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Schutt J, Bohr NL, Cao K, Pocivavsek L, Milner R. Social Determinants of Health Factors and Loss-To-Follow-Up in the Field of Vascular Surgery. Ann Vasc Surg 2024; 105:316-324. [PMID: 38609010 DOI: 10.1016/j.avsg.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/27/2023] [Accepted: 01/21/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND It is estimated that 22-57% of vascular patients are lost to follow-up (LTF) which is of concern as the Society of Vascular Surgery recommends annual patient follow-up. The purpose of this report was to identify social determinants of health factors (SDoH) and their relationship to LTF in vascular patients. METHODS The methods employed were a systematic literature review of 29 empirical articles and a retrospective quality improvement report with 27 endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR) patients at the University of Chicago. RESULTS The systematic literature review resulted in 2,931 articles which were reduced to 29 articles meeting the inclusion criteria. Demographic variables were more frequently cited than SDoH factors, but the most common were smoking, transportation, and socioeconomic status/insurance. Additionally, 176 EVAR and TEVAR patients were called resulting in 27 patients who completed a SDoH questionnaire. Twenty-six percent indicated they had missed at least 1 appointment with the top reasons being work or family responsibilities. Due to limited patient size no statistical analyses were performed, but frequencies of responses to SDoH questions were reported to augment the existing limited literature and guide future research into variables such as one's ability to pay for basics like food or mortgage. CONCLUSIONS SDoH factors are important yet understudied aspects of endovascular repairs that require more research to understand their impact on vascular surgery follow-up rates and outcomes. Additional research is needed as lack of consideration of such factors may impact the generalizability of existing research and such knowledge may help in informing clinician treatment plans.
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Affiliation(s)
- Jonathon Schutt
- Midwestern University Chicago College of Osteopathic Medicine, Downers Grove, IL.
| | - Nicole L Bohr
- Department of Nursing Research, UChicago Medicine, Chicago, IL; Department of Surgery, University of Chicago, Chicago, IL
| | - Kathleen Cao
- Department of Surgery, University of Chicago, Chicago, IL
| | | | - Ross Milner
- Department of Surgery, University of Chicago, Chicago, IL
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Kang J. Does "no pain, no gain" hold true for patients with aortic aneurysms? J Vasc Surg 2024; 80:96-97. [PMID: 38906669 DOI: 10.1016/j.jvs.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/01/2024] [Indexed: 06/23/2024]
Affiliation(s)
- Jeanwan Kang
- University of Maryland School of Medicine, Division of Vascular Surgery, Baltimore, MD
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Wolf S, Ashouri Y, Succar B, Hsu CH, Abuhakmeh Y, Goshima K, Devito P, Zhou W. Follow-up compliance in patients undergoing abdominal aortic aneurysm repair at Veterans Affairs hospitals. J Vasc Surg 2024; 80:89-95. [PMID: 38462060 DOI: 10.1016/j.jvs.2024.02.040] [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: 11/06/2023] [Revised: 01/28/2024] [Accepted: 02/01/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE The Society for Vascular Surgery guidelines recommend annual imaging surveillance following endovascular aneurysm repair (EVAR) and every 5 years following open surgical repairs (OSR) of abdominal aortic aneurysms (AAAs). Adherence to these guidelines is low outside of clinical trials, and compliance at Veterans Affairs (VA) hospitals is not yet well-established. We examined imaging follow-up compliance and mortality rates after AAA repair at VA hospitals. METHODS We queried the VA Surgical Quality Improvement Program database for elective infrarenal AAA repairs, EVAR and OSR, then merged in follow-up imaging and mortality information. Mortality rate over time was derived using Kaplan-Meier estimation. Generalized estimating equation with a logit link and a sandwich standard error estimate was performed to compare the probability of having annual follow-up imaging over time between procedure types and to identify variables associated with follow-up imaging for EVAR patients. RESULTS Our analysis included 11,668 patients who underwent EVAR and 4507 patients who underwent OSR at VA hospitals between the years 2000 and 2019. The 30-day mortality rate for EVAR and OSR was 0.37% and 0.82%, respectively. OSR was associated with lower long-term mortality after adjusting age, sex, American Society of Anesthesiologists classification and preoperative renal failure with an adjusted hazard ratio of 0.88 (95% confidence interval, 0.84-0.92; P < .01). Of surviving patients, the follow-up imaging rate was 69.1% by 1 year post-EVAR. The follow-up rate after 5 years was 45.6% post-EVAR compared with 63.6% post-OSR of surviving patients. A history of smoking or drinking, baseline hypertension, and known cardiac disease were independently associated with poor follow-up after EVAR. CONCLUSIONS Patients undergoing elective open AAA repair in the VA hospital system had lower long-term mortality compared with patients who underwent endovascular repair. Compliance with post-EVAR imaging is low. Patient factors associated with poor post-EVAR imaging surveillance were smoking within the last year, excess alcohol consumption, and cardiac risk factors including hypertension, prior myocardial infarction, and congestive heart failure.
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Affiliation(s)
- Sona Wolf
- University of Arizona College of Medicine, Tucson, AZ
| | - Yazan Ashouri
- University of Arizona, Division of Vascular Surgery, Department of Surgery, Tucson, AZ
| | - Bahaa Succar
- University of Arizona, Division of Vascular Surgery, Department of Surgery, Tucson, AZ
| | - Chiu-Hsieh Hsu
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | - Yousef Abuhakmeh
- University of Arizona, Division of Vascular Surgery, Department of Surgery, Tucson, AZ
| | - Karou Goshima
- University of Arizona, Division of Vascular Surgery, Department of Surgery, Tucson, AZ
| | - Peter Devito
- University of Arizona, Division of Vascular Surgery, Department of Surgery, Tucson, AZ
| | - Wei Zhou
- University of Arizona, Division of Vascular Surgery, Department of Surgery, Tucson, AZ.
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Rašiová M, Koščo M, Pavlíková V, Hudák M, Moščovič M, Kočan L. Predictors of overall mortality after endovascular abdominal aortic repair - A single centre study. Vascular 2024:17085381241262350. [PMID: 38872254 DOI: 10.1177/17085381241262350] [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: 06/15/2024]
Abstract
OBJECTIVES A current and ongoing challenge is to reduce patient mortality after endovascular abdominal aortic repair (EVAR). This study aimed to assess the predictors of all-cause mortality after EVAR. METHODS Data regarding the demographic characteristics, comorbidities, laboratory values, selected anatomical factors, post-EVAR treatment, surveillance and complications of patients who underwent elective EVAR for non-ruptured abdominal aortic aneurysm (AAA) between January 2010 and January 2021 were evaluated. Mortality was assessed until 10 October 2023. Multivariate analyses were performed after adjusting for age, hypertension, diabetes mellitus, dyslipidaemia, sex, smoking, number of lumbar arteries, patency of inferior mesenteric artery (IMA), IMA diameter and reinterventions. RESULTS This study included 196 patients (183 men and 13 women) with a mean age of 72.4 ± 7.67 years. The overall mortality rate during a mean follow-up period of 5.75 ± 3.1 years was 50.0% (N = 98). The 2-, 5- and 10-year mortality rates were 9.7%, 32.0% and 66.6%, respectively. The mortality rates decreased by 59% in patients with reinterventions (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.23-0.73; p = .002) and by 59% in patients treated with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (HR: 0.41; 95% CI: 0.26-0.66; p < .001). Chronic anticoagulation was associated with 2.09-fold higher mortality (HR: 2.09; 95% CI: 1.19-3.67; p = .010), and coronary artery disease (CAD) was associated with 1.74-fold higher mortality (HR: 1.74; 95% CI: 1.09-2.78; p = .021). Pre-EVAR AAA diameter and 1-year post-EVAR sac diameter were positively associated with mortality (HR: 1.05; 95% CI: 1.03-1.08; p < .001, and HR: 1.05; 95% CI: 1.03-1.07; p < .001, respectively), that is, an increase of pre-EVAR and/or 1-year post-EVAR AAA diameter by 1 mm was associated with a 5% higher risk of all-cause mortality. CONCLUSIONS Reinterventions and treatment with ACE inhibitors or ARBs may be associated with decreased post-EVAR mortality. A greater pre-EVAR, a post-EVAR AAA diameter, CAD and chronic anticoagulation were associated with higher all-cause mortality post-EVAR.
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Affiliation(s)
- Mária Rašiová
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Martin Koščo
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Veronika Pavlíková
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Marek Hudák
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Matej Moščovič
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
| | - Ladislav Kočan
- Department of Angiology, East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine, Šafárik University, Košice, Slovakia
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Zettervall SL, Schanzer A. Surveillance after EVAR Should Continue to Be a Priority. Eur J Vasc Endovasc Surg 2024; 67:701-702. [PMID: 38754944 DOI: 10.1016/j.ejvs.2024.01.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 05/18/2024]
Affiliation(s)
- Sara L Zettervall
- University of Washington, Division of Vascular Surgery, Seattle, WA, USA.
| | - Andres Schanzer
- UMass Chan Medical School, Division of Vascular Surgery, Worcester, MA, USA. https://twitter.com/AndresSchanzer
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Özdemir-van Brunschot DMD, Holzhey D, Botsios S. Mid-term results of "off-label" use of the Endurant stentgraft in patients with infrarenal abdominal aortic aneurysms. Vascular 2024:17085381241247265. [PMID: 38606774 DOI: 10.1177/17085381241247265] [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: 04/13/2024]
Abstract
OBJECTIVES EVAR is the preferred treatment modality for patients with an infrarenal abdominal aortic aneurysm with suitable anatomy. Each manufacturer of aortic stentgrafts has specific anatomic requirements. In some patients, it is not possible to adhere to the instructions for use, but alternative treatment is also not possible. In these patients, EVAR can be performed outside instructions for use. METHODS In this study, all consecutive patients in whom an Endurant II or IIS stentgraft was used between 1 January and 31 December were reviewed. We compared the two patient groups in whom this stentgrafts was used outside and inside instructions for use. Patients with planned adjuvant therapy, for example, chimney procedure or iliac side branches, were excluded. RESULTS In 74 of 178 (41.6%) patients, the instructions for use were not adhered. The main reason was pathology of the aortic neck. There were more patients with type IA endoleak, this difference was borderline significant (p = .06). There were more patients with limb occlusion in the early postoperative period, but at the end of the follow-up period, the incidence was comparable. Aneurysm-related mortality and all-cause mortality were comparable in both groups. CONCLUSION In this study, real-life experience with the Endurant II and IIS stentgraft is described. Non-adherence with instructions for use was associated with a higher risk of endoleak type IA (p = .06). In the early postoperative period, there were more patients with limb occlusion; this finding was not observed anymore at the end of the follow-up period.
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Affiliation(s)
- Denise Michelle Danielle Özdemir-van Brunschot
- Faculty of Health, Witten/Herdecke University, Witten, Germany
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
| | - David Holzhey
- Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Spiridon Botsios
- Faculty of Health, Witten/Herdecke University, Witten, Germany
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
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Gedney R, Barksdale C, Wright AS, Genovese EA, Ruddy JM. Hostile neck anatomy contributes to higher rates of reintervention following endovascular aortic repair for ruptured infrarenal abdominal aortic aneurysm. Vascular 2024:17085381241239428. [PMID: 38478714 DOI: 10.1177/17085381241239428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Ruptured abdominal aortic aneurysms (AAA) presenting with hostile neck anatomy can represent a challenge in surgical decision-making. We hypothesized that, patients who require reinterventions have higher rates of compromised neck anatomy at initial presentation and may indicate a need for altered surveillance paradigm. METHODS Patients presenting with ruptured AAA to a single tertiary care institution from 2014 to 2021 were retrospectively reviewed. Those treated with infrarenal EVAR, with no prior aortic surgeries, and with available pre-operative computed tomography (CT) scans were included. Demographics, timing and type of reintervention, follow-up, and survival were collected. CT scans were assessed for hostile neck anatomy via measurements of diameter, length, angle, taper, bulge, calcification, and thrombus. Demographics, comorbidities, and neck anatomy of those with and without reintervention were compared using Fischer's Exact and Student's T-test. Survival was analyzed via Kaplan-Meier and log-rank test. RESULTS Eighty-nine patients were available for analysis, 37 of which met inclusion criteria. Intraoperative death occurred in 3 patients (8.1%) and 1 patient (2.7%) was intraoperatively converted to an open repair. Thirty-day and 1-year survival were 97% and 91%, respectively. The reintervention rate was 30% (n = 10), occurring at a median of 200 days (18-2053 days) after the index operation. All patients requiring reintervention met hostile neck criteria (p = .002) and had a statistically higher number of hostile neck criteria (1.80 vs 0.87, p = .03). Thirty percent (n = 3) of patients that received a reintervention had neck diameter greater than 3 cm, compared to zero patients in the non-reintervention group (p = .022). Proximal reinterventions (n = 5) had statistically higher neck diameters and neck angle compared to the non-reintervention group. CONCLUSION Infrarenal rEVAR is effective at preventing acute mortality despite specific anatomic considerations that may contribute to the higher reintervention rates, and therefore those parameters ought to be considered when following patients in the post-intervention period.
