Defining high risk in endovascular aneurysm repair

Age is not a sole predictor of outcomes in octogenarians undergoing complex endovascular aortic repair

OBJECTIVE

To examine the perioperative, postoperative, and long-term outcomes of fenestrated/branched endovascular aneurysm repair (F/BEVAR) in octogenarians compared with nonoctogenarians.

METHODS

A multicenter, retrospective cohort study was conducted using the Vascular Quality Improvement database, which prospectively captures information on patients who undergo vascular surgery across 1021 academic and community hospitals in North America. All patients who underwent F/BEVAR endovascular aortic repair from 2012 to 2022 were included. Patients were stratified into two groups: those aged <80 years and those aged ≥80 years at the time of the procedure. The preoperative, intraoperative, and postoperative factors were compared between the two groups. The primary outcome was long-term all-cause mortality; secondary outcomes included aortic-specific mortality and aortic-specific reintervention.

RESULTS

A total of 6007 patients (aged <80 years, n = 4860; aged ≥80 years, n = 1147) who had undergone F/BEVAR procedures were included. No significant difference was found in technical success, postoperative length of stay, length of intensive care unit stay, postoperative bowel ischemia, and spinal cord ischemia. After adjustment for baseline covariates, octogenarians were more likely to suffer from a postoperative complication (odds ratio [OR]: 1.16; [95% confidence interval (CI): 0.98-1.37], P < .001) and be discharged to a rehabilitation center (OR: 1.60; [95% CI: 1.27-2.00], P < .001) or nursing home (OR: 2.23; [95% CI: 1.64-3.01], P < .001). Five-year survival was lower in octogenarians (83% vs 71%, hazard ratio [HR]: 1.70; [95% CI: 1.46-2.0], P < .0001). Multivariate Cox proportional hazard analysis demonstrated that age was associated with increased all-cause mortality (HR: 1.72, [95% CI: 1.39-2.12], P < .001) and aortic-specific mortality (HR: 1.92, [95% CI: 1.04-3.68], P = .038). Crawford extent II aortic disease was associated with an increase in all-cause mortality (HR 1.49; [95% CI: 1.01-2.19], P < .001), aortic-specific mortality (HR: 5.05; [95% CI: 1.35-18.9], P = .016), and aortic-specific reintervention (HR: 1.91; [95% CI: 1.24-2.93], P = .003). Functional dependence was associated with increased all-cause mortality (HR: 2.90; [95% CI: 1.87-4.51], P < .001) and aortic-specific mortality (HR: 4.93; [95% CI: 1.69-14.4], P = .004).

CONCLUSIONS

Our findings suggest that octogenarians do have a mildly increased mortality rate and rate of adverse events after F/BEVAR procedures. Despite this, when adjusted for other risk factors, on par with other medical comorbidities and therefore age should be strict exclusion criterion for F/BEVAR procedures, rather age should be considered in the global context of patient's aortic anatomy, health, and functional status.

Predictors of 30-Day Postoperative Outcome after Elective Endovascular Abdominal Aortic Aneurysm Repair: A Tertiary Referral Center Experience

BACKGROUND

We evaluated the 30-day postoperative outcome after elective endovascular aneurysm repair (EVAR) and the possible predictors for the 30-day postoperative outcome.

MATERIALS

Demographics, medical history, laboratory values, intensive care unit (ICU) admission and 30-day complications classified as major (major adverse cardiovascular events (MACEs), acute kidney injury (AKI) and death of any cause) and minor (postimplantation syndrome (PIS), postoperative delirium (POD), urinary tract infection (UTI) and technical graft failure) were documented (March 2016 to February 2019).

RESULTS

We included 322 patients. The majority were managed under general anesthesia (83%) with femoral cutdown (98.1%). Overall, 121 (37.5%) complications, mostly minor (n = 103, 31.9%), were recorded. In total, 11 patients (3.4%) developed MACEs, 5 (1.6%) experienced AKI and 2 (0.6%) died in the ICU. Moreover, 77 patients (23.9%) suffered from PIS, 11 from POD, 11 from UTI and 4 from technical graft failure. The multivariate logistic regression analysis revealed that aneurysm diameter (p = 0.01) and past smoking (p = 0.003) were predictors for complications. PAD was an independent predictor of MACEs (p = 0.003), preoperative neutrophil to lymphocyte ratio (NLR) of AKI (p = 0.003) and past smoking of PIS (p = 0.008), respectively.

CONCLUSIONS

Our study showed that the 30-day morbidity after EVAR exceeded 35%. However, the majority of complications were minor, and the associated mortality was low. Aneurysm diameter and past smoking were independent predictors for postoperative outcome.

Increased Aortic Exclusion in Endovascular Treatment of Complex Aortic Aneurysms

PURPOSE

Perioperative risk assessments for complex aneurysms are based on the anatomical extent of the aneurysm and do not take the length of the aortic exclusion into account, as it was developed for open repair. Nevertheless, in the endovascular repair (ER) of complex aortic aneurysms, additional segments of healthy aorta are excluded compared with open repair (OR). The aim of this study was to assess differences in aortic exclusion between the ER and OR of complex aortic aneurysms, to subsequently assess the current classification for complex aneurysm repair.

METHODS

This retrospective observational study included patients that underwent complex endovascular aortic aneurysm repair by means of fenestrated endovascular aneurysm repair (FEVAR), fenestrated and branched EVAR (FBEVAR), or branched EVAR (BEVAR). The length of aortic exclusion and the number of patent segmental arteries were determined and compared per case in ER and hypothetical OR, using a Wilcoxon signed-rank test.

