reduction of death caused by aortic aneurysms but not aortic dissections

INTRODUCTION

We asked if there is a significant correlation between the increasing trend in aortic repair (AR) and decreasing aortic aneurysm (AA) and aortic dissection (AD) mortality? Therefore, we retrospectively analyzed all aortic repairs in patients with AA and AD and its correlation with disease-specific death rates and hospitalizations for ruptured AA and AD in Germany.

METHODS

We retrieved the number of cases hospitalized for AA and AD as well as the procedures in these cases from the Federal Bureau of Statistics (DRG statistics) and death rates from the national mortality statistic published by the Federal Statistical Office in Germany for the years 2006-2017.

RESULTS

From 2006 to 2017, the total number of hospitalized cases admitted with principal diagnosis of AA increased by 25.8% and that of AD by 56.7%. That of cases with the principal diagnosis of ruptured AA (rAA) remained unchanged (-2.5%) and that with rAD increased by 54.6%. The number of (open and endovascular) procedures in cases hospitalized for AA increased by 39.4% and for AD by 126.4%. The age-adjusted death rates in Germany for AA decreased from 4.0 to 2.9 per 100,000 inhabitants and that for AD increased from 1.0 to 1.4. The decrease in death attributed to AA cases can be described by linear regression as y = -0.0003*y + 6.7076 (p < 0.0001). Accepting this association between increased elective procedures and reduced AA mortality, each/all 1000 procedures save 0.3 lives per 100,000 inhabitants.

CONCLUSION

Despite increasing numbers of AR for AA and AD, only the mortality rate for all AAs decreased, while we did not observe a decrease in overall mortality of AD in Germany.

Long-Term Results of Complex Abdominal Aortic Aneurysm Open Repair

This study investigated the long-term outcomes of patients treated with open surgical repair for complex abdominal aortic aneurysms (c-AAAs). A total of 119 patients with c-AAAs undergoing repair between January 2010 and June 2016 in a high-volume aortic center were included. The long-term imaging follow-up consisted of yearly abdominal ultrasound examinations and 5-year computed tomography angiography. At a median follow-up of 76 months (IQR 38 months), forty-three deaths (37%) and three (2.5%) aortic-related deaths were observed. Long-term chronic renal decline was observed in fifty (43.8%) patients, significantly correlated with post-operative acute kidney injury. During the follow-up, five reinterventions (4.3%) were performed. The present study suggests that open c-AAA repair can be performed with acceptable operative risk with durable results. To achieve the best possible long-term outcome, the open surgery repair of complex AAA should be performed in high-volume aortic centers and tailored to the patient.

Embolization for Type Ia Endoleak after EVAR for Abdominal Aortic Aneurysms: A Systematic Review of the Literature

(1) Successful endovascular repair for abdominal aortic aneurysms is based on the complete exclusion of the aneurysm sac from the systemic circulation. Type Ia endoleak (ELIA) is defined as the persistent perfusion of the aneurysm sac due to incomplete proximal sealing between aorta and endograft, with a consequent risk of rupture and death. Endoleak embolization has been sporadically reported as a viable treatment for ELIA. (2) A systematic literature search in PubMed of all publications in English about ELIA embolization was performed until February 2022. Research methods and reporting were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Data regarding patient numbers, technical success (endoleak absence at control angiography), reinterventions, clinical and imaging follow-up, and outcomes were collected and examined by two independent authors. (3) Twenty-one papers (12 original articles, 9 case reports) reported on 126 patients (age range 58-96 years) undergoing ELIA embolization 0-139 months after the index procedure. Indication for embolization was most often founded on unfavorable anatomy and patient comorbidities. Embolic agents used include liquid embolic agents, coils, plugs and combinations thereof. Technical success in this highly selected cohort ranged from 67-100%; the postprocedural complication rate within 30 days was 0-24%. ELIA recurrence was reported as 0-42.8%, with a secondary ELIA-embolization-intervention success rate of 50-100%. At a follow-up at 0-68 months, freedom from sac enlargement amounted to 76-100%, freedom from ELIA to 66.7-100%. (4) Specific literature about ELIA embolization is scant. ELIA embolization is a valuable bailout strategy for no-option patients; the immediate technical success rate is high and midterm and long-term outcomes are acceptable.

Single centre experience with Excluder® stent graft; 17-year outcome

BACKGROUND

Endovascular abdominal aortic aneurysm repair (EVAR) has become a mainstay of abdominal aorta aneurysm treatment. Long term follow-up on specific stent grafts is needed.

PATIENTS AND METHODS

This study included 123 patients (104 men; mean age 73.0 years, range 51-89) with abdominal aorta aneurysm, treated with Excluder^® stent graft between October 2002 and June 2008. Periprocedural and follow-up data were retrieved by reviewing the records of our institution, while time and cause of death were retrieved from the National Institute of Public Health. If an abdominal aortic aneurysm rupture was listed as the cause of death, records were retrieved from the institution that issued the death certificate. Our primary goal was to assess the primary technical success rate, type 1 and type 2 endoleak, reintervention free survival, 30-day mortality, the overall survival and aneurysm rupture-free survival.

RESULTS

The median follow-up was 9.7 years (interquartile range, 4.6-13.8). The primary technical success was 98.4% and the 30-day mortality accounted for 0.8%. Secondary procedures were performed in 29 (23.6%) patients during the follow-up period. The one-, five-, ten-, fifteen- and seventeen-year overall survival accounted for 94.3%, 74.0%, 47.2%, 35.8% and 35.8%, while the aneurysm-related survival was 98.4%, 96.3%, 92.6%, 92.6%, 92.6%. In seven (5.7%) patients, abdominal aortic rupture was found as the primary cause of death during follow-up.

CONCLUSIONS

Our data showed that EVAR with Excluder^® stent graft offers good long-term results. More than 75% of patients can be treated completely percutaneously. Late ruptures do occur in the first ten years, raising awareness about regular medical controls.

Racial Disparities Associated With Reinterventions After Elective Endovascular Aortic Aneurysm Repair

BACKGROUND

There are substantial racial and socioeconomic disparities underlying endovascular abdominal aortic aneurysm repair (EVAR) in the United States. To date, race-based variations in reinterventions following elective EVAR have not been studied. Here, we aim to examine racial disparities associated with reinterventions following elective EVAR in a real-world cohort.

MATERIALS AND METHODS

We used the Vascular Quality Initiative EVAR dataset to identify all patients undergoing elective EVAR between January 2009 and December 2018 in the United States. We compared the association of race with reinterventions after EVAR and all-cause mortality using Welch two-sample t-tests, multivariate logistic regression, and Cox proportional hazards analyses adjusting for baseline differences between groups.

RESULTS

At median follow-up of 1.1 ± 1.1 y (1.3 ± 1.4 y Black, 1.1 ± 1.1 y White; P = 0.02), a total of 1,164 of 42,481 patients (2.7%) underwent reintervention after elective EVAR, including 2.7% (n = 1,096) White versus 3.2% (n = 68) Black (P = 0.21). Black patients requiring reintervention were more frequently female, more frequently current or former smokers, and less frequently insured by Medicare/Medicaid (P < 0.05). After adjusting for baseline differences, the risk of reintervention after elective EVAR was significantly lower for Black versus White patients (HR 0.74, 95% CI 0.55-0.99; P = 0.04). All-cause mortality was comparable between groups (HR 0.81, 95% CI 0.33-2.00, P = 0.65).

