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Png CYM, Pendleton AA, Altreuther M, Budtz-Lilly JW, Gunnarsson K, Kan CD, Khashram M, Laine MT, Mani K, Pederson CC, Srivastava SD, Eagleton MJ. Effect of EVAR on International Ruptured AAA Mortality-Sex and Geographic Disparities. J Clin Med 2024; 13:2464. [PMID: 38730993 PMCID: PMC11084331 DOI: 10.3390/jcm13092464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/04/2024] [Accepted: 04/12/2024] [Indexed: 05/13/2024] Open
Abstract
Background: We sought to investigate the differential impact of EVAR (endovascular aneurysm repair) vis-à-vis OSR (open surgical repair) on ruptured AAA (abdominal aortic aneurysm) mortality by sex and geographically. Methods: We performed a retrospective study of administrative data on EVAR from state statistical agencies, vascular registries, and academic publications, as well as ruptured AAA mortality rates from the World Health Organization for 14 14 states across Australasia, East Asia, Europe, and North America. Results: Between 2011-2016, the proportion of treatment of ruptured AAAs by EVAR increased from 26.1 to 43.8 percent among females, and from 25.7 to 41.2 percent among males, and age-adjusted ruptured AAA mortality rates fell from 12.62 to 9.50 per million among females, and from 34.14 to 26.54 per million among males. The association of EVAR with reduced mortality was more than three times larger (2.2 vis-à-vis 0.6 percent of prevalence per 10 percentage point increase in EVAR) among females than males. The association of EVAR with reduced mortality was substantially larger (1.7 vis-à-vis 1.1 percent of prevalence per 10 percentage point increase in EVAR) among East Asian states than European+ states. Conclusions: The increasing adoption of EVAR coincided with a decrease in ruptured AAA mortality. The relationship between EVAR and mortality was more pronounced among females than males, and in East Asian than European+ states. Sex and ethnic heterogeneity should be further investigated.
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Affiliation(s)
- C Y Maximilian Png
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - A Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Martin Altreuther
- Department of Vascular Surgery, St. Olavs Hospital, 7030 Trondheim, Norway
| | - Jacob W Budtz-Lilly
- Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Skejby, 8200 Aarhus, Denmark
| | - Kim Gunnarsson
- Department of Surgical Sciences, Uppsala University, 75237 Uppsala, Sweden
| | - Chung-Dann Kan
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 701, Taiwan
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland 1010, New Zealand
| | - Matti T Laine
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, 75237 Uppsala, Sweden
| | - Christian C Pederson
- Department of Vascular Surgery, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
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Talvitie M, Jonsson M, Roy J, Hultgren R. Association of women-specific size threshold and mortality in elective abdominal aortic aneurysm repair. Br J Surg 2024; 111:znad376. [PMID: 37963191 PMCID: PMC10776526 DOI: 10.1093/bjs/znad376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/17/2023] [Accepted: 10/22/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND It is unclear whether women derive mortality benefit from early repair of abdominal aortic aneurysms (AAA). The aim of this study was to compare short- and mid-term mortality for women treated at small versus large diameters. METHOD Women receiving elective repair of AAA at small (49-54 mm) and large (≥55 mm) diameters from 2008 to 2022 were extracted from the Swedish National Registry for Vascular Surgery (n = 1642 women). The effect of diameter on 90-day, 1- and 3-year mortality was studied in logistic regression and propensity score models. Age, co-morbidities, smoking and repair modality were considered as confounders. Men (n = 9047) were analysed in parallel. RESULTS Some 1642 women were analysed, of whom 34% underwent repair at small diameters (versus 52% of men). Women with small (versus large) AAAs were younger (73 versus 75 years, P < 0.001), and 63% of women in both size groups had endovascular repairs (P = 0.120). Mortality was 3.5% (90 days), 7.1% (1 year) and 15.8% (3 years), with no differences between the size strata. There was no consistent association between AAA size and mortality in multivariable models. Sex differences in mortality were almost entirely due to mortality in younger-than-average women versus men (3-year mortality: small AAAs 11.1% versus 7.3%, P < 0.030, or large 14.4% versus 10.7%, P < 0.038). CONCLUSION Mortality in women is high and unaffected by AAA size at repair. The optimal threshold for women remains undefined. The higher rupture risk in women should not automatically translate into a lower, women-specific threshold.
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Affiliation(s)
- Mareia Talvitie
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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De Freitas S, Falls G, Weis T, Bakhshi K, Korepta LM, Bechara CF, Erben Y, Arya S, Fatima J. Comprehensive framework of factors accounting for worse aortic aneurysm outcomes in females: A scoping review. Semin Vasc Surg 2023; 36:508-516. [PMID: 38030325 DOI: 10.1053/j.semvascsurg.2023.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/15/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Sex-based outcome studies have consistently documented worse results for females undergoing care for abdominal aortic aneurysms. This review explores the underlying factors that account for worse outcomes in the females sex. A scoping review of studies reporting sex-based disparities on abdominal aortic aneurysms was performed. The review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews. Factors that account for worse outcomes in the females sex were identified, grouped into themes, and analyzed. Key findings of each study are reported and a comprehensive framework of these factors is presented. A total of 35 studies were identified as critical in highlighting sex-based disparities in care of patients with aortic aneurysms. We identified the following 10 interrelated themes in the chain of aneurysm care that account for differential outcomes in females: natural history, risk factors, pathobiology, biomechanics, screening, morphology, device design and adherence to instructions for use, technique, trial enrollment, and social determinants. Factors accounting for worse outcomes in the care of females with aortic aneurysms were identified and described. Some factors are immediately actionable, such as screening criteria, whereas device design improvement will require further research and development. This comprehensive framework of factors affecting care of aneurysms in females should serve as a blueprint to develop education, outreach, and future research efforts to improve outcomes in females.
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Affiliation(s)
| | | | - Tahlia Weis
- Marshfield Clinic Health System, Marshfield, WI
| | | | | | | | | | - Shipra Arya
- Stanford University School of Medicine, Stanford, CA
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Mulatti GC, Joviliano EE, Pereira AH, Fioranelli A, Pereira AA, Brito-Queiroz A, Von Ristow A, Freire LMD, Ferreira MMDV, Lourenço M, De Luccia N, Silveira PG, Yoshida RDA, Fidelis RJR, Boustany SM, de Araujo WJB, de Oliveira JCP. Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm. J Vasc Bras 2023; 22:e20230040. [PMID: 38021279 PMCID: PMC10648059 DOI: 10.1590/1677-5449.202300402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/15/2023] [Indexed: 12/01/2023] Open
Abstract
The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.
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Affiliation(s)
- Grace Carvajal Mulatti
- Universidade de São Paulo - USP, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil.
| | - Edwaldo Edner Joviliano
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto - FMRP, Ribeirão Preto, SP, Brasil.
| | - Adamastor Humberto Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | | | - Alexandre Araújo Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | - André Brito-Queiroz
- Universidade Federal da Bahia - UFBA, Hospital Ana Nery, Salvador, BA, Brasil.
| | - Arno Von Ristow
- Pontifícia Universidade Católica do Rio de Janeiro - PUC-Rio, Rio de Janeiro, RJ, Brasil.
| | | | | | | | - Nelson De Luccia
- Universidade de São Paulo - USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | | | - Ricardo de Alvarenga Yoshida
- Universidade Estadual Paulista “Júlio de Mesquita Filho” - UNESP, Faculdade de Medicina de Botucatu, Botucatu, SP, Brasil.
| | | | - Sharbel Mahfuz Boustany
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
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Chinsakchai K, Sirivech T, Moll FL, Tongsai S, Hongku K. The Correlation of Aortic Neck Angle and Length in Abdominal Aortic Aneurysm with Severe Neck Angulation for Prediction of Intraoperative Neck Complications and Postoperative Outcomes after Endovascular Aneurysm Repair. J Clin Med 2023; 12:5797. [PMID: 37762737 PMCID: PMC10531816 DOI: 10.3390/jcm12185797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/02/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVES Endovascular aneurysm repair (EVAR) in a hostile neck has been associated with adverse outcomes. We aimed to determine the association of infrarenal aortic neck angle and length and establish an optimal cutoff value to predict intraoperative neck complications and postoperative outcomes. METHODS This was a retrospective review of patients with an intact infrarenal abdominal aortic aneurysm (AAA) with severe neck angulation (>60 degrees) who underwent EVAR from October 2010 to October 2018. Demographic data, aneurysm morphology, and operative details were collected. The ratio of neck angle and length was calculated as the optimal cutoff value of the aortic neck angle-length index. The patients were categorized into two distinct groups using latent profile analysis, a statistical technique employed to identify concealed subgroups within a larger population by examining a predetermined set of variables. Intraoperative neck complications, adjunct neck procedures, and early and late outcomes were compared. RESULTS 115 patients were included. Group 1 (G1) had 95 patients with an aortic neck angle-length index ≤ 4.8, and Group 2 (G2) had 20 patients with an aortic neck angle-length index > 4.8. Demographic data and aneurysm morphology were not significantly different between groups except for neck length (p < 0.001). G2 had more intraoperative neck complications than G1 (21.1% vs. 55%, p = 0.005). Adjunctive neck procedures were more common in G2 (18.9% vs. 60%, p < 0.001). The thirty-day mortality rate was not statistically different. G1 patients had a 5-year proximal neck re-intervention-free rate comparable to G2 patients (93.7% G1 vs. 87.5% G2, p = 0.785). The 5-year overall survival rate was not statistically different (59.9% G1 vs. 69.2% G2, p = 0.891). CONCLUSIONS Patients with an aortic neck angle-length index > 4.8 are at greater risk of intraoperative neck complications and adjunctive neck procedures than patients with an aortic neck angle-length index ≤ 4.8. The 5-year proximal neck re-intervention-free rate and the 5-year survival rate were not statistically different. Based on our findings, this study suggests that the aortic neck angle-length index is a reliable predictor of intraoperative neck complications during EVAR in AAA with severe neck angulation.
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Affiliation(s)
- Khamin Chinsakchai
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (T.S.); (K.H.)
| | - Thana Sirivech
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (T.S.); (K.H.)
| | - Frans L. Moll
- Vascular Surgery Department, University Medical Center Utrecht, 3584 Utrecht, The Netherlands;
| | - Sasima Tongsai
- Research Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand;
| | - Kiattisak Hongku
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (T.S.); (K.H.)
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Talvitie M, Åldstedt-Nyrønning L, Stenman M, Roy J, Cohnert T, Hultgren R. Women with large intact abdominal aortic aneurysms remain untreated. J Vasc Surg 2023; 78:657-667.e5. [PMID: 37211143 DOI: 10.1016/j.jvs.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/20/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE A lower elective repair rate among women with abdominal aortic aneurysms (AAAs) has been a consistent finding. Reasons behind this gender gap have not been thoroughly outlined. METHODS This was a retrospective multicenter cohort study (ClinicalTrials.gov: NCT05346289) at three European vascular centers in Sweden, Austria and Norway. Patients in surveillance with AAAs were consecutively identified starting from January 1, 2014, until reaching a total sample size of 200 women and 200 men. All individuals were followed for 7 years through medical records. Final treatment distributions and the proportion of "truly untreated" (surgically untreated despite reaching guideline-directed thresholds: 50 mm for women and 55 mm for men) were determined. In a complementary analysis, a universal 55-mm threshold was used. Gender-specific primary reasons behind untreated statuses were clarified. Eligibility for endovascular repair among the truly untreated was assessed in a structured computed tomography analysis. RESULTS Women and men had similar median diameters at inclusion (46 mm; P = .54) and at treatment decisions (55 mm; P = .36). After 7 years, the repair rate was lower among women (47% vs 57%). More women were truly untreated (26% vs 8%; P < .001) despite similar mean ages as for male counterparts (79.3 years; P = .16). With the 55-mm threshold, 16% women still classified as truly untreated. Similar reasons for nonintervention were captured for women and men (50% due to comorbidities alone, 36% morphology and comorbidity). The endovascular repair imaging analysis revealed no gender differences. Among truly untreated women, ruptures were common (18%), and mortality was high (86%). CONCLUSIONS Surgical AAA management differed between women and men. Women could be underserved in terms of elective repairs: one in every four women was untreated with over-the-threshold AAAs. The lack of obvious gender differences in eligibility analyses could imply unmeasured discrepancies (eg, in disease extent or patient frailty).