RESULTS

A total of 71 patients were included, who were treated with FEVAR (n = 44), FBEVAR (n = 8), or BEVAR (n = 19) for Crawford types I (n = 5), II (n = 7), III (n = 6), IV (n = 7), and V (n = 2) thoracoabdominal or juxtarenal (n = 44) aneurysms. There was a significant increase in the median exclusion of types I, II, III, IV, and juxtarenal aneurysms (p < 0.05) in ER, compared with hypothetical OR. The number of patent segmental arteries in the ER of type I-IV and juxtarenal aneurysms was significantly lower than in hypothetical OR (p < 0.05).

CONCLUSION

There are significant differences in the length of aortic exclusion between ER and hypothetical OR, with the increased exclusion in ER resulting in a lower number of patent segmental arteries. The ER and OR of complex aortic aneurysms should be regarded as distinct modalities, and as each approach deserves a particular risk assessment, future efforts should focus on reporting on the extent of exclusion per treatment modality, to allow for appropriate comparison.

Aneurysm extent-based mortality differences in complex endovascular repair of thoracoabdominal aneurysms in the Vascular Quality Initiative and the United States Aortic Research Consortium

BACKGROUND

Endovascular management of thoracoabdominal aneurysms (TAAA) is becoming more common. Technological advances including custom devices under the Physician-Sponsored Investigational Device Exemption (PS-IDE), physician-modified endografts (PMEG), and parallel stenting techniques have expanded the extent of disease that is amenable to endovascular treatment. Patients within the PS-IDE studies are a highly selected group of patients, whereas patients treated with PMEG as captured within the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI) represent a real-world experience. Research within both the SVS VQI on PMEG and the US Aortic Research Consortium (US-ARC) has demonstrated a relationship between extent of aneurysmal disease and mortality after complex endovascular TAAA repair, but no direct comparison of these cohorts has been conducted. In this study, we sought to compare outcomes of custom PS-IDE devices with off-label uses of commercially available devices for the endovascular management of TAAAs.

METHODS

A retrospective review of patients presenting for elective endovascular TAAA repair for asymptomatic disease between 2011 and 2019 was conducted within both the SVS VQI registry and the US-ARC. Patients within the SVS VQI registry were treated with either PMEG or with parallel stenting techniques. Patients within the US-ARC were treated with PS-IDE custom devices. The extent of aneurysm disease was defined by the deployment zones documented for the devices entered in the registry using Crawford extents I to V. Primary outcomes were 30-day and 1-year mortality rates.

RESULTS

A total of 3212 patients were included in the study: 1571 PMEG/parallel stenting within the VQI registry and 1641 with PS-IDE within the US-ARC database. The majority of patients presented with extent IV aneurysms (n = 1827 [57%]), with extent IV aneurysms being slightly more prevalent within the US-ARC cohort. Maximal aneurysm diameter within each extent did not vary between the US-ARC and VQI cohorts. Across all patients, the 30-day mortality was 4.4% and the 1-year mortality was 12.2%. Unadjusted mortality at 30-days was 6.7% within the VQI, and 2.2% in the US-ARC (P < .001). The unadjusted 1-year mortality was 14.3% within the VQI and 10.2% within the US-ARC (P < .001). When adjusted for aneurysm extent, similar differences in 30-day and 1-year survivals were identified.

CONCLUSIONS

Patients treated in PS-IDE studies had better 30-day and 1-year survival rates compared with those treated with a similar extent of disease using off-label approaches in a real-world registry. These differences are complex and likely associated with a number of factors, including arterial anatomy, patient comorbidities, device construct, and volume outcomes, as well as complex and unmeasurable surgeon- and patient-specific factors.

Comparative performance of three comorbidity scores in predicting survival after the elective repair of abdominal aortic aneurysms

BACKGROUND

We aimed to study the discriminative power of 3 comorbidity scores for predicting 5-year survival after the elective repair of aorto-iliac aneurysms (AAA).

METHODS

444 patients with AAA undergoing elective repair (33% open and 67% endovascular) between 2000 and 2020 were reviewed. The Charlson Comorbidity Index (CCI) and subsequent adjustments by Schneeweiss, Quan and Armitage, the Modified Frailty Index (MFI) and the American Society of Anesthesiologists Score (ASA) were calculated from preoperative data. Their association with 5-year survival was analyzed using Cox regression models and their discriminative power and its changes with C statistics and Net Reclassification Index (NRI).

RESULTS

All comorbidity scores were associated with survival after adjusting by age, sex and type of surgical repair: original CCI HR=1.24, P<0.001; Schneeweiss CCI HR=1.23, P<0.001; Quan CCI HR=1.27, P<0.001, Armitage CCI HR=1.46, P<0.001, MFI HR=1.39, P<0.001 and ASA HR=1.68 (P=0.04) and 2.86 (P=0.01) for classes III and IV, respectively. Associated C statistics were of 0.64, 0.65, 0.65, 0.64, 0.61 and 0.59, respectively. Compared with the original CCI, models based on Schneeweiss CCI and Armitage CCI provided minor improvements in NRI (0.32 and 0.23), and the model based on ASA showed lower C statistics (P=0.014) and NRI (-0.30).

CONCLUSIONS

Established comorbidity scores, such as CCI, MFI or ASA, are all associated with 5-year survival after the elective repair of AAAs, being ASA the worst of them. However, their predictive power is in no case sufficient to identify, by themselves, those patients who may not be eligible for intervention on the basis of life expectancy.

Prognostic model for survival of patients with abdominal aortic aneurysms treated with endovascular aneurysm repair

The role of endovascular aneurysm repair (EVAR) in patients with asymptomatic abdominal aortic aneurysm (AAA) who are unfit for open surgical repair has been questioned. The impending risk of aneurysm rupture, the risk of elective repair, and the life expectancy must be balanced when considering elective AAA repair. This retrospective observational cohort study included all consecutive patients treated with standard EVAR for AAA at a referral centre between 2001 and 2020. A previously published predictive model for survival after EVAR in patients treated between 2001 and 2012 was temporally validated using patients treated at the same institution between 2013 and 2020 and updated using the overall cohort. 558 patients (91.2% males, mean age 74.9 years) were included. Older age, lower eGFR, and COPD were independent predictors for impaired survival. A risk score showed good discrimination between four risk groups (Harrel's C = 0.70). The 5-years survival probabilities were only 40% in "high-risk" patients, 68% in "moderate-to-high-risk" patients, 83% in "low-to-moderate-risk", and 89% in "low-risk" patients. Low-risk patients with a favourable life expectancy are likely to benefit from EVAR, while high-risk patients with a short life expectancy may not benefit from EVAR at the current diameter threshold.