CONCLUSIONS

There are significant differences between Black and White patients in the risk of reintervention after elective EVAR in the United States. The etiology of this difference deserves investigation.

Effect of vertebral compression fractures on aortic neck angulation after endovascular aneurysm repair

OBJECTIVE

Aortic neck angulation (ANA) prior to endovascular aneurysm repair (EVAR) and its changes after EVAR are considered important predictors of postoperative complications. We sought to assess the effects of vertebral body height loss on ANA in patients post-EVAR.

METHODS

All patients who had undergone EVAR for infrarenal aortic aneurysms in our institution between August 2010 and December 2018 were assessed. Anterior and posterior vertebral body heights were measured in all patients on preoperative, early postoperative, and follow-up computed tomography scans (T12-L5 vertebral bodies). Patients who had significant height loss in their follow-up period were designated as the Study group. These were matched to a Control group of the same size using propensity-score matching based on age, gender, and duration between follow-up scans. Aortic neck morphology indices including ANA and its changes were measured, and information related to postoperative endoleaks and aneurysm sac size were extracted in the Study and Control groups.

RESULTS

During the follow-up period, 10 of 185 patients had a radiologically significant vertebral body compression fracture. There was no significant difference between the Study (n = 10) and Control groups in age (77.6 ± 6.9 vs 77.2 ± 7.5 years; P = .64), gender (seven males and three females in each group; P = 1.0), duration between postoperative scans (1830 ± 665 vs 1800 ± 670 days; P = .25), preoperative ANA (36.0° ± 15.6° vs 42.4° ± 18.6°; P = .41), and early postoperative ANA (21.9° ± 11.7° vs 20.9° ± 16.3°; P = .72). Changes in ANA in the postoperative period (7.2° ± 11.1° vs -4.7° ± 6.7°; P = .009; power = .838) were significantly higher in the Study group.

CONCLUSION

Post-EVAR vertebral body compression fractures exacerbate ANA. Awareness of this can guide both preoperative assessment and postoperative management and follow-up.

Long-term outcome results after endovascular aortoiliac aneurysm repair with the bifurcated EXCLUDER Endoprosthesis

OBJECTIVE

To report the long-term outcome of patients presenting with an aortic, aortoiliac, or isolated common iliac aneurysm treated with the bifurcated EXCLUDER Endoprosthesis. Furthermore, potential differences in late outcome results between the original- and low-permeability endoprosthesis were analyzed.

METHODS

A retrospective analysis of prospectively collected data of 182 patients who underwent endovascular aneurysm repair with the EXCLUDER Endoprosthesis between June 1998 and October 2015 in an academic, tertiary care center for aortic disease was performed. Patient follow-up was from 3 to 20 years (mean follow-up of 6.9 years). Primary end points were overall survival and reintervention-free survival. Secondary end points were device-related complications, endoleaks, and reinterventions.

RESULTS

Overall survival at 5, 10, and 15 years was 72.8%, 42.1%, and 12.2%, respectively, with no aneurysm-related mortality and no difference in overall survival between the original- vs low-permeability endoprosthesis group (P = .617). Freedom from type I endoleak at 5 years was 94.8%. No new type I endoleak was detected beyond the 5-year follow-up mark. No type III endoleak was identified. Reintervention-free survival was 83.6%, 66.7%, and 66.7% at 5-, 10-, and 15-year follow-up, respectively. There was a significant difference in intervention-free survival between the original- vs low-permeability endoprosthesis group (P = .029) and after the 5-year follow-up mark. In addition, patients with the low-permeability endoprosthesis showed significantly fewer device-related complications (P = .002) and endoleaks (P = .005).

CONCLUSIONS

Endovascular aneurysm repair using the EXCLUDER Endoprosthesis is effective and durable on long-term follow-up, with acceptably low device-related complications and reinterventions. The low-permeability endoprosthesis was associated with significantly fewer new device-related complications and endoleaks after 5 years of follow-up.

Risk Analysis of Aneurysm Sac Enlargement Caused by Type II Endoleak after Endovascular Aortic Repair

BACKGROUND

Although the preoperative risk factors associated with the occurrence of type II endoleak (ETII) after endovascular aortic repair (EVAR) have gradually become more evident, the preoperative risk factors associated with aneurysm sac enlargement caused by ETII remain unclear. This study aimed to determine the preoperative risk factors associated with aneurysm sac enlargement caused by ETII after EVAR.

METHODS

This retrospective cohort study reviewed 519 EVARs performed for true abdominal aortic aneurysm between January 2006 and December 2018 at our institution. EVARs using commercially available bifurcated devices with no type I or III endoleaks during follow-up and with ≥12 months follow-up were included. A total of 320 patients were enrolled in the study. To identify the preoperative risk factors of sac enlargement after EVAR, Cox regression analysis was used to assess preoperative data.

RESULTS

The median follow-up period was 60.8 months. Overall, 135 of 320 patients (42%) had ETII during follow-up, and 47 of 135 patients (35%) developed aneurysm sac enlargement. Multivariate analysis revealed that chronic kidney disease (CKD) stage ≥4 (hazard ratio [HR], 4.65; 95% confidence interval [CI], 2.13-10.15; P = 0.001), patent inferior mesenteric artery (IMA) (HR, 17.85; 95% CI, 2.46-129.73; P< 0.001), and number of patent lumbar arteries (LAs) (HR, 1.37; 95% CI, 1.13-1.68; P= 0.002) were risk factors of aneurysm sac enlargement caused by ETII.

CONCLUSIONS

CKD stage ≥4, patent IMA, and number of patent LAs were independent risk factors for aneurysm sac enlargement after EVAR. In particular, patent IMA had the highest HR and seemed to have the greatest impact on long-term aneurysm sac enlargement. Hence, taking preoperative measures to address a patent IMA appears to be important in reducing the incidence of sac enlargement.

Intraluminal thrombus: Innocent bystander or factor in abdominal aortic aneurysm pathogenesis?

BACKGROUND

Abdominal aortic aneurysms (AAAs) represent a complex multifactorial hemodynamic, thrombotic, and inflammatory process that can ultimately result in aortic rupture and death. Despite improved screening and surgical management of AAAs, the mortality rates have remained high after rupture, and little progress has occurred in the development of nonoperative treatments. Intraluminal thrombus (ILT) is present in most AAAs and might be involved in AAA pathogenesis. The present review examined the latest clinical and experimental evidence for possible involvement of the ILT in AAA growth and rupture.

METHODS

A literature review was performed after a search of the PubMed database from 2012 to June 2020 using the terms "abdominal aortic aneurysm" and "intraluminal thrombus."

RESULTS

The structure, composition, and hemodynamics of ILT formation and propagation were reviewed in relation to the hemostatic and proteolytic factors favoring ILT deposition. The potential effects of the ILT on AAA wall degeneration and rupture, including a review of the current controversies regarding the position, thickness, and composition of ILT, are presented. Although initially potentially protective against increased wall stress, increasing evidence has shown that an increased volume and greater age of the ILT have direct detrimental effects on aortic wall integrity, which might predispose to an increased rupture risk.

CONCLUSIONS

ILT does not appear to be an innocent bystander in AAA pathophysiology. However, its exact role remains elusive and controversial. Despite computational evidence of a possible protective role of the ILT in reducing wall stress, increasing evidence has shown that the ILT promotes AAA wall degeneration in humans and in animal models. Further research, with large animal models and with more chronic ILT is crucial for a better understanding of the role of the ILT in AAAs and for the potential development of targeted therapies to slow or halt AAA progression.