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Affiliation(s)
- Mareia Talvitie
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Linn Åldstedt-Nyrønning
- Department of Surgery, Vascular Surgery, St Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, NTNU, Trondheim, Norway
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Tina Cohnert
- Department of Vascular Surgery, Medical University of Graz, Graz, Austria
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Varkevisser RRB, Patel PB, Swerdlow NJ, Li C, Rastogi V, Verhagen HJM, Lyden SP, Schermerhorn ML. The Impact of Proximal Neck Anatomy on the 5-Year Outcomes Following Endovascular Aortic Aneurysm Repair With the Ovation Stent Graft. J Endovasc Ther 2023:15266028231195771. [PMID: 37646116 DOI: 10.1177/15266028231195771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
PURPOSE Hostile proximal neck anatomy has historically been associated with worse outcomes for endovascular aortic aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA). We investigated the impact of proximal neck anatomy on the outcomes following EVAR with the Ovation abdominal stent graft (Endologix, Irving, Calif). METHODS We used prospectively collected data from the Effectiveness of Custom Seal with Ovation: Review of the Evidence database, compromised of pooled data from 6 clinical trials and the European Post-Market Registry of patients undergoing elective infrarenal EVAR (2009-2017). We investigated the impact of short neck length (<10 mm), wide neck diameter (≥28 mm), reverse taper shape (>10%), and neck angulation (>45°) on the outcomes. The primary outcome was type IA endoleak. Secondary outcomes included any type I/III endoleak, sac expansion, aneurysm-related reinterventions, and all-cause and aneurysm-related mortality, and a combined endpoint of type IA endoleak, graft migration, AAA-related reintervention, conversion, and aneurysm rupture. We used Kaplan-Meier analysis and Cox proportional hazards models to estimate the 30 day and 5 year rates and assess univariate and risk-adjusted differences. RESULTS Of the 1020 patients, 60 patients had a short neck, 113 had a wide neck diameter, 279 were reverse taper shaped, and 99 had neck angulation >45°. Wide proximal neck was associated with higher 5 year type IA endoleak estimates compared with favorable neck anatomy (7.1% vs 4.3%; p=0.02). No association with 5 year type IA endoleak was found for short neck length (1.7% vs 4.3%; p=0.52), reverse taper shape (3.2% vs 4.3%; p=0.99), or neck angulation (6.1% vs 4.3%; p=0.13). A wide neck diameter compared with favorable anatomy was also associated with higher 5 year estimates of graft migration (3.8% vs 0.4%; p=0.03) and the combined neck-related adverse outcome endpoint (16% vs 9.5%; p=0.002). The estimates of aneurysm sac expansion, rupture, and overall and aneurysm-related mortality were similar between the hostile proximal neck anatomy cohorts and favorable anatomy. CONCLUSION Wide proximal neck is associated with higher 5 year type IA endoleak rates for patients treated with the Ovation stent graft. However, short neck length, reverse taper shape, and neck angulation are not associated with higher 5 year type IA endoleak rates. CLINICAL IMPACT Hostile proximal neck anatomy has historically been associated with worse outcomes for endovascular aortic aneurysm repair of abdominal aortic aneurysms. The Ovation stent graft platform uses a different proximal sealing method using a polymer inflatable ring, aiming to improve sealing between the graft and aortic wall. This study demonstrated that short, angulated, and reverse taper-shaped neck anatomy did not result in increased type IA endoleak estimates in patients treated with the Ovation stent graft platform. Potentially, the different sealing mechanisms played a role in mitigating the historically worse outcomes in patients with short, angulated, and reverse taper-shaped neck anatomy.
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Affiliation(s)
- Rens R B Varkevisser
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Braet DJ, Graham NJ, Albright J, Osborne NH, Henke PK. A novel pre-operative risk assessment tool to identify patients at risk of contrast associated acute kidney injury after endovascular abdominal aortic aneurysm repair. Ann Vasc Surg 2023:S0890-5096(23)00117-6. [PMID: 36863491 DOI: 10.1016/j.avsg.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVES Contrast-associated acute kidney injury (CA-AKI) after endovascular abdominal aortic aneurysm repair (EVAR) is associated with mortality and morbidity. Risk stratification remains a vital component of preoperative evaluation. We sought to generate and validate a pre-procedure CA-AKI risk stratification tool for elective EVAR patients. METHODS We queried the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) database for elective EVAR patients and excluded those on dialysis, with a history of renal transplant, death during procedure, and without creatinine measures. Association with CA-AKI (rise in creatinine > 0.5 mg/dL) was tested using mixed effects logistic regression. Variables associated with CA-AKI were used to generate a predictive model via a single classification tree. The variables selected by the classification tree were then validated by fitting a mixed effects logistic regression model into the Vascular Quality Initiative (VQI) dataset. RESULTS Our derivation cohort included 7,043 patients, 3.5% of whom developed CA-AKI. After multivariate analysis, age (OR 1.021, 95% CI 1.004-1.040), female sex (OR 1.393, CI 1.012-1.916), GFR < 30 ml/min (OR 5.068, CI 3.255-7.891), current smoking (OR 1.942, CI 1.067-3.535), COPD (OR 1.402, CI 1.066-1.843), maximum AAA diameter (OR 1.018, CI 1.006-1.029), and presence of iliac artery aneurysm (OR 1.352, CI 1.007-1.816) were associated with increased odds of CA-AKI. Our risk prediction calculator demonstrated that patients with a GFR <30 ml/min, females, and patients with a maximum AAA diameter of > 6.9 cm are at higher risk of CA-AKI after EVAR. Using the VQI dataset (N = 62,986), we found that GFR <30 ml/min (OR 4.668, CI 4.007-5.85), female sex (OR 1.352, CI 1.213-1.507), and maximum AAA diameter > 6.9 cm (OR 1.824, CI 1.212-1.506) were associated with increased risk of CA-AKI after EVAR. CONCLUSIONS Herein, we present a simple and novel risk assessment tool that can be used pre-operatively to identify patients at risk of CA-AKI after EVAR. Patients with a GFR < 30 ml/min, maximum AAA diameter > 6.9 cm, and females who are undergoing EVAR may be at risk for CA-AKI after EVAR. Prospective studies are needed to determine the efficacy of our model.
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Affiliation(s)
- Drew J Braet
- Section of Vascular Surgery, Department of Surgery, University of Michigan.
| | | | | | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan
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9
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A Systematic Review of the Recruitment and Outcome Reporting by Sex and Race/Ethnicity in Stent Device Development Trials for Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2023; 89:353-361. [PMID: 36272665 DOI: 10.1016/j.avsg.2022.09.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/20/2022] [Accepted: 09/30/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Women and racial/ethnic minority groups have been shown to experience poor outcomes after endovascular aortic aneurysm repair (EVAR). One potential reason is the rare inclusion of these populations in initial phases of device development. The objective of this systematic review is to understand enrollment and outcome reporting by sex and race/ethnicity in industry-funded EVAR device development trials. METHODS MEDLINE, PubMed, and Embase were searched from inception to January 2022 without language restrictions using the following terminology: "stent", "graft", "endograft", "device", and "abdominal aortic aneurysm" (AAA). CLINICALTRIALS gov was also searched from inception to January 2022 for "AAA." Two independent reviewers screened and extracted data. All phase I-III and postmarket evaluation trials that included patients ≥18 years of age, who underwent EVAR were assessed. Participation-to-prevalence ratios (PPRs) were calculated to estimate representation of participants by sex and race/ethnicity in trials compared with their share of disease burden. RESULTS Among the 4,780 retrieved articles, 55 industry-funded trials met inclusion criteria for this review. A total of 51 trials (93%) reported enrollment by sex/gender, and only 7 trials (13%) reported enrollment by race/ethnicity of the participants. A median of 19 (interquartile range [IQR]: 4.5, 51) women participants were recruited compared to 171 (IQR: 57, 311.5) men, and 17 (IQR: 7.5, 21.5) racial/minority patients were recruited compared to 241 (IQR: 123, 463.5) White participants. Women represent 16.6% of the disease population, and the median PPR is 0.62 (IQR: 0.42, 0.88), which has remained constant over time (Figure 1). None of the device trials reported outcomes based on sex/gender or race/ethnicity. CONCLUSIONS This systematic review highlights the disparities in recruitment and outcome reporting based on sex and race/ethnicity in EVAR device development trials. While most trials may be underpowered to study these differences, recent registry studies show differential outcomes based on sex and race/ethnicity of vascular patients. Therefore, it is imperative to include and report outcomes in these participants, starting from the initial device development phases to improve generalizability of device-use and understand sources of variation in device performance.
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10
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Locham S, Rodriguez A, Ford B, Glocker R, Ellis J, Mix D, Doyle A, Stoner M. Gender Differences in Aortic Anatomic Severity Grade and Long-Term Survival Following Elective Abdominal Aortic Aneurysm Repair at a Single Tertiary Center. Ann Vasc Surg 2022; 92:222-230. [PMID: 36572094 DOI: 10.1016/j.avsg.2022.12.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Anatomic severity grade (ASG) score is utilized to assess preoperative abdominal aortic aneurysms (AAA) and provide a quantitative data on its anatomic complexity. The aim of this study is to determine the anatomical differences and long-term survival between male and female patients undergoing elective AAA repair. METHODS All patients undergoing intact AAA repair from 2007 to 2014 were included. ASG scores were calculated based on preoperative anatomical characteristics including aortic neck, aneurysm, and iliac artery. Standard univariate analysis was used to evaluate patient and anatomical characteristics. Kaplan-Meier survival curves were used to evaluate long-term survival at 1 and 5 years. RESULTS A total of 379 patients were identified, of which, majority of them were males (80%). Females were on average 3 years older (mean [SD]: 74.32 [8.63] vs. 71.92 [8.64] years) and were more likely to undergo open repair (29.7% vs. 17.5%) (both P < 0.05). Both groups had similar comorbidities. The mean long-term follow-up (S.D.) was 6.21 (3.81) years. No significant difference was seen between males versus females in long-term survival at both 1 year (86.3% vs. 92.8, P = 0.06) and 5 year (68.5% vs. 72.7%, P = 0.38). In regard to the anatomical characteristics, females had shorter aortic neck length (mean in mm [S.D.]: 17.67 [1.41] vs. 27.20 [15.76]), increased tortuosity index [mean (S.D.): 1.11 (0.07) vs. 1.09 (0.07)]) and higher calcification [mean % (S.D.): 17.12 (21.17) vs. 10.59 (16.82)] (All P < 0.05). In contrast, males had larger aortic neck (mean in mm (S.D.): 23.81 (4.17) vs. 22.41 (4.16)] and iliac artery [mean in mm (S.D.): 7.70 (1.91) vs. 6.28 (1.67)] diameter (both P < 0.05). The mean total ASG score was significantly higher among females versus males [mean (S.D.): 17.23 (4.01) vs. 15.67 (3.96), P = 0.003]. After stratifying by ASG score ≥15, females had significantly lower survival at 1 year compared to males (82.6% vs. 92.1%, P = 0.04). However, this difference disappeared at 5 years. CONCLUSIONS The data demonstrate that females present at an older age with more complex AAA anatomy than males. Based on anatomical complexities, females were more likely to undergo open repair, with a corresponding increase in 1-year mortality, but not at 5 year. The data suggest that care processes for optimization of aortic surgery in females are needed to improve 1-year survival.
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Affiliation(s)
- Satinderjit Locham
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Alejandra Rodriguez
- Division of Vascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Benjamin Ford
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Roan Glocker
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Jennifer Ellis
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Doran Mix
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY
| | - Michael Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY; University of Rochester School of Medicine & Dentistry, Rochester, NY.
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Georgakarakos E, Dimitriadis K, Memet Efenti G, Karaolanis GI, Argyriou C, Georgiadis GS. The Altura endograft system for endovascular aneurysm repair: presentation of its unique design with clinical implications. Expert Rev Med Devices 2022; 19:941-948. [PMID: 36524429 DOI: 10.1080/17434440.2022.2159808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The Altura aortic endograft for the treatment of abdominal aortic aneurysms (AAA) consists of two separate components with a proximal double D-shaped design. The braided endoskeleton of the endograft is attached only at the proximal and distal ends of the inner surface of the fabric resulting in adjustable length of the Altura components. To ensure optimal orientation and sealing, the design of Altura permits collapse, readjustment, and deployment of the repositioned D-shaped endografts. AREAS COVERED Since this new endograft design by Lombard presents unique characteristics, the aim of this article is to present its unique structure and deployment method and discuss its applicability, indications and associated concerns. EXPERT OPINION The Altura endograft revolutionizes the mechanism of infrarenal sealing by containing no main body at all. This feature allows ideal treatment of AAA with considerable offset of the renal arteries and permits also relining in cases of failing endografts or in cases where the short length of existing structures precludes deployment of conventional bifurcated endografts.