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Affiliation(s)
- Ryan Gedney
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Christian Barksdale
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Antwana Sharee Wright
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Elizabeth A Genovese
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Jean Marie Ruddy
- Division of Vascular Surgery, Medical University of South Carolina, Charleston, SC, USA
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Özdemir-van Brunschot DM, Zerellari R, Tevs M, Wassiljew S, Holzhey D. Multilayer Flow Modulator Stent for Aortic Pathology: A Meta-Analysis and Additional Data from a Single-Centre Retrospective Cohort. Rev Cardiovasc Med 2024; 25:90. [PMID: 39076940 PMCID: PMC11263838 DOI: 10.31083/j.rcm2503090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 07/31/2024] Open
Abstract
Background Thoracoabdominal aneurysms and aortic dissections are a challenge for vascular surgeons. Open surgery, fenestrated or branched endograft, and the chimney technique are not possible in some patients, because of comorbidities or anatomical restrictions. However, the multilayer flow modulator (MFM) can be implanted in some of these patients. In this systematic review, we will describe the experience with the multilayer stent. To augment the limited number of studies available, we will include a cohort of patients from our hospital. Methods We retrieved data on all consecutive patients treated using the MFM between May 2013 and August 2020. This included patients with type B dissections and thoracoabdominal or thoracic aneurysms who were unfit for open surgery. The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included all the studies that used the MFM in the aortic segment. Single-arm meta-analyses were performed using OpenMeta (Brown University, Providence, RI, USA). Results A total of 37 patients were treated in our hospital during the study period. The technical success was 97.3% and the 30-day mortality was 5.4%. In 40.5% of the included patients, the instructions for use were not followed. Off-label implantation was associated with a higher aneurysm-related mortality. A total of 12 studies were included in the meta-analysis and the technical success was 97.8%. In 68.5%, the aneurysm sack or false lumen remained perfused, 97% of all the covered side branches remained patent. After a follow-up period of 1 year, five patients in the meta-analysis presented with a ruptured aneurysm. Conclusions The overall quality of evidence is poor because long-term results are lacking, patients are frequently lost during follow-up and all the studies were non-comparative. Our retrospective study suggests a relatively low incidence of perioperative complications, although there was a high incidence of persistent perfusion in the aneurysm sac (102 of 149 patients). The risk of rupture at the 1-year follow-up was 2.1%.
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Affiliation(s)
- Denise M.D. Özdemir-van Brunschot
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, 40472 Düsseldorf, Germany
- Faculty of Health, Witten/Herdecke University, 58544 Witten, Germany
| | - Romina Zerellari
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, 40472 Düsseldorf, Germany
| | - Maria Tevs
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, 40472 Düsseldorf, Germany
| | - Sergei Wassiljew
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group Düsseldorf, 40472 Düsseldorf, Germany
| | - David Holzhey
- Faculty of Health, Witten/Herdecke University, 58544 Witten, Germany
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Rakemaa L, Aho PS, Tulamo R, Laine MT, Laukontaus SJ, Hakovirta H, Venermo M. Ultrasound Surveillance is Feasible After Endovascular Aneurysm Repair. Ann Vasc Surg 2024; 100:223-232. [PMID: 37926137 DOI: 10.1016/j.avsg.2023.09.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/05/2023] [Accepted: 09/09/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Surveillance after endovascular aneurysm repair (EVAR) is traditionally done with computed tomography angiography (CTA) scans that exposes patient to radiation, nephrotoxic contrast media, and potentially increased risk for cancer. Ultrasound (US) is less labor intensive and expensive and might thus provide a good alternative for CTA surveillance. The aim of this study was to evaluate in real-life patient cohorts whether US is able to detect post-EVAR aneurysm-related complications similarly to CTA. METHODS This retrospective study compared the outcome of consecutive patients who underwent EVAR for intact abdominal aortic aneurysm and were surveilled solely by CTA (CTA-only cohort, n = 168) in 2000-2010 or by combined CTA and US (CTA/US cohort, n = 300) in 2011-2016, as a standard surveillance protocol in the department of vascular surgery, Helsinki University Hospital. The CTA-only patients were imaged at 1, 3, and 12 months and annually thereafter. The CTA/US patients were imaged with CTA at 3 and 12 months, US at 6 months and annually thereafter. If there were suspicion of >5 mm aneurysm growth, CTA scan was performed. The patients were reviewed for imaging data, reinterventions, aneurysm ruptures, and death until December 2018. The 2 groups were compared for secondary rupture, aneurysm-related and cancer-related death, reintervention related to abdominal aortic aneurysm, and maximum aneurysm diameter increase ≥5 mm. The mean follow-up in the CTA-only cohort was 67 months and in CTA/US cohort 43 months. RESULTS The 2 cohorts were alike for basic characteristics and for the mean aneurysm diameter. The total number of CT scans for detecting aneurysm was 84.1/100 patient years in the CTA-only cohort compared to 74.5/100 patient years for US/CTA cohort. Forty percent of patients under combined CTA/US surveillance received 1 or more additional CTA scans. The 2 cohorts did not differ for 1-year, 5-year and 8-year freedom from aneurysm related death, secondary sac rupture, nor the incidence of rupture preventing interventions. CONCLUSIONS Based on the follow-up data of this real-life cohort of 468 patients, combined surveillance with US and additional CTA either per protocol or due to suspicion of aneurysm-related complications had comparable outcome with sole CTA-surveillance. Thus, US can be considered a reasonable alternative for the CTA. However, our study showed also that the need of additional CTAs due to suspicion of endoleak or aneurysm nonrelated reasons is substantial.
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Affiliation(s)
- Lotta Rakemaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Pekka S Aho
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Riikka Tulamo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Matti T Laine
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Sani J Laukontaus
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Harri Hakovirta
- Department of Vascular Surgery, University of Turku and Turku University Hospital, Turku, Varsinais-Suomi, Finland; Department of Surgery, Satasairaala Hospital, Pori, Satakunta, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland.
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Zettervall SL, Schanzer A. ESVS 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms: A North American Perspective. Eur J Vasc Endovasc Surg 2024; 67:187-189. [PMID: 37918617 DOI: 10.1016/j.ejvs.2023.10.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/30/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Sara L Zettervall
- Division of Vascular Surgery, University of Washington, Seattle, WA, USA.
| | - Andres Schanzer
- Division of Vascular Surgery, UMass Chan Medical School, Worcester, MA, USA. https://twitter.com/AndresSchanzer
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Özdemir-van Brunschot D, Zerellari R, Tevs M, Holzhey D, Botsios S. Factors Influencing Compliance to Follow-Up After Endovascular Aneurysm Repair. Vasc Endovascular Surg 2023; 57:878-883. [PMID: 37306151 DOI: 10.1177/15385744231183790] [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] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Regular follow-up after endovascular repair of aortic aneurysm is necessary to detect endoleak and/or migration of the stentgraft. However, absence or incomplete compliance to follow-up is common in this patient population. In this study we will analyse the frequency of non-compliance to post-EVAR follow-up and explore the underlying reasons. METHODS All patients undergoing EVAR for infrarenal aortic aneurysm between 1st January 2011 and 31st December 2020 were included in this retrospective study. Absence of compliance to FU was defined as not showing up at the out-patient clinic; incomplete FU was defined as a surveillance gap of >18 months. RESULTS AND CONCLUSION Non-compliance to follow-up was 35.9% (175 patients). In the multivariate analysis the patients who came with a ruptured aneurysm and patients who needed secondary therapy in the first 30 days more often did not comply with the FU protocol (P = .03 and P < .01). Other studies have confirmed the low attendance to follow-up after EVAR.
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Affiliation(s)
- Denise Özdemir-van Brunschot
- Faculty of Health, Witten/Herdecke University, Witten, Germany
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospitaland Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
| | - Romina Zerellari
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospitaland Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
| | - Maria Tevs
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospitaland Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
| | - David Holzhey
- Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Spiridon Botsios
- Faculty of Health, Witten/Herdecke University, Witten, Germany
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospitaland Catholic Hospital Group Düsseldorf, Düsseldorf, Germany
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12
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Väärämäki S, Uurto I, Suominen V. Possible implications of device-specific variability in post-endovascular aneurysm repair sac regression and endoleaks for surveillance categorization. J Vasc Surg 2023; 78:1204-1211. [PMID: 37451372 DOI: 10.1016/j.jvs.2023.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/07/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Significant sac regression during early surveillance has been shown to best predict reintervention-free long-term surveillance after endovascular aneurysm repair (EVAR). Furthermore, a persistent endoleak has been related to a worse outcome. Individualized surveillance algorithms based on these findings have been suggested. There are no studies comparing the performance of different stent grafts regarding sac regression, the presence of type II endoleaks, and their possible implications for individualized surveillance. The objective of this study was to evaluate device-specific differences and how these may affect patient categorization for surveillance. METHODS Patients were treated electively with standard EVAR between 2005 and 2015 using three different devices (Zenith by Cook, Excluder by Gore, and Endurant by Medtronic). The data were reviewed retrospectively until 2020. Patients' computed tomography angiographies (CTAs) at 30 days and at 2 years were analyzed for freedom from endoleaks and for sac regression of ≥5 mm. Reinterventions during long-term surveillance were counted. Patients were categorized according to the presence of any endoleak and sac regression at 30 days and 2 years, and the probability of reintervention-free long-term surveillance was evaluated based on these findings. RESULTS A total of 435 patients were treated for an abdominal aortic aneurysm with EVAR during the study period. At 30 days, 80.0% (n = 339) of the patients were free from endoleaks, and at 2 years, 78.9% (n = 273) were free from endoleaks. There was a significant difference in endoleak rate at 30 days and 2 years between the devices (P < .001 and P = .001). There was no significant difference in sac regression between the devices at 2 years (P = .096). The categorization at 30 days based on endoleak status had a sensitivity of 44.9%, specificity of 87.4%, and negative predictive value of 84.1% for finding a reintervention-requiring complication during long-term follow-up. The corresponding figures at 2 years were 63.3%, 91.4%, and 89.4%, respectively. The combination of freedom from endoleaks and sac regression of ≥5 mm in the 2-year CTA best predicted an uneventful long-term surveillance. Patients who met this criterion had a 95.6% probability (negative predictive value) of having a reintervention-free long-term surveillance. CONCLUSIONS There are significant differences in the prevalence of endoleaks between devices at 30 days and 2 years, but there is no difference in sac regression. Patients with sac regression of ≥5 mm and no endoleaks in the 2-year CTA can be safely categorized for infrequent surveillance regardless of the stent graft model that has initially been used.
