In patients stratified by preoperative risk, endovascular repair of ruptured abdominal aortic aneurysms has a lower in-hospital mortality and morbidity than open repair

Emergency Open Surgical Repair for Ruptured Abdominal Aortic Aneurysm in Octogenarians and Nonagenarians: A Single-Center Retrospective Observational Study

BACKGROUND

In the endovascular aneurysm repair era, open surgical repair (OSR) is performed for ruptured abdominal aorta aneurysm (RAAA) in patients with complex aneurysm neck and technical difficulties. Understanding the risk factors of OSR is essential for the clinical selection of the ideal surgical procedure. We aimed to re-evaluate the outcomes of OSR and treatment options for RAAA.

METHODS

Patients who underwent OSR for RAAA between January 2010 and December 2022 were enrolled in this single-center retrospective observational study. Preoperative status, operative findings, and postoperative course were retrospectively reviewed. The Cox proportional hazards model was used to evaluate the association between age and early postoperative mortality.

RESULTS

Among 142 patients, 43 (30.3%) and 99 (69.7%) were aged ≥80 and <80 years, respectively. Postoperative mortality within 30 days occurred in 24 (16.9%) patients (11/43 [25.6%] and 13/99 [13.1%] patients aged ≥80 and <80 years, respectively; hazard ratio = 1.95; P = 0.069). In a multivariable analysis, increased postoperative mortality within 30 days was associated with age ≥80 years (adjusted hazard ratio, aHR = 2.36; P = 0.049), the presence of preoperative or intraoperative cardiopulmonary arrest (aHR = 12.0; P < 0.001), and postoperative gastrointestinal disorder (aHR = 4.42; P = 0.003).

CONCLUSIONS

Endovascular aneurysm repair may be preferable in older people; however, its use in cases of preoperative or intraoperative cardiopulmonary arrest or perioperative gastrointestinal disorders remains controversial, and a careful discussion on the surgical indications is needed in such cases.

Transition from Open Repair to Endovascular Aneurysm Repair for Rupture Aortic Aneurysms throughout a 16-Year Period of Time in a Single Tertiary Center

BACKGROUND

Endovascular aneurysm repair (EVAR) is recommended as the first option for both elective and ruptured abdominal aortic aneurysms (rAAAs) with suitable anatomy. The aim of this study was to evaluate the outcomes of the gradual adoption of ruptured EVAR (rEVAR) as first option in the management of rAAAs in a reference tertiary center over a 16 year-period.

METHODS

A retrospective analysis of prospectively collected clinical data was undertaken, including all patients that were treated for rAAA infrarenal or juxtarenal either with open surgical repair (OSR) or EVAR from 2006-2023. Three periods were identified and analyzed: Initial (2006-2011); intermediate (2012-2017); and current (2018-2023). The primary outcomes were the 30-day mortality rate in relation to the changing pattern of treatment. Secondary outcomes were re-intervention and mortality during the follow up period.

RESULTS

Two hundred patients were treated for rAAA; 52% by endovascular means [EVAR (94), Ch-EVAR (9), and branched endovascular aneurysm repair (1)] and 48% by OSR (96). In the initial period, 61 patients were treated for rAAA (21% EVAR vs. 79% OSR), 68 in intermediate patients (47% EVAR vs. 53% OSR), and 71 in current period (83% EVAR vs. 17% OSR). Only in the current period juxta -renal rAAAs were treated by endovascular means (14%). The 30-day mortality rate was 46% in initial period (31% for EVAR vs. 50% for OSR), 64% in second period (46% in EVAR vs. 80% for OSR), and 35% in third period (25% for EVAR vs. 83% for OSR). The mean follow up did not differ between the groups, (EVAR 28.3 ± 2 months, vs. OSR 33.1 ± 3 months, P = 0.56). The survival rate did not differ between the groups; in rEVAR was 82% (SE 5%), 74% (SE 6%), 68% (SE 6.5%), and 63% (SE 7.7%) at 12, 24, 36, and 48 months, respectively, and in OSR was 76% (SE 7%), 66% (SE 8%), and 56% (SE 9.5%) at 6, 24, and 48 months, respectively (P = 0.544).