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Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Konstantinos Dimitriadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Georgios I Karaolanis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina, School of Medicine, Ioannina, Greece
| | - Christos Argyriou
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
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12
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Marcaccio CL, O'Donnell TFX, Dansey KD, Patel PB, Hughes K, Lo RC, Zettervall SL, Schermerhorn ML. Disparities in reporting and representation by sex, race, and ethnicity in endovascular aortic device trials. J Vasc Surg 2022; 76:1244-1252.e2. [PMID: 35623599 PMCID: PMC9613501 DOI: 10.1016/j.jvs.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/15/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Vulnerable populations, including women and racial and ethnic minorities, have been historically underrepresented in clinical trials. We, therefore, studied the demographics of patients enrolled in pivotal endovascular aortic device trials in the United States. METHODS We queried the Food and Drug Administration (FDA) medical devices database for all FDA-approved endografts for the treatment of aortic aneurysms, transections, and dissections from September 1999 to November 2021. These included abdominal endovascular aortic repair (EVAR), thoracic EVAR (TEVAR), fenestrated EVAR (FEVAR) devices, and dissection stents. Multiple cases of approval for expanded indications were included separately. The primary outcomes included the proportion of trials reporting participant sex, race, and ethnicity and the proportion of enrolled participants across sex, racial, and ethnic groups. RESULTS The FDA provided 29 approvals from 29 trials of 24 devices: 15 EVAR devices (52%), 12 TEVAR devices (41%), 1 FEVAR device (3.4%), and 1 dissection stent (3.4%). These trials had included 4046 patients. Of the 29 trials, all had reported on the sex of the participants, and the median female enrollment was 21% (interquartile range [IQR], 11%-34%). The EVAR trials had the lowest female enrollment (11%; IQR, 8.7%-13%) compared with 41% (IQR, 27%-45%) in the TEVAR trials, 21% in the FEVAR trial, and 34% in the dissection stent trial (P < .01 for the difference). Only 52% of the trials had reported the three most common racial groups (White, Black, Asian), and only 48% had reported Hispanic ethnicity. The TEVAR trials were the most likely to report all three racial groups and Hispanic ethnicity (92% and 75%, respectively), while the EVAR trials had the lowest reporting rates (13% and 20%, respectively). Where reported, the median enrollment of racial and ethnic groups across the trials was as follows: Black patients, 9.8% (FEVAR, 0%; EVAR, 1.9%; TEVAR, 12%; dissection stent, 25%; P = .01); Asian patients, 2.4% (EVAR, 0.6%; FEVAR, 2.4%; TEVAR, 2.5%; dissection stent, 11%; P = .24); and Hispanic patients, 3.8% (EVAR, 1.3%; FEVAR, 2.4%; TEVAR, 3.9%; dissection stent, 4.1%; P = .75). CONCLUSIONS Racial and ethnic minority groups were underrepresented and underreported in pivotal aortic device trials that led to FDA approval. Female patients were also underrepresented in these aortic trials, especially for EVAR. These data suggest the need for standardization of reporting practices and minimum thresholds for minority and female participation in pivotal trials to promote equitable representation.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kirsten D Dansey
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kakra Hughes
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Ruby C Lo
- Division of Vascular Surgery, Department of Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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13
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Corsi T, Ciaramella MA, Palte NK, Carlson JP, Rahimi SA, Beckerman WE. Female Sex Is Associated With Reintervention and Mortality Following Elective Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg 2022; 76:1494-1501.e1. [PMID: 35705120 DOI: 10.1016/j.jvs.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/15/2022] [Accepted: 05/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE While sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes are increasingly reported, but contributing factors remain without consensus. We investigated disparities in sex-specific outcomes following elective EVAR at our institution and evaluated factors that may predispose females to increased morbidity and mortality. METHODS A retrospective chart review of all patients undergoing elective EVAR from 2011 to 2020 at a suburban tertiary care center was performed. The primary outcomes were five-year survival and freedom from reintervention. Fisher's exact test, t-tests, and Kaplan-Meier analysis using the rank-log test investigated associations between sex and outcomes. A multivariable Cox proportional hazard model controlling for age and common comorbidities evaluated the effect of sex on survival and freedom from reintervention. RESULTS Two hundred and seventy-three patients underwent elective EVAR during the study period, including 68 (25%) females and 205 (75%) males. Females were older on average than males (76 years vs. 73 years, p= <0.01) and were more likely to have chronic obstructive pulmonary disease (COPD; 38% versus 23%, p=0.01), require home oxygen therapy (9% versus 2%, p=0.04) or dialysis preoperatively (4% versus 0%, p=0.02). Distribution of other common vascular comorbidities was similar between the sexes. Thirty-day readmission was greater in females than males (18% versus 8%, p=0.02). Females had significantly lower survival at five years (48% ± 7.9% versus 65% ± 4.3%, p<0.01) and significantly lower one-year (89% ± 4.1% for females vs. 94% ± 1.7% for males, p=0.01) and five-year freedom from reintervention (69% ± 8.9% versus 84% ± 3.3%, p=0.02). On multivariable analysis, female sex (hazard ratio [HR]: 1.8, 95% confidence interval [CI]: 1.1-2.9), congestive heart failure (HR: 2.2, 95% CI: 1.2-3.9) and age (HR: 1.1, 95% CI: 1.0-1.1) were associated with 5-year mortality. Female sex remained as the only variable with a statistically significant association with five-year reintervention (HR: 2.4, 95% CI: 1.1-4.9). CONCLUSIONS Female sex was associated with decreased five-year survival and increased one and five-year reintervention following elective EVAR. Data from our institution suggests factors beyond patient age and baseline health risk likely contribute to greater surgical morbidity and mortality for females following elective EVAR.
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Affiliation(s)
- Taylor Corsi
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | | | - Nadia K Palte
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - John P Carlson
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - Saum A Rahimi
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - William E Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ.
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14
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Rhee R, Oderich G, Han S, Long C, Muck P, Moore E, Matsumura J. One year results of the GORE® EXCLUDER® Conformable AAA Endoprosthesis (EXCC) system in the United States regulatory trial. J Vasc Surg 2022; 76:951-959.e2. [DOI: 10.1016/j.jvs.2022.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/05/2022] [Indexed: 11/26/2022]
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15
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Nikol S, Nikol L. Update Aortenerkrankungen. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1746-8079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDie vorliegende Arbeit berichtet über die neuesten wissenschaftlichen Erkenntnisse im Zusammenhang mit Aortenaneurysmen und -dissektionen. Schwerpunkt hierbei sind die Pathophysiologie und
Genetik, der Einfluss von Fluorochinolonen auf Aortenaneurysmen und -dissektionen sowie Marker der Aortitis. Ferner werden die wichtigsten aktuellen Leitlinienempfehlungen aus den Jahren
2017 bis 2020 zusammengefasst – der Fokus liegt hierbei auf dem Screening, der Diagnostik, den Grenzwerten für die Therapieindikationen, der Art und den technischen Details der Behandlung
sowie Nachsorge von Aneurysmen der Aorta ascendens, des Aortenbogens, der Aorta descendens und abdominalis, Penetrating aortic Ulcers, bei genetisch bedingten Bindegewebserkrankungen mit
Aortenbeteiligungen, Aortitis und mykotischen Aneurysmen.
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Affiliation(s)
- Sigrid Nikol
- Klinische und Interventionelle Angiologie, Asklepios Kliniken Hamburg GmbH, Hamburg, Deutschland
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16
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Siada S, Malgor EA, Al-Musawi M, Giannopoulos S, Jacobs DL, Malgor RD. Iliac Artery Endoconduits Should be the Preferred Adjunctive Access Procedure to Facilitate Complex Endovascular Aortic Aneurysm Repair. Vasc Endovascular Surg 2022; 56:376-384. [PMID: 35200054 DOI: 10.1177/15385744211037616] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Iliac artery anatomy can have a dramatic impact on the success of endovascular complex aortic aneurysm (CAA) procedures as endograft delivery systems need to be advanced and manipulated through these access vessels. The aim of this study was to evaluate the outcomes of iliac artery conduits with emphasizes on open vs endovascular conduits performed to facilitate CAA endovascular repair. METHODS All patients who had open or endovascular iliac conduits prior to endovascular CAA repair to treat thoracoabdominal, juxtarenal, or suprarenal aneurysms at the University of Colorado Hospital from January 2009 through January 2019 were included. Patients who presented with symptomatic or ruptured aortic aneurysms were excluded. Outcomes of interest included postoperative complications and mortality in patients undergoing iliac conduits. RESULTS Twenty-seven patients with a total of 42 conduits were included in the study. The majority of patients (N = 15, 56%) were female and the average age was 72 ± 9 years. The calculated VQI cardiac index was .6% (range, .3%-.8%). Eighteen (43%) endovascular and 24 (57%) open iliac conduits were performed during the study period. Thirty (71%) conduits were performed in a staged fashion, while 12 (29%) were performed at the same time as endovascular CAA repair. The mean time between conduit and definitive aneurysm repair surgery was 130 ± 68 days in the endovascular and 107 ± 79 days in the open groups (P = .87). No aneurysm rupture occurred during the staging period in either group. The median follow-up for the entire cohort was 18 ± 22 months. The median length of hospital stay for patients undergoing endovascular and open ICs was 6 (ranging, 1-28 days) and 7 days (ranging, 3-18 days), respectively. Patients undergoing open conduits had significantly more complications than those undergoing endovascular conduit (endoconduit) creation. A total of 4 (15%) patients died within 30 days after aneurysm repair. Out of 23 survivors, 18 (78%) patients were discharged home, 4 (18%) patients were discharged to a skilled nursing facility, and 1 (4%) patient was discharged to an acute rehabilitation facility. No mortality difference based on type of conduit was found. CONCLUSIONS Overall complication rate associated with creation of open iliac artery conduits is not negligible. Endoconduits, which carry less morbidity than open conduits, are preferred as a first-line adjunctive access procedure to facilitate complex endovascular aortic aneurysm repair.
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Affiliation(s)
- Sammy Siada
- Division of Vascular Surgery, University of California at Fresno, Fresno, CA, USA
| | - Emily A Malgor
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Mohammed Al-Musawi
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Donald L Jacobs
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
| | - Rafael D Malgor
- Division of Vascular and Endovascular Surgery, 129263University of Colorado, Anschutz Medical Center, Aurora, CO, USA
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Edman NI, Zettervall SL, Dematteis MN, Ghaffarian A, Shalhub S, Sweet MP. Women with Thoracoabdominal Aortic Aneurysms Have Increased Frailty and More Complex Aortic Anatomy Compared with Men. J Vasc Surg 2022; 76:61-69.e3. [DOI: 10.1016/j.jvs.2022.01.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
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Pouncey AL, Khan A, Alharahsheh B, Bicknell C, Powell JT. Hypothesis for the Increased Rate of Thromboembolic and Microembolic Complications Following Abdominal Aortic Aneurysm Repair in Women. Eur J Vasc Endovasc Surg 2021; 63:348-349. [PMID: 34972626 DOI: 10.1016/j.ejvs.2021.10.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Anna L Pouncey
- Department of Surgery and Cancer, Imperial College London, UK.
| | - Aqeilah Khan
- Department of Medical Sciences, Imperial College London, UK
| | | | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, UK
| | - Janet T Powell
- Department of Surgery and Cancer, Imperial College London, UK
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Gregory M, Metcalfe M, Steiner K. Profile of the Ovation ALTO abdominal stent graft for the treatment of abdominal aortic aneurysms: overview of its safety and efficacy. Expert Rev Med Devices 2021; 18:1145-1153. [PMID: 34851807 DOI: 10.1080/17434440.2021.2013804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The Ovation ALTO is the next generation aortic stent graft from Endologix for the treatment of infra-renal abdominal aortic aneurysms. The device uses polymer-injected rings to create a proximal seal at the aneurysm neck. AREAS COVERED Results from the first clinical study of the ALTO graft are analyzed and the potential benefits of the graft in minimizing post-treatment aneurysmal neck dilation discussed. The implications of the ALTO's Instructions-For-Use (IFU) and low-profile delivery system are also reviewed. EXPERT OPINION The re-positioning of the sealing rings higher on the graft and an integrated compliant balloon are the most significant improvements on the Ovation iX, facilitating accurate placement of the proximal sealing ring and prompt balloon dilation of the polymer rings. The expansion the IFU to include neck lengths of ≥7 mm will mean more patients are eligible for infra-renal EVAR within IFU with the ALTO device. The published data on the device to date is limited. With over 1000 implants worldwide we would hope for more published data to become available. If this demonstrates similar mid-term results to that seen with the Ovation iX in arguably more hostile neck anatomy, then the Ovation ALTO is likely to be more widely used.