Characteristics and Prognosis of Abdominal or Thoracic Aortic Aneurysm Patients Admitted to Intensive Care Units After Surgical Treatment: A Multicenter Retrospective Observational Study

Objective

To investigate the characteristics and prognosis of abdominal or thoracic aortic aneurysm (AAA or TAA) patients admitted to intensive care unit (ICU) postoperatively.

Methods

Patients admitted to ICU postoperatively with a primary diagnosis of AAA or TAA were screened in the eICU Collaborative Research Database, which contained data from multiple ICUs throughout the continental United States in 2014 and 2015. Baseline characteristics and comorbidities and were investigated and factors associated with ICU mortality were explored using univariable logistic regression. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the prognosis predictive performance of the widely used severity scoring system APACHE IVa.

Results

A total of 974 patients including 677 AAA and 297 TAA patients admitted to ICU postoperatively were included. Compared with TAA, AAA patients had a significantly higher median age (72 versus 64 years, P<0.001). 89.07% AAA and 84.51% TAA patients underwent elective surgery (P=0.046), 8.71% AAA and 31.99% TAA patients were with aortic dissection (P<0.001), and 10.19% AAA and 2.36% TAA patients suffered from rupture of aortic aneurysm (P<0.001). Hypertension requiring treatment was the most common comorbidity (57.31% for AAA and 61.95% for TAA). TAA patients had significantly higher ICU mortality (9.43% versus 2.36%, P<0.001) than AAA. Several factors were found to be significantly associated with ICU mortality, including urgent surgery, with aortic dissection, rupture of aortic aneurysm, TAA, and a higher APACHE IVa score on ICU admission. APACHE IVa showed a good predictive performance for ICU mortality with an area under the ROC curve of 0.9176 (95% CI 0.8789–0.9390).

Conclusion

The prognosis of aortic aneurysm patients admitted to ICU postoperatively is yet to improve, and factors associated with prognosis are mainly related to the condition itself. APACHE IVa can be used for prognosis prediction.

A Case Report on Endovascular Aortic Repair Rupture

Endovascular repair of an abdominal aortic aneurysm (AAA) is a widely accepted alternative to open surgical AAA repair. A ruptured AAA is among the emergency surgeries with the highest risk of death, with an overall mortality rate close to90%. However, the classic symptom triad for ruptured AAAs of hypotension, a pulsatile mass, and abdominal/back pain is seen in only in 25% to 50% of affected patients. Thus, many present with symptoms and signs that suggest adifferent diagnosis. Recognizing uncommon presentations and limitations of imaging and interpretation, in addition to clinical gestalt, can save many lives. This report discusses an unusual case involving a previously repaired AAA presenting with acute rupture at the endograft site.

Hospital Volume Matters: The Volume-Outcome Relationship in Open Juxtarenal AAA Repair

OBJECTIVE

We studied whether the volume-outcome relationship would persist in more complex aortic operations.

BACKGROUND

Despite the added complexity of the involvement of the renal arteries in open juxtarenal abdominal aortic aneurysm (AAA) repair, the volume effect in these difficult operations has yet to be defined.

METHODS

We identified all patients in the Vascular Quality Initiative (VQI) who underwent open AAA repair from 2003 to 2016. We calculated each hospital's average annual volume for total open AAA repairs, and total open juxtarenal AAA repairs. We compared adjusted perioperative and long-term survival across quintiles of hospital volume, and constructed models including both volume metrics to evaluate the cross-volume effects.

RESULTS

Of 8880 total open AAA repairs, there were 3470 open juxtarenal cases. Centers with low (<4), medium (4-14), and high (>14) volumes of open juxtarenal repair demonstrated adjusted perioperative mortality of 9.0%, 4.9%, and 3.9%, respectively (P < 0.01). When both volume metrics were considered, open juxtarenal volume, but not total open AAA volume was associated with perioperative mortality (lowest quintile of juxtarenal volume: OR 2.36 [1.29-4.30], P < 0.01). Hospital volume was not associated with adjusted long-term mortality. High volume centers were more likely to use renal protective strategies such as mannitol and cold renal perfusion (both P < 0.01). Low volume centers performed a similar proportion of cases each year, but 22 centers (13%) did stop performing repairs during the study period.

CONCLUSION

Hospitals with low annualized volumes of open juxtarenal repair have higher perioperative mortality, irrespective of their total open aortic volume. Complex open AAA repairs should be performed at experienced centers, and future efforts should focus on centralization of complex aortic care.

Geographic disparities in the application of endovascular repair of unruptured abdominal aortic aneurysm - Polish population analysis

PURPOSE

Differences between the regions of the same country regarding the management of abdominal aortic aneurysm (AAA) have rarely been published. The aim of the study was to analyze the absolute and relative number of unruptured AAA repairs, utilizing endovascular aneurysm repair (EVAR) vs. open aneurysm repairs (OAR) and compare the AAA patients population from all 16 administrative districts in Poland.

MATERIAL AND METHODS

We used the Polish National Health Fund data of all patients who underwent elective treatment of AAA between 1^st January 2011 and 22^nd March 2016 and analyzed the absolute/relative number of all AAA repairs, OAR, EVAR and incidence of concomitant diseases in distinctive regions. Relationships between the utilization of EVAR and the number of procedures, age, gender and concomitant diseases were studied.

RESULTS

A total of 7805 patients (mean age 70.9 ± 8.1 yrs) underwent OAR (n = 2336) or EVAR (n = 5469). The age and the incidence of concomitant diseases differed significantly between districts. The highest absolute number of all repairs was performed in the Masovian district (n = 1442), while the highest relative number of all repairs in the Lublin district (36.3/100,000 65+/year). The utilization of EVAR ranged from 34.5% to 93.9% and correlated positively with the number of EVAR, age and chronic obstructive pulmonary disease occurrence and negatively with OAR number.

CONCLUSIONS

Striking differences in the relative numbers of unruptured AAA repairs and in the population characteristics in various districts of the country point to the possibility of different health needs in the regions and variations in standards of care.

Long-Term Outcomes of Endovascular vs Open Surgical Repair for Abdominal Aortic Aneurysms: A Meta-Analysis of Randomized Trials

OBJECTIVE

The aim of this meta-analysis was to investigate whether Endovascular abdominal aortic aneurysm repair (EVAR) is inferior to open surgical repair in terms of adverse events during late follow up, defined as >8 years after the procedure.

BACKGROUND

EVAR is associated with reduced morbidity and mortality compared to open surgery in the early perioperative period. However, it is unknown whether this pattern remains during long-term follow up >8 years.

METHODS

A meta-analysis was conducted with the use of random effects modeling. Hazard ratios were calculated for mortality at different time intervals, and risk ratios were calculated in cases where the total number of events was available.

RESULTS

There was no difference in all-cause mortality during follow up of each study (HR: 1.04; 95%CI: 0.93-1.17; I² = 16.0%). Subgroup analyses for all-cause mortality at 4 to 8 years of follow up (HR: 1.13; 95%CI: 0.94-1.35; I² = 0.0%) and all-cause mortality at follow up >8 years (HR: 1.07; 95%CI: 0.89-0.28; I² = 36.6%) also did not show any significant difference between the two approaches. The risks of aneurysm-related mortality and aneurysm rupture were similar during follow-up. However, the cumulative risk for reintervention during follow up was greater in the EVAR group (RR: 2.18; 95%CI: 1.50-3.17; I² = 76.1%) and occurred in 29% vs 15% of patients in the EVAR vs surgery groups respectively.