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Affiliation(s)
- Suvi Väärämäki
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland.
| | - Ilkka Uurto
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Velipekka Suominen
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland
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13
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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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14
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Li C, de Guerre LEVM, Dansey K, Lu J, Patel PB, Yao M, Malas MB, Jones DW, Schermerhorn ML. The impact of completion and follow-up endoleaks on survival, reintervention, and rupture. J Vasc Surg 2023; 77:1676-1684. [PMID: 36841312 PMCID: PMC10213115 DOI: 10.1016/j.jvs.2023.02.009] [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: 03/21/2021] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/27/2023]
Abstract
OBJECTIVE Endoleaks may be seen at case completion of endovascular abdominal aortic aneurysm repair (EVAR), and the presence of an endoleak may impact outcomes. However, the clinical implications of various endoleaks seen during follow-up is not well-described. Therefore, we studied the impact of endoleaks at completion and at follow-up on mid-term outcomes. METHODS We reviewed patients who underwent EVAR from 2003 to 2016 within the Vascular Quality Initiative-Medicare database and identified patients with endoleak at procedure completion and during follow-up, excluding those presenting with rupture. We stratified cohorts by presence of completion and follow-up endoleak subtypes. The primary outcome was 5-year survival, and secondary outcomes included 5-year freedom from reintervention and freedom from rupture. We used Kaplan-Meier estimates and log-rank tests to analyze differences in time-to-event endpoints. RESULTS Of 21,745 patients with completion endoleak data, 5085 (23%) had an endoleak. Compared with those without endoleak, those with type I endoleaks had lower 5-year survival (69% vs 75%; P < .001), type II endoleaks had higher survival (79%; P < .001), and types III, IV, and indeterminate were not statistically different (73%, 73%, and 75%, respectively). Freedom from reintervention for types I and III endoleaks were significantly lower than no endoleak cohort (I: 76%; P < .001; III: 72%; P < .001 vs 83%), but freedom from rupture was higher for those with type II and III endoleak (95% and 97% vs 94%; P < .001). Of 14,479 patients with detailed follow-up endoleak data, 2290 (16%) had an endoleak. Compared with those without endoleak, types I and III had significantly lower 5-year survival (I: 80%; P = .002; III: 66%; P < .001 vs 84%), but there were no differences for types II (82%) and indeterminate (77%). Those with any type of follow-up endoleak had lower 5-year freedom from reintervention (I: 70%; P < .001; II: 76%; P = .006; III: 36%; P < .001; indeterminate: 60%; P = .007 vs 84%), and lower freedom from rupture (I: 92%; P < .001; II: 91%; P = .16; III: 88%; P = .01; indeterminate: 90%; P = .11 vs 94%). CONCLUSIONS Compared with patients with no endoleak, those with type I completion endoleaks have lower 5-year survival and freedom from reintervention. Patients with types I and III follow-up endoleaks also have lower survival, and any endoleak at follow-up is associated with lower freedom from reintervention and freedom from rupture. These data highlight the importance of careful patient selection and close postoperative follow-up after EVAR, as the presence of endoleaks, specifically type I and III, over time portends worse outcomes.
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Affiliation(s)
- Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Livia E V M de Guerre
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Kirsten Dansey
- Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Jinny Lu
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Mengdi Yao
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego Health System, San Diego CA, USA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, University of Massachusetts, Worchester, MA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston MA, USA.
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15
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Elsayed N, Patel R, Naazie I, Hicks CW, Siracuse JJ, Malas MB. Loss of follow-up after carotid revascularization is associated with worse long-term stroke and death. J Vasc Surg 2023; 77:548-554.e1. [PMID: 36183990 PMCID: PMC9868074 DOI: 10.1016/j.jvs.2022.09.023] [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: 07/14/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Society for Vascular Surgery practice guidelines recommend surveillance with duplex ultrasound scanning at baseline (within 3 months from discharge), every 6 months for 2 years, and annually afterward following carotid endarterectomy or carotid artery stenting. There is a growing concern regarding the significance of postoperative follow-up after several vascular procedures. We sought to determine whether 1-year loss to follow-up (LTF) after carotid revascularization was associated with worse outcomes in the Vascular Quality Initiative (VQI) linked to Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database. METHODS All patients who underwent carotid revascularization in the VQI VISION database between 2003 and 2016 were included. LTF was defined as failure to complete 1-year follow-up in the VQI long-term follow-up dataset. Data about stroke and mortality were captured in the VISION dataset using a list of Current Procedural Terminology, International Classification of Diseases (Ninth Revision), and International Classification of Diseases (Tenth Revision) codes linked to index procedures in VQI. Kaplan-Meier life-table methods and Cox proportional hazard modeling were used to compare 5- and 10-year outcomes between patients with no LTF and those who were LTF. RESULTS A total of 58,840 patients were available for analysis. The 1-year LTF rate was 43.8%. Patients who were LTF were older and more frequently symptomatic, with chronic obstructive pulmonary diseases, chronic kidney diseases, and congestive heart failure. Also, patients who underwent carotid artery stenting were more likely to be LTF compared with carotid endarterectomy patients (54.5% vs 42.3%; P < .001). The incidence of postoperative (30 days) stroke was higher in the LTF group (2.9% vs 1.7%; P < .001). Cox regression analysis revealed that LTF was associated with an increased risk of long-term stroke at 5 years (hazard ratio [HR]: 1.4, 95% confidence interval [CI]: 1.2-1.6; P < .001) and 10 years (HR: 1.3, 95% CI: 1.2-1.5; P < .001). It was also associated with significantly higher mortality at 5 years (HR: 2.5, 95% CI: 2.3-2.8; P < .001) and 10 years (HR: 2.2, 95% CI: 1.9-2.5; P < .001). Stroke or death was significantly worse in the LTF group at 5 years (HR: 2.3, 95% CI: 2.1-2.5; P < .001) and up to 10 years (HR: 2.02, 95% CI: 1.8-2.3; P < .001). CONCLUSIONS One-year follow-up after carotid revascularization procedures was found to be associated with better stroke- and mortality-free survival. Surgeons should emphasize the importance of follow-up to all patients who undergo carotid revascularization, especially those with multiple comorbidities and postoperative neurological complications.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Rohini Patel
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA.
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16
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Salvi C, Besancenot A, Sebahi S, Rinckenbach S, Salomon Du Mont L. Influence of Home Location on Follow-Up Compliance after Endovascular Treatment for Abdominal Aortic Aneurysm. Ann Vasc Surg 2023:S0890-5096(23)00001-8. [PMID: 36641089 DOI: 10.1016/j.avsg.2022.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND The complications of EVAR require compliance to a close follow-up imaging. The purpose of this study was to determine whether home location predicted a poor compliance to imaging follow-up after EVAR. METHODS We analyzed a cohort of patients treated by EVAR at the Besançon University Hospital between 2007 and 2017. Follow-up imaging followed the French High Health Authority recommendations. Noncompliance with follow-up compliance was defined as a first missed postoperative appointment or 2 consecutive missed appointments after the first control CT-scan, and 2 groups of patients were identified: compliant (group C) or noncompliant (group NC). Univariate and multivariate analyzes were used to investigate compliance risk factors. Collected complications included endoleaks, limb thrombosis, infections, and secondary ruptures. RESULTS Two hundred and fifty-eight of the 359 patients treated during this period were enrolled, including 233 men (90.3%), with a mean age of 74.0 years (±9.0) and a mean follow-up of 5.0 years (±2.6). The compliance rate was 38.8% and the 1-year mortality rate was 12.0%. Using univariate and multivariate analysis, a place of residence greater located over 60 min away from the hospital had a poor effect on compliance (Odd ratio [OR] = 0.58; P = 0.047). Peripheral arterial occlusive disease (PAD) and an abdominal aortic aneurysm (AAA) diameter greater than 5.0 cm were protective factors (OR = 2.23; P = 0.006 and OR = 1.85, respectively; P = 0.002). Four-year all-cause mortality was 21.0% in group C and 17.0% in the NC group (P = 0.54). Complications were more significant in group C (59.0%) compared to group NC (39.0%) (P = 0.001). Two ruptures occurred in the NC group (1.3%), versus none in the C group (P = 0.25). CONCLUSIONS In this study, a long distance from the home to the hospital was a detrimental factor for follow up compliance. However, a good compliance did not decrease the 4-year mortality rate. The high rate of noncompliance found should lead to a more personalized follow-up strategy taking into account the anatomical elements but also the comorbidities and some social aspects.
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Affiliation(s)
- Charlène Salvi
- University Hospital, Vascular Surgery Unit, Besançon, France.
| | | | - Soumia Sebahi
- University Hospital, Vascular Surgery Unit, Besançon, France
| | - Simon Rinckenbach
- University Hospital, Vascular Surgery Unit, Besançon, France; University of Franche Comté, Besançon, France
| | - Lucie Salomon Du Mont
- University Hospital, Vascular Surgery Unit, Besançon, France; University of Franche Comté, Besançon, France
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17
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Gray DE, Samaan C, Oikonomou K, Gruber-Rouh T, Schmitz-Rixen T, Derwich W. Age and Oversizing Influence Iliac Dilatation after EVAR. J Clin Med 2022; 11:jcm11237113. [PMID: 36498686 PMCID: PMC9738790 DOI: 10.3390/jcm11237113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/16/2022] [Accepted: 11/27/2022] [Indexed: 12/02/2022] Open
Abstract
In the past two decades, endovascular aortic repair (EVAR) of abdominal aortic aneurysm (AAA) has become the first line treatment for infrarenal AAA repair in many countries. While short-term results are good, concerns have been raised about long-term durability. Changes in aortoiliac anatomy, especially at the landing zones, could play a role in EVAR failure over time. The current study aimed to determine certain morphological changes in the distal iliac landing zone after EVAR implantation, as well aspossible risk factors associated with iliac sealing failure. In a retrospective analysis of a tertiary single-centre registry, including patients treated with EVAR between January 2008 and July 2018, clinical follow-up data were assessed, and computer tomography (CT) imaging was evaluated regarding morphological changes in the iliac anatomy during follow-up. For clinical analysis all patients with a minimum follow-up of one year were included; for morphological analysis of iliac anatomy all patients with available CT follow-up of a minimum of one year and a minimum of two CT scans were included. Overall, 127 out of 241 treated patients (92.1% male) were included in the clinical follow-up. Complete CT imaging of 99 iliac arteries in 55 patients was available for morphological analysis. Median postoperative follow-up (FU) for these patients was 33 months (IQR 31; min−max: 12−124). Incidence of type 1b endoleak was 3% but iliac limb detachment from the vessel wall was seen in 18.2% of the target vessels. There was a significant difference in oversizing in iliac limbs with detachment (median 13.9%, IQR 23.1) vs. without detachment (median 23.1%, IQR 19.1) (p = 0.034). Iliac arteries at the landing zone showed a significant diameter increase independent of an endoleak presence (overall cohort median diameter increase at one year 23.1 mm; at two years 0 mm; at three years 4.9 mm). Iliac arteries with detachment (median 14.4%; IQR 23.9) showed a significantly higher diameter increase at the landing zone after four years compared to arteries without detachment (median 5.3%; IQR 9) (p = 0.042). Oversizing correlated positively with an iliac diameter increase at the landing zone over time (3 m: p= 0.001; one year: p < 0.001; two years: p < 0.001; three years: p = 0.006). Older patients showed a significantly lower diameter increase at the distal landing zone over time than younger patients in the first two years after EVAR (p < 0.001/r = −0.606 after two years). In the current study, iliac limb oversizing was associated with increased dilatation of the distal landing zone during a three-year follow-up, while iliac limb detachment was observed less often. An older age was inversely associated to the iliac diameter increase. Future studies should clarify the association between stent graft oversizing, age, and changes in the iliac anatomy in order to identify parameters that affect EVAR durability.
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Affiliation(s)
- Daphne Elisabeth Gray
- Department of Vascular and Endovascular Surgery, Goethe University Hospital Frankfurt, 60590 Frankfurt, Germany
- Correspondence:
| | - Carla Samaan
- Department of Vascular and Endovascular Surgery, Goethe University Hospital Frankfurt, 60590 Frankfurt, Germany
| | - Kyriakos Oikonomou
- Department of Vascular and Endovascular Surgery, Goethe University Hospital Frankfurt, 60590 Frankfurt, Germany
| | - Tatjana Gruber-Rouh
- Department of Radiology, Goethe University Hospital Frankfurt, 60590 Frankfurt, Germany
| | - Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery, Goethe University Hospital Frankfurt, 60590 Frankfurt, Germany
| | - Wojciech Derwich
- Department of Vascular and Endovascular Surgery, Goethe University Hospital Frankfurt, 60590 Frankfurt, Germany
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18
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Sultan S, Acharya Y, Hezima M, Chua Vi Long K, Soliman O, Parodi J, Hynes N. Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned. Front Surg 2022; 9:963172. [PMID: 36570807 PMCID: PMC9774497 DOI: 10.3389/fsurg.2022.963172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/26/2022] [Indexed: 12/13/2022] Open
Abstract
Objectives We aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation. Methods We performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV). Results Forty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure. Conclusions Our re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma.