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Affiliation(s)
- Mark Gregory
- East and North Hertfordshire Nhs Trust, Department of Radiology, Stevenage, UK
| | - Matt Metcalfe
- East and North Hertfordshire Nhs Trust, Department of Vascular Surgery, Stevenage, UK
| | - Kate Steiner
- East and North Hertfordshire Nhs Trust, Department of Radiology, Stevenage, UK
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Nana P, Dakis K, Brodis A, Spanos K, Kouvelos G, Eckstein HH, Giannoukas A. A systematic review and meta-analysis on early mortality after abdominal aortic aneurysm repair in females in urgent and elective setting. J Vasc Surg 2021; 75:1082-1088.e6. [PMID: 34740807 DOI: 10.1016/j.jvs.2021.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/24/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Females represent a group of patients with higher mortality after abdominal aortic aneurysm (AAA), endovascular (EVAR) or open (OSR), repair. This systematic review aimed to evaluate the 30-day mortality after AAA repair in females, comparing both EVAR and OSR, in elective and urgent settings. METHODS The protocol of the review was registered to the PROSPERO (CRD42021242686). A search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, from inception to March 5, 2021, using the Systematic Reviews and Meta-Analysis guidelines (PRISMA). Only studies reporting on 30-day mortality of AAA repair, in urgent and elective setting, comparing EVAR and OSR, in female population were eligible. Patients were stratified according to the need for elective or urgent repair. Symptomatic and ruptured cases were included into the urgent group. Individual studies were assessed for risk of bias using the ROBINS-I tool. The GRADE approach was used to evaluate the quality of evidence. The primary outcome was 30-day mortality after AAA repair in the female population, comparing EVAR and OSR. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis. RESULTS Eight studies reported data on 30-day mortality following AAA repair. A total of 56,982 females (22,995 EVAR vs. 33,987 OSR) were included. A significantly reduced total 30-day mortality rate was recorded among females that underwent EVAR compared to OSR (OR, 0.25; 95% CI, 0.23-0.27; P<.001, Ι2=86%). Also a reduced 30-day mortality was found in females that underwent elective EVAR compared to OSR (OR, 0.37; 95% CI, 0.33-0.41; P< .001, Ι2=48%). Despite that OSR was more frequently offered in the urgent setting (OR, 0.21; 95% CI, 0.19-0.23; P< .001, Ι2=84%), EVAR was associated with a reduced 30-day mortality (OR, 0.48; 95% CI, 0.40-0.57; P<.001, Ι2=0%). CONCLUSIONS In females, EVAR is associated with lower 30-day mortality in both elective and urgent AAA repair, although it appears as less likely to be offered in the setting of urgent AAA repair.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Konstantinos Dakis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Brodis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Technical University of Munich TUM, Germany
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Powell JT. Great vascular surgeons needed for great aneurysms. J Vasc Surg 2021; 74:1161-1162. [PMID: 34598755 DOI: 10.1016/j.jvs.2021.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Janet T Powell
- Imperial College London, Department of Surgery & Cancer, Charing Cross Hospital, London, UK
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22
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Sciria CT, Osorio B, Wang J, Lu DY, Amin N, Vohra A, Yeo I, Feldman DN, Cheung JW, Narula N, Wong SC, Kim LK. Sex-Based Disparities in Outcomes With Abdominal Aortic Aneurysms. Am J Cardiol 2021; 155:135-148. [PMID: 34294407 DOI: 10.1016/j.amjcard.2021.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/06/2021] [Accepted: 06/14/2021] [Indexed: 12/20/2022]
Abstract
Although abdominal aortic aneurysms (AAA) are more common in men, women with AAA have increased morbidity and mortality. Additionally, there are discrepancies among professional society guidelines for AAA screening in women. In this retrospective study from the Nationwide Inpatient Sample (NIS) database from 2003 to 2014, we compared rates of AAA repair (rupture and elective) and AAA-related mortality in men vs. women to identify predictors of death among men and women with AAA. We divided the population into 1) AAA rupture 2) elective AAA repair. The main outcomes included temporal trends in AAA rupture, rupture-related death, AAA repair, in-hospital death, and predictors of AAA-related death. There were 570,253 discharge records for AAA admissions between 2003 and 2014, including 22.8% women and 77.2% men. Women had a higher proportion of rupture (18.4% vs 12.6%, p <0.01). A smaller proportion of women underwent endovascular aortic repair (EVAR) compared with men in the ruptured AAA (13.9% vs. 20.3%, p <0.01) and elective repair (55.7% vs. 67.4%, p <0.01) cohorts. Within the ruptured cohort, a higher proportion of women did not receive repair (46.4% vs. 26.1%, p <0.01). On multivariable analysis, female gender was a significant predictor of death with rupture (OR 1.39, 95% CI 1.16 to 1.66) and elective repair (OR 1.74, 95% CI 1.36 to 2.22), with both elective EVAR (OR 2.52, 95% CI 2.06 to 3.09) and elective open aortic repair (OAR; OR 1.50, 95% CI 1.33 to 1.68). Propensity score matching confirmed a higher risk of death in women in both the rupture (OR 1.19, 95% CI 1.09 to 1.30) and elective repair (OR 1.50, 95% CI 1.35 to 1.67) cohorts. In conclusion, AAA poses significant morbidity and mortality, especially in women. Women were more likely to die before repair with AAA rupture and female gender was an independent predictor of mortality in both the rupture and elective repair groups.
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Affiliation(s)
- Christopher T Sciria
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York.
| | - Benedict Osorio
- Weill Cornell Department of Internal Medicine, New York, New York
| | - Joseph Wang
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York
| | - Daniel Y Lu
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York
| | - Nivee Amin
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York; Weill Cornell Medicine Women's Heart Program, New York, New York
| | - Adam Vohra
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York
| | - Ilhwan Yeo
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York; Division of Cardiology, Department of Medicine, New York-Presbyterian Queens, New York, New York
| | - Dmitriy N Feldman
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York
| | - Jim W Cheung
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York
| | - Nupoor Narula
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York
| | - S Chiu Wong
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York
| | - Luke K Kim
- Department of Medicine, Division of Cardiology, Weill Cornell Cardiovascular Outcomes Research Group (CORG), New York, New York
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Gunnarsson K, Wanhainen A, Björck M, Djavani-Gidlund K, Mani K. Nationwide Study of Ruptured Abdominal Aortic Aneurysms During Twenty Years (1994-2013). Ann Surg 2021; 274:e160-e166. [PMID: 31425332 DOI: 10.1097/sla.0000000000003555] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyze the epidemiology of ruptured abdominal aortic aneurysms (RAAA) in Sweden over 20 years, and assess the effect of endovascular repair (EVAR) on surgical treatment rate and outcome. METHODS All Swedish citizens >50 years with RAAA 1994 to 2013 were extracted from 3 national (Cause of Death, Patient, and Vascular Surgical) registries. Incidence, proportion repaired, surgical techniques, and 90-day mortality were assessed based on sex and age groups, with regression analysis. RESULTS 18,726 individuals with RAAA were identified, 74.0% men. The incidence of RAAA decreased from 33.1/100,000: 1994 to 21.3/100,000: 2013 (relative change -35.6%, P < 0.001). The proportion of men with RAAA undergoing repair was 44.5%: 1994-1998, 49.7%: 2009-2013 (+11.7%, P < 0.001). In women, 22.3% were repaired in 1994-1998, versus 28.2%: 2009-2013 (+26.4%, P < 0.001). The proportion undergoing repair increased in octogenarians (men: +44.3%, P < 0.001; women +49.3%, P = 0.001). EVAR increased from 0% initially to 42.3% in men and 41.2% in women 2013. Overall, mortality rate among all individuals with RAAA decreased, men 75.8%: 1994-1998, 64.8%: 2009-2013 (-14.5%, P < 0.001); women 88.5%: 1994-1998, 82.2%: 2009-2013 (-7.1%, P < 0.001). Among those who underwent repair, mortality was 47.0% in men: 1994-1998, 31.8%: 2009-2013 (-32.3%, P < 0.001); women 51.8%: 1994-1998, 41.4%: 2009-2013 (-20.1%, P = 0.010). CONCLUSION RAAA mortality among men decreased, mainly attributed to falling incidence of RAAA. The mortality was further reduced by more patients being offered repair, increasingly often with EVAR, and improved survival after repair. Incidence of rupture remained unchanged among women, who had higher RAAA mortality. Focused efforts to reduce RAAA mortality among women are warranted.
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Affiliation(s)
- Kim Gunnarsson
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Centre for Research and Development, Uppsala University, Region Gävleborg, Sweden
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Martin Björck
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Khatereh Djavani-Gidlund
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Centre for Research and Development, Uppsala University, Region Gävleborg, Sweden
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Pouncey AL, David M, Morris RI, Ulug P, Martin G, Bicknell C, Powell JT. Editor's Choice - Systematic Review and Meta-Analysis of Sex Specific Differences in Adverse Events After Open and Endovascular Intact Abdominal Aortic Aneurysm Repair: Consistently Worse Outcomes for Women. Eur J Vasc Endovasc Surg 2021; 62:367-378. [PMID: 34332836 DOI: 10.1016/j.ejvs.2021.05.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/12/2021] [Accepted: 05/23/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Previously, reports have shown that women experience a higher mortality rate than men after elective open (OAR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With recent improvements in overall AAA repair outcomes, this study aimed to identify whether sex specific disparity has been ameliorated by modern practice, and to define sex specific differences in peri- and post-operative complications and pre-operative status; factors which may contribute to poor outcome. METHODS This was a systematic review, meta-analysis, and meta-regression of sex specific differences in 30 day mortality and complications conducted according to PRISMA guidance (Prospero registration CRD42020176398). Papers with ≥ 50 women, reporting sex specific outcomes, following intact primary AAA repair, from 2000 to 2020 worldwide were included; with separate analyses for EVAR and OAR. Data sources were Medline, Embase, and CENTRAL databases 2005 - 2020 searched using ProQuest Dialog. RESULTS Twenty-six studies (371 215 men, 65 465 women) were included. Meta-analysis and meta-regression indicated that sex specific odds ratios (ORs) for 30 day mortality were unchanged from 2000 to 2020. Mortality risk was higher in women for OAR and more so for EVAR (OR [95% CI] 1.49 [1.37 - 1.61]; 1.86 [1.59 - 2.17], respectively) and this remained following multivariable risk adjustment. Transfusion, pulmonary complications, and bowel ischaemia were more common in women after OAR and EVAR (OAR: ORs 1.81 [1.60 - 2.04], 1.40 [1.28 - 1.53], 1.54 [1.36 - 1.75]; EVAR: ORs 2.18 [2.08 - 2.29] 1.44 [1.17 - 1.77], 1.99 [1.51 - 2.62], respectively). Arterial injury, limb ischaemia, renal and cardiac complications were more common in women after EVAR (ORs 3.02 [1.62 - 5.65], 2.13 [1.48 - 3.06], 1.46 [1.22 - 1.72] and 1.19 [1.03 - 1.37], respectively); the latter was associated with greater mortality risk on meta-regression. CONCLUSION Increased mortality risk for women following AAA repair remains. Women had a higher incidence of transfusion, pulmonary and bowel complications after EVAR and OAR. Higher mortality risk ratios for EVAR may result from cardiac complications, additional arterial injury, and embolisation, leading to renal and limb ischaemia. These findings indicate possible causes for observed outcome disparities and targets for quality improvement.
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Affiliation(s)
- Anna L Pouncey
- Department of Surgery and Cancer, Imperial College London, UK.
| | - Michael David
- Care Research and Technology Centre, Dementia Research Institute, Imperial College London, UK
| | - Rachael I Morris
- Academic Department of Vascular Surgery, Cardiovascular Division, St. Thomas' Hospital, King's College London, UK
| | - Pinar Ulug
- Department of Surgery and Cancer, Imperial College London, UK
| | - Guy Martin
- Department of Surgery and Cancer, Imperial College London, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, UK
| | - Janet T Powell
- Department of Surgery and Cancer, Imperial College London, UK
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Non-guideline-compliant endovascular abdominal aortic aneurysm repair in women is associated with increased mortality and reintervention compared with men. J Vasc Surg 2021; 75:118-125.e1. [PMID: 34302934 DOI: 10.1016/j.jvs.2021.07.109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 07/15/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Sex-based disparities in surgical outcomes have emerged as an important focus in contemporary healthcare delivery. Likewise, the appropriate usage of endovascular abdominal aortic aneurysm repair (EVAR) in the United States remains a subject of ongoing controversy, with a significant number of U.S. EVARs failing to adhere to the Society for Vascular Surgery (SVS) clinical practice guideline (CPG) diameter thresholds. The purpose of the present study was to determine the effect of sex among patients undergoing EVAR that was not compliant with the SVS CPGs. METHODS All elective EVAR procedures for abdominal aortic aneurysms without a concomitant iliac aneurysm (≥3.0 cm) in the SVS Vascular Quality Initiative were analyzed (2015-2019; n = 25,112). SVS CPG noncompliant repairs were defined as a size of <5.5 cm for men and <5.0 cm for women. The primary endpoint was 30-day mortality. The secondary endpoints were all-cause mortality, complications, and reintervention. Logistic regression was performed to control for surgeon- and patient-level factors. Freedom from the endpoints was determined using the Kaplan-Meier method. RESULTS Noncompliant EVAR was performed in 9675 patients (38.5%). Although men were significantly more likely to undergo such procedures (90% vs 10%; odds ratio [OR], 3.1; 95% confidence interval [CI], 2.9-3.4; P < .0001), the 30-day mortality was greater for the women than the men (1.8% vs 0.5%; P = .0003). Women also experienced significantly higher rates of multiple complications, including postoperative myocardial infarction (1% vs 0.3%; P = .006), respiratory failure (1.4% vs 0.6%; P = .01), intestinal ischemia (0.7% vs 0.2%; P = .003), access vessel hematoma (3% vs 1.2%; P = .0006), and iliac access vessel injury (2.4% vs 0.8%; P < .0001). Additionally, women experienced increased overall 1-year reintervention rates (11.5% vs 5.8%; P < .0001). In the adjusted analysis, 30-day mortality and any in-hospital complication risk remained significantly greater for the women (30-day death: OR, 3.1; 95% CI, 1.6-5.8; P = .0005; in-hospital complication: OR, 1.9; 95% CI, 1.4-2.6; P < .0001). Women also experienced increased reintervention rates over time compared with men (OR, 1.5; 95% CI, 1.1-2.2; P = .02). CONCLUSIONS Although men were more likely to undergo non-CPG compliant EVAR, women experienced increased short-term morbidity and 30-day mortality and higher rates of reintervention when undergoing non-CPG compliant EVAR. These unanticipated findings necessitate increased scrutiny of current U.S. sex-based EVAR practice and should caution against the use of non-CPG compliant EVAR for women.