CONCLUSIONS

EVAR and open surgical repair of AAA are equally safe and have no difference in all-cause mortality. However, endovascular repair is associated with an increased need for re-intervention. Emerging technology in endovascular devices will likely further improve the outcomes of EVAR. Subject codes: Meta-analysis; aneurysm; atherosclerosis; complications.

Cross-clamp location affects short-term survival in patients undergoing open abdominal aortic aneurysm repair

INTRODUCTION

Open abdominal aortic aneurysm (oAAA) repair in the era of advanced endovascular aortic techniques is used in challenging anatomy. The impact of the location of the proximal aortic cross-clamp (suprarenal [SR] vs infrarenal [IR]) on outcomes remains to be determined. The aim of this study was to analyze the effect of proximal aortic cross-clamp location on short-term and overall survival after oAAA repair in a contemporary series.

METHODS

A retrospective cohort study was performed comparing the outcomes of patients undergoing oAAA repair with SR and IR aortic cross-clamping using the Vascular Quality Initiative registry from January 2003 to September 2018. Our primary end point was short-term mortality.

RESULTS

There were 7601 patients who underwent oAAA repair. Their mean age was 69.3 ± 8.5 years and 5555 patients (73.1%) were male. The aortic cross-clamp location was IR in 4044 patients (53.2%). The SR group had increased maximum AAA diameter (58 mm vs 56 mm; P < .0001), hypertension (85.5% vs 82.0%; P < .0001), preoperative creatinine (1.11 vs 1.08; P = .001), and were more likely to be in American Society of Anesthesiologists class IV (37.4% vs 30.6%; P < .0001). Postoperative renal failure occurred significantly more often in the SR group (24.4 vs 11.4%; P < .0001). Short-term mortality was 2.7% in the IR group and 4.7% in the SR group (P < .0001). Kaplan-Meier survival estimates were 93.7% and 83.8% in the IR group and 90.9% and 81.2% in the SR group at 1 and 5 years, respectively (P = .007). Multivariable analysis demonstrated that SR cross-clamping was significantly associated with short-term mortality (hazard ratio, 1.38; 95% confidence interval, 1.07-1.78; P = .01); however, it did not affect overall survival (hazard ratio, 1.13; 95% confidence interval, 1.00-1.28; P = .06).

CONCLUSIONS

A SR cross-clamp location is associated with an increased short-term mortality in patients undergoing oAAA repair. Overall survival is not affected by a SR cross-clamp location.

Morphologic and Operative Evolution of Open Ruptured Abdominal Aortic Aneurysm Repair

BACKGROUND

Increased use of endovascular repair for intact abdominal aortic aneurysms has fundamentally shifted the approach to ruptured aneurysms. Unfortunately, not all patients are anatomically suited for endovascular repair. It is hypothesized that, in the endovascular era, patients undergoing open repair are increasingly complex; with an unknown impact on postoperative morbidity and mortality.

MATERIAL AND METHODS

The Cleveland Clinic Foundation database was queried for all patients undergoing open repair of ruptured abdominal aortic aneurysms (rAAA) from 2006 to 2015. Electronic medical charts and cross-sectional imaging were retrospectively reviewed. The overall patient cohort was dichotomized between early (E-OR, 2006 to 2010) and late open repairs (L-OR, 2011 to 2015). Groups were compared based on demographic, anatomic, and perioperative variables. The primary endpoint was perioperative mortality. Secondary endpoints included overall mortality, late aneurysm-related mortality, and perioperative morbidity.

RESULTS

Of 140 patients who underwent open repair of rAAA (63, E-OR; 77, L-OR), 76% had cross-sectional imaging available for review. Aneurysm repairs in the later time period had significantly shorter infrarenal neck lengths, were more likely to have a prior aortic intervention, tended to have poor access vessels, and were more likely to require visceral or renal revascularization (each P < 0.05). While late survival did not differ between time periods, perioperative mortality (27 vs. 46%, P = 0.021) and late aneurysm-related mortality (29.9% vs. 47.6%, P = 0.031) was lower for L-OR compared with E-OR. While no anatomic variables significantly impacted survival, early time period of repair, presence of chronic kidney disease, and need for cardiopulmonary resuscitation were predictive of both perioperative and overall mortality on univariate and multivariate analysis.

CONCLUSIONS

Despite the increasing anatomic and operative complexity of patients undergoing open repair of rAAAs, perioperative mortality and late aneurysm-related mortality have improved over time. These results highlight the need for both systems and expertise needed to appropriately treat this changing patient population.

Long-term radiation exposure in patients undergoing EVAR: Reflecting clinical day-to-day practice to assess realistic radiation burden

Endovascular repair of aortic aneurysms (EVAR) has become an established treatment option currently applied in an increasing numbers of patients with aortic aneurysms. Advantages include reduced surgical trauma, procedural time, intensive care unit and hospital lengths of stay, blood loss as well as morbidity and mortality.The optimal imaging modalities in EVAR follow-up as well as the appropriate intervals between these follow-ups remain subject of controversial discussion. Objective of this study was the evaluation of the realistic radiation exposure and risk estimate postop EVAR treatment.Of the follow-ups required according to the surveillance schedule during the first year post-EVAR, only 68.3% were actually implemented. Of those required from the second year onwards, an average of 70% was actually performed. During the observation period, each patient underwent a mean of 4.3 CTAs. The median ED calculated from all CTAs was 24. 5 mSv. The minimum and maximum cumulative EDs for the entire observation period were 55 mSv and 310 mSv, respectively.

Five-year results of endovascular abdominal aortic aneurysm repair with the Ovation abdominal stent graft

OBJECTIVE

Endovascular abdominal aortic aneurysm repair (EVAR) has been rigorously compared with open repair for the treatment of abdominal aortic aneurysms in randomized trials and observational studies, but a comparison of individual devices is lacking, and single-device registries and trials are limited by small sample size. Here we report a descriptive analysis of the Effectiveness of Custom Seal with Ovation: Review of the Evidence (ENCORE) database, pooled results of multiple studies evaluating the midterm results of EVAR with the Ovation Abdominal Stent Graft Platform.

METHODS

This is a retrospective analysis of the ENCORE database, a cohort of patients undergoing EVAR with the Ovation platform composed of pooled, prospectively collected data from 1296 patients from five clinical trials and the prospectively maintained European Union Post-Market Registry. The primary outcomes were 5-year rates of type IA and type I or III endoleak. Secondary outcomes included were 30-day mortality, 30-day major adverse event, technical success (successful deployment of the aortic body and iliac limbs), as well as 5-year survival, and freedom from aneurysm-related mortality, type II endoleak, device-related intervention, aneurysm rupture, sac expansion, and conversion to open repair.

RESULTS

A total of 1296 patients were included in the analysis. The average age was 73 ± 8 years and 81% of patients were male. Fifty percent of patients had complex aortic anatomy, (neck length <10 mm, neck diameter >28 mm, neck angle >60°, reverse neck taper >10%, distal common iliac artery diameter <10 mm, or external iliac artery diameter <6 mm). Technical success was 99.7%. Thirty-day mortality was 0.3%, 30-day rate of major adverse event was 1.6%, and polymer leak rate was 0.2%. Freedom from type IA endoleak at 1, 3, and 5 years was 97.6%, 97.1%, and 95.8%, respectively; type I or III endoleak at 1, 3, and 5 years was 96.9%, 95.7%, and 94.0%, respectively. Freedom from device-related reintervention at 1, 3, and 5 years was 96.2%, 94.4%, and 92.4% and primary freedom from sac expansion was 97.0% at 1 year, 90.3% at 3 years, and 84.9% at 5 years. Freedom from all-cause mortality and aneurysm-related mortality at 5 years were 78.9% and 99.3%, respectively.