CONCLUSIONS

Through a 16-year period, the implementation of EVAR as treatment of choice for rAAAs over OSR resulted in a noticeable reduction in the 30-day mortality. rEVAR was feasible in over 80% of rAAA patients.

Modified Harborview Risk Score improves ease in predicting mortality after ruptured abdominal aortic aneurysm repair

OBJECTIVE

The Harborview Risk Score (HRS) is a simple, accurate 4-point preoperative risk scoring system used to predict 30-day mortality following ruptured abdominal aortic aneurysm (rAAA) repair. The HRS assigns 1 point for each of the following: age >76 years, pH <7.2, creatinine >2 mg/dL, and any episode of severe hypotension (systolic blood pressure <70 mmHg). One potential limitation of this risk scoring system is that arterial blood gas (ABG) analysis is required to determine arterial pH. Because ABG analysis is not routinely performed prior to patient transfer or rAAA repair, we sought to determine if the HRS could be modified by replacing pH with the international normalized ratio (INR), a factor that has been previously shown to have a strong and independent association with 30-day death after rAAA repair.

METHODS

A retrospective review of all rAAA repairs done at a single academic medical center between January 2002 and December 2018 was performed. Our traditional HRS was compared with a modified score, in which pH <7.2 was replaced with INR >1.8. Patients were included if they underwent rAAA repair (open or endovascular), and if they had preoperative laboratory values available to calculate both the traditional and modified HRS.

RESULTS

During the 17-year study period, 360 of 391 repairs met inclusion criteria. Observed 30-day mortality using the modified scoring system was 17% (18/106) for a score of 0 points, 43% (53/122) for 1 point, 54% (52/96) for 2 points, 84% (27/32) for 3 points, and 100% (4/4) for 4 points. Receiver operating characteristic analysis revealed similar ability of the two scoring systems to predict 30-day death: there was no significant difference in the area under the curve (AUC) comparing the traditional (AUC = 0.74) and modified (AUC = 0.72) HRS (P = .3).

CONCLUSIONS

Although previously validated among a modern cohort of patients with rAAA, our traditional 4-point risk score is limited in real-world use by the need for an ABG. Substituting INR for pH improves the usefulness of our risk scoring system without compromising accuracy in predicting 30-day mortality after rAAA repair.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Treatment Location Variation for Chronic Limb-Threatening Ischemia in Patients With Kidney Failure

INTRODUCTION

End-stage kidney disease (ESKD) is an established risk factor for chronic limb-threatening ischemia (CLTI). Procedural location for ESKD patients has not been well described. This study aims to examine variation in index procedural location in ESKD versus non-ESKD patients undergoing peripheral vascular intervention for CLTI and identify preoperative risk factors for tibial interventions.

METHODS

Chronic limb-threatening ischemia (CLTI) patients were identified in the Vascular Quality Initiative (VQI) peripheral vascular intervention dataset. Patient demographics and comorbidities were compared between patients with and without ESKD and those undergoing index tibial versus nontibial interventions. A multivariable logistic regression evaluating risk factors for tibial intervention was conducted.

RESULTS

A total of 23,480 procedures were performed on CLTI patients with 13.6% (n = 3154) with ESKD. End-stage kidney disease (ESKD) patients were younger (66.56 ± 11.68 versus 71.66 ± 12.09 y old, P = 0.019), more often Black (40.6 versus 18.6%, P < 0.001), male (61.2 versus 56.5%, P < 0.001), and diabetic (81.8 versus 60.0%, P < 0.001) than non-ESKD patients. Patients undergoing index tibial interventions had higher rates of ESKD (19.4 versus 10.6%, P < 0.001) and diabetes (73.4 versus 57.5%, P < 0.001) and lower rates of smoking (49.9 versus 73.0%, P < 0.001) than patients with nontibial interventions. ESKD (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.52-1.86, P < 0.001), Black race (OR 1.19, 95% CI 1.09-1.30, P < 0.001), and diabetes (OR 1.82, 95% CI 1.71-2.00, P < 0.001) were risk factors for tibial intervention.