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Kim S, Jeon-Slaughter H, Chen X, Ramanan B, Kirkwood ML, Timaran CH, Modrall JG, Tsai S. Effect of Abdominal Aortic Aneurysm Size on Mid-Term Mortality After Endovascular Repair. J Surg Res 2021; 267:443-451. [PMID: 34237629 DOI: 10.1016/j.jss.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/17/2021] [Accepted: 06/01/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Previous studies have suggested that large preoperative AAA size may impact late survival after elective EVAR. It is unclear, however, whether this association applies to patients with smaller AAA between 5.0-5.5 cm, who constitute a substantial portion of patients undergoing elective EVAR. The purpose of this study was to delineate the effect of AAA size between 5.0 and 5.5 cm on mid-term mortality after EVAR by analyzing a large national cohort, the Vascular Quality Initiative (VQI) database. METHODS Using the Vascular Quality Initiative (VQI) national database, patients who underwent EVAR for intact AAA between 2003 and 2018 were identified and stratified based on maximal AAA diameter into 3 groups: Group 1 (4.0 cm ≤ AAA <5.0 cm); Group 2 (5.0 cm ≤ AAA < 5.5 cm); and Group 3 (AAA ≥ 5.5 cm). Cox proportional hazard model and propensity score matching method were used to estimate AAA size effect on all-cause mortality at 1, 3, and 5 years after EVAR while adjusting for potential confounders. RESULTS The study included 32,398 patients, of whom 81% were men with a mean age of 74. The most common group who underwent EVAR was Group 2 (5.0 cm ≤ AAA < 5.5 cm). Larger AAA size was associated with male sex (75% versus 79% versus 84%, for Groups 1, 2, and 3 respectively; P < 0.0001) and with coronary artery disease (27% versus 29% versus 31%, for Groups 1, 2, and 3 respectively, P< 0.0001); but was negatively associated with active smoking (33% versus 31% versus 30%, for Groups 1, 2, and 3, respectively, P< 0.001). While 10% of the largest and smallest AAA groups (Groups 3 and 1, respectively) were symptomatic, only 5% of patients in Group 2 were symptomatic (P < 0.01). Adjusted Cox proportional hazard modeling revealed that patients in Group 2 were at significantly lower risk of 5-year mortality when compared to patients in Group 3 (HR 0.66, 95% CI 0.61-0.72, P< 0.01), while similar in risk when compared to patients in Group 1 (HR 1.11, 95% CI 0.93-1.32, P= 0.26). CONCLUSION Our analysis found that over 40% of EVAR in the national VQI cohort were performed for AAA < 5.5 cm, with the greatest number of patients undergoing EVAR at AAA size 5.0-5.5cm. Patients with AAA size 5.0-5.5 cm had better 5-year survival outcomes than patients with AAA ≥ 5.5 cm, and similar survival to patients with small AAA between 4.0-5.0 cm.
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Affiliation(s)
- Sooyeon Kim
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX
| | - Haekyung Jeon-Slaughter
- Veterans Affairs North Texas Health Care System, Dallas TX; Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Xiaofei Chen
- Department of Statistical Science, Southern Methodist University, Dallas, TX
| | - Bala Ramanan
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX; Surgical Services, Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Melissa L Kirkwood
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX
| | - Carlos H Timaran
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX
| | - J Gregory Modrall
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX; Surgical Services, Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Shirling Tsai
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas TX; Surgical Services, Dallas Veterans Affairs Medical Center, Dallas, TX.
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Qin KR, Perera M, Papa N, Mitchell D, Chuen J. Open versus Endovascular Abdominal Aortic Aneurysm Repair in the Australian Private Sector Over Twenty Years. J Endovasc Ther 2021; 28:844-851. [PMID: 34212777 DOI: 10.1177/15266028211028215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE Over the past two decades, the proliferation of endovascular surgery has changed the approach to abdominal aortic aneurysm (AAA) repair. In Australia, close to two-thirds of surgical procedures are performed in the private healthcare system. We aimed to describe the trends in AAA repair in the Australian private sector throughout the early 21st century. MATERIALS AND METHODS Medicare Benefits Schedule (MBS) statistics were accessed to determine the number of infrarenal open AAA repair (OAR) and endovascular AAA repair (EVAR) procedures performed between January 2000 and December 2019. Population data were extracted from the Australian Bureau of Statistics and used to calculate incidence per 100,000 population. Further analysis was performed according to age, gender, and state. RESULTS During the study period, 13,193 (67.0%) EVARs and 6504 (33.0%) OARs were performed in the Australian private sector. OARs fell from 70.5% (n=567) of AAA repairs in 2000 to 15.7% (n=237) in 2019, while EVARs rose from 29.5% (n=151) to 84.3% (n=808). The frequency of EVAR surpassed OAR in 2004. The overall incidence of AAA repair varied minimally over the time period (range: 4.9-6.5 per 100,000 adults per year). AAA repair was more common in males than females (9.7 vs 1.7 per 100,000 population) and more common in older age groups. There was a 4-fold increase in EVAR among males older than 85 years (12.8-57.4 per 100,000 population), the largest rise of any group. The overall EVAR:OAR ratio increased from 0.4 to 5.4. There were considerable state-based discrepancies. CONCLUSION The landscape of AAA repair in Australian private sector has drastically changed with a clear preference toward EVAR. EVAR saw increased use across all genders, age groups and states, despite stable rates of AAA surgery. Further research is necessary to compare our findings to national trends in the Australian public sector.
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Affiliation(s)
- Kirby R Qin
- Department of Vascular Surgery, Austin Health, Heidelberg, Victoria, Australia.,Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Marlon Perera
- Department of Surgery, Austin Health, Heidelberg, Victoria, Australia.,Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
| | - Nathan Papa
- Department of Surgery, Austin Health, Heidelberg, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Mitchell
- Department of Vascular Surgery, Austin Health, Heidelberg, Victoria, Australia
| | - Jason Chuen
- Department of Vascular Surgery, Austin Health, Heidelberg, Victoria, Australia.,Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
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Panthofer AM, Olson SL, Rademacher BL, Grudzinski JK, Chaikof EL, Matsumura JS. Anatomic eligibility for endovascular aneurysm repair preserved over 2 years of surveillance. J Vasc Surg 2021; 74:1527-1536.e1. [PMID: 33957227 DOI: 10.1016/j.jvs.2021.04.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 04/10/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Endovascular aneurysm repair (EVAR) is a widely used option for patients with suitable vascular anatomy who have a large infrarenal abdominal aortic aneurysm (AAA). Patients with small AAAs are managed with careful surveillance and it is a common concern that their anatomy may change with AAA growth, and their option for EVAR may become limited. Device innovation has resulted in expanded ranges of anatomy that may be eligible for EVAR. This study sought to identify changes in anatomic eligibility for repair with contemporary endovascular devices in AAA patients, monitored by computed tomography scan over the course of 2 years. METHODS Patients from the Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA3CT, NCT01756833) were included in this analysis. Females had baseline AAA maximum transverse diameter between 3.5 and 4.5 cm, and males had baseline maximum transverse diameter between 3.5 and 5.0 cm. Patients were included in this analysis if they completed pre-enrollment and 2-year follow-up computed tomography imaging. Pertinent anatomic measurements were performed on a postprocessing workstation in a centralized imaging core laboratory. EVAR candidacy was determined by measuring proximal aortic neck diameter, AAA length, and infrarenal neck angulation. Patients were considered to be eligible for EVAR if they qualified for at least one of the seven studied devices' instructions for use at baseline and at 2 years. A paired t test analysis was used to detect differences in aortic measurements over 2 years, and the McNemar test was used to compare eligibility over 2 years. RESULTS We included 192 patients in this analysis-168 male and 24 female. Of these patients, 85% were eligible for EVAR at baseline and 85% after 2 years of follow-up (P = 1.00; 95% confidence interval -0.034 to 0.034). Of the 164 EVAR candidates at baseline, 160 (98%) remained eligible over 2 years of surveillance. Insufficient neck length was the most common reason for both ineligibility at baseline (18 of 28 patients) as well as loss of candidacy over 2 years (3 of 4 patients). CONCLUSIONS The majority of patients eligible for EVAR when entering a surveillance program for small AAA remain eligible after 2 years. Substantial changes in AAA neck anatomy resulting in loss of EVAR treatment options are infrequent. Patients with anatomic AAA progression beyond EVAR eligibility remain candidates for complex EVAR and open repair.
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Affiliation(s)
- Annalise M Panthofer
- School of Medicine and Public Health, Division of Vascular Surgery, University of Wisconsin, Madison, Wisc.
| | - Sydney L Olson
- School of Medicine and Public Health, Division of Vascular Surgery, University of Wisconsin, Madison, Wisc
| | - Brooks L Rademacher
- School of Medicine and Public Health, Division of Vascular Surgery, University of Wisconsin, Madison, Wisc
| | - Jennifer K Grudzinski
- School of Medicine and Public Health, Division of Vascular Surgery, University of Wisconsin, Madison, Wisc
| | - Elliot L Chaikof
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Cambridge, Mass
| | - Jon S Matsumura
- School of Medicine and Public Health, Division of Vascular Surgery, University of Wisconsin, Madison, Wisc
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Charlton-Ouw KM, Ikeno Y, Bokamper M, Zakhary E, Smeds MR. Aortic endograft sizing and endoleak, reintervention, and mortality following endovascular aneurysm repair. J Vasc Surg 2021; 74:1519-1526.e2. [PMID: 33940075 DOI: 10.1016/j.jvs.2021.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Endograft sizing for endovascular abdominal aortic aneurysm repair (EVAR) is not consistent despite published instructions for use (IFU). We sought to identify factors associated with over/undersizing, determine sex influence on sizing, and examine sizing effects on endoleak, reintervention, and mortality by analyzing data obtained from the W.L. Gore & Associates Global Registry for Endovascular Aortic Treatment (GREAT). METHODS All patients enrolled in GREAT undergoing EVAR were included for analysis. Proximal/distal aortic landing zones were compared with device implanted to assess sizing as related to IFU. χ2/Fisher exact tests were used to evaluate associations between IFU sizing and demographics. Logistic regression modeling was used to identify predictors of outside IFU sizing. Cox proportional hazards regression analyzed the relationship between sizing and endoleak, device-related reinterventions, and all-cause/aortic mortality. RESULTS There were 3607 EVAR subjects enrolled in GREAT as of March 2020. Of them, 1896 (53%) were within IFU for sizing, 791 (22%) were oversized, 540 (15%) were undersized, and 380 (10%) had both over- and undersized components. Factors predictive of use outside of IFU included female sex (P = .001), non-white race (P = .0003), decreased proximal neck length (P < .061), or larger iliac diameters (P < .0001). Women were more likely than men to have proximal neck undersizing and iliac limb oversizing, and men were more likely to have iliac limb undersizing. On multivariate analysis, undersizing of the proximal graft was associated with endoleak (hazard ratio [HR], 1.8) and aortic (HR, 60.5) and all-cause (HR, 18.0) mortality. Undersizing of iliac limbs was associated with endoleak (HR, 1.5) and device-related reintervention (HR, 1.4). Iliac limb outside IFU sizing was associated with aortic (HR, 2.6) and all-cause (HR, 1.3) mortality. Proximal and distal oversizing was not associated with adverse outcomes. Female sex was associated with mortality on univariate but not multivariate analysis. CONCLUSIONS Women undergoing EVAR with GORE EXCLUDER abdominal aortic aneurysm Endoprosthesis (W.L. Gore & Associates Inc, Flagstaff, Ariz) are more likely to have proximal stent-graft undersizing and iliac limb oversizing, whereas men are more likely to have undersized iliac limbs. Proximal aortic graft undersizing is associated with endoleak and all-cause/aortic mortality, whereas undersizing of iliac limbs is associated with endoleak and device-related reintervention. Oversizing was not associated with adverse outcomes.
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Affiliation(s)
- Kristofer M Charlton-Ouw
- HCA Houston Healthcare, Gulf Coast Division, Department of Clinical Sciences, University of Houston College of Medicine, Houston, Tex; Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Yuki Ikeno
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Matthew Bokamper
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University School of Medicine, St. Louis, Mo
| | - Emad Zakhary
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, St. Louis, Mo
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, St. Louis, Mo.
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30
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Volpe P, Alberti A, Alberti V, Massara M. Stent-Graft Relining Using the Altura Endograft for Type Ia and IIIb Endoleaks after Kissing Iliac Arteries Stent. Ann Vasc Surg 2021; 75:532.e15-532.e19. [PMID: 33901614 DOI: 10.1016/j.avsg.2021.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
A 79 years old man, affected by serious comorbidities, occurred to the Emergency Room of our Hospital complaining abdominal pain. He was previously submitted to kissing iliac arteries stent for iliac aneurysms. An urgent CT scan showed a type Ia and a type IIIb endoleaks with left common iliac artery enlargement, occlusion of both hypogastric arteries and inferior mesenteric artery, and a severe stenosis of the right iliac external artery. We opted for a relining with a two-piece D-shaped Altura endograft for the aorta, with bilateral iliac components, landing at the level of the external iliac arteries. Postoperative course was uneventful with no endoleak or endograft migration on CT scan control at 6 months.
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Affiliation(s)
- Pietro Volpe
- Vascular and Endovascular Surgery Unit, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli" - Reggio Calabria Italy
| | - Antonino Alberti
- Vascular and Endovascular Surgery Unit, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli" - Reggio Calabria Italy
| | - Vittorio Alberti
- Vascular and Endovascular Surgery Unit, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli" - Reggio Calabria Italy
| | - Mafalda Massara
- Vascular and Endovascular Surgery Unit, Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli" - Reggio Calabria Italy.