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Affiliation(s)
- Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland,Galway: Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Hospital, Galway, Ireland,CORRIB-CURAM-Vascular Group, National University of Ireland, Galway, Ireland,Correspondence: Sherif Sultan ,
| | - Yogesh Acharya
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland,Galway: Department of Vascular Surgery and Endovascular Surgery, Galway Clinic, Doughiska, Royal College of Surgeons in Ireland and National University of Ireland, Galway affiliated Hospital, Galway, Ireland
| | - Mohieldin Hezima
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Keegan Chua Vi Long
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Osama Soliman
- CORRIB-CURAM-Vascular Group, National University of Ireland, Galway, Ireland
| | - Juan Parodi
- Department of Vascular Surgery and Biomedical Engineering Department, Alma mater, University of Buenos Aires, and Trinidad Hospital, Buenos Aires, Argentina,Winston-Salem and St. Louis: Wake Forest University, Winston-Salem, North Carolina and Washington University in St. Louis, St. Louis, Missouri, United States of America
| | - Niamh Hynes
- CORRIB-CURAM-Vascular Group, National University of Ireland, Galway, Ireland
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Eldrup-Jorgensen J, Goodney PP, Weaver FA. Better care through better data. J Vasc Surg 2022; 76:42-45. [PMID: 35738794 DOI: 10.1016/j.jvs.2022.03.873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 03/27/2022] [Indexed: 11/24/2022]
Affiliation(s)
| | - Phil P Goodney
- Division of Vascular Surgery, USC Cardiac and Vascular Institute, University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Dartmouth Hitchcock Medical Center, Lebanon, NH; White River Junction Veterans Affairs Medical Center, Hartford, VT
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20
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Hu YD, Jones JM, Sensenig CJ, Eid MA, Mehta K, Goldwag JL, Barnes JA, Moore KO, Halpern V, Henke P, Tang G, Mureebe L, Alabi O, Tzeng E, Stone D, Brooke B, Nelson P, Spangler E, Barry M, Kang R, Scali S, O'Connell J, Goodney P. The Impact of Work Status and Age in Choosing Type of Abdominal Aortic Aneurysm Repair. J Surg Res 2022; 275:149-154. [DOI: 10.1016/j.jss.2021.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 11/24/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022]
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21
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Väärämäki S, Uurto I, Hahl T, Suominen V. Reliability and safety of individualized follow-up based on the 30-day CTA after endovascular aneurysm repair (EVAR). Ann Vasc Surg 2022; 86:305-312. [DOI: 10.1016/j.avsg.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/02/2022] [Accepted: 04/06/2022] [Indexed: 11/16/2022]
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22
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Establishing and maintaining a remote vascular surgery aortic program: A single-center 5-year experience at the Veterans Affairs. J Vasc Surg 2022; 75:1063-1072. [PMID: 34562570 PMCID: PMC8863634 DOI: 10.1016/j.jvs.2021.08.083] [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: 03/22/2021] [Accepted: 08/24/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We sought to detail the process of establishing a surgical aortic telehealth program and report the outcomes of a 5-year experience. METHODS A telehealth program was established between two regional Veterans Affairs hospitals, one of which was without a comprehensive aortic surgical program, until such a program was established at the referring institution. A retrospective review was performed of all patients who underwent aortic surgery from 2014 to 2019. The operative data, demographics, perioperative complications, and follow-up data were reviewed. RESULTS From 2014 to 2019, 109 patients underwent aortic surgery for occlusive and aneurysmal disease. Preoperative evaluation and postoperative follow-up were done remotely via telehealth. The median age of the patients was 68 years, 107 were men (98.2%), 28 (25.7%) underwent open aortic repair, and 81 (74.3%) underwent endovascular repair. Of the 109 patients, 101 (92.7%) had a median follow-up of 24.3 months, 5 (4.6%) were lost to follow-up or were noncompliant, 2 (1.8%) were noncompliant with their follow-up imaging studies but responded to telephone interviews, and 1 (0.9%) moved to another state. At the 30-day follow-up, eight patients (7.3%) required readmission. Four complications were managed locally, and four patients (3.6%) required transfer back to the operative hospital for additional care. CONCLUSIONS Telehealth is a great tool to provide perioperative care and long-term follow-up for patients with aortic pathologies in remote locations. Most postoperative care and complications can be managed remotely, and patient compliance for long-term follow-up is high.
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Phillips AR, Andraska EA, Reitz KM, Gabriel L, Salem KM, Sridharan ND, Tzeng E, Liang NL. Any Postoperative Surveillance Improves Survival after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2022; 80:50-59. [PMID: 34775012 PMCID: PMC8897248 DOI: 10.1016/j.avsg.2021.09.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has advanced the care of patients with ruptured abdominal aortic aneurysms (rAAA) with improved early postoperative morbidity and mortality. However, this comes at the cost of a rigorous postoperative surveillance schedule to monitor for further aneurysmal degeneration. Adherence to surveillance recommendations is known to be poor in the elective setting, but has yet to be studied in the ruptured population. The aim of this study is to investigate predictors of incomplete surveillance after EVAR for rAAA (rEVAR) and examine how adherence impacts outcomes. METHODS This was a retrospective case control study of patients undergoing rEVAR at a multiple hospital single healthcare center (2003-2020). Patients were excluded if they underwent open conversion during their index hospitalization or died within 60 days of surgery. Follow-up was broadly categorized as complete surveillance (60-day postoperative visit and annually thereafter) or incomplete surveillance, comprising both patients with less than recommended surveillance (minimal surveillance) and completely lost to follow-up (LTF). Any follow-up was defined as patients with complete or minimal surveillance. We investigated predictors of complete versus incomplete surveillance by multivariate logistic regression. Secondary outcomes included overall survival and cumulative incidence of reintervention controlling for the competing risk of mortality, generating hazard ratios (HR) and subdistribution hazard ratios (SHR). RESULTS One-hundred and sixty patients (mean age 74 ± 10.1 years, 81.2% male) out of 673 total rAAA met study inclusion criteria. Complete surveillance was seen in 41.3% of our cohort, with the remainder with minimal surveillance (29.4%) or LTF (29.4%). Incomplete surveillance was associated with male sex (odds ratio [OR] 2.56; 95% CI 1.02-6.43), lack of a primary care provider (PCP; OR 0.20; 95% CI 0.04-0.99), and longer driving distance from home to treating hospital (OR 2.37; 95% CI 1.08-5.20). Survival was not different between complete and incomplete surveillance groups, however any follow-up conferred improved survival over LTF (HR 0.57; 95% CI 0.331-0.997; P = 0.049). Reintervention was associated with incomplete surveillance (SHR 0.29; 95% CI 0.11-0.75), and discharge to a facility (SHR 0.25; 95% CI 0.067-0.94). CONCLUSIONS Incomplete surveillance was observed in over 50% of patients who underwent rEVAR and was associated with male sex, lack of PCP, and longer driving distance. Any follow-up conferred a survival benefit, yet incomplete surveillance was associated with a lower risk of reintervention. Targeted strategies to prevent LTF, and less stringent, personalized follow-up plans that may confer similar survival benefit with better patient adherence should be investigated.
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Affiliation(s)
- Amanda R. Phillips
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Elizabeth A. Andraska
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Katherine M. Reitz
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Lucine Gabriel
- University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Karim M. Salem
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Natalie D. Sridharan
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Edith Tzeng
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Nathan L. Liang
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
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Editor's Choice - Post-operative Surveillance and Long Term Outcome after Endovascular Aortic Aneurysm Repair in Patients with an Initial Post-operative Computed Tomography Angiogram Without Abnormalities: the Multicentre Retrospective ODYSSEUS Study. Eur J Vasc Endovasc Surg 2022; 63:390-399. [PMID: 35181224 DOI: 10.1016/j.ejvs.2021.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 11/01/2021] [Accepted: 11/14/2021] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Lifelong imaging surveillance is recommended following endovascular aneurysm repair (EVAR). This study aimed to examine the association between adherence to post-operative surveillance and survival and secondary interventions in patients with an initial post-operative computed tomography angiogram (CTA) without abnormalities. METHODS All consecutive patients undergoing EVAR for intact abdominal aortic aneurysm (AAA) in 16 hospitals between 2007 and 2012 were identified retrospectively, with follow up until December 2018. Patients were included if the initial post-operative CTA showed no types I - III endoleak, kinking, infection, or limb occlusion. Discontinued follow up was defined as at least one 16 month period in which no imaging surveillance was performed. Primary outcomes were aneurysm related mortality and secondary interventions, and secondary outcome all cause mortality. Kaplan-Meier analysis was used to estimate survival, and Cox regression analyses to identify the association between independent variables and outcome. Sensitivity analyses were performed by varying the definition of continued yearly follow up. The study protocol was published (bmjopen-2019-033584). RESULTS 1 596 patients (552 continued, 1 044 discontinued follow up) were included with a median (interquartile range) follow up of 89.1 months (52.6). Cumulative aneurysm related, overall, and intervention free survival was 99.4/94.8/96.1%, 98.5/72.9/85.9%, and 96.3/45.4/71.1% at 1, 5, and 10 years, respectively. American Society of Anesthesiologists (ASA) classification (ASA IV hazard ratio [HR] 3.810, 95% confidence interval [CI] 1.296 - 11.198), increase in AAA diameter (HR 3.299, 95% CI 1.408 - 7.729), and continued follow up (HR 3.611, 95% CI 1.780 - 7.323) were independently associated with aneurysm related mortality. The same variables and age (HR 1.063 per year, 95% CI 1.052 - 1.074) were significantly associated with all cause mortality. No difference in secondary interventions was observed between patients with continued vs. discontinued follow up (89/552; 16% vs. 136/1044; 13%; p = .091). Sensitivity analyses showed worse aneurysm related and overall survival in patients with continued follow up. CONCLUSION Discontinued follow up is not associated with poor outcomes. Future prospective studies are indicated to determine in which patients imaging follow up can be safely reduced.
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Ghaly P, Wang K, Vicaretti M. Management of a giant non-ruptured aortic aneurysm: the importance of lifelong surveillance following endovascular aneurysm repair. ANZ J Surg 2022; 92:3067-3069. [PMID: 35132752 DOI: 10.1111/ans.17535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 01/03/2022] [Accepted: 01/21/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Paul Ghaly
- Vascular Surgery Department, Westmead Hospital, WSLHD, Westmead, New South Wales, Australia
| | - Kejia Wang
- Vascular Surgery Department, Westmead Hospital, WSLHD, Westmead, New South Wales, Australia
| | - Mauro Vicaretti
- Vascular Surgery Department, Westmead Hospital, WSLHD, Westmead, New South Wales, Australia
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Scali ST, Suckow BD, Goodney PP, de Guerre LE, Schermerhorn ML, Huber TS, Upchurch GR, Neal D, Columbo JA, Kang J, Powell RJ, Stone DH. A Significant Proportion of Current EVAR Practice Fails to Meet SVS Clinical Practice Guideline Recommended AAA Diameter Treatment Thresholds in the Vascular Quality Initiative. J Vasc Surg 2022; 75:1234-1241.e1. [DOI: 10.1016/j.jvs.2021.08.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/18/2021] [Indexed: 11/28/2022]
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Geraedts ACM, Mulay S, Terwee CB, Vahl AC, Verhagen HJM, Ünlü Ç, Ubbink DT, Koelemay MJW, Balm R. Patient-Reported Outcomes of Yearly Imaging Surveillance in Patients Following Endovascular Aortic Aneurysm Repair. Ann Vasc Surg 2021; 82:221-227. [PMID: 34902477 DOI: 10.1016/j.avsg.2021.11.003] [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: 09/15/2021] [Revised: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 11/16/2022]
Abstract
Little is known about the impact of standardized imaging surveillance on anxiety levels and well-being of patients after endovascular aortic aneurysm repair (EVAR). We hypothesize that patient anxiety levels increase just before receiving the imaging results compared with standard anxiety levels. METHODS Prospective cohort study from November 2018 to May 2020 including post-EVAR patients visiting the outpatient clinics of 4 Dutch hospitals for imaging follow-up. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used. Patients completed the PROMIS Anxiety v1.0 Short Form (SF) 4a, PROMIS-Global Health Scale v1.2, and PROMIS-Physical Function v1.2 SF8b at 2 time points: prior to the result of the imaging study (T1: pre-visit) and 6-8 months later (T2: reference measurement). Mean T-scores at T1 were compared to T2, and T2 to the general 65+ Dutch population. RESULTS Altogether 342 invited patients were eligible, 214 completed the first questionnaire, 189 returned 2 completed questionnaires and 128 patients did not participate. Out of 214 respondents, 195 were male (91.1%) and the mean (standard deviation) age was 75.2 (7.0) years. There were no significant differences between T1 and T2 in anxiety levels (0.48; 95% confidence interval[CI] -0.42-1.38), global mental health (0.27; 95% CI -0.79-0.84), global physical health (0.10; 95% CI -0.38-1.18) and physical function (0.53; 95% CI -0.26-1.32). Compared with the 65+ Dutch population, at T2 patients experienced more anxiety (3.8; 95% CI 2.96-5.54), had worse global physical health (-3.2; 95% CI -4.38 - -2.02) and physical function (-2.4; 95% CI -4.00 - -0.80). Global mental health was similar (-1.0; 95% CI -2.21 - 0.21). CONCLUSIONS Post-EVAR patients do not experience more anxiety just before receiving surveillance imaging results than outside this period, but do suffer from more anxiety and worse physical outcomes than the 65+ Dutch population.