Antithrombotic Therapy for Aortic Aneurysms: A Systematic Review and Meta-Analysis

OBJECTIVES

The role of antithrombotic therapy in the management of aortic and peripheral aneurysms is unclear. This systematic review and meta-analysis aimed to assess the impact of antithrombotics on clinical outcomes for aortic and peripheral aneurysms.

METHODS

Medline, Embase, and CENTRAL databases were searched. Randomised controlled trials and observational studies investigating the effect of antithrombotic therapy on clinical outcomes for patients with any aortic or peripheral artery aneurysm were included.

RESULTS

Fifty-nine studies (28 with antiplatelet agents, 12 anticoagulants, two intra-operative heparin, and 16 any antithrombotic agent) involving 122 102 patients were included. Abdominal aortic aneurysm (AAA) growth rate was not significantly associated with the use of antiplatelet therapy (SMD -0.36 mm/year; 95% CI -0.75 - 0.02; p = .060; GRADE certainty: very low). Antithrombotics were associated with increased 30 day mortality for patients with AAAs undergoing intervention (OR 2.30; 95% CI 1.51 - 3.51; p < .001; GRADE certainty: low). Following intervention, antiplatelet therapy was associated with reduced long term all cause mortality (HR 0.84; 95% CI 0.76 - 0.92; p < .001; GRADE certainty: moderate), whilst anticoagulants were associated with increased all cause mortality (HR 1.64; 95% CI 1.14 - 2.37; p = .008; GRADE certainty: very low), endoleak within three years (OR 1.99; 95% CI 1.10 - 3.60; p = .020; I² = 60%; GRADE certainty: very low), and an increased re-intervention rate at one year (OR 3.25; 95% CI 1.82 - 5.82; p < .001; I² = 35%; GRADE certainty: moderate). Five studies examined antithrombotic therapy for popliteal aneurysms. Meta-analysis was not possible due to heterogeneity.

CONCLUSIONS

There was a lack of high quality data examining antithrombotic therapy for patients with aneurysms. Antiplatelet therapy was associated with a reduction in post-intervention all cause mortality for AAA, whilst anticoagulants were associated with an increased risk of all cause mortality, endoleak, and re-intervention. Large, well designed trials are still required to determine the therapeutic benefits of antithrombotic agents in this setting.

Predictive factors for major adverse cardiac and cerebrovascular events in octogenarians after elective endovascular aneurysm repair

OBJECTIVES

The aim of this study was to identify risk factors of major adverse cardiac and cerebrovascular events (MACCE) in octogenarians who received elective endovascular aneurysm repair (EVAR).

METHODS

Consecutive patients aged ≥ 80 years undergoing elective EVAR from 2009 to 2020 were retrospectively evaluated. The primary outcome was long-term MACCE. All independent risk factors for outcomes were determined by multivariate logistic analysis or Cox regression analysis.

RESULTS

A total of 163 patients were enrolled in this study. The median age was 81 (interquartile range, IQR, 80-84) years and 85.9% (140/163) of them were male. MACCE happened in 2.5% (4/163) patients within 30 days. With median follow-up of 28 (IQR, 15-46) months, the incidence of long-term MACCE was 26.4% (43/163). Arrythmia was significantly associated with long-term MACCE (hazard ratio, HR = 2.64, 95% confidence interval, CI, 1.16-6.03, P = .021). Carotid artery disease was found a significant association with 2-year MACCE (odd ratio, OR = 6.50, 95% CI, 1.07-39.51, P = .042). Besides, we found that arrythmia and congestive heart failure (CHF) were predictors for overall survival (arrythmia, HR = 2.56, 95% CI, 1.05-6.28, P = .039; CHF, HR = 8.96, 95% CI, 2.12-37.79, P = .003).

CONCLUSIONS

EVAR in octogenarians had acceptable perioperative risk and long-term outcome. Considering high risk of 2-year MACCE, intervention strategy should be more cautious for patients with carotid artery disease. Octogenarians with arrythmia and CHF should receive stricter postoperative management in case of MACCE.

What factors counteract mid-term survival following endovascular repair of abdominal aortic aneurysms?

Introduction

Endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used, and has become the standard treatment option for AAA.

Aim

To evaluate the outcomes and predictors of survival of endovascular treatment of AAA in the short- and medium-term.

Material and methods

A total of 222 patients having endovascular AAA repair between January 2013 and December 2019 by the same surgical team were included in the study. Patient demographics, perioperative and follow-up data including mortality, complications, and need for secondary intervention were collected. The primary endpoint was all-cause mortality. Kaplan-Meier analysis was conducted for survival and Cox regression models were assessed for predictors of survival.

Results

The median age was 70 years, with male predominance (202 patients, 91%). Thirty-day mortality was 1.8%. Median follow-up to the primary endpoint was 20 months (range: 1–80 months). Survival rates at 1, 3, and 5 years were 93.5%, 81.4%, and 62.2%, respectively. Freedom from secondary intervention rates were 95.5% at 1 year, 88.7% at 3 years, and 82.1% at 5 years. Cox proportional hazard models showed that preoperative creatinine levels ≥ 1.8 mg/dl (hazard ratio (HR) = 2.68, 95% CI: 1.21–6.42, p = 0.027), haemoglobin levels < 10 gr/dl (HR = 3.38, 95% CI: 1.16–9.90, p = 0.026), ejection fraction < 30% (HR = 5.67, 95% CI: 1.29–24.86, p = 0.021), and AAA diameter ≥ 6.0 cm (HR = 2.20, 95% CI: 1.01–4.81, p = 0.049) were independently associated with mid-term survival.