CONCLUSIONS

This analysis of the ENCORE database demonstrates that EVAR with the Ovation platform has favorable midterm durability evidenced by successful aneurysm exclusion and 5-year freedom from aneurysm-related mortality.

Flow dynamics of type II endoleaks can determine sac expansion after endovascular aneurysm repair using four-dimensional flow-sensitive magnetic resonance imaging analysis

OBJECTIVE

The objective of this study was to investigate the hemodynamic parameters of type II endoleaks (T2ELs) to predict sac expansion using four-dimensional flow-sensitive magnetic resonance imaging (4D-flow MRI) analysis.

METHODS

Patients who underwent endovascular aneurysm repair (EVAR) and were diagnosed with a T2EL were included in the study. Using 4D-flow MRI at 7 days, the peak flow velocity and amplitude of dynamics of blood flow per minute were measured in each T2EL vessel. The peak flow velocity was defined as the maximum of the absolute value of the blood flow velocity. The amplitude of dynamics of blood flow in the tributary arteries was defined as the sum of the absolute values of the inflow and outflow volume in each vessel. The amplitude of dynamics of blood flow in the tributary arteries per sac was calculated in each sac. The aneurysm sac diameter was measured by computed tomography (CT) at 1 year. The patients were divided into two groups according to the presence or absence of sac expansion.

RESULTS

Of 155 patients who underwent EVAR, both CT angiography and 4D-flow MRI were performed in 107 patients at 7 days after EVAR. Among them, 39 (36.4%) were found to have a T2EL, of whom 28 were re-evaluated with CT angiography and 4D-flow at 1 year; 7 patients had expanding sacs (expanding group), whereas 21 had nonexpanding sacs (not-expanding group). At 7 days, 28 patients had 80 T2EL vessels detected by 4D-flow MRI, of which 39 vessels (48.8%) had stopped flowing at 1 year (transient vessels); 41 vessels (51.3%) had sustained flow (persistent vessels). The persistent vessels had significantly larger peak flow velocity and amplitude of dynamics of blood flow. The comprehensive analysis of T2EL vessels per sac identified that the amplitude of dynamics of blood flow in the tributary arteries per sac was significantly higher in the expanding group than in the not-expanding group. A receiver operating characteristic curve analysis revealed that the sensitivity and specificity of sac enlargement at a cutoff value of 3750 mm³/min were 85.7% and 76.2%, respectively.

CONCLUSIONS

The fate of aneurysm sacs with T2ELs after EVAR has remained difficult to predict. A comprehensive analysis of concurrent multiple T2EL vessels using 4D-flow MRI analysis may enable prediction of the sac expansion after EVAR.

A Narrative Review on Contrast-Enhanced Ultrasound in Aortic Endograft Endoleak Surveillance

Endovascular repair of abdominal aortic aneurysms have been performed successfully since 1991. However, 20% to 50% of these patients may develop an endoleak or continued aneurysmal sac expansion or perfusion despite stent graft coverage. Current recommendations suggest lifelong surveillance with computed tomographic angiography (CTA) at least 1 month after intervention and yearly after that. In select patients with a stable aneurysm sac on computed tomography performed 1 year after treatment, future screening could be performed with ultrasonography. However, color Doppler ultrasound can fail to detect as many as 31% of endoleaks. Contrast-enhanced ultrasound (CEUS) provides an alternative approach to excluded aneurysm sac follow-up imaging. The Society for Vascular Surgery notes a need for further research on the role of CEUS in endovascular aortic repair surveillance. The European Federation of Societies for Ultrasound in Medicine and Biology suggests that early results are promising. Meta-analyses report pooled sensitivities and specificities of CEUS compared with CTA for the detection of endoleak between 89% and 98% and 86% and 88%, respectively. Owing to the dynamic flow information it provides, CEUS may actually be more sensitive than CTA at detection and characterization in select circumstances. Challenges with adoption, patient selection, and operator dependency remain, but current and future research suggests a role for CEUS in endoleak surveillance.

Comparison of major adverse event rates after elective endovascular aneurysm repair in New England using a novel measure of complication severity

OBJECTIVE

Major adverse event (MAE) rates are used as an outcome measure after surgical procedures. Although MAE rates summarize the occurrences of adverse events, they do not reflect differences in severity of these events. We propose that a measure of complication severity could provide a more accurate assessment about the quality of care. We aimed to analyze and to describe the regional variation in elective endovascular aneurysm repair (EVAR) MAE rates across centers in the Vascular Study Group of New England and to create an index for describing complication severity.

METHODS

Patients undergoing elective EVAR (n = 4731) at 30 Vascular Study Group of New England centers between 2003 and 2016 were studied. The MAE composite end point was defined as the occurrence of any of the following postoperative events: myocardial infarction, dysrhythmia, congestive heart failure, leg ischemia, renal insufficiency, bowel complication, reoperation, surgical site infection, stroke, respiratory complication, and no home discharge. An adjustment factor (complication severity index) was calculated as a ratio of length of stay for complicated to uncomplicated cases. Multivariate logistic regression was used to calculate predicted MAE rates. The observed and predicted MAE rates as well as complication severity index rates were compared among centers and across quintiles of center volume.

RESULTS

Observed MAE rates varied widely, ranging from 0% to 39%. Multivariate predictors of MAE included abdominal aortic aneurysm diameter >6 cm (odds ratio [OR], 2.1; 95% confidence interval [CI], 2.0-2.3), female sex (OR, 2.0; 95% CI, 1.8-2.2), chronic renal insufficiency (OR, 1.9; 95% CI, 1.7-2.1), age >75 years (OR, 1.9; 95% CI, 1.8-2.1), congestive heart failure (OR, 1.7; 95% CI, 1.5-1.9), chronic obstructive pulmonary disease (OR, 1.5; 95% CI, 1.4-1.6), diabetes (OR, 1.4; 95% CI, 1.1-1.7), positive stress test result (OR, 1.2; 95% CI, 1.1-1.4), preoperative beta blocker (OR, 1.2; 95% CI, 1.1-1.3), and no preoperative statin (OR, 1.2; 95% CI, 1.1-1.3). Predicted MAE rates had little variation (range, 21%-29%). In comparing observed MAE rates and complication severity, there was an inverse relation between the two, suggesting that although certain centers had a greater number of MAEs, the complications were less severe.

CONCLUSIONS

MAE rates after elective EVAR vary widely. However, centers with higher MAE rates tended to have less severe complications, suggesting that observed MAE rates may not be a good measure of outcomes assessment after elective EVARs.

What Did Endovascular Aortic Repair Bring for the Treatment Strategy of Abdominal Aortic Aneurysm?

Objective: We examined the effects of the introduction of endovascular aortic repair (EVAR) on treatment for abdominal aortic aneurysms (AAAs).

Subjects: We compared patients in the following three periods: period I (January 2002–December 2006, 105 patients), period II (January 2007–December 2011, 242 patients, duration of 5 years after the introduction of EVAR), and period III (January 2012–December 2016, 237 patients, duration of 5 years after period II). We used the American Society of Anesthesiologists (ASA) classification for risk assessment.