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de Donato G, Pasqui E, Panzano C, Brancaccio B, Grottola G, Galzerano G, Benevento D, Palasciano G. The Polymer-Based Technology in the Endovascular Treatment of Abdominal Aortic Aneurysms. Polymers (Basel) 2021; 13:1196. [PMID: 33917214 PMCID: PMC8068055 DOI: 10.3390/polym13081196] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/02/2021] [Accepted: 04/04/2021] [Indexed: 12/18/2022] Open
Abstract
An abdominal aortic aneurysm (AAA) is a dilatation of the abdominal aorta that progressively grows until it ruptures. Treatment is typically recommended when the diameter is more than 5 cm. The EVAR (Endovascular aneurysm repair) is a minimally invasive procedure that involves the placement of an expandable stent graft within the aorta to treat aortic disease without operating directly on the aorta. For years, stent grafts' essential design was based on metallic stent frames to support the fabric. More recently, a polymer-based technology has been proposed as an alternative method to seal AAA. This review underlines the two platforms that are based on a polymer technology: (1) the polymer-filled endobags, also known as Endovascular Aneurysm Sealing (EVAS) with Nellix stent graft; and (2) the O-ring EVAR polymer-based proximal neck sealing device, also known as an Ovation stent graft. Polymer characteristics for this particular aim, clinical applications, and durability results are hereby summarized and commented critically. The technique of inflating endobags filled with polymer to exclude the aneurysmal sac was not successful due to the lack of an adequate proximal fixation. The platform that used polymer to create a circumferential sealing of the aneurysmal neck has proven safe and effective.
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Affiliation(s)
- Gianmarco de Donato
- Department of Vascular Surgery, University of Siena, 53100 Siena, Italy; (E.P.); (C.P.); (B.B.); (G.G.); (G.G.); (D.B.); (G.P.)
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Sirignano P, Mansour W, Capoccia L, Cuozzo S, Camparini S, de Donato G, Mangialardi N, Ronchey S, Talarico F, Setacci C, Speziale F. Endovascular aortic repair in patients with challenging anatomies: the EXTREME study. EUROINTERVENTION 2021; 16:e1544-e1550. [PMID: 31793884 PMCID: PMC9725024 DOI: 10.4244/eij-d-19-00547] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to report the 30-day technical and clinical success with endovascular repair using the ultra-low-profile Ovation stent graft in patients judged to be outside the instructions for use (IFU) for conventional endografts, while amenable to treatment within the IFU for Ovation. METHODS AND RESULTS One hundred and twenty-two patients (78.65±7.67 years; 111 male) were enrolled. Patients were evaluated as being outside the IFU for standard endografts because of the absence of a suitable proximal aortic neck in 109 cases (89.3%), of inadequate access vessels in 13 (10.7%), or both in 111 (90.9%). Mean aneurysm (abdominal aortic aneurysm [AAA]) diameter was 52.96±10.1 mm; mean aortic neck length was 7.75±6.05 mm. Technical success (98.4%) was achieved in all but two patients due to a type Ia endoleak. At completion angiography, 15 (12.3%) patients presented a type II endoleak. All patients underwent 30-day follow-up. Primary clinical success at one month was 96.8%, assisted clinical success 98.4%. There were no type I endoleaks, while 12 (9.8%) type II endoleaks were still evident, in the absence of sac expansions. Two patients (1.6%) presented an asymptomatic limb occlusion. CONCLUSIONS Our experience suggests that, in a selected population of patients with challenging anatomy outside the IFU for conventional endografts, endovascular aneurysm repair (EVAR) using the Ovation stent graft can be performed safely with satisfactory immediate outcomes.
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Affiliation(s)
- Pasqualino Sirignano
- Vascular and Endovascular Surgery Division, Policlinico Umberto I, Viale del Policlinico, 155, 00161 Rome, Italy
| | - Wassim Mansour
- Vascular and Endovascular Surgery Unit, Department of Surgery “Paride Stefanini”, Policlinico Umberto I of Rome, “Sapienza” University of Rome, Rome, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Unit, Department of Surgery “Paride Stefanini”, Policlinico Umberto I of Rome, “Sapienza” University of Rome, Rome, Italy
| | - Simone Cuozzo
- Vascular and Endovascular Surgery Unit, Department of Surgery “Paride Stefanini”, Policlinico Umberto I of Rome, “Sapienza” University of Rome, Rome, Italy
| | - Stefano Camparini
- Vascular and Endovascular Surgery Unit, Department of Thoraco-Vascular Surgery, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Gianmarco de Donato
- Vascular and Endovascular Surgery Unit, Department of Medicine, Surgery, and Neuroscience, University of Siena, Siena, Italy
| | - Nicola Mangialardi
- Department of Vascular Surgery, “San Camillo Forlanini” Hospital, Rome, Italy
| | - Sonia Ronchey
- Department of Vascular Surgery, “San Filippo Neri” Hospital, Rome, Italy
| | - Francesco Talarico
- Division of Vascular and Endovascular Surgery, Ospedale Civico, Palermo, Italy
| | - Carlo Setacci
- Vascular and Endovascular Surgery Unit, Department of Medicine, Surgery, and Neuroscience, University of Siena, Siena, Italy
| | - Francesco Speziale
- Vascular and Endovascular Surgery Unit, Department of Surgery “Paride Stefanini”, Policlinico Umberto I of Rome, “Sapienza” University of Rome, Rome, Italy
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Mukherjee K, Pingili AK, Singh P, Dhodi AN, Dutta SR, Gonzalez FJ, Malik KU. Testosterone Metabolite 6β-Hydroxytestosterone Contributes to Angiotensin II-Induced Abdominal Aortic Aneurysms in Apoe-/- Male Mice. J Am Heart Assoc 2021; 10:e018536. [PMID: 33719500 PMCID: PMC8174379 DOI: 10.1161/jaha.120.018536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Sex is a prominent risk factor for abdominal aortic aneurysms (AAAs), and angiotensin II (Ang II) induces AAA formation to a greater degree in male than in female mice. We previously reported that cytochrome P450 1B1 contributes to the development of hypertension, as well as AAAs, in male mice. We also found that a cytochrome P450 1B1‐generated metabolite of testosterone, 6β‐hydroxytestosterone (6β‐OHT), contributes to Ang II‐induced hypertension and associated cardiovascular and renal pathogenesis in male mice. The current study was conducted to determine the contribution of 6β‐OHT to Ang II‐induced AAA development in Apoe–/– male mice. Methods and Results Intact or castrated Apoe–/–/Cyp1b1+/+ and Apoe–/–/Cyp1b1–/– male mice were infused with Ang II or its vehicle for 28 days, and administered 6β‐OHT every third day for the duration of the experiment. Abdominal aortas were then evaluated for development of AAAs. We observed a significant increase in the incidence and severity of AAAs in intact Ang II‐infused Apoe–/–/Cyp1b1+/+ mice, compared with vehicle‐treated mice, which were minimized in castrated Apoe–/–/Cyp1b1+/+ and intact Apoe–/–/Cyp1b1–/– mice infused with Ang II. Treatment with 6β‐OHT significantly restored the incidence and severity of AAAs in Ang II‐infused castrated Apoe–/–/Cyp1b1+/+ and intact Apoe–/–/Cyp1b1–/– mice. However, administration of testosterone failed to increase AAA incidence and severity in Ang II‐infused intact Apoe–/–/Cyp1b1–/– mice. Conclusions Our results indicate that the testosterone‐cytochrome P450 1B1‐generated metabolite 6β‐OHT contributes to Ang II‐induced AAA development in Apoe–/– male mice.
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Affiliation(s)
- Kamalika Mukherjee
- Department of Pharmacology Addiction Science and Toxicology College of Medicine University of Tennessee Health Science Center Memphis TN
| | - Ajeeth K Pingili
- Department of Pharmacology Addiction Science and Toxicology College of Medicine University of Tennessee Health Science Center Memphis TN
| | - Purnima Singh
- Department of Pharmacology Addiction Science and Toxicology College of Medicine University of Tennessee Health Science Center Memphis TN
| | - Ahmad N Dhodi
- Department of Pharmacology Addiction Science and Toxicology College of Medicine University of Tennessee Health Science Center Memphis TN
| | - Shubha R Dutta
- Department of Pharmacology Addiction Science and Toxicology College of Medicine University of Tennessee Health Science Center Memphis TN
| | | | - Kafait U Malik
- Department of Pharmacology Addiction Science and Toxicology College of Medicine University of Tennessee Health Science Center Memphis TN
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Abstract
Abdominal aortic aneurysm (AAA) disease remains a major source of morbidity in developed countries and can progress to life-threatening rupture if left untreated, with exceedingly high mortality. The goal of AAA management is to identify and electively repair AAAs before rupture. AAA disease burden and outcomes have improved over time with declining tobacco use and advancements in care across patients' disease course. The introduction of endovascular AAA repair, in particular, has allowed for elective AAA repair in patients previously considered too high risk for open surgery and has contributed to lower rates of AAA rupture over time. However, these improved outcomes are not universally experienced, and disparities continue to exist in the detection, treatment, and outcomes of AAA by sex, race, and ethnicity. Mitigating these disparities requires enhanced, focused efforts at preventing disease, promoting health, and delivering appropriate care among an increasingly diverse patient population.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis Street, Suite 5B, Boston, MA 02215
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis Street, Suite 5B, Boston, MA 02215.
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Chaudhuri A, Heim F, Chakfe N. Estimating the "Pull" on a Pullthrough Wire: A Pilot Study. EJVES Vasc Forum 2021; 50:24-26. [PMID: 33937900 PMCID: PMC8076957 DOI: 10.1016/j.ejvsvf.2020.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/27/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022] Open
Abstract
Objective Pullthrough/body floss wires are used to track endovascular devices across tortuous aorto-iliac anatomy encountered during endovascular repair of abdominal or thoracic aortic aneurysms. The tension imparted on such wires is arbitrary and has never been quantified. This pilot study attempted to quantify the tension used to stiffen the floppy hydrophilic wires typically used in such a scenario. Methods Two linked experiments were undertaken, the first by tasking 13 blinded vascular surgeons (eight male, five female; mean age 36 ± 11 years, including nine trainees) with pulling a long floppy hydrophilic wire (Radifocus Guidewire M Stiff, Terumo UK, Bagshot, Surrey, UK) attached at the other end to a horizontally configured industrial scale (HDN-N Hanging Scale, Kern & Sohn GmbH, Balingen, Germany), to simulate what they individually felt was an “appropriate” tension; the second by using the derived average tensioning force to set up a pullthrough wire within a rigid life like aorto-iliac model to assess whether a test device (16F Sentrant Introducer Sheath, Medtronic Limited, Watford, UK) could be delivered over such a tensioned wire in both brachiofemoral and femorofemoral configurations. Results The mean tension exerted by the group on the wire was 38.3 ± 14.8 N (equivalent to 3.9 kgf). Pullthrough wire tensioning was undertaken by fixing one end and applying a 3.9 kg weight at the other. The test device was successfully deployed into the infrarenal aortic position and also across the aortic bifurcation, via brachiofemoral and femorofemoral pullthrough configurations, respectively. Conclusion Successful test device deliveries suggest that a minimum tension equivalent to almost 4 kgf applied to a floppy wire can provide “stiffeningˮ to allow device tracking across tortuous aorto-iliac anatomy. More studies are needed to ascertain whether lower tensions can be applied; these results may help provide a platform for other such studies depending on configuration, aortic geometry, and device or wire/tension characteristics. Pullthrough wires are used at EVAR/TEVAR when tortuous anatomy is encountered The tension on such pullthrough wires has not been quantified Typically floppy hydrophilic wires are used to traverse such tortuous anatomy Floppy wires become the functional equivalent of stiff wires when tensioned This study for the first time quantifies the tension forces on pullthrough wires
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Affiliation(s)
- Arindam Chaudhuri
- Bedfordshire-Milton Keynes Vascular Centre, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK.,Groupe Européen de Recherche sur les Prothèses appliquées à la Chirurgie Vasculaire, Strasbourg, France
| | - Frederic Heim
- Groupe Européen de Recherche sur les Prothèses appliquées à la Chirurgie Vasculaire, Strasbourg, France.,Université de Haute-Alsace, Laboratoire de Physique et Mécanique Textiles, Mulhouse Cedex, France
| | - Nabil Chakfe
- Groupe Européen de Recherche sur les Prothèses appliquées à la Chirurgie Vasculaire, Strasbourg, France
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Willemsen SI, Ten Berge MG, Statius van Eps RG, Veger HTC, van Overhagen H, van Dijk LC, Putter H, Wever JJ. Nationwide Study to Predict Colonic Ischemia after Abdominal Aortic Aneurysm Repair in The Netherlands. Ann Vasc Surg 2020; 73:407-416. [PMID: 33383137 DOI: 10.1016/j.avsg.2020.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Colonic ischemia remains a severe complication after abdominal aortic aneurysm (AAA) repair and is associated with a high mortality. With open repair being one of the main risk factors of colonic ischemia, deciding between endovascular or open aneurysm repair should be based on tailor-made medicine. This study aims to identify high-risk patients of colonic ischemia, a risk that can be taken into account while deciding on AAA treatment strategy. METHODS A nationwide population-based cohort study of 9,433 patients who underwent an AAA operation between 2014 and 2016 was conducted. Potential risk factors were determined by reviewing prior studies and univariate analysis. With logistic regression analysis, independent predictors of intestinal ischemia were established. These variables were used to form a prediction model. RESULTS Intestinal ischemia occurred in 267 patients (2.8%). Occurrence of intestinal ischemia was seen significantly more in open repair versus endovascular aneurysm repair (7.6% vs. 0.9%; P < 0.001). This difference remained significant after stratification by urgency of the procedure, in both intact open (4.2% vs. 0.4%; P < 0.001) and ruptured open repair (15.0% vs. 6.2%); P < 0.001). Rupture of the AAA was the most important predictor of developing intestinal ischemia (odds ratio [OR], 5.9, 95% confidence interval [CI] 4.4-8.0), followed by having a suprarenal AAA (OR 3.4; CI 1.1-10.6). Associated procedural factors were open repair (OR 2.8; 95% CI 1.9-4.2), blood loss >1L (OR 3.6; 95% CI 1.7-7.5), and prolonged operating time (OR 2.0; 95% CI 1.4-2.8). Patient characteristics included having peripheral arterial disease (OR 2.4; 95% CI 1.3-4.4), female gender (OR 1.7; 95% CI 1.2-2.4), renal insufficiency (OR 1.7; 1.3-2.2), and pulmonary history (OR 1.6; 95% CI 1.2-2.2). Age <68 years proved to be a protective factor (OR 0.5; 95% CI 0.4-0.8). Associated mortality was higher in patients with intestinal ischemia versus patients without (50.6% vs. 5.1%, P < 0.001). Each predictor was given a score between 1 and 4. Patients with a score of ≥10 proved to be at high risk. A prediction model with an excellent AUC = 0.873 (95% CI 0.855-0.892) could be formed. CONCLUSIONS One of the main risk factors is open repair. Several other risk factors can contribute to developing colonic ischemia after AAA repair. The proposed prediction model can be used to identify patients at high risk for developing colonic ischemia. With the current trend in AAA repair leaning toward open repair for better long-term results, our prediction model allows a better informed decision can be made in AAA treatment strategy.