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Affiliation(s)
- A C M Geraedts
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands.
| | - S Mulay
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - C B Terwee
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A C Vahl
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - H J M Verhagen
- Department of Vascular Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Ç Ünlü
- Department of Vascular Surgery, Noordwest Hospital, Alkmaar, The Netherlands
| | - D T Ubbink
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - M J W Koelemay
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - R Balm
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands.
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Affiliation(s)
- Andres Schanzer
- From the Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester (A.S.); and the Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston (G.S.O.)
| | - Gustavo S Oderich
- From the Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester (A.S.); and the Division of Vascular and Endovascular Surgery, University of Texas Health Science Center, Houston (G.S.O.)
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Jones JM, Hu YD, Eid MA, Sensenig CJ, Mehta KS, Goldwag JL, Barnes JA, Kang R, Barry MJ, Spangler EL, Nelson PR, Mureebe L, Tang G, Tzeng E, Alabi O, Halpern VJ, Stone DH, Brooke BS, Moore K, Henke P, Scali S, O'Connell J, Goodney PP. Short-Term Concerns Primarily Determine Patient Preference for Abdominal Aortic Aneurysm Repair. J Surg Res 2021; 269:119-128. [PMID: 34551368 DOI: 10.1016/j.jss.2021.07.019] [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: 03/02/2021] [Revised: 06/26/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA) repair may be performed through open or endovascular approaches, but the factors influencing a patient's repair-type preference are not well characterized. Here we performed a qualitative analysis to better understand factors influencing patient preference within the Preference for Open Versus Endovascular Repair of AAA Trial. METHODS Open-ended responses regarding primary (n = 21) and secondary (n = 47) factors influencing patient preference underwent qualitative analysis using the constant comparative method with iterative reviews. Codes were used to generate themes and themes grouped into categories, with each step conducted via consensus agreement between three researchers. Relative prevalence of themes were compared to ascertain trends in patient preference. RESULTS Patient responses regarding both primary and secondary factors fell into four categories: Short-term concerns, long-term concerns, advice & experience, and other. Patients most frequently described short-term concerns (23) as their primary influence, with themes including post-op complications, hospitalization & recovery, and intraoperative concerns. Long-term concerns were more prevalent (20) as secondary factors, which included themes such as survival, and chronic management. The average age of patients voicing only long-term concerns as a primary factor was 11 years younger than those listing only short-term concerns. CONCLUSION Short-term concerns relating to the procedure and recovery are more often the primary factor influencing patient preference, while long term concerns play a more secondary role. Long-term concerns are more often a primary factor in younger patients. Vascular surgeons should consider this information in shared decision making to reach an optimal outcome.
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Affiliation(s)
- J M Jones
- The Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Y D Hu
- The Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - M A Eid
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | | | - K S Mehta
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - J L Goldwag
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - J A Barnes
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - R Kang
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - M J Barry
- Massachusetts General Hospital Center for Shared Decision Making, Boston, Massachusetts
| | | | - P R Nelson
- Muskogee VAMC, Muskogee, Okla; Tampa VAMC, Tampa Bay, Florida
| | | | - G Tang
- Seattle VAMC, Seattle, Washington
| | - E Tzeng
- Pittsburgh VAMC, Pittsburgh, Pennsylvania
| | - O Alabi
- Atlanta VAMC, Atlanta, Georgia
| | | | - D H Stone
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | - K Moore
- The Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - P Henke
- Ann Arbor VAMC, Ann Arbor, Michigan
| | - S Scali
- Gainesville VAMC, Gainesville, Florida
| | | | - P P Goodney
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont.
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Singh B, Resch T, Sonesson B, Abdulrasak M, Dias NV. Simple diameter measurements with ultrasound can be safely used to follow the majority of patients after infrarenal endovascular aneurysm repair. INT ANGIOL 2021; 40:425-434. [PMID: 34282856 DOI: 10.23736/s0392-9590.21.04706-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The optimal imaging follow-up after infrarenal EVAR is still undefined. The objective was to study the outcome of a personalized follow-up program after infrarenal EVAR based on ultrasound AAA diameter measurements for low-risk patients. METHODS All consecutive patients followed-up locally after elective and acute infrarenal EVAR between 2010 and 2015 were retrospectively reviewed. Patients underwent CTA at 1 month post-EVAR whereby the attending surgeon defined the subsequent follow-up. Patients considered at low risk were followed with ultrasound only assessing AAA diameter at 1, 2, 3 and every 5 years postoperatively (group A). Low-risk required a favourable preoperative anatomy especially regarding the aneurysm neck, satisfactory intraoperative result and uneventful 1 month CTA (type 2 endoleaks acceptable). Patients not fulfilling the criteria for group A were followed with yearly 3-phase-CTAs (group B). RESULTS 222 patients with a AAA median diameter of 58 (54-68) mm were included. 191 were allocated into group A and 31 in group B. Median follow-up time was 36 (24-59) months. Five year primary and primary assisted success was 82 ± 5 % and 93 ± 3 % for group A and 70 ± 13% and 93 ± 5% for group B, respectively (P= 0.042 and P= 0.504, respectively). 16 late aneurysm-related re-interventions were performed in 12 patients (7 in group A and 9 in group B). In group A, 5 re-interventions were rupture-preventing and 2 were symptomatic. All late re-interventions in group B were performed following findings on follow-up imaging. Five-year late re-intervention-free survival was 95 ± 2 % and 84 ± 7 % for groups A and B, respectively (P=0.046). Five-year survival was 80 ± 3 % and 63 ± 10 % for group A and B, respectively (P= 0.024). CONCLUSIONS A customized follow-up program after infrarenal EVAR based on ultrasound AAA diameter measurements in low-risk patients seems to be effective in maintaining a very high mid-term clinical success rate.
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Affiliation(s)
- Bharti Singh
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden - .,Clinical Sciences Malmö, Lund University, Malmö, Sweden -
| | - Timothy Resch
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.,Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Björn Sonesson
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.,Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Mohammed Abdulrasak
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.,Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Nuno V Dias
- Vascular Center, Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.,Clinical Sciences Malmö, Lund University, Malmö, Sweden
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Is Compliance With Guideline Recommended Follow-Up After Aortic Dissection Associated With Survival? Ann Thorac Surg 2021; 113:846-852. [PMID: 33878311 DOI: 10.1016/j.athoracsur.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/27/2021] [Accepted: 04/06/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with acute aortic dissection (AD) remain at risk for long-term complications and thus are recommended to adhere closely to American College of Cardiology and American Heart Association aorta guideline-based follow-up imaging and clinic visits. The long-term outcomes of compliance with such a model are not well understood. METHODS This was a retrospective cohort study of patients at a regional AD center who survived hospital discharge for AD and who were analyzed by compliance with initial follow-up at 3 months and long term after AD. The primary end point was death. RESULTS A total of 172 (66% type A; 33% type B) patients survived hospitalization and were followed up over 48 months (interquartile range [IQR], 21, 88 months). Of these patients, 122 (71%) attended the first follow-up appointment, and 90 (52%) attended more than two-thirds of recommended appointments. Patients who attended the first follow-up visit had improved long-term follow-up compliance (75% [IQR, 50%, 91%]) compared with patients who did not attend the first visit (18% [IQR, 0%, 57%]). Noncompliance with the scheduled long-term follow-up was associated with a 50% increase in the risk of death (hazard ratio, 1.6; 95% confidence interval, 1.2, 2.1; P < .001). Furthermore, in patients with low compliance (consistently attending less than one-third of follow-up appointments), the lifetime risk of death after AD was more than double that of patients with high compliance (consistently attending more than two-thirds of appointments) (hazard ratio, 2.2; 95% confidence interval, 1.5, 3.1; P < .001). CONCLUSIONS Nearly one-third of patients with AD do not attend the first recommended follow-up visit, and such failure was associated with later noncompliance with subsequent follow-up. Low-compliant patients have double the lifetime risk of death after AD than do high-compliant patients.
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Nana P, Spanos K, Kouvelos G, Stamoulis K, Rountas C, Arnaoutoglou E, Matsagkas M, Giannoukas AD. Ten-year single center experience in elective standard endovascular abdominal aortic aneurysm repair. INT ANGIOL 2021; 40:240-247. [PMID: 33739077 DOI: 10.23736/s0392-9590.21.04648-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has become the treatment of choice for abdominal aortic aneurysm (AAA), demonstrating excellent early outcomes. However, EVAR durability has been questioned in the long-term period. The aim of this study was to assess EVAR outcomes in terms of survival and freedom from re-intervention during a long-term period. METHODS All consecutive patients being treated, with elective standard EVAR, in a single tertiary center, were included between 2008 and 2018. Outcomes were defined as survival and freedom from re-intervention and were reported using Kaplan-Meyer lifetables. In subgroup analyses, sex, age (threshold at 65 and 80 years), neck diameter>28mm and type of fixation were also analyzed. Type of re-intervention and endoleak type I (ETIa) were also reported. RESULTS Five hundred and eight patients (94% males, mean age 72±7.3, mean AAA diameter 59±9mm) were included. The median follow-up was 3 years (range 0-10 years). The survival rate was 92.8% (SE 1.5%), 76.5% (SE 3.1%) and 41.6% (SE 6%), at 2, 5 and 10 years of follow-up, respectively. In total, 78 patients died; 8 deaths (8/75, 10%) were aneurysm related. In multivariate regression analysis, age (CI. 1.02-1.14; p=0.006) and ever tobacco use (CI. 1.02-6.12, P=0.045) were associated with the long-term mortality. Freedom from re-intervention was 96% (SE 1.1%), 93% (SE 1.8%), 85.5% (SE 5%) at 2, 5 and 9 years of follow-up. Limb occlusion was a common complication (n/n; 30% of re-intervention), particularly within the first 2 postoperative years. Six patients presented with rupture and were treated with open conversion. EVAR cases with supra-renal fixation graft presented lower rates of ETIa (CI. 76-87.27, P<0.001). CONCLUSIONS Elective standard EVAR is associated with good long-term survival showing low aneurysm-related mortality. Common risk factors such as advanced age and smoking are associated to higher mortality. The procedure presents low re-intervention rates, while limb occlusion is a complication presented within the first 2 postoperative years.