Results: In the Open repair (OR) group, the incidences of ASA class 2 increased and classes 3 and 4 decreased significantly in periods II and III compared with period I. In all periods, there were no in-hospital deaths. Suprarenal aortic cross-clamping was required in 18 patients (19.1%) in period III and 5 patients (6.3) in period I, and the difference was significant (P<0.05). In the EVAR group, no differences in age, sex, or ASA classification class were observed between periods II and III. In period II, one patient died due to aneurysm rupture during surgery. Significant differences were observed when comparing both groups in periods II and III: patients in the EVAR group were older (P<0.01) and the OR group had a higher proportion of ASA class 2 patients and the EVAR group had a higher proportion of ASA class 3 or 4 patients (P<0.01). Among all AAA surgeries, rupture occurred in 25 patients (23.8%) in period I, 18 patients (7.4) in period II, and 16 patients (6.8) in period III. The number of ruptures was significantly lower in periods II and III than in period I (P<0.01).

Conclusions: The findings of this study suggest that EVAR should be indicated for high-risk patients and had the good outcome of AAA treatment. (This is a translation of Jpn J Vasc Surg 2018; 27: 27–32.)

Select type I and type III endoleaks at the completion of fenestrated endovascular aneurysm repair resolve spontaneously

OBJECTIVE

The Society for Vascular Surgery reporting standards for endovascular aneurysm repair (EVAR) consider the presence of a type I or type III endoleak a technical failure. However, the nature and implications of these endoleaks in fenestrated EVAR (FEVAR) are not well understood.

METHODS

We performed a single-center retrospective review of 53 patients who underwent FEVAR with the Zenith Fenestrated AAA Endovascular Graft (Cook Medical, Bloomington, Ind) from 2013 to 2018. We excluded one patient without contrast-enhanced postoperative imaging who was lost to follow-up after discharge. Small, slow, type I and type III endoleaks on completion angiography were routinely observed. We identified patients with completion type I or type III endoleaks by angiography review and characterized endoleak type, location, and rate of resolution on initial postoperative imaging.

RESULTS

Fifty-two patients were included; mean age was 75 ± 8 years, 75% were male, and 91% were white. Of 146 visceral vessels (100 renal arteries and 46 superior mesenteric arteries), 145 (99%) were preserved with 103 fenestrations and 43 scallops; 102 (70%) target vessels were stented. After implantation of all device components, 31 patients (60%) had evidence of type I or type III endoleak. Twelve patients (39%) underwent further intervention at the index procedure, and three endoleaks resolved completely. Twenty-eight patients (54%) had a type I or type III endoleak on completion angiography. There were no differences between patients with and without completion endoleaks in baseline demographics, graft design, neck anatomy, or proportion of cases performed within the instructions for use of the device. Perioperative mortality was 1.9%. On initial postoperative imaging, 27 of 28 (96%) endoleaks resolved spontaneously. One small, persistent type IA or type III endoleak was identified on postoperative day 27 and was observed. This endoleak had resolved completely on computed tomography angiography 6 months postoperatively. In patients without a completion endoleak, one type IA endoleak secondary to graft infolding was discovered on postoperative imaging and was successfully treated with placement of endoanchors and Palmaz stent. Median follow-up was 269 days. No additional type I or type III endoleaks were identified in any patient for the duration of follow-up.

CONCLUSIONS

Whereas completion type I and type III endoleaks are common after FEVAR with the ZFEN device, nearly all of these endoleaks resolve spontaneously by the initial postoperative imaging. These results suggest that select completion endoleaks after FEVAR with the ZFEN device do not require intervention at the index procedure.

Long-Term Evaluation of Percutaneous Groin Access for EVAR

BACKGROUND

Percutaneous endovascular aneurysm repair (PEVAR) has been shown to have high success rates, shorter operating times and length of stay compared to open access. However, there exists a lack of long-term follow-up data on these patients, and questions remain regarding longer-term outcomes. This study aims to assess the long-term complications and evolution of accessed vessels post-PEVAR.

METHODS

Sixty-one cases of bilateral PEVAR (122 groins) with > 36 months follow-up were analysed. Vessel diameter, calcification, dissection, lymphocele, pseudoaneurysm and thrombus formation were reviewed at 30th day and at the most recent follow-up CT. Notes were reviewed for groin infections, haematomas and nerve injury. Complications were considered 'major' if they required intervention or treatment.

RESULTS

Mean follow-up time from procedure to most recent scan was 49.9 months. There were no major short- or long-term complications. The early complication rate was 9.8%, with six pseudoaneurysms, four dissections, one thrombus, one nerve injury and no lymphoceles, haematomas or groin infections. The long-term complication rate was 0.8%, with only one pseudoaneurysm. The remainder of early complications resolved naturally without intervention. Accessed vessel showed significantly (P ≤ 0.05) increased diameter and calcification between 30th day and last follow-up scan.

CONCLUSION

This study provides the largest clinical cohort and the longest mean follow-up time reported in the literature and demonstrates the long-term safety of PEVAR. PEVAR has a very low long-term complication rate, without any major complications in our cohort. The accessed common femoral arteries do not show stenosis or thrombosis. Minor short-term complications appear to gradually resolve without intervention. Larger multi-centre studies are recommended.

Vascular Surgery in Japan: 2011 Annual Report by the Japanese Society for Vascular Surgery

This is an annual report indicating the number and early clinical results of annual vascular treatments performed by vascular surgeons in Japan during 2011, as analyzed by database management committee (DBC) members of the Japanese Society for Vascular Surgery (JSVS). Materials and Methods: To survey the current status of vascular treatments performed by vascular surgeons in Japan, the DBC members of the JSVS analyzed the vascular treatment data provided from National Clinical Database (NCD), including the number of treatments and early clinical results such as operative and in-hospital mortality. Given that NCD data were prospectively built by a nationwide registration, this annual report reports prospective clinical data. Results: In total 71,707 vascular treatments including open repairs and endovascular treatments were registered by 992 institutions in 2011. This database is composed of 7 fields including treatment of aneurysms, chronic arterial occlusive disease, acute arterial occlusive disease, vascular injury, complication of vascular reconstruction, venous diseases, and other vascular treatments. The number of vascular treatments in each field was 17,524, 11,278, 3,799, 1,030, 1,615, 19,371, and 17,510, respectively. In the field of aneurysm treatment, 13,218 cases with abdominal aortic aneurysms (AAA) including iliac aneurysms were registered, including 1,253 ruptured cases. Forty-five percent of AAA cases were treated by stent graft. The operative mortality of ruptured and non-ruptured AAA was 18.8% and 0.8%, respectively. Regarding chronic arterial occlusive disease, open repair was performed in 7,115 cases including 984 distal bypasses to the crural or pedal artery, whereas endovascular procedures were performed in 4,163 cases. For acute arterial occlusive disease, more than 90% of cases were treated with open repair. Vascular injury treatment included 81 venous injury cases and 949 arterial injury cases, and 60% of arterial injuries were iatrogenic. Treatment for complication of previous vascular treatment included 445 cases of graft infections, 240 cases of anastomotic aneurysms, and 811 cases of graft revision operations. The venous treatment included 18,864 varicose vein treatments, 343 cases with lower limb deep venous thrombosis, and 67 cases with vena cava reconstructions. Regarding other vascular operations, 16,296 cases of vascular access operations and 1,037 amputation surgeries are included. Conclusions: This vascular surgery database indicates not only the number of vascular treatments but also the early clinical outcomes for each treatment procedure, thereby representing a useful source for researching the clinical background of poor outcomes and for finding improvements in the quality of treatment. Continuing this work will provide information regarding changing the treatment modality in response to the changing structure of disease and societal needs. (This is a translation of Jpn J Vasc Surg 2017; 26: 45-64.).