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Affiliation(s)
| | | | | | | | - Hans van Overhagen
- Department of Interventional Radiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Lukas Carolus van Dijk
- Department of Interventional Radiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Hein Putter
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan Jacob Wever
- Department of Vascular Surgery, Haga Teaching Hospital, The Hague, the Netherlands
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Georgakarakos E, Papatheodorou N, Argyriou C, Tasopoulou KM, Doukas D, Georgiadis GS. An update on the ovation abdominal stent graft for the treatment of abdominal aortic aneurysms: current evidence and future perspectives. Expert Rev Med Devices 2020; 17:1249-1256. [PMID: 33166478 DOI: 10.1080/17434440.2020.1848539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Introduction: The Ovation stent-graft has presented satisfactory mid-term results in the management of abdominal aortic aneurysms (AAA). Its unique design with uncoupling of fixation and sealing and the lowest profile in the market has expanded the treatment in AAA with challenging neck anatomies and, especially, in the females presenting mostly with narrow iliac access vessels. Morever, a new design modification, the Ovation Alto was recently introduced in the Market, while certain off-label uses of the Ovation in treating either juxtarenal- or short-necked AAA have been proposed. Areas covered: Aim of this article was to present the current articles with the long-term results of the Ovation endograft and discuss the new developments and modifications in its use. Expert commentary: the Ovation stent-graft exhibits very satisfactory clinical long-term results in AAA treated within the instructions-for-use, expands significantly the treatment of AAA in females and overcomes reliably challenging anatomical issues of the infrarenal neck that would render these cases ineligible for treatment with any other endograft. Εxperience with the specific, unique technical features of Ovation as well as careful selection of patients and meticulous preoperative study of the AAA anatomy are key-elements to the successful performance of this endograft.
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Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace , Alexandroupolis, Greece
| | - Nikolaos Papatheodorou
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace , Alexandroupolis, Greece
| | - Christos Argyriou
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace , Alexandroupolis, Greece
| | - Kalliopi-Maria Tasopoulou
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace , Alexandroupolis, Greece
| | - Damianos Doukas
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace , Alexandroupolis, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace , Alexandroupolis, Greece
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Barleben A, Mathlouthi A, Mehta M, Nolte T, Valdes F, Malas MB. Long-term outcomes of the Ovation Stent Graft System investigational device exemption trial for endovascular abdominal aortic aneurysm repair. J Vasc Surg 2020; 72:1667-1673.e1. [DOI: 10.1016/j.jvs.2020.01.066] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/31/2020] [Indexed: 12/22/2022]
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Georgiadis GS, Chatzigakis PK, Kouvelos G, Argyriou C, Kopadis GC, Georgakarakos EI, Matsagkas M. Multicenter Mid-term Results After Endovascular Aortic Aneurysm Repair with the Incraft® Device. Ann Vasc Surg 2020; 72:464-478. [PMID: 32946999 DOI: 10.1016/j.avsg.2020.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Durability after endovascular aortic aneurysm repair (EVAR) is considered an ongoing topic of investigation and was always a point of concern with smaller profile devices. Recently released five-year clinical trial results using the Incraft® ultralow profile device are encouraging. However, additional real-life experience will need to assist these initial findings. Herein, we investigated the outcomes after EVAR, in real world practice using the Incraft® endograft (EG). MATERIAL AND METHODS Seventy-seven patients with infrarenal abdominal aortic aneurysms (AAA) ≥50 mm in diameter treated with the Incraft® device in three vascular centers were enrolled from November 2015 to July 2018. Follow-up was completed in August 2020. Selection of EVAR using the Incraft® device was individualized according to aorto-iliac morphologic features, comorbidities, history of previous abdominal surgery and preference of the patient. At the early phase of the study, we specifically opted for preferential use of this low profile EG mainly in cases of small and tortuous iliac vessels (more challenging access routes). At later stages, it was used according to surgeon preference and not specifically in complex anatomies (real-world conditions). End-points included technical success, perioperative complications, 30-day survival, endoleg patency, presence of endoleaks, sac enlargement >5 mm and clinical success. RESULTS The primary technical success rate was 97.4% before the addition of an aortic cuff and iliac extension for a type Ia and type Ib endoleak respectively, and the repair of a maldeployment iliac component (primary-assisted and secondary technical success, 100%). Intraoperative small type II endoleaks (visible in final angiogram) were noted in 19 patients (24.7%). There were no intraoperative deaths from AAA rupture, primary conversions or conversions to aortounilateral grafts. Two complications occurred, necessitating hybrid techniques for repair (replaced of a dislodged endoleg and distal external iliac artery hemostasis). No deaths were reported within 30 days. Occlusion of an endoleg, was observed in two patients, 6 and 14 months respectively after implantation (2.6%), and were treated by femoral-femoral PTFE bypass after unsuccessful endovascular recanalization. The latter required open conversion, 3 mo later, to repair compromised flow to the inflow iliac axis. Three patients (3.9%) experienced sac enlargement >5 mm in diameter compared with the 1-month CT scan. All of these had type II endoleaks and two received embolization procedures. Eleven patients died from causes unrelated to AAA repair. Clinical success was 97.3%, 92.8% and 89.4% through 1, 2 and 3 years respectively. CONCLUSIONS EVAR with the Incraft® device might be considered a reliable option in real-world conditions and not specifically only in complex iliac anatomies.
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Affiliation(s)
- George S Georgiadis
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece.
| | - Petros K Chatzigakis
- Department of Vascular Surgery, Gennimatas General Hospital of Athens, Athens, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University of Thessaly, Larissa, Greece
| | - Christos Argyriou
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Georgios C Kopadis
- Department of Vascular Surgery, Gennimatas General Hospital of Athens, Athens, Greece
| | - Efstratios I Georgakarakos
- Department of Vascular Surgery, "Democritus" University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
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Lomazzi C, Mascoli C, de Beaufort HW, Cao P, Weaver F, Milner R, Fillinger M, Verhoeven E, Grassi V, Gargiulo M, Trimarchi S, Piffaretti G. Gender Related Access Complications After TEVAR: Analysis from the Retrospective Multicentre Cohort GORE® GREAT Registry Study. Eur J Vasc Endovasc Surg 2020; 60:203-209. [DOI: 10.1016/j.ejvs.2020.04.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/14/2020] [Accepted: 04/09/2020] [Indexed: 11/16/2022]
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Edman NI, Bartek MA, Kang PC, Sweet MP. Anatomic Eligibility for Commercial Branched Endograft Repair of Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2020; 70:481-490. [PMID: 32603844 DOI: 10.1016/j.avsg.2020.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND First-generation "off-the-shelf" branched endovascular stent grafts are in development for treatment of thoracoabdominal aortic aneurysms (TAAAs). Prior studies have assessed eligibility rates among highly selected cohorts of patients referred for endovascular treatment, and the broader applicability of these devices to all patients with TAAA is unknown. The aims of this study were to assess the overall suitability of the 3 commercial 4-branched devices with or without adjunct procedure(s) in an unselected cohort of patients with TAAA and to identify areas for improvement in the next generation of devices. METHODS A retrospective review of three-dimensional centerline reconstructions of contrast-enhanced computed tomography (CT) imaging was performed in consecutive patients with TAAA seen between 2013 and 2017. All patients with contrast-enhanced CT imaging were included, regardless of prior evaluation for suitability for endovascular repair. Eligibility for a device was assessed based on instructions for use (IFU) from the device manufacturer along with prespecified anatomic criteria. Adjunct procedures were defined as carotid-subclavian revascularization, target vessel endovascular intervention, and iliac conduit/revascularization. RESULTS Of 165 patients with TAAA, 122 had CT scans adequate for study inclusion. Eighteen patients (14.8%) were eligible for at least 1 device by IFU, and 41 (33.6%) could have been made eligible for at least 1 device by an adjunct procedure. Sixty-three (51.6%) were not eligible for any device within IFU even with adjunct procedures, including 31 of 32 patients with TAAA due to dissection. The most common reasons for ineligibility were perivisceral flow channel diameter <20 mm (n = 43) and an inadequate proximal seal zone (n = 29). Women were significantly less likely to be eligible for an off-the-shelf device (P = 0.03) and were more likely to require an iliac procedure to become eligible (P = 0.006). Almost none of the patients with dissection could receive a device even if adjunct procedures were used. CONCLUSIONS Over half of patients with TAAA could not be made eligible for an off-the-shelf device based on manufacturers' criteria, even with adjunct procedures. Women and patients with TAAA due to dissection had higher rates of ineligibility. These data demonstrate that custom fenestrated devices and low-profile devices are needed to expand eligibility for endovascular repair of TAAA.
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Affiliation(s)
- Natasha I Edman
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Matthew A Bartek
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - P Chulhi Kang
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA.
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Endurant stent graft demonstrates promising outcomes in challenging abdominal aortic aneurysm anatomy. J Vasc Surg 2020; 73:69-80. [PMID: 32442605 DOI: 10.1016/j.jvs.2020.04.508] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We aimed to assess the 5-year safety and effectiveness outcomes of patients enrolled in the Endurant Stent Graft Natural Selection Global Post Market Registry (ENGAGE) who were treated outside the approved indications for use (IFU) of the Endurant stent graft. METHODS Our primary outcome measure was 12-month treatment success, defined as successful endograft delivery and deployment and the absence of type I or III endoleak, stent migration or limb occlusion, late conversion, and abdominal aortic aneurysm diameter increase or rupture. Secondary outcome measures included 30-day all-cause mortality, major adverse events, secondary procedures, technical observations, aneurysm-related mortality, and all-cause mortality within 12 months. RESULTS Demographic characteristics of ENGAGE patients treated outside (225 [17.8%]) and within (1038 [82.2%]) the IFUs were similar, except that female patients comprised a much higher percentage of the outside IFU group (19.1% vs 8.7%; P < .001). The outside IFU group presented with lower rates of coronary artery disease and cardiac revascularization and a greater number of symptomatic patients compared with the within IFU group (21.3% vs 15.0%; P = .020). Technical success was achieved in more than 99% of all patients. The outside and within IFU groups showed a comparable and low occurrence of uncorrected type I (0.9% vs 1.2%; P = 1.00) and type III endoleak (0.4% vs 0.3%; P = .54) immediately after device implantation. The 5-year freedom from type IA endoleaks was 89.4% vs 96.7% (P < .0001) for those patients outside and within the IFUs, respectively, although both groups had similar type III endoleaks through 5 years (P = .61). Stent graft limb occlusion estimated overall survival, and freedom from aneurysm-related mortality and endovascular interventions were comparable in both patient groups through the 5-year follow-up. The Kaplan-Meier estimates at 5 years showed a trend for low but increased need for type I or III endoleak correction procedures in the outside IFU group compared with the within IFU group (7.2% vs 5.2%; P = .099). CONCLUSIONS Differences were not observed in all-cause mortality, aneurysm-related mortality, and secondary procedures between within and outside IFU patients through a 5-year follow-up in the ENGAGE registry. Proximal necks with angulation or diameters outside the IFUs were the most common reasons for patients identified as being outside IFU, and the cohort had increased incidence of type IA endoleaks. Despite the challenges presented from the broad range of aortic and abdominal aortic aneurysm morphologies, the Endurant stent graft showed promising 5-year outcomes.
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Chinsakchai K, Suksusilp P, Wongwanit C, Hongku K, Hahtapornsawan S, Puangpunngam N, Moll FL, Sermsathanasawadi N, Ruangsetakit C, Mutirangura P. Early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between severe and non-severe infrarenal neck angulation. Vascular 2020; 28:683-691. [DOI: 10.1177/1708538120924552] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Abdominal aortic aneurysm with severe infrarenal neck angle (>60°) has long been thought to be an obstacle to endovascular aneurysm repair. However, some previous studies reported endovascular aneurysm repair to be safe and efficacious for treating abdominal aortic aneurysm in patients with severe neck angulation. The aim of this study was to investigate the early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between patients with severe and non-severe infrarenal neck angulation. Methods Fifty-four severe and 144 non-severe neck angulation patients who were treated at Siriraj Hospital (Bangkok, Thailand) during January 2010–October 2013 were recruited. The primary endpoints were intraoperative neck complications (e.g., type 1A endoleak or proximal graft migration) and immediate adjunct aortic neck procedures. The secondary endpoints included perioperative mortality, overall survival, and the proportion of patients that were reintervention-free at five years compared between the severe and non-severe groups. Results Severe angulation patients were significantly older than non-severe angulation patients (77 ± 6.3 vs. 74 ± 7.9 years; p = 0.021). The median proximal angle was significantly greater in the severe group (82° vs. 13.5°; p < 0.001). Intraoperative proximal neck complications developed in 29.6% of patients in the severe angulation group compared with 9.0% in the non-severe group ( p < 0.001). Significantly more patients in the severe group required intraoperative adjunct procedures (29.6% vs. 7.6%; p < 0.001). There was no significant difference in perioperative mortality between groups. At the five-year follow-up, there was no significant difference between groups for overall survival or the proportion of patients that remained reintervention-free. Conclusions Endovascular aneurysm repair to treat abdominal aortic aneurysm in patients with severe proximal neck angulation is technically feasible and safe Although the severe angulation group had a higher rate of intraoperative neck complications and immediate adjunct neck procedures than the non-severe group, there was no significant difference between groups for 30-day mortality, overall survival or the proportion of patients who remained reintervention-free at five years.
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Affiliation(s)
- Khamin Chinsakchai
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pichawat Suksusilp
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chumpol Wongwanit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kiattisak Hongku
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suteekhanit Hahtapornsawan
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nattawut Puangpunngam
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nuttawut Sermsathanasawadi
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanean Ruangsetakit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pramook Mutirangura
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Salata K, Hussain MA, Al-Omran M. Letter by Salata et al Regarding Article, "Utilization of Advanced Cardiovascular Therapies in the United States and Canada: An Observational Study of New York and Ontario Administrative Data". Circ Cardiovasc Qual Outcomes 2020; 13:e006569. [PMID: 32366115 DOI: 10.1161/circoutcomes.120.006569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Konrad Salata
- Division of Vascular Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, ON, Canada (K.S., M.A.H., M.A.-O.)
| | - Mohamad A Hussain
- Division of Vascular Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, ON, Canada (K.S., M.A.H., M.A.-O.)
| | - Mohammed Al-Omran
- Division of Vascular Surgery, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, ON, Canada (K.S., M.A.H., M.A.-O.).,Department of Surgery, King Saud University, Riyadh, Saudi Arabia (M.A.-O.)
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O'Donnell TFX, Verhagen HJ, Pratesi G, Pratesi C, Teijink JAW, Vermassen FEG, Mwipatayi P, Forbes TL, Schermerhorn ML. Female sex is associated with comparable 5-year outcomes after contemporary endovascular aneurysm repair despite more challenging anatomy. J Vasc Surg 2020; 71:1179-1189. [PMID: 31477480 PMCID: PMC7048667 DOI: 10.1016/j.jvs.2019.05.065] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Women with abdominal aortic aneurysms less often meet anatomic criteria for endovascular repair and experience worse perioperative and long-term survival. METHODS We compared long-term survival, aneurysm-related mortality, and rates of endoleaks and reinterventions between male and female patients in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) using 2:1 propensity score matching. RESULTS There were 1130 male patients and 133 female patients, yielding 399 patients after matching (266 male patients, 133 female patients). Female patients were older, with smaller aneurysms, smaller iliac arteries, and shorter, more angulated necks, and they were more often treated outside the device instructions for use (all P < .001). Through 5 years, female patients experienced overall mortality comparable to that of well-matched male patients (34% vs 38%, respectively; hazard ratio, 0.89 [0.61-1.29]; P = .54) and lower aneurysm-related mortality (0% vs 3%; P = .047). Female patients experienced higher rates of any postoperative type IA endoleak through 5 years (10% vs 1%; P < .001) but comparable rates of secondary endovascular procedures (14% vs 16%; P = .40). Female sex was independently associated with significantly higher risk of long-term type IA endoleaks (hazard ratio, 4.8 [1.2-20.8]; P = .04), even after accounting for anatomic factors. No female patient experienced aneurysm rupture during follow-up, and only one female patient underwent conversion to open repair. CONCLUSIONS Despite more challenging anatomy, female patients in the ENGAGE registry had long-term outcomes comparable to those of male patients. However, female patients experienced higher rates of type IA endoleaks. Although standard endovascular aneurysm repair remains a viable solution for most women, whether high-risk patients may be better served with open surgery, custom-made devices, EndoAnchors (Aptus Endosystems, Sunnyvale, Calif), or chimneys is worthy of further study.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Hence J Verhagen
- Division of Vascular and Endovascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Giovanni Pratesi
- Vascular Surgery, Department of Biomedicine and Prevention, University of Roma Tor Vergata, Rome, Italy
| | - Carlo Pratesi
- Department of Vascular Surgery, University of Florence, Florence, Italy
| | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; Department of Epidemiology, CAPRHI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Frank E G Vermassen
- Department of Vascular Surgery, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Patrice Mwipatayi
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Trenner M, Salvermoser M, Busch A, Reutersberg B, Eckstein HH, Kuehnl A. Effect Modification of Sex and Age for the Hospital Volume-Outcome Relationship in Abdominal Aortic Aneurysm Treatment: Secondary Data Analysis of the Nationwide German Diagnosis Related Groups Statistics From 2005 to 2014. J Am Heart Assoc 2020; 9:e014534. [PMID: 32172655 PMCID: PMC7335519 DOI: 10.1161/jaha.119.014534] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Trials and registries associated female sex and high age with unfavorable outcomes in abdominal aortic aneurysm treatment. Many studies showed an inverse correlation between annual hospital volume and in-hospital mortality. The volume-outcome relationship has not been investigated separately for women and men or across the age range. The aim was to analyze whether sex and age are effect modifiers or confounders of the volume-outcome association. Methods and Results In a nationwide setting, all in-hospital cases from 2005 to 2014 with a diagnosis of intact abdominal aortic aneurysm and procedure codes for endovascular or open aortic repair were included. Primary outcome was in-hospital mortality. Using a multilevel multivariable regression model, hospital volume was modeled as a continuous variable. Separate analyses were performed for women and men and for predefined age groups. A total of 94 966 cases were included (12% women; median age, 72 years). Mortality was 4.9% in women and 3.0% in men (3.2% overall). Mortality increased with age. Although there was no significant volume-outcome association in women (P=0.57), there was in men (P=0.02). The strongest volume-outcome association was found in younger men. The younger female subpopulation was found to show a trend for an inverse volume-outcome relationship, whereas an opposite association was found for the women aged >79 years. Conclusions Women have a higher mortality risk after elective abdominal aortic aneurysm treatment. Sex and age are modifiers of the volume-outcome relationship. Unlike in male patients, in women there is no consistent effect of hospital volume on outcome.
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Affiliation(s)
- Matthias Trenner
- Department for Vascular and Endovascular Surgery Klinikum rechts der Isar Technical University of Munich and Munich Aortic Center Munich Germany
| | - Michael Salvermoser
- Department for Vascular and Endovascular Surgery Klinikum rechts der Isar Technical University of Munich and Munich Aortic Center Munich Germany
| | - Albert Busch
- Department for Vascular and Endovascular Surgery Klinikum rechts der Isar Technical University of Munich and Munich Aortic Center Munich Germany
| | - Benedikt Reutersberg
- Department for Vascular and Endovascular Surgery Klinikum rechts der Isar Technical University of Munich and Munich Aortic Center Munich Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery Klinikum rechts der Isar Technical University of Munich and Munich Aortic Center Munich Germany
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery Klinikum rechts der Isar Technical University of Munich and Munich Aortic Center Munich Germany
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Holden A, Lyden S. Initial experience with polymer endovascular aneurysm repair using the Alto stent graft. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:6-11. [PMID: 32025596 PMCID: PMC6995883 DOI: 10.1016/j.jvscit.2019.04.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 04/24/2019] [Indexed: 12/17/2022]
Abstract
The Alto Abdominal Stent Graft System (Endologix Inc, Irvine, Calif) is the next-generation Ovation system for polymer endovascular aneurysm repair. The most significant design change relocates the sealing ring closer to the top of the fabric, but a number of additional design changes were made. This report describes the first seven patients treated with the Alto stent graft at a single center (Auckland Hospital, Auckland, New Zealand) from August 2016 to February 2017. There was 100% procedural technical success. At 12-month follow-up, no type I or type III endoleak, stent graft migration, abdominal aortic aneurysm rupture, abdominal aortic aneurysm-related mortality, or secondary intervention was reported.
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Affiliation(s)
- Andrew Holden
- Department of Interventional Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Sean Lyden
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Ash J, Chandra V, Rzucidlo E, Vouyouka A, Hunter M. LUCY results show females have equivalent outcomes to males following endovascular abdominal aortic aneurysm repair despite more complex aortic morphology. J Vasc Surg 2020; 72:566-575.e4. [PMID: 31918999 DOI: 10.1016/j.jvs.2019.10.080] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/15/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Females remain underrepresented in studies of endovascular aneurysm repair (EVAR) owing to anatomic ineligibility for EVAR devices. The aim of the LUCY study is to explore the comparative safety and effectiveness of EVAR using a low-profile stent graft (Ovation; Endologix, Inc, Irvine, Calif) in females as well as males. METHODS The LUCY registry was a prospective, nonrandomized, multicenter study where patient enrollment was stratified by sex in a two-to-one ratio (male-to-female). Main outcomes were procedural data, 30-day major adverse events, device-related adverse events confirmed with contrast-enhanced computed tomography scans, secondary interventions, and hospital readmissions. Adverse events were adjudicated by a clinical events committee. Patients were followed at their 1-month and 1-year follow-up visits. RESULTS A total of 225 patients (76 females, 149 males) were enrolled at 39 U.S. centers. No statistically significant sex differences were observed in demographics or medical history. Females presented with smaller access vessels (6.2 vs 7.7 mm; P < .001), statistically smaller neck diameter (22 mm vs 23 mm; P = .001), similar neck angulation (11% vs 9% angulation >45°; P = .81), and smaller maximum abdominal aortic aneurysm (AAA) diameter (50 mm vs 53 mm; P = .01), however, these factors do not seem to be clinically significant. Technical success was 99%, and the median hospital stay was 1 day. The incidence of MAE through 30 days was 1.3% in females and 2.0% in males. There were no differences between sexes observed among the 30-day perioperative outcomes. The 30-day secondary intervention rate was 0.4%. The all-cause readmission rate through 30 days was 5.3% in females and 6.7% in males. There were no reports of limb occlusion or deaths within the first 30 days. At 1 year, there were no deaths in the female arm but nine deaths (6.0%) were observed in males, two of which were AAA related (1.3%). Through 1 year, there were eight type IA endoleaks (one female, seven males; P = .27) and three cases with limb occlusion (one female, two males). There were no reports of migration, AAA rupture, or surgical conversion through the end of follow-up. CONCLUSIONS Despite more complex aortic morphology in females than males, EVAR with a low-profile stent graft was associated with comparable procedural and perioperative outcomes through 1 year between the sexes.
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Affiliation(s)
- Jennifer Ash
- Christie Clinic Vein & Vascular Center, Champaign, Ill.
| | | | | | | | - Monica Hunter
- Southview Medical Group, St. Vincent's Birmingham, Birmingham, Ala
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Jones DW, Deery SE, Schneider DB, Rybin DV, Siracuse JJ, Farber A, Schermerhorn ML. Differences in patient selection and outcomes based on abdominal aortic aneurysm diameter thresholds in the Vascular Quality Initiative. J Vasc Surg 2019; 70:1446-1455. [DOI: 10.1016/j.jvs.2019.02.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 02/20/2019] [Indexed: 11/25/2022]
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Clancy K, Wong J, Spicher A. Abdominal Aortic Aneurysm: A Case Report and Literature Review. Perm J 2019; 23:18.218. [PMID: 31926569 DOI: 10.7812/tpp/18.218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Abdominal aortic aneurysms (AAA) more commonly affect men than women and are estimated to affect 4% to 8% of men older that age 60 years. Mortality because of a ruptured AAA is high, but elective repair is an effective and relatively safe intervention. CASE PRESENTATION A 79-year-old man came to the Emergency Department because of worsening back pain. Workup revealed a previously unknown, 10-cm aneurysm that had ruptured. Unfortunately, the patient died during emergency surgery. DISCUSSION A literature review of proper screening, referral timeframe, the most common surgical techniques, potential complications, and postoperative surveillance was conducted. Early detection, referral to vascular surgery, and possible open or endovascular repair are key to limiting the morbidity and mortality associated with AAA.
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