Conclusions

EVAR is a safe procedure with low postoperative morbidity and mortality. This study confirms that the mid-term survival and results are favourable. However, the analysed factors in this study that predict reduced survival (high preoperative creatinine, low haemoglobin, low ejection fraction and larger aneurysms) should be judged when planning endovascular repair of AAA.

Incidence of Acute and Chronic Renal Failure Following Branched Endovascular Repair of Complex Aortic Aneurysms

BACKGROUND

The purpose of this study was to examine the incidence of acute kidney injury and chronic renal impairment following branched endovascular aneurysm repair (BEVAR) of complex thoracoabdominal aortic aneurysms (TAAA) using the Medtronic Valiant Thoracoabdominal Aortic Aneurysm stent graft system (MVM), the physician-modified Visceral Manifold, and Unitary Manifold stent graft systems. The objective was to report the acute and chronic renal function changes in patients following complex TAAA aneurysm repair.

METHODS

This is an analysis of 139 patients undergoing branched endovascular repair for complex TAAAs between 2012 and 2020. Patient renal function was evaluated using serum creatinine and estimated glomerular filtration rate at baseline, 48 hr, discharge, 1 month, 6 months, and annually to 2 years. Patients on dialysis prior to the procedure were excluded from data analysis.

RESULTS

A total of 139 patients (mean age 71.13; 64.7% male) treated for TAAA with BEVAR met inclusion criteria and were evaluated. A total of 530 visceral vessels were stented. A majority of patients (n = 131, 94.2%) underwent a single procedure while 8 required staged procedures. Thirty-day, 1-year and 2-year all-cause mortality rates were 5.8%, 25.2%, and 32.4%, respectively. Primary and secondary patency rates at a median follow-up of 26.9 months (95% CI; 21.1 - 32.7) were 96.2% and 97.5% for all vessels and 95.4% and 96.9% for renal arteries, respectively. Postoperative acute kidney injury (AKI) was identified in 22 (15.8%) patients. At discharge, 16 patients (11.6%) had an increase in CKD stage with 3 requiring permanent dialysis. Five additional patients required permanent dialysis over the 2-year follow-up period for a total of 8 (5.8%). Increasing age (HR = 1.0327, P= 0.0477), hemoglobin < 7 prior to procedure (HR = 2.4812, P= 0.0093), increasing maximum aortic diameter (HR = 1.0189, P= 0.0084), presence of AKI (HR = 2.0757, P= 0.0182), and increase in CKD stage (HR = 1.3520, P= 0.002) at discharge were significantly associated with decreased patient survival.

CONCLUSIONS

Postoperative AKI and a chronic decline in renal function continue to be problematic in endovascular repair of complex aortic aneurysms. This study found that BEVAR using the manifold configuration resulted in immediate and mid-term renal function that is comparable to similar analyses of branched and/or fenestrated grafts.

Bridging Stents in Fenestrated and Branched Endovascular Aneurysm Repair: A Systematic REVIEW

BACKGROUND

Concern exists about durability of stent grafts used to bridge aortic grafts to visceral and renal arteries during fenestrated and branched endovascular aneurysm repair (F/B-EVAR). There are no guidelines regarding the ideal technique for joining target vessels (TVs).

METHODS

We systematically reviewed data published from 2014 to 2019 using PRISMA guidelines and PICO models. Keywords were searched in MEDLINE, EMBASE, and Cochrane Library. All articles were screened by two authors (a third author in case of discrepancies). Only original articles regarding F/B-EVAR in complex aortic aneurysm, reporting the number and type of TVs mated, the onset of bridging stent complications, and reinterventions on TVs were included. Analysis included quality assessment scoring, types of stent grafts, and complications related to bridging stents.

RESULTS

19 studies were included with 2,796 patients and 9556 TV; 4,797 renal arteries (50.2%), 4,174 visceral arteries (43.6%), and undefined TV (n = 585; 6.1%) were bridged. Balloon-expandable stent-grafts (B-EXP) were used in 40.9% and self-expandable (S-EXP) in 22.7% and undefined stents in 36.3%. The included studies had quality assessment scores ranging between 11/15 and 15/15, with high grade of accordance on reporting general results, but a low grade of accordance on reporting detailed data. Despite study heterogeneity, high-volume analysis confirmed a higher rate of complication in renal arteries than visceral arteries, 6% (95% CI 4-8) vs. 2% (95% CI 1-3), respectively. The rate of reinterventions was similar, 3% (95% CI 2-4) and 2% (95% CI 1-3). S-EXP versus B-EXP stent complication was 4% (95% CI 2-7) vs. 3% (95% CI 2-5), respectively.

CONCLUSIONS

This systematic review underlines the low grade of accordance in reporting detailed data of bridging stents in F/B-EVAR. Renal TVs were more prone to complications, with an equivalent reintervention rate to visceral TVs. As to B-EVAR, the choice of B-EXP over S-EXP is still uncertain.

Impact of bridging stent design and configuration on branch vessel durability after fenestrated endovascular repair of complex aortic aneurysms

OBJECTIVE

The ideal mating stent for target vessel revascularization in fenestrated endovascular aneurysm repair (FEVAR) of juxtarenal and thoracoabdominal aortic aneurysms remains unknown. The objective of this study was to assess the outcomes associated with use of different stent types and configurations mated with reinforced fenestrations during FEVAR.

METHODS

Clinical data from patients undergoing FEVAR for juxtarenal and thoracoabdominal aortic aneurysms in a prospective physician-sponsored investigational device exemption trial were analyzed. Outcomes for two different balloon-expandable covered stents (BECSs) mated with reinforced fenestrations were assessed along with the impact of distal extension with a self-expanding stent (SES). Primary patency, branch-related endoleak, and reintervention rates were determined. Cox proportional hazards model was used for time-to-event analysis.

RESULTS

From 2001 to 2016, there were 918 patients who underwent fenestrated or branched endograft repair of complex aortic aneurysms; 1604 renal arteries (RAs), 714 superior mesenteric arteries (SMAs), and 333 celiac arteries (CAs) were mated with reinforced fenestrations using JOMED (n = 2014; Abbott Vascular, Santa Clara, Calif) or iCAST (n = 637; Atrium Medical, Hudson, NH) BECSs. The type of BECS did not affect short-term or long-term patency, branch-related endoleaks, or reintervention rates in the RA, SMA, or CA. Twenty-five percent (402/1604) of RAs, 84% (598/714) of SMAs, and 8% (27/333) of CAs underwent distal SES extension at the index operation. RAs with a distal SES in addition to the BECS had a higher likelihood of an occlusion event (hazard ratio, 2.791; 95% confidence interval, 1.42-5.48; P = .003) and reinterventions (P = .036) compared with those without an SES. Addition of a distal SES to the BECS in the SMA or CA did not have an impact on patency or reintervention rates.

CONCLUSIONS

BECS choice does not appear to have an impact on branch durability after FEVAR. Selective distal SES placement in RAs with high-risk anatomy does not appear to significantly protect against an occlusion event or to prevent secondary interventions. Routine addition of a distal SES does not improve SMA fenestration durability.

Treatment of High Surgical Risk Thoracoabdominal Aortic Aneurysms with Stent Graft and Multilayer Bare Stents Joint Technique: Mid-Long-Term Clinical Results

BACKGROUND

This study aims to present the performance data on stent-graft and multilayer bare stents (MBS) joint technique in the treatment of high-risk thoracoabdominal aortic aneurysm (TAAA).

METHODS

From May 2012 to December 2015, 8 selective TAAA cases (ages 46-75 years) ineligible for surgical repair underwent the stent-graft and MBS joint procedure, and were closely followed up for a median of 32 months (range 14-58). Using computed tomography images, the aneurysm size, luminal blood flow diameter, and the covered visceral branches were analyzed.

RESULTS

Technical success was achieved in all patients (100%, 8/8). Twenty-four visceral branches were covered by MBS in total. There was no complication or death during hospital stay. During follow-up period, no death or complication occurred. Aneurysm shrinkage (maximum diameter decrease ≥5 mm) was observed in 7 patients. No aneurysm expansion was observed. Total aneurysm sac thrombosis was observed in all patients. The majority of covered side branches (23/24) were successfully preserved. No visceral ischemia or bleeding complications was observed during follow-up.

CONCLUSIONS

Total endovascular repair of TAAA using stent-graft and MBS joint technique may be a safe and effective alternative in high surgical risk patients. More approving clinical evidences about the safety and efficacy of this procedure are anticipated.

Predictors of in-hospital adverse events after endovascular aortic aneurysm repair

BACKGROUND

Endovascular aneurysm repair (EVAR) offered outstanding survival benefit but at the expense of cost, periodic radiographic monitoring, and higher reinterventions rates. Perioperative complications, although rare, can occur after EVAR, contributing to longer hospitalization, higher cost, and significant comorbidity and mortality. Therefore, the aim of this study was to identify the predictors of in-hospital events (IHEs) after elective EVAR.

METHODS

The Vascular Quality Initiative database was explored from 2003 to 2017. Patients who had converted to open repair were excluded. IHEs were defined as any in-hospital myocardial infarction, dysrhythmia, congestive heart failure (CHF), stroke, pneumonia, respiratory failure, renal failure, lower extremity ischemia, bowel ischemia, or reoperation. Stepwise backward selection based on the Akaike information criterion statistic was implemented to select the predictors of IHE from the multivariable logistic regression models. Bootstrapping was performed with 1000 replications to internally validate the model and to obtain bias-corrected estimates. Receiver operating characteristic curves (area under the curve [AUC]) and Hosmer-Lemeshow tests were used to assess the discrimination and calibration of the models.

RESULTS

A total of 28,240 patients with full information about IHEs were included. Any IHE took place in 2365 (8.4%) patients. Patients who had an IHE were slightly older (mean age ± standard deviation, 75.6 ± 8.1 years vs 73.3 ± 8.5 years; P < .001]. A higher proportion of women had an IHE (25.6% vs 17.9%; P < .001). Comorbid conditions were more prevalent in patients who developed an IHE (chronic kidney disease, 49.1% vs 33.2%; coronary artery disease, 34.3% vs 29.0%; moderate to severe CHF, 3.9% vs 1.4%; chronic obstructive pulmonary disease, 42.5% vs 31.9%; hypertension, 87.0% vs 83.1%; and diabetes, 18.0% vs 16.1%; all P ≤ .015). An IHE was associated with high in-hospital (5.6% vs 0.03%) and 30-day mortality (6.3% vs 0.3%; both P < .001) and worse 3-year survival beyond the perioperative period (81.1% [79.3%-82.9%] vs 91.1% [90.7%-91.5%]; P < .001). Two models were constructed, one from preoperative factors and the second from preoperative and intraoperative factors. The selected predictors of IHEs were female sex, moderate or severe CHF, chronic kidney disease, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and aneurysm diameter. Intraoperative factors were contrast material volume, operative time, and packed red blood cell transfusion. Nomograms were constructed from the final models. AUC significantly improved after adding intraoperative factors (AUC [95% confidence interval], 0.71 [0.70-0.73] vs 0.65 [0.64-0.66]; P < .001].

CONCLUSIONS

In-hospital adverse events can complicate the perioperative course of EVAR and increase the risk of operative and long-term mortality. Predicting IHEs and identifying their risk factors can potentially mitigate their development in patients at high risk. Predicting IHE risk can have tremendous prognostic value and help disposition planning. This study introduces an internally validated tool to enable vascular surgeons to identify patients' chance of having an IHE.

Ischemia-induced lower extremity neurologic impairment after fenestrated endovascular aneurysm repair

OBJECTIVE

Placement of large sheaths in the iliac system during fenestrated endovascular aneurysm repair (FEVAR) leads to lower extremity (LE) ischemia that can be associated with serious neurologic complications. We sought to determine the effect of LE ischemic time on neurologic impairment after FEVAR.

METHODS

Consecutive patients who underwent FEVAR at a single institution were analyzed. LE ischemic time was calculated from the time of large sheath (≥18F) insertion to the time of sheath removal from the iliac arteries that led to continuous LE ischemia. The primary outcome was neurologic impairment defined as any new sensory or motor deficit in either LE. Outcomes were analyzed using descriptive statistics and modeled with logistic regression with interaction terms. Each individual LE was used as a unit of analysis.

RESULTS

We examined 101 patients (202 lower extremities) who underwent FEVAR over a 5-year period. The median LE ischemic time was 2.75 hours (range, 0.8-5.2 hours). Neurologic impairment developed in 18 extremities (9%). Of those, 12 (67%) developed mild sensory loss, 6 (33%) complete sensory loss, 4 (22%) loss of proprioception, and 2 (11%) motor dysfunction. Sensory deficit was permanent in four limbs (2%) and motor dysfunction in one limb (0.5%). In all other cases, the neurologic examination returned to baseline by postoperative day 15. Duration of LE ischemic time (odds ratio, 6.3; 95% confidence interval, 3.1-12.4; P < .001) and common iliac artery (CIA) stenosis to a lumen of 8 mm or less (odds ratio, 2.7; 95% confidence interval, 1.5-7.3; P = .002) were independent predictors for the development of neurologic impairment. An interaction term between LE ischemic time and CIA stenosis was statistically significant (P = .042), indicating that the presence of CIA stenosis modifies the effect of LE ischemic time. In those with CIA stenosis to a lumen of 8 mm or less, the risk of neurologic impairment increased rapidly after 2.5 hours of LE ischemia, and became nearly certain after 4 hours of ischemic time. By contrast, patients without CIA stenosis tolerated longer ischemic times and demonstrated a less steep increase in the risk for LE neurologic impairment.

CONCLUSIONS

LE neurologic impairment after FEVAR is strongly associated with LE ischemic time and CIA occlusive disease to a lumen of 8 mm or less. Our data indicate that, when the LE ischemic time is expected to exceed 2.5 hours (in patients with CIA stenosis) or 3 hours (in patients without CIA stenosis), measures to ensure LE perfusion should be given consideration.

Hybrid thoracoabdominal aortic aneurysm repair: is the future here?

Open surgical repair has been the gold standard for thoracoabdominal aortic aneurysm (TAAA) repair for more than 6 decades, but 2 additional options have emerged: total endovascular TAAA repair and a hybrid approach that combines open and endovascular repair. Despite the optimism for an endovascular approach, long-term results for these repairs are still lacking. Some of the issues with this emerging technology include the risk of paraplegia after extensive endovascular repair, the need for multiple reinterventions, continuous stent-graft surveillance, endograft branch stenosis, as well as the significant learning curve. Interest in a hybrid approach has resurged despite the non-superior results compared to open TAAA. Commonly, the focus of the hybrid approach is now on performing a less extensive open TAAA repair, which is then extended with a stent-graft or vice versa. Moreover, this approach is now often performed in two stages in an effort to decrease the associated spinal cord ischemia. Open surgical repair after endovascular aortic repair is increasingly being performed to address serious complications, such as infection or fistula, that cannot be repaired by further endovascular intervention. As with any new technology, there will be an increase in the number of procedure-related complications and a decrease in the number of surgeons who can perform the traditional open operation with good results.

Systematic review of mortality risk prediction models in the era of endovascular abdominal aortic aneurysm surgery

BACKGROUND

The introduction of endovascular aneurysm repair (EVAR) has reduced perioperative mortality after abdominal aortic aneurysm (AAA) surgery. The objective of this systematic review was to assess existing mortality risk prediction models, and identify which are most useful for patients undergoing AAA repair by either EVAR or open surgical repair.

METHODS

A systematic search of the literature was conducted for perioperative mortality risk prediction models for patients with AAA published since 2006. PRISMA guidelines were used; quality was appraised, and data were extracted and interpreted following the CHARMS guidelines.

RESULTS

Some 3903 studies were identified, of which 27 were selected. A total of 13 risk prediction models have been developed and directly validated. Most models were based on a UK or US population. The best performing models regarding both applicability and discrimination were the perioperative British Aneurysm Repair score (C-statistic 0·83) and the preoperative Vascular Biochemistry and Haematology Outcome Model (C-statistic 0·85), but both lacked substantial external validation.

CONCLUSION

Mortality risk prediction in AAA surgery has been modelled extensively, but many of these models are weak methodologically and have highly variable performance across different populations. New models are unlikely to be helpful; instead case-mix correction should be modelled and adapted to the population of interest using the relevant mortality predictors.

Outcomes of thoracic endovascular aortic repair using aortic arch chimney stents in high-risk patients

BACKGROUND

Aortic arch disease is a challenging clinical problem, especially in high-risk patients, in whom open repair can have morbidity and mortality rates of 30% to 40% and 2% to 20%, respectively. Aortic arch chimney (AAC) stents used during thoracic endovascular aortic repair (TEVAR) are a less invasive treatment strategy than open repair, but the current literature is inconclusive about the role of this technology. The focus of this analysis is on our experience with TEVAR and AAC stents.

METHODS

All TEVAR procedures performed from 2002 to 2015 were reviewed to identify those with AAC stents. Primary end points were technical success and 30-day and 1-year mortality. Secondary end points included complications, reintervention, and endoleak. Technical success was defined as a patient's surviving the index operation with deployment of the AAC stent at the intended treatment zone with no evidence of type I or type III endoleak on initial postoperative imaging. The Kaplan-Meier method was used to estimate survival.

RESULTS

Twenty-seven patients (age, 69 ± 12 years; male, 70%) were identified, and all were described as being at prohibitive risk for open repair by the treating team. Relevant comorbidity rates were as follows: coronary artery disease/myocardial infarction, 59%; oxygen-dependent emphysema, 30%; preoperative creatinine concentration >1.8 mg/dL, 19%; and congestive heart failure, 15%. Presentations included elective (67%; n = 18), symptomatic (26%; n = 7), and ruptured (7%; n = 2). Eleven patients (41%) had prior endovascular or open arch/descending thoracic repair. Indications were degenerative aneurysm (49%), chronic residual type A dissection with aneurysm (15%), type Ia endoleak after TEVAR (11%), postsurgical pseudoaneurysm (11%), penetrating ulcer (7%), and acute type B dissection (7%). Thirty-two brachiocephalic vessels were treated: innominate (n = 7), left common carotid artery (LCCA; n = 24), and left subclavian artery (n = 1). Five patients (19%) had simultaneous innominate-LCCA chimneys. Brachiocephalic chimney stents were planned in 75% (n = 24), with the remainder placed for either LCCA or innominate artery encroachment (n = 8). Overall technical success was 89% (one intraoperative death, two persistent type Ia endoleaks in follow-up). The 30-day mortality was 4% (n = 1; intraoperative death of a patient with a ruptured arch aneurysm), and median length of stay was 6 (interquartile range, 4-9) days. Seven (26%) patients experienced a major complication (stroke, three [all with unplanned brachiocephalic chimney]; respiratory failure, three; and death, one). Nine (33%) patients underwent aorta-related reintervention, and no chimney occlusion events occurred during follow-up (median follow-up, 9 [interquartile range, 1-23] months). The 1-year and 3-year survival is estimated to be 88% ± 6% and 69% ± 9%, respectively.

CONCLUSIONS

TEVAR with AAC can be performed with high technical success and acceptable morbidity and mortality in high-risk patients. Unplanned AAC placement during TEVAR results in an elevated stroke risk, which may be related to the branch vessel coverage necessitating AAC placement. Acceptable midterm survival can be anticipated, but aorta-related reintervention is not uncommon, and diligent follow-up is needed.

A retrospective observational cohort study investigating the association between acute kidney injury and all-cause mortality among patients undergoing endovascular repair of abdominal aortic aneurysms

BACKGROUND

Acute kidney injury (AKI) has been found to be associated with short- and long-term mortality and morbidity in various clinical settings. However, it is unknown whether AKI after endovascular repair of abdominal aortic aneurysms (EVAR) is associated with postoperative mortality.

METHODS

This observational study analyzed patients who underwent EVAR. The primary outcome was all-cause mortality. The outcomes of patients with and without postoperative AKI were compared using the Kaplan-Meier method and log-rank test. Factors with P < 0.05 on the univariate analysis were entered into the multivariate Cox regression model. Predictors of AKI were also determined using Cox univariate and multivariate analysis. The identified predictors of AKI were excluded from multivariate analysis for all-cause mortality because these factors could intermediate outcome.

RESULTS

There were 490 eligible patients. After a follow-up of 28.3 (16.8) months [mean (standard deviation)], 62 patients (12.7%) died. AKI occurred in 59 patients (12.0%). AKI was found by the log-rank test to be associated with a significant increase of all-cause mortality (P < 0.001). Preoperative estimated glomerular filtration rate, preoperative peripheral vascular disease, and emergency surgery were found to be independent predictors of AKI and these variables were excluded from the main analysis. Multivariate analysis showed AKI [hazard ratio (HR) = 1.19, 95% confidence interval (CI) 1.01-3.60, P = 0.045] and transfusion (HR = 1.05, 95% CI 1.01-1.09, P = 0.011) were independent predictors of mortality.

CONCLUSIONS

In the present study, AKI and transfusion were associated with significant increases in all-cause mortality after EVAR.

Durability of iliac artery preservation associated with endovascular repair of infrarenal aortoiliac aneurysms

OBJECTIVE

This study evaluated and compared the long-term clinical outcomes of endovascular repair of infrarenal aortoiliac aneurysms (EVAR) vs EVAR with preservation of antegrade internal iliac artery (IIA) perfusion using iliac branched devices (EVAR-IBDs).

METHODS

From October 1998 to August 2015, patients with infrarenal aortoiliac aneurysmal (AIA) disease at high risk for conventional open surgery were enrolled in a prospective physician-sponsored investigational device exemption trial. Clinical data of 75 patients treated with EVAR-IBD and 255 with standard EVAR were analyzed. Technical success, perioperative outcomes, mortality, device patency, endoleak rates, and reinterventions during a follow-up of 10 years were analyzed.

RESULTS

There were 87 IBDs deployed in 75 patients. Technical success rate was 97%. Mortality at 30 days was 1.3%. Freedom from aneurysm-related mortality at 3, 5, and 10 years was 99%. Freedom from a type I or III endoleak at 3, 5, and 10 years was 99%. Freedom from secondary reinterventions at 3, 5, and 10 years was 86%, 81%, and 81%, respectively. Primary patency of the IBDs at 3, 5, and 10 years was 94%, 94%, and 77%, respectively. Twenty-four percent of patients underwent EVAR for concomitant AIA disease (EVAR-AIA), and 78% were managed by staged IIA embolization before EVAR. No statistically significant difference in freedom from aneurysm-related mortality, limb occlusions, or endoleak rates was identified in patients with EVAR-AIA vs EVAR-IBD (P > .05). There were significantly more secondary reinterventions in the EVAR-AIA group compared with the EVAR-IBD group (hazard ratio, 0.476, 95% confidence interval, 0.226-1.001; P = .045).

CONCLUSIONS

EVAR of infrarenal AIAs with preservation of antegrade flow to the IIA using IBDs is feasible with long-term sustained durability. Serious considerations should be given to the use of IBDs in patients with infrarenal AIAs meeting appropriate anatomic criteria.

Does the diameter of abdominal aortic aneurysm influence late survival following abdominal aortic aneurysm repair? A systematic review and meta-analysis

Background

Studies reporting the influence of preoperative abdominal aortic aneurysm diameter on late survival following abdominal aortic aneurysm repair have not been consistent. Aim: To report the influence of abdominal aortic aneurysm diameter on overall long-term survival following abdominal aortic aneurysm repair.

Methods

Embase, Medline and the Cochrane electronic databases were searched to identify articles reporting the influence of abdominal aortic aneurysm diameter on late survival following open aneurysm repair and endovascular aneurysm repair published up to April 2015. Data were extracted from multivariate analysis; estimated risks were expressed as hazard ratio.

Results

A total of 2167 titles/abstracts were retrieved, of which 76 studies were fully assessed; 19 studies reporting on 22,104 patients were included. Preoperative larger abdominal aortic aneurysm size was associated with a worse survival compared to smaller aneurysms with a pooled hazard ratio of 1.14 (95% CI: 1.09–1.18), per 1 cm increase in abdominal aortic aneurysm diameter. Subgroup analysis of the different types of repair was performed and the hazard ratio (95% CI), for open aneurysm repair and endovascular aneurysm repair were 1.08 (1.03–1.12) and 1.20 (1.15–1.25), respectively, per 1 cm increase. There was a significant difference between the groups p < 0.02.

Conclusions

This meta-analysis suggests that preoperative large abdominal aortic aneurysm independently influences overall late survival following abdominal aortic aneurysm repair, and this association was greater in abdominal aortic aneurysm repaired with endovascular aneurysm repair.

Systematic Review and Meta-analysis of Factors Influencing Survival Following Abdominal Aortic Aneurysm Repair

BACKGROUND

Predicting long-term survival following repair is essential to clinical decision making when offering abdominal aortic aneurysm (AAA) treatment. A systematic review and a meta-analysis of pre-operative non-modifiable prognostic risk factors influencing patient survival following elective open AAA repair (OAR) and endovascular aneurysm repair (EVAR) was performed.

METHODS

MEDLINE, Embase and Cochrane electronic databases were searched to identify all relevant articles reporting risk factors influencing long-term survival (≥1 year) following OAR and EVAR, published up to April 2015. Studies with <100 patients and those involving primarily ruptured AAA, complex repairs (supra celiac/renal clamp), and high risk patients were excluded. Primary risk factors were increasing age, sex, American Society of Anaesthesiologist (ASA) score, and comorbidities such as ischaemic heart disease (IHD), cardiac failure, hypertension, chronic obstructive pulmonary disease (COPD), renal impairment, cerebrovascular disease, peripheral vascular disease (PVD), and diabetes. Estimated risks were expressed as hazard ratio (HR).

RESULTS

A total of 5,749 study titles/abstracts were retrieved and 304 studies were thought to be relevant. The systematic review included 51 articles and the meta-analysis 45. End stage renal disease and COPD requiring supplementary oxygen had the worst long-term survival, HR 3.15 (95% CI 2.45-4.04) and HR 3.05 (95% CI 1.93-4.80) respectively. An increase in age was associated with HR of 1.05 (95% CI 1.04-1.06) for every one year increase and females had a worse survival than men HR 1.15 (95% CI 1.07-1.27). An increase in ASA score and the presence of IHD, cardiac failure, hypertension, COPD, renal impairment, cerebrovascular disease, PVD, and diabetes were also factors associated with poor long-term survival.

CONCLUSION

The result of this meta-analysis summarises and quantifies unmodifiable risk factors that influence late survival following AAA repair from the best available published evidence. The presence of these factors might assist in clinical decision making during discussion with patients regarding repair.

Preliminary results of Zenith Fenestrated abdominal aortic aneurysm endovascular grafts

BACKGROUND

Patients with juxtarenal aortic aneurysms who are unfit for open repair may be considered for fenestrated endovascular repair (fenEVAR). We report our initial experience with fenEVAR.

METHODS

We reviewed the data on all our patients receiving fenEVAR for juxtarenal aortic aneurysms.

RESULTS

Eight patients, average age 75 years, underwent fenEVAR. Endografts were designed from details obtained from preoperative computed tomography angiography. There were 6 grafts with superior mesenteric scallops and bilateral renal fenestrations, 1 with bilateral renal scallops, and 1 with a single renal fenestration. All patients survived 30 days. There was no renal failure requiring dialysis. At 10 weeks, 1 patient died from acute intestinal ischemia and multisystem organ failure, and another died from respiratory failure.

CONCLUSIONS

It is feasible to offer fenEVAR to patients who are poor candidates for open repair. However, these procedures are technically challenging. Early outcomes are less favorable than other aortic endovascular procedures.

Eight-year follow-up of a high-risk patient treated for Crawford Type II thoracoabdominal aortic aneurysm (TAAA) with a multistage hybrid open-endovascular repair

The case of a patient with type II TAAA (thoracoabdominal aortic aneurysm), who underwent multistage hybrid procedure, is presented. This high-risk patient was excluded as ineligible for conventional open repair. At first, the bypass between both common carotid arteries was inserted. Then, the transperitoneal viscerorenal revascularization was performed to ensure blood perfusion. At the end, the stent graft from the aorta arch to its bifurcation was deployed with endovascular techniques. This stent graft covered left common carotid artery, left subclavian artery, visceral trunk, superior mesenteric artery and both renal arteries. The patient had been observed for eight years with relatively low complication rate. The hybrid open-endovascular repair (HOER) shows promising results in patients at prohibitive risk for classic reconstruction.