Statin therapy is associated with higher long-term but not perioperative survival after abdominal aortic aneurysm repair

BACKGROUND

Although preoperative and perioperative statin therapy improves postoperative outcomes in several populations, few data examine its association with survival after abdominal aortic aneurysm (AAA) repair. In addition, no data exist regarding the benefits of starting statins in patients with AAA not currently taking them.

METHODS

We performed a registry-based study of all patients undergoing repair of AAAs in the Vascular Quality Initiative between 2003 and 2017 without documented statin intolerance. In our primary analysis, we evaluated the association between preoperative statin therapy and long-term mortality, 30-day mortality, and in-hospital myocardial infarction and stroke. As a secondary analysis, we studied the cohort of patients not taking a statin preoperatively and compared their long-term mortality on the basis of whether they were discharged on a statin. To account for nonrandom assignment to treatment, we constructed propensity scores and applied inverse probability weighting.

RESULTS

We identified 40,452 AAA repairs, of which 37,950 fit our entry criteria (29,257 endovascular and 8693 open). Overall, 25,997 patients (69%) were taking a statin preoperatively, with patients undergoing endovascular aneurysm repair more frequently taking a statin than those undergoing open repair (69% compared with 66%; P < .001). After propensity weighting, preoperative statin therapy was not associated with 30-day death or in-hospital stroke or myocardial infarction. However, patients taking statins preoperatively experienced higher adjusted 1-year (94% vs 90%) and 5-year (85% vs 81%) survival from the date of surgery compared with those who were not (P < .001 overall), although subgroup analysis showed that this applied only to intact or symptomatic aneurysms. Of the 11,941 patients not taking a statin preoperatively and discharged alive, 2910 (24%) started on a statin before discharge. In our secondary analysis of the subset of patients not taking statins preoperatively, those initiated on a statin before discharge experienced higher survival at 1 year (94% vs 91%) and 5 years (89% vs 81%; P < .001 overall) than those who remained off statin therapy, with the greatest absolute long-term survival difference in patients with rupture (87% vs 62%; P < .001 overall).

CONCLUSIONS

Preoperative statin therapy is associated with higher long-term survival but not perioperative mortality and morbidity in patients undergoing AAA repair, and initiating statin therapy in previously statin-naive patients is associated with markedly higher survival. All patients with AAAs without contraindications should receive statin therapy. In patients not taking a statin at the time of AAA repair, clinicians should consider initiating one before discharge.

Short- and long-term survival after open versus endovascular repair of abdominal aortic aneurysm-Polish population analysis

OBJECTIVES

The aim of the study was to compare short and long-term mortality and readmissions in patients with non-ruptured abdominal aortic aneurysm (AAA) treated with endovascular aortic repair (EVAR) or open aneurysm repair (OAR).

DESIGN

Retrospective survival analysis based on prospectively collected medical records of the national Polish public health insurer.

MATERIALS

In the National Health Fund database we identified all patients who underwent elective open or endovascular treatment of AAA between January 1st 2011 and March 22nd 2016. The data on mortality, selected concomitant diseases and readmissions were collected. A total of 7805 patients (mean age 70.9±8.1 yrs, 85.8% males) underwent OAR (n = 2336) or EVAR (n = 5469). A median follow up was 27.5 months (IQR range 10.0-38.4 months).

METHODS

The primary outcome variable was all-cause mortality, secondary outcomes included 30-day mortality and readmissions. Kaplan-Meier (K-M), Cox proportional-hazards and propensity score analyses were performed for primary and secondary outcomes adjusting for repair type of AAA (OAR vs. EVAR), age, sex and concomitant diseases.

RESULTS

EVAR patients had higher all-cause mortality (6.4% vs. 4.6% P = 0.002, adjHR 1.34, 95%CI 1.07-1.67, P = 0.010) compared with OAR. The mortality risks for OAR patients decreased below those for EVAR patients after 9.9 months. Of all the tested confounding factors only age independently and significantly influenced long-term mortality. Readmissions occurred more often in EVAR than in OAR (16.5% vs. 8.4% P<0.001, adjHR 2.15, 95%CI 1.84-2.52, P<0.001) independently from other covariants. Survival and readmissions Kaplan-Meier curves remained statistically different between OAR and EVAR patients after propensity score matching.

CONCLUSIONS

Survival benefit of EVAR over OAR disappeared early during the first year after procedure, particularly in patients below 70 years of age, accompanied by an increased frequency of readmissions of EVAR patients. Our data suggest re-evaluation of the strategy for AAA management in vascular units in the country.

Abdominal Aortic Aneurysm: Evolving Controversies and Uncertainties

Abdominal aortic aneurysm (AAA) is defined as a permanent dilatation of the abdominal aorta that exceeds 3 cm. Most AAAs arise in the portion of abdominal aorta distal to the renal arteries and are defined as infrarenal. Most AAAs are totally asymptomatic until catastrophic rupture. The strongest predictor of AAA rupture is the diameter. Surgery is indicated to prevent rupture when the risk of rupture exceeds the risk of surgery. In this review, we aim to analyze this disease comprehensively, starting from an epidemiological perspective, exploring etiology and pathophysiology, and concluding with surgical controversies. We will pursue these goals by addressing eight specific questions regarding AAA: (1) Is the incidence of AAA increasing? (2) Are ultrasound screening programs for AAA effective? (3) What causes AAA: Genes versus environment? (4) Animal models: Are they really relevant? (5) What pathophysiology leads to AAA? (6) Indications for AAA surgery: Are surgeons over-eager to operate? (7) Elective AAA repair: Open or endovascular? (8) Emergency AAA repair: Open or endovascular?

Treatment of Aortic and Iliac Artery Aneurysms with Multilayer Flow Modulator: Single Centre Experiences

Objective

Presenting early and midterm results of aortic and iliac artery aneurysms treated with Multilayer Flow Modulators (MFM).

Methods

We retrospectively reviewed the medical records of 23 patients (19 males and 4 females) who are admitted to our clinic between April of 2014 and February of 2016, diagnosed with thoracoabdominal aortic aneurysm and/or iliac aneurysm, and treated using MFM. The patients were followed up for the development of potential clinical presentations for 12 months.

Results

MFM implantation was successfully completed in all the patients. During the process, two patients developed endoleak and so they were treated with postdilatation that was performed through balloon intervention, whereby the patients fully recovered. Although a short-term ischemic cerebrovascular event occurred in one of the patients 36 hours after the MFM, the patient recuperated without any noticeable neurological sequelae. Overall, three patients died after the procedure, one of whom died in hospital three days following the intervention due to acute renal failure, while the second one lost his life at the end of the first month due to the occlusion of superior mesenteric and celiac arteries. The third patient died at the end of the third month due to acute myocardial infarction. The rest of the patients developed no complications or had no mortality at their 12-month follow-ups.

Conclusion

MFM can be preferred as an alternative approach in the treatment of aorta and iliac artery aneurysms including major lateral branches. The present results should be confirmed with additional future studies conducted with larger patient groups for longer periods.