CONCLUSIONS

Patients with ESKD and CLTI have higher rates of diabetes and tibial disease and lower rates of smoking than non-ESKD patients. Tibial disease was associated with ESKD, diabetes, and Black race.

The Impact of Intra-Operative Heparin on Thromboembolism and Death in a Matched Cohort of Patients with a Ruptured Abdominal Aortic Aneurysm

Objective

Portuguese nationwide estimates indicate that 20% of abdominal aortic aneurysms (AAAs) are treated when ruptured. In these cases, intra-operative unfractionated heparin (UFH) usage rates vary widely. Evidence on this topic is scarce and focused on patients treated by open repair (OSR). The aim was to determine the influence of UFH on peri-operative thromboembolic events (TEs) and death in a cohort of ruptured AAA (rAAA).

Methods

Retrospective, single-centre, comparative study. From 2011 to April 2023, all consecutive rAAAs (endovascular repair [EVAR] and OSR) were considered. Primary outcomes were 30-day TE free survival and TE rates. The secondary outcome was 30-day death. Safety endpoints were procedural blood loss, blood product requirements, and secondary interventions due to haemorrhage. Using propensity score matching (PSM) each UFH patient was matched with one no UFH patient in a 1:1 ratio.

Results

The study included 250 patients. After PSM, 190 patients were analysed (EVAR: 60.0% no-UFH vs. 64.4% UFH). TE free survival estimates favoured the UFH group (67.3% vs. 47.2%, p = .009; UFH adjusted odds ratio [aOR] 2.01, 95% confidence interval [CI] 1.04-4.17). TEs were more frequent in the no UFH group (20.0% vs. 44.2% patients, p < .001; UFH aOR 0.31, 95% CI 0.15-0.65 for any TE), driven by an increase in bowel ischaemia (17.9% no UFH vs. 3.2% UFH, p = .001). Most events occurred in the first 72 hours. EVAR was associated with reduced TE and improved TE free survival (aOR 0.20, 95% CI 0.09-0.45 and aOR 5.54, 95% CI 2.34-13.08, respectively). No significant differences in 30-day survival were noted (75% no-UFH vs. 83% UFH, p = .26; aOR 1.08, 95% CI 0.48-2.43) nor in blood loss, peri-operative red blood cell and fresh frozen plasma requirements, or secondary interventions due to haemorrhage (p = .10; p = .11; p = .13 and p = .18 respectively).

Conclusion

In this cohort, intra-operative UFH was safe and associated with improved TE free survival, driven by a reduction in bowel ischaemia. Conversely, mortality remained unaffected. Randomised controlled trials are required to confirm these findings.

Long-term Mortality and Reintervention After Repair of Ruptured Abdominal Aortic Aneurysms Using VQI-matched Medicare Claims

OBJECTIVE

The objective of this study was to compare endovascular aortic aneurysm repair (EVAR) versus open aortic repair (OAR) on mortality and reintervention after ruptured infrarenal abdominal aortic aneurysm (rAAA) repair in the Vascular Quality Initiative (VQI).

BACKGROUND

The optimal treatment modality for rAAA remains debated, with little data on long-term comparisons.

METHODS

VQI rAAA repairs (2004-2018) were matched with Medicare claims (VQI-VISION). Primary outcomes were in-hospital and long-term mortality. Secondary outcome was reintervention. Inverse probability weighting was used to adjust for treatment selection, and Cox Proportional Hazards models and negative binomial regressions were used for analysis. Landmark analysis was performed among patients surviving hospital discharge.

RESULTS

Among 1885 VQI/Medicare rAAA patients, 790 underwent OAR, and 1095 underwent EVAR. Median age was 76 years; 73% were male. Inverse probability weighting produced comparable groups. In-hospital mortality was lower after EVAR versus OAR (21% vs 37%, odds ratio: 0.52, 95% CI, 0