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Affiliation(s)
- Petroula Nana
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece -
| | - Konstantinos Spanos
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - George Kouvelos
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Konstantinos Stamoulis
- School of Health Sciences, Department of Anesthesiology, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Christos Rountas
- School of Health Sciences, Department of Radiology, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Elena Arnaoutoglou
- School of Health Sciences, Department of Anesthesiology, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Miltiadis Matsagkas
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Athanasios D Giannoukas
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
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de Guerre LEVM, Dansey K, Li C, Lu J, Patel PB, van Herwaarden JA, Jones DW, Goodney PP, Schermerhorn ML. Late outcomes after endovascular and open repair of large abdominal aortic aneurysms. J Vasc Surg 2021; 74:1152-1160. [PMID: 33684475 DOI: 10.1016/j.jvs.2021.02.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/09/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The risk of aortic abdominal aneurysm (AAA) rupture increases with an increasing aneurysm diameter. However, the effect of the AAA diameter on late outcomes after aneurysm repair is unclear. Therefore, we assessed the association of a large AAA diameter with late outcomes for patients undergoing open and endovascular AAA repair. METHODS We identified all patients who had undergone elective open or endovascular infrarenal aneurysm repair from 2003 to 2016 in the Vascular Quality Initiative linked to Medicare claims for long-term outcomes. A large AAA diameter was defined as a diameter >65 mm. We assessed the 5-year reintervention, rupture, mortality, and follow-up rates. We constructed propensity scores and used inverse probability-weighted Kaplan-Meier estimations and Cox proportional hazard models to identify independent associations between large AAA repair and our outcomes. RESULTS Of the 21,119 aneurysm repairs identified, 15.2% were for large AAAs. Of the 21,119 repairs, 19,017 were endovascular and 2102 were open. The large AAA cohort was less likely to have undergone endovascular aneurysm repair (EVAR; 84.9% vs 91%; P < .001), more likely to be older (median age, 76 vs 75 years; P < .001), and were less likely to be women (16.2% vs 21.7%; P < .001). After EVAR, patients with large AAAs had had lower adjusted 5-year freedom from reintervention (73.9% vs 84.6%; P < .001), freedom from rupture (88.5% vs 93.6%; P < .001), survival (58.0% vs 66.4%; P < .001), and freedom from loss to follow-up (77.7% vs 83.3%; P < .001) compared with patients with smaller AAAs. However, after open repair, the adjusted 5-year freedom from reintervention (95.8% vs 93.3%; P = .11), freedom from rupture (97.4% vs 97.8%; P = .32), survival (70.4% vs 74.0%; P = .13), and loss to follow-up (60.5% vs 62.8%; P = .86) were similar to the results for patients with smaller AAAs. For patients with large AAAs, the adjusted 5-year survival was lower after EVAR than that after open repair (55.3% vs 63.7%) but not after smaller AAA repair (67.3% vs 70.6%). CONCLUSION The 5-year adjusted reintervention, ruptures, mortality, and loss to follow-up rates for patients who had undergone large AAA EVAR were higher than those for patients who had undergone small AAA EVAR and large AAA open repair. Therefore, for patients with large AAAs who are medically fit, open repair should be strongly considered. Furthermore, these findings highlight the necessity for rigorous long-term follow-up after EVAR.
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Affiliation(s)
- Livia E V M de Guerre
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht
| | - Kirsten Dansey
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Jinny Lu
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, UMass Memorial Medical Center, Worcester, Mass
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Yu H, Ellis JS, Burke LMB, Isaacson AJ, Burke CT. Type II Endoleak Nidus Volume on Arterial and Delayed Phases of Initial CT Angiography after Endovascular Abdominal Aortic Aneurysm Repair Predicts Persistent Endoleak and Aneurysm Sac Enlargement. Radiol Cardiothorac Imaging 2021; 3:e200527. [PMID: 33778662 DOI: 10.1148/ryct.2021200527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/20/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023]
Abstract
Purpose To evaluate type II endoleak nidus volume (ENV) in the arterial phase (ENVAP) and delayed phase (ENVDP) of the first postoperative CT angiography (CTA) as a predictor of persistent endoleak and aneurysm sac enlargement at follow-up CTA in patients with endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm. Materials and Methods Ninety-three patients (mean age ± standard deviation, 72 years ± 8; range, 56-88 years) with EVAR and type II endoleak were included in a single-institution retrospective study conducted between March 1, 2005, and December 31, 2018. ENVAP, ENVDP, change of volume (ENVDP-AP), and percentage of ENVAP and ENVDP in aneurysm sac volume (ASV) (ENVAP/ASV%, ENVDP/ASV%, respectively) were measured on first postoperative CTA images. The mean follow-up was 31.6 months ± 26.6 (range, 6-163.8 months). Patients were divided into two groups (group A, spontaneous resolution of endoleak without intervention [n = 29] and group B, persistent endoleak at follow-up CTA [n = 64]) and compared by using the Mann-Whitney U, Wilcoxon signed rank, and Pearson χ2 tests. Receiver operating characteristic (ROC) analysis was used to compare accuracies of parameters at first postoperative CTA. Results The accuracy of ENVDP (area under the ROC curve [AUC], 0.78) was superior to the accuracy of ENVDP/ASV% (AUC, 0.76), ENVDP-AP (AUC, 0.74), ENVAP (AUC, 0.71), and ENVAP/ASV% (AUC, 0.69) in indicating persistent endoleak. In group B, 46 patients (72%) showed ASV enlargement and 44 patients (69%) underwent endoleak embolization. ENVAP (1.7 cm3 ± 2.9 vs 3.4 cm3 ± 4.2; P = .001), ENVDP (2.9 cm3 ± 3.8 vs 8.0 cm3 ± 9.6; P < .001), ENVDP-AP (1.1 cm3 ± 1.8 vs 4.5 cm3 ± 7.8; P < .001), ENVAP/ASV% (0.9% ± 1.5 vs 1.7% ± 2.2; P = .003), and ENVDP/ASV% (1.6% ± 2.2 vs 3.7% ± 3.6; P < .001) were smaller in group A than in group B. Conclusion ENVDP of the first postoperative CTA is an accurate predictor of persistent endoleak compared with ENVAP, and persistent endoleak is associated with aneurysm sac enlargement, in which earlier intervention is recommended.© RSNA, 2021.
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Affiliation(s)
- Hyeon Yu
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, 2016 Old Clinic, CB 7510, Chapel Hill, NC 27599 (H.Y., A.J.I., C.T.B.); Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC (L.M.B.B.), Department of Surgery, Massachusetts General Hospital, Boston, Mass (J.S.E.)
| | - Joshua S Ellis
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, 2016 Old Clinic, CB 7510, Chapel Hill, NC 27599 (H.Y., A.J.I., C.T.B.); Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC (L.M.B.B.), Department of Surgery, Massachusetts General Hospital, Boston, Mass (J.S.E.)
| | - Lauren M B Burke
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, 2016 Old Clinic, CB 7510, Chapel Hill, NC 27599 (H.Y., A.J.I., C.T.B.); Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC (L.M.B.B.), Department of Surgery, Massachusetts General Hospital, Boston, Mass (J.S.E.)
| | - Ari J Isaacson
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, 2016 Old Clinic, CB 7510, Chapel Hill, NC 27599 (H.Y., A.J.I., C.T.B.); Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC (L.M.B.B.), Department of Surgery, Massachusetts General Hospital, Boston, Mass (J.S.E.)
| | - Charles T Burke
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina at Chapel Hill, 2016 Old Clinic, CB 7510, Chapel Hill, NC 27599 (H.Y., A.J.I., C.T.B.); Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC (L.M.B.B.), Department of Surgery, Massachusetts General Hospital, Boston, Mass (J.S.E.)
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Boelitz K, Jirka C, Eberhardt RT, Kalish JA, Siracuse JJ, Farber A, Jones DW. Inadequate Adherence to Imaging Surveillance and Medical Management in Patients with Duplex Ultrasound-Detected Carotid Artery Stenosis. Ann Vasc Surg 2021; 74:63-72. [PMID: 33508459 DOI: 10.1016/j.avsg.2020.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/08/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND It is recommended that patients with ≥50% carotid artery stenosis undergo surveillance imaging and atherosclerotic risk reduction medical therapies, regardless of whether revascularization is performed. The objective of this study was to determine rates of adherence to these recommended measures and to identify risk factors for nonadherence. METHODS A retrospective analysis was performed of all carotid duplex ultrasound (DUS) from 2016 to 2017 at a single institution. Patients with unilateral or bilateral ≥50% carotid stenosis were included. Primary outcomes were rates and timing of surveillance imaging and medication regimen. Patient and study characteristics were compared using univariate and multivariable analyses. A subgroup analysis of patients with a new finding of carotid stenosis was also performed. RESULTS Carotid stenosis >50% was detected in 340 patients. Overall, 182 patients (54%) had follow-up imaging (median 261 days [IQR 166-366]) and 158 patients (46%) had no imaging follow-up (NIFU). NIFU patients had similar rates of aspirin use (86% vs. 88%, P = 0.6) and tobacco cessation counseling (71% vs. 71%, P = 0.8) but had less statin use (85% vs. 94%, P = 0.01) compared to those with imaging follow-up. Subsequent carotid revascularization was more common in patients with imaging follow-up (18% vs. 3%, P < 0.001). NIFU patients were less likely to have Medicare or commercial insurance (54% vs. 75%, P < 0.001). The indication for DUS in NIFU patients, compared to those in follow up, was less commonly neurologic symptoms (11% vs. 14%), more commonly other clinical findings (35% vs. 16%), and more commonly as work up before nonvascular surgery (25% vs. 4%, P < 0.001), respectively. NIFU rates decreased with increasing degree of carotid stenosis. Prior carotid intervention, prior DUS, or DUS ordered by a vascular surgeon were characteristics associated with imaging follow-up (P < 0.05 for all). In a subgroup of 160 patients with new carotid stenosis, a majority (64%) had NIFU and statin use was lower in these patients (82% vs. 96%, P = 0.007). On multivariable analysis, preop indication was predictive of NIFU (odds ratio [OR] 8.1 [95% confidence interval, CI 2.5-26.4], P < 0.001) whereas protective factors included: 70-80% stenosis (OR 0.33 [95% CI 0.14-0.76], P = 0.01), study ordered by vascular surgeon (OR 0.40 [95% CI 0.19-0.83], P = 0.01), and Medicare/commercial insurance (OR 0.36 [95% CI 0.2-0.66], P = 0.001). CONCLUSIONS Nearly half of patients found to have ≥50% carotid stenosis on DUS had no imaging follow-up; these patients were less likely to be on recommended statin therapy. The benefits of nonrevascularization-based treatments for carotid disease require adherence to therapy. Forgoing surveillance imaging in patients with hemodynamically significant carotid stenosis should be a shared decision between provider and patient and does not obviate the need for medical therapies.
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Affiliation(s)
- Kris Boelitz
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Caroline Jirka
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Robert T Eberhardt
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA
| | - Douglas W Jones
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston MA.
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George J, Tadros RO, Rao A, Png CYM, Han DK, Ilonzo N, Faries PL, McKinsey JF. Duplex Ultrasound Can Successfully Identify Endoleaks and Renovisceral Stent Patency in Patients Undergoing Complex Endovascular Aneurysm Repair. Vasc Endovascular Surg 2020; 55:234-238. [PMID: 33317440 DOI: 10.1177/1538574420980605] [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: 11/16/2022]
Abstract
Efficacy of duplex ultrasound (DU) surveillance of complex EVAR such as FEVAR and ChEVAR has not been studied. All patients undergoing FEVAR or ChEVAR at a single multihospital institution were retrospectively reviewed. Postoperative surveillance included DU at 1 month and CTA at 3 months. 82 patients met inclusion criteria including 39 (47.6%) ChEVAR and 43 (52.4%) FEVAR cases. DU identified endoleak with aneurysm sac enlargement in 3 cases requiring reintervention. CTA at 3 months detected 2 new endoleaks without growth and 1 renal artery stent occlusion. Replacement of initial postoperative imaging with DU did not result in any missed endoleaks, deaths, ruptures, or branch occlusions.
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Affiliation(s)
- Justin George
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami O Tadros
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajit Rao
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Y Maximilian Png
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel K Han
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicole Ilonzo
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter L Faries
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James F McKinsey
- 5925Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Mazzaccaro D, Mazzeo G, Zuccon G, Modafferi A, Malacrida G, Righini PC, Marrocco-Trischitta MM, Nano G. Factors affecting the occurrence of proximal endoleak after endovascular abdominal aortic repair for abdominal aneurysms. J Int Med Res 2020; 48:300060520971515. [PMID: 33256478 PMCID: PMC7711229 DOI: 10.1177/0300060520971515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective This retrospective study was performed to assess the clinical and
radiological variables associated with proximal type IA endoleak (EL) in
patients treated with elective endovascular repair for abdominal aortic
aneurysms. Methods The chi-square test, t-test, and logistic regression analysis were performed
as appropriate. A P value of <0.05 was considered statistically
significant. Results The data of 79 patients were analyzed. No mortality occurred. During
follow-up (median, 28.5 months; interquartile range, 12.8–43.0 months), 10
patients developed type IA EL. In the logistic regression analysis,
undersizing of the endograft diameter by <10% significantly affected the
occurrence of type IA EL. When the diameter was used for measurements, less
oversizing was significantly associated with a higher risk of type IA EL.
When the area was used for measurements, oversizing of >20% significantly
affected the occurrence of type IA EL. Conclusion When sizing endografts, a discrepancy was noted between the measurements of
the diameter and area of the proximal neck. The area might represent a more
accurate measurement than the axial diameter to optimize the proximal
sealing and lower the risk of developing type IA EL.
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Affiliation(s)
- Daniela Mazzaccaro
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Girolomina Mazzeo
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Gianmarco Zuccon
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alfredo Modafferi
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Giovanni Malacrida
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Paolo C Righini
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Giovanni Nano
- Operative Unit of Vascular Surgery, 27288IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.,Department of Biomedical Sciences for Health, 9304University of Milan, Milan, Italy
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Wanken ZJ, Barnes JA, Trooboff SW, Columbo JA, Jella TK, Kim DJ, Khoshgowari A, Riblet NB, Goodney PP. A systematic review and meta-analysis of long-term reintervention after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2020; 72:1122-1131. [DOI: 10.1016/j.jvs.2020.02.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/03/2020] [Indexed: 01/12/2023]
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Geraedts ACM, Mulay S, Vahl A, Wisselink W, Koelemay MJW, Balm R. Secondary Interventions and Long-term Follow-up after Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2020; 71:381-391. [PMID: 32768546 DOI: 10.1016/j.avsg.2020.07.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Early morbidity and mortality are low after endovascular abdominal aneurysm repair (EVAR), but secondary interventions and late complications are common. The aim of the present multicenter cohort study is to detail the frequency and indication for interventions after EVAR and the impact on long-term survival. METHODS A retrospective multicenter cohort study of secondary interventions after elective EVAR for an infrarenal abdominal aortic aneurysm was conducted. Consecutive patients (n = 349) undergoing EVAR between January 2007 and January 2012 were analyzed, with long-term follow-up until December 2018. Those requiring intervention were classified in accordance with the indications and specific nature of the intervention and treatment. The primary study end point was overall survival classified for patients with and without intervention. Kaplan-Meier analysis was used to estimate overall survival for those who did and who did not undergo secondary interventions. Univariable and multivariable Cox regression were performed to identify independent variables associated with mortality. RESULTS Some 56 patients (16%) underwent 72 secondary interventions after EVAR during a median (interquartile range) follow-up period of 53.2 months (60.1). Some 45 patients (80.4%) underwent one intervention. Indications for intervention included mainly endograft kinking/outflow obstruction and type II endoleak. An endovascular technique was used in 40.3% of interventions. Median time to secondary intervention was 24.1 months. In 93 patients with abnormalities on imaging, no intervention was performed mainly because the abnormality had disappeared on follow-up imaging (43%). Kaplan-Meier curves showed no difference in survival for patients with and without secondary interventions (P = 0.153). Age (hazard ratio [HR]: 1.089, 95% confidence interval [CI]: 1.063-1.116), ASA classification (ASA III, IV HR: 1.517, 95% CI: 1.056-2.178) were significantly related to mortality. CONCLUSIONS Secondary intervention rates are still considerable after EVAR. Endograft kinking/outflow obstruction and endoleak type II are the most common indications for a secondary intervention. Secondary interventions did not adversely affect long-term overall survival after EVAR.
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Affiliation(s)
- Anna C M Geraedts
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Sana Mulay
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Anco Vahl
- OLVG, Department of Surgery, Amsterdam, The Netherlands
| | - Willem Wisselink
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mark J W Koelemay
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ron Balm
- Department of Surgery, Amsterdam University Medical Centres, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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de Guerre L, Venermo M, Mani K, Wanhainen A, Schermerhorn M. Paradigm shifts in abdominal aortic aneurysm management based on vascular registries. J Intern Med 2020; 288:38-50. [PMID: 32118339 DOI: 10.1111/joim.13051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abdominal aortic aneurysm (AAA) is a relatively common and potentially fatal disease. The management of AAA has undergone extensive changes in the last two decades. High quality vascular surgical registries were established early and have been found to be instrumental in the evaluation and monitoring of these changes, most notably the wide implementation of minimally invasive endovascular surgical technology. Trends over the years showed the increased use of endovascular aneurysm repair (EVAR) over open repair, the decreasing perioperative adverse outcomes and the early survival advantage of EVAR. Also, data from the early EVAR years changed the views on endoleak management and showed the importance of tracking the implementation of new techniques. Registry data complemented the randomized trials performed in aortic surgery by showing the high rate of laparotomy-related reinterventions after open repair. Also, they are an essential tool for the understanding of outcomes in a broad patient population, evaluating the generalizability of findings from randomized trials and analysing changes over time. By using large-scale data over longer periods of time, the importance of centralization of care to high-volume centres was shown, particularly for open repair. Additionally, large-scale databases can offer an opportunity to assess practice and outcomes in patient subgroups (e.g. treatment of AAA in women and the elderly) as well as in rare aortic pathologies. In this review article, we point out the most important paradigm shifts in AAA management based on vascular registry data.
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Affiliation(s)
- L de Guerre
- Division of Vascular Surgery and Endovascular Therapy, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Venermo
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
| | - K Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - A Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - M Schermerhorn
- Division of Vascular Surgery and Endovascular Therapy, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Midy D, Bastrot L, Belhomme D, Faroy F, Frisch N, Bouillanne PJ, Delaunay T, Aguilar P, Francis-Oliviero F, Caradu C, Belhomme D, Faroy F, Frisch N, Midy D, Bouillanne PJ, Delaunay T, Aguilar P, Hoehne M, Gheysens B, Gardet E, Maillard P, Chakfe N, Mugnier B, Rossi A, Malikov S, El Douaihy M, Grognet A, Nicolini P, Moumouni Y, Magne JL, Gayet P, Calen S. Five Year Results of the French EPI-ANA-01 Registry of AnacondaTM Endografts in the Treatment of Infrarenal Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2020; 60:16-25. [DOI: 10.1016/j.ejvs.2020.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/12/2020] [Accepted: 02/05/2020] [Indexed: 10/24/2022]
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Jean-Baptiste E, Feugier P, Cruzel C, Sarlon-Bartoli G, Reix T, Steinmetz E, Chaufour X, Chavent B, Salomon du Mont L, Ejargue M, Maurel B, Spear R, Midy D, Thaveau F, Desgranges P, Rosset E, Hassen-Khodja R, Bureau P, Ravoux M, Bozzetto C, Sevestre-Pietri MA, Terriat B, Favier C, Degeilh M, Le Hello C, Favre JP, Rinckenbach S, Loppinet A, Goueffic Y, Connault J, Alimi Y, Barthélémy P, Magne JL, Seinturier C, Choukroun ML, Rouyer O, Bitton L, Becquemin JP. Computed Tomography-Aortography Versus Color-Duplex Ultrasound for Surveillance of Endovascular Abdominal Aortic Aneurysm Repair. Circ Cardiovasc Imaging 2020; 13:e009886. [DOI: 10.1161/circimaging.119.009886] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Color-duplex ultrasonography (DUS) could be an alternative to computed tomography-aortography (CTA) in the lifelong surveillance of patients after endovascular aneurysm repair (EVAR), but there is currently no level 1 evidence. The aim of this study was to assess the diagnostic accuracy of DUS as an alternative to CTA for the follow-up of post-EVAR patients.
Methods
Between December 16, 2010, and June 12, 2015, we conducted a prospective, blinded, diagnostic-accuracy study, in 15 French university hospitals where EVAR was commonly performed. Participants were followed up using both DUS and CTA in a mutually blinded setup until the end of the study or until any major aneurysm-related morphological abnormality requiring reintervention or an amendment to the follow-up policy was revealed by CTA. Database was locked on October 2, 2017. Our main outcome measures were sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratios of DUS against reference standard CTA. CIs are binomial 95% CI.
Results
This study recruited prospectively 659 post-EVAR patients of whom 539 (82%) were eligible for further analysis. Following the baseline inclusion visit, 940 additional follow-up visits were performed in the 539 patients. Major aneurysm-related morphological abnormalities were revealed by CTA in 103 patients (17.2/100 person-years [95% CI, 13.9–20.5]). DUS accurately identified 40 patients where a major aneurysm-related morphological abnormality was present (sensitivity, 39% [95% CI, 29–48]) and 403 of 436 patients with negative CTA (specificity, 92% [95% CI, 90–95]). The negative predictive value and positive predictive value of DUS were 92% (95% CI, 90–95) and 39% (95% CI, 27–50), respectively. The positive likelihood ratio was 4.87 (95% CI, 2.9–9.6). DUS sensitivity reached 73% (95% CI, 51–96) in patients requiring an effective reintervention.
Conclusions
DUS had an overall low sensitivity in the follow-up of patients after EVAR, but its performance improved meaningfully when the subset of patients requiring effective reinterventions was considered.
Registration
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01230203.
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Affiliation(s)
- Elixène Jean-Baptiste
- Service de Chirurgie Vasculaire, INSERM U1065, CHU de Nice, Université Côte D’Azur, Nice, France (E.J.-B., R.H.-K.)
| | - Patrick Feugier
- Service de Chirurgie Vasculaire, CHU Edouard Herriot, Université Claude Bernard Lyon1, Lyon, France (P.F.)
| | - Coralie Cruzel
- Délégation à la Recherche Clinique et à l’innovation, CHU de Nice, Université Côte D’Azur, Nice, France (C.C.)
| | - Gabrielle Sarlon-Bartoli
- C2VN, APHM, CHU Timone, Service de Chirurgie Vasculaire, Aix Marseille Université, Marseille, France (G.S.-B.)
| | - Thierry Reix
- Service de Chirurgie Vasculaire, CHU Amiens-Picardie, Université de Picardie Jules Verne, Amiens, France (T.R.)
| | - Eric Steinmetz
- Service de Chirurgie Vasculaire, CHU Dijon-Bourgogne, Université de Bourgogne, Dijon, France (E.S.)
| | - Xavier Chaufour
- Service de Chirurgie Vasculaire et angiologie, CHU de Toulouse, Université Paul Sabatier, Toulouse, France (X.C.)
| | - Bertrand Chavent
- Service de Chirurgie Cardio-Vasculaire, CHU de Saint-Etienne, Université Jean Monnet, Saint-Etienne, France (B.C.)
| | - Lucie Salomon du Mont
- Service de Chirurgie Vasculaire et Endovasculaire, CHU de Besançon, Université de Franche-Comté, Besançon, France (L.S.d.M.)
| | - Meghann Ejargue
- AP-HM, Department of Vascular Surgery, University Hospital Nord, Aix-Marseille Université, Marseille, France (M.E.)
| | - Blandine Maurel
- CHU Nantes, l’institut du thorax, service de chirurgie vasculaire, Inserm-UN UMR-957, Nantes, France (B.M.)
| | - Rafaelle Spear
- Service de Chirurgie Vasculaire, CHU de Grenoble, Université Grenoble-Alpes, Grenoble, France (R.S.)
| | - Dominique Midy
- Service de Chirurgie Vasculaire, CHU de Bordeaux, Bordeaux, France (D.M.)
| | - Fabien Thaveau
- Service de Chirurgie Vasculaire, CHU de Strasbourg, Strasbourg, France (F.T.)
| | - Pascal Desgranges
- Service de Chirurgie Vasculaire, CHU Henri Mondor, Créteil, France (P.D.)
| | - Eugenio Rosset
- Service de Chirurgie Vasculaire, CHU de Clermont-Ferrand, Université d’Auvergne, Clermont-Ferrand, France (E.R.)
| | - Réda Hassen-Khodja
- Service de Chirurgie Vasculaire, INSERM U1065, CHU de Nice, Université Côte D’Azur, Nice, France (E.J.-B., R.H.-K.)
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Khanh LN, Helenowski I, Zamor K, Scott M, Hoel AW, Ho KJ. Predictors and Consequences of Loss to Follow-up after Vascular Surgery. Ann Vasc Surg 2020; 68:217-225. [PMID: 32439521 DOI: 10.1016/j.avsg.2020.04.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Loss to follow-up (LTF) after surgery impacts quality of care and can adversely affect short- and long-term clinical outcomes. This study identifies modifiable factors contributing to LTF after vascular surgery and the factors' effect on short- and long-term clinical outcomes. METHODS This is a retrospective single-center cohort study of 440 consecutive adult patients who underwent carotid endarterectomy, infrainguinal bypass, percutaneous lower extremity revascularization, or endovascular aortic aneurysm repair at Northwestern Memorial Hospital between November 2011 and November 2013. Twenty-six patients who died within 9 months after surgery were excluded because of competing risks with the study end points. Demographics, medical history and medications, hospitalization and procedure-related factors, and postoperative complications were collected from the medical record. The primary end point was LTF 1 month after surgery (LTF1M), defined as lack of an in-person outpatient visit with a vascular surgeon 1 month after the index procedure. Secondary outcomes were LTF 1 year after surgery (LTF1Y), defined as lack of an in-person outpatient visit with a vascular surgeon between 9 and 22 months after discharge, and overall 5-year survival. RESULTS Overall LTF1M and LTF1Y rates were 27.3% and 46.8%, respectively. Kaplan-Meier analysis revealed no difference in survival based on the LTF1M status (P = 0.72), but patients who were LTF1Y had significantly worse survival at 5 years (P < 0.001). Seeing a nonvascular surgeon specialist at our institution (odds ratio (OR) 0.58, 95% confidence interval (CI): 0.35-0.94, P = 0.03) and having a reintervention (OR 0.17, 95% CI: 0.08-0.37, P < 0.001) were associated with decreased LTF1Y in a multivariable model. Overall mortality was more likely with LTF1Y (hazard ratio (HR) 3.27, 95% CI: 1.86-5.76, P < 0.001) and less likely with seeing another specialist at our institution (HR 0.38, 95% CI: 0.20-0.75, P = 0.005). CONCLUSIONS LTF rates after vascular surgery are high and associated with poor long-term outcomes. Patients who did not see a nonvascular surgeon specialist at our institution had higher rates of LTF1Y and worse overall mortality, suggesting that improved integration of care can improve LTF and survival.
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Affiliation(s)
- Linh Ngo Khanh
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Irene Helenowski
- Department of Preventive Medicine and Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Kimberly Zamor
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, NH, Lebanon
| | - Morgan Scott
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Andrew W Hoel
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Karen J Ho
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Wanken ZJ, Trooboff SW, Gladders B, Columbo JA, Ramkumar N, Austin AM, Stone DH, Mell MW, Sedrakyan A, Goodney PP. Characterization of Endovascular Abdominal Aortic Aneurysm Repair Surveillance in the Vascular Quality Initiative. Circulation 2020; 141:866-868. [PMID: 32150470 PMCID: PMC7101002 DOI: 10.1161/circulationaha.119.043625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Zachary J Wanken
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Z.J.W., J.A.C., D.H.S., P.P.G.).,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (Z.J.W., S.W.T., B.G., J.A.C., N.R., A.M.A., P.P.G.)
| | - Spencer W Trooboff
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (Z.J.W., S.W.T., B.G., J.A.C., N.R., A.M.A., P.P.G.)
| | - Barbara Gladders
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (Z.J.W., S.W.T., B.G., J.A.C., N.R., A.M.A., P.P.G.)
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Z.J.W., J.A.C., D.H.S., P.P.G.).,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (Z.J.W., S.W.T., B.G., J.A.C., N.R., A.M.A., P.P.G.)
| | - Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (Z.J.W., S.W.T., B.G., J.A.C., N.R., A.M.A., P.P.G.)
| | - Andrea M Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (Z.J.W., S.W.T., B.G., J.A.C., N.R., A.M.A., P.P.G.)
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Z.J.W., J.A.C., D.H.S., P.P.G.)
| | - Matthew W Mell
- Section of Vascular Surgery, UC Davis Health, Sacramento, CA (M.W.M.)
| | | | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (Z.J.W., J.A.C., D.H.S., P.P.G.).,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (Z.J.W., S.W.T., B.G., J.A.C., N.R., A.M.A., P.P.G.)
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Davidovic LB, Palombo D, Treska V, Sladojevic M, Koncar IB, Houdek K, Spinella G, Zlatanovic P, Pane B. Late open conversion after endovascular abdominal aortic aneurysm repair: experience of three-high volume centers. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:183-190. [DOI: 10.23736/s0021-9509.19.10972-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Camacho N, Bastos Gonçalves F. Commentary: Sealing the Deal: Easier Methods Are on the Horizon for Postoperative Evaluation of Stent-Graft Seal Zones. J Endovasc Ther 2019; 26:853-854. [PMID: 31608739 DOI: 10.1177/1526602819879942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nelson Camacho
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Frederico Bastos Gonçalves
- Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,NOVA Medical School, Lisbon, Portugal
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Optimizing Surveillance and Re-intervention Strategy Following Elective Endovascular Repair of Abdominal Aortic Aneurysms. Ann Surg 2019; 274:e589-e598. [PMID: 31592810 DOI: 10.1097/sla.0000000000003625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND EVAR for abdominal aortic aneurysm has an initial survival advantage over OR, but more frequent complications increase costs and long-term aneurysm-related mortality. Randomized controlled trials of EVAR versus OR have shown EVAR is not cost-effective over a patient's lifetime. However, in the EVAR-1 trial, postoperative surveillance may have been sub-optimal, as the importance of sac growth as a predictor of graft failure was overlooked. METHODS Real-world data informed a discrete event simulation model of postoperative outcomes following EVAR. Outcomes observed EVAR-1 were compared with those from 5 alternative postoperative surveillance and re-intervention strategies. Key events, quality-adjusted life years and costs were predicted. The impact of using complication and rupture rates from more recent devices, imaging and re-intervention methods was also explored. RESULTS Compared with observed EVAR-1 outcomes, modeling full adherence to the EVAR-1 scan protocol reduced abdominal aortic aneurysm (AAA) deaths by 3% and increased elective re-interventions by 44%. European Society re-intervention guidelines provided the most clinically effective strategy, with an 8% reduction in AAA deaths, but a 52% increase in elective re-interventions. The cheapest and most cost-effective strategy used lifetime annual ultrasound in primary care with confirmatory computed tomography if necessary, and reduced AAA-related deaths by 5%. Using contemporary rates for complications and rupture did not alter these conclusions. CONCLUSIONS All alternative strategies improved clinical benefits compared with the EVAR-1 trial. Further work is needed regarding the cost and accuracy of primary care ultrasound, and the potential impact of these strategies in the comparison with OR.
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Brooke BS, Beck AW, Kraiss LW, Hoel AW, Austin AM, Ghaffarian AA, Cronenwett JL, Goodney PP. Association of Quality Improvement Registry Participation With Appropriate Follow-up After Vascular Procedures. JAMA Surg 2019; 153:216-223. [PMID: 29049809 DOI: 10.1001/jamasurg.2017.3942] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Benjamin S. Brooke
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City
| | - Adam W. Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama- Birmingham
| | - Larry W. Kraiss
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City
| | - Andrew W. Hoel
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrea M. Austin
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire
| | - Amir A. Ghaffarian
- Division of Vascular Surgery, University of Utah School of Medicine, Salt Lake City
| | - Jack L. Cronenwett
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Philip P. Goodney
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire,Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Columbo JA, Ramkumar N, Martinez-Camblor P, Kang R, Suckow BD, O'Malley AJ, Sedrakyan A, Goodney PP. Five-year reintervention after endovascular abdominal aortic aneurysm repair in the Vascular Quality Initiative. J Vasc Surg 2019; 71:799-805.e1. [PMID: 31471231 DOI: 10.1016/j.jvs.2019.05.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/14/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patients who undergo endovascular abdominal aortic aneurysm repair (EVR) remain at risk for reintervention and rupture. We sought to define the 5-year rate of reintervention and rupture after EVR in the Vascular Quality Initiative (VQI). METHODS We identified all patients in the VQI who underwent EVR from 2003 to 2015. We linked patients in the VQI to Medicare claims for long-term outcomes. We stratified patients on baseline clinical and procedural characteristics to identify those at risk for reintervention. Our primary outcomes were 5-year rates of reintervention and late aneurysm rupture after EVR. We assessed these with Kaplan-Meier survival estimation. RESULTS We studied 12,911 patients who underwent EVR. The mean age was 75.5 years, 79.9% were male, 3.9% were black, and 89.1% of operations were performed electively. The 5-year rate of reintervention for the entire cohort was 21%, and the 5-year rate of late aneurysm rupture was 3%. Reintervention rates varied across categories of EVR urgency. Patients who underwent EVR electively had the lowest 5-year rate of reintervention at 20%. Those who underwent surgery for symptomatic aneurysms had higher rates of reintervention at 25%. Patients undergoing EVR emergently for rupture had the highest rate of reintervention, 27% at 4 years (log-rank across the three groups, P < .001). Black race and aneurysm size of 6.0 cm or greater were associated with significantly elevated reintervention rates (black, 31% vs white, 20% [log-rank, P < .001]; aneurysm size 6.0 cm or greater, 27% vs all others, <20% [log-rank, P < .001]). There were no significant associations between age or gender and the 5-year rate of reintervention. CONCLUSIONS More than one in five Medicare patients undergo reintervention within 5 years after EVR in the VQI; late rupture remains low at 3%. Black patients, those with large aneurysms, and those who undergo EVR urgently and emergently have a higher likelihood of adverse outcomes and should be the focus of diligent long-term surveillance.
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Affiliation(s)
- Jesse A Columbo
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
| | - Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Pablo Martinez-Camblor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Ravinder Kang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Bjoern D Suckow
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Art Sedrakyan
- Department of Surgery, Weill-Cornell Medical School, New York, NY
| | - Philip P Goodney
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
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50
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Asenbaum U, Schoder M, Schwartz E, Langs G, Baltzer P, Wolf F, Prusa AM, Loewe C, Nolz R. Stent-graft surface movement after endovascular aneurysm repair: baseline parameters for prediction, and association with migration and stent-graft-related endoleaks. Eur Radiol 2019; 29:6385-6395. [PMID: 31250169 PMCID: PMC6828830 DOI: 10.1007/s00330-019-06282-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/25/2019] [Accepted: 05/22/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To evaluate the influence of baseline parameters on the occurrence of stent-graft surface movement after endovascular aneurysm repair (EVAR) and to investigate its association with migration and stent-graft-related endoleaks (srEL). METHODS In this retrospective, cross-sectional study, three-dimensional surface models of the stent-graft, delimited by landmarks using custom-built software, were derived from the pre-discharge and last follow-up computed tomography angiography (CTA). Stent-graft surface movement in the proximal anchoring zone between these examinations was considered significant at a threshold of 9 mm. The Cox proportional hazards model was used to determine baseline variables associated with the occurrence of stent-graft surface movement. The association between migration and srEL with stent-graft surface movement was tested with the chi-square and the Fisher exact test, respectively. RESULTS Stent-graft surface movement was observed in 54 (28.9%) of 187 patients. Multivariate analysis revealed that age ([HR] 1.05; p = 0.017), proximal neck diameter ([HR] 5.07; p < 0.001), infrarenal aortic neck angulation ([HR] 1.02, p = 0.002), and proximal neck length ([HR] 0.62, p < 0.001) were significantly associated with the occurrence of stent-graft surface movement. Migration and srEL occurred in 17 (31.5%) and 5 (9.3%) patients, with and 11 (8.3%) and 2 (1.5%) without stent-graft surface movement (p < 0.001, p = 0.022). CONCLUSIONS Age, neck diameter, infrarenal neck angulation, and proximal neck length were significantly associated with the occurrence of stent-graft surface movement. Apart from possible use of adjunctive sealing systems, concerned patients may benefit from regular CTA surveillance, enabling timely diagnosis of subtle changes of stent-graft position. KEY POINTS • Stent-graft surface movement, demonstrating subtle, three-dimensional changes in stent-graft position in the proximal anchoring zone, can be derived from CTA examinations. • Age, proximal neck diameter, and infrarenal neck angulation were significantly associated with an increased incidence of stent-graft surface movement. Stent-graft surface movement is significantly more frequent in patients with stent-graft migration and stent-graft-related endoleaks. • Consideration of risk factors for stent-graft surface movement may help to identify patients who might benefit from regular CTA surveillance and timely diagnosis of subtle changes of stent-graft position, enabling re-interventions to prevent migration and srEL.
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Affiliation(s)
- Ulrika Asenbaum
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Maria Schoder
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Ernst Schwartz
- Computational and Imaging Research Laboratory, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Georg Langs
- Computational and Imaging Research Laboratory, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Pascal Baltzer
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Florian Wolf
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Alexander M Prusa
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Richard Nolz
- Division of Cardiovascular and Interventional Radiology, Department of Bio-medical Imaging and Image-Guided Therapy, Medical University of Vienna - Vienna General Hospital, Waehringer Guertel 18-20, A-1090, Vienna, Austria.
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