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.

Complications of endovascular aneurysm repair of the thoracic and abdominal aorta: evaluation and management

In recent decades, endovascular aneurysm repair or endovascular aortic repair (EVAR) has become an acceptable alternative to open surgery for the treatment of thoracic and abdominal aortic aneurysms and other aortic pathologies such as the acute aortic syndromes (e.g., penetrating aortic ulcer, intramural hematoma, dissection). Available data suggest that endovascular repair is associated with lower perioperative 30-day all-cause mortality as well as a significant reduction in perioperative morbidity when compared to open surgery. Additionally, EVAR leads to decreased blood loss, eliminates the need for cross-clamping the aorta and has shorter recovery periods than traditional surgery. It is currently the preferred mode of treatment of thoracic and abdominal aortic aneurysms in a subset of patients who meet certain anatomic criteria conducive to endovascular repair. The main disadvantage of EVAR procedures is the high rate of post-procedural complications that often require secondary re-intervention. As a result, most authorities recommend lifelong imaging surveillance following repair. Available surveillance modalities include conventional radiography, computed tomography, magnetic resonance angiography, ultrasonography, nuclear imaging and conventional angiography, with computed tomography currently considered to be the gold standard for surveillance by most experts. Following endovascular abdominal aortic aneurysm (AAA) repair, the rate of complications is estimated to range between 16% and 30%. The complication rate is higher following thoracic EVAR (TEVAR) and is estimated to be as high as 38%. Common complications include both those related to the endograft device and systemic complications. Device-related complications include endoleaks, endograft migration or collapse, kinking and/or stenosis of an endograft limb and graft infection. Post-procedural systemic complications include end-organ ischemia, cerebrovascular and cardiovascular events and post-implantation syndrome. Secondary re-interventions are required in approximately 19% to 24% of cases following endovascular abdominal and thoracic aortic aneurysm repair respectively. Typically, most secondary reinterventions involve the use of percutaneous techniques such as placement of cuff extension devices, additional endograft components or stents, enhancement of endograft fixation, treatment of certain endoleaks using various embolization techniques and embolic agents and thrombolysis of occluded endograft components. Less commonly, surgical conversion and/or open surgical modification are required. In this article, we provide an overview of the most common complications that may occur following endovascular repair of thoracic and AAAs. We also summarize the current surveillance recommendations for detecting and evaluating these complications and discuss various current secondary re-intervention approaches that may typically be employed for treatment.

Improved access to health care in Massachusetts after 2006 Massachusetts Healthcare Reform Law is associated with a significant decrease in mortality among vascular surgery patients

BACKGROUND

Access to medical care, by adequate insurance coverage, has a direct impact on outcomes for patients undergoing vascular procedures. We evaluated in-hospital mortality for patients undergoing index vascular procedures before and after the Massachusetts Healthcare Reform Law (MHRL) in 2006, which mandated insurance for all Massachusetts residents, both in Massachusetts and throughout the United States.

METHODS

The National Inpatient Sample was queried to identify patients undergoing interventions for peripheral arterial disease, carotid artery stenosis, and abdominal aortic aneurysms based on International Classification of Diseases, Ninth Revision, Clinical Modification procedural and diagnostic codes. The cohort was then divided into patients treated within Massachusetts (MA) and non-Massachusetts (NMA) hospitals. Two time intervals were examined: before (2003-2006, P1) and after the MHRL (2007-2011, P2). The primary outcome of interest included in-hospital mortality. Patients in MA and NMA hospitals were described in terms of demographics and presentation by time interval (P2 vs P1) compared using χ² and t-tests. Weighted logistic regression with term modeling change in the odds ratio (OR) for P2 was performed to test and to estimate trends in mortality. Time (year of procedure) and region interactions were investigated by inclusion of time-region interactions in our analyses. Subgroup analysis was performed for P2 vs P1 among nonwhite, nonelderly, and low-income patients.

RESULTS

We identified 306,438 patients who underwent repair of abdominal aortic aneurysm, lower extremity bypass, or carotid endarterectomy in MA and NMA hospitals. MA hospital patients had an increase in both Medicaid and private insurance status after the MHRL (P1 = 2.6% and 21% vs P2 = 3.3% and 21.7%, respectively; P = .034). In-hospital mortality trended down for all groups across the entire study. In comparing P2 vs P1 trends, MA hospital odds of mortality per year was lowered by 26% (OR, 0.74; 95% confidence interval [CI], 0.56-0.99; P = .042) not seen in NMA hospitals (OR, 1.03; 95% CI, 0.97-1.09; P = .405). Time and region interaction terms indicated significant time trend difference in both unadjusted (P = .031) and adjusted (P = .033) analysis in MA hospitals not observed in NMA hospitals. This pattern continued when the samples were stratified by procedure. Patients undergoing vascular procedures in MA hospitals had a significantly lowered OR of mortality, with fewer patients presenting at late disease stages in P2 vs P1. Nonelderly patients in Massachusetts, who benefit from the Medicaid expansion provided by the MHRL, had a profound 92% drop in odds of mortality in P2 vs P1 (OR, 0.08; 95% CI, 0.010-0.641; P = .017) compared with the 14% drop in NMA (OR, 0.86; 95% CI, 0.709-1.032; P = .103).

CONCLUSIONS

The 2006 MHRL is associated with a decrease in mortality for patients undergoing index vascular surgery procedures in MA compared with NMA hospitals. This study suggests that governmental policy may play a key role in positively affecting the outcomes for patients.

Epidemiology of abdominal aortic aneurysms in a Chinese population during introduction of endovascular repair, 1994 to 2013: A retrospective observational study

The aim of this study was to examine changes in abdominal aortic aneurysm repair and mortality during a period when endovascular aneurysm repair (EVAR) was introduced.Open repair surgery was the mainstay of treatment for abdominal aortic aneurysm (AAA), but EVAR is increasingly utilized. Studies in the Western population have reported improved short-term or postoperative mortality and shorter length of hospital stay with EVAR. However, scant data are available in the Chinese population.We conducted a retrospective observational study using the database of the Hospital Authority, which provides public health care to most of the Hong Kong population. AAA patients admitted to public hospitals for intact repair or rupture from 1994 to 2013 were included in this study. We calculated the incidence of ruptured AAA, annual repair rates according to type of AAA and surgery, as well as death rates (operative and overall short-term). We calculated whether there were significant changes over time and compared short-term mortality between open surgery and EVAR.One thousand eight hundred eighty-five patients were admitted for intact repair and 1306 patients were admitted for AAA rupture, of whom 795 underwent rupture repair. Intact repair rates significantly increased in all age groups (7.3-37.8%, P < .001) over the study period.The incidence of ruptured AAA increased, in all age groups, except in < 64 years old. By 2013, 85% of intact repairs and 55.4% of rupture repair were done by EVAR. Over time, there was a significant decrease in operative mortality for intact repair (16.5 in 1994 to 7.1 in 2013, P = .01) and rupture repair (59.7 in 1994 to 30.8 in 2013, P = .003). Over the same time period, short-term AAA-related deaths decreased by more than half (73% in 1994 to 24% in 2013, P < .001), with a significant decline in all age groups, except < 64 years old. Short-term mortality was significantly lower for EVAR than for open repair (17.2% vs 40.3%, P < .01).Short-term AAA-related deaths have declined likely due to decreased operative mortality and rupture deaths during the period of EVAR introduction and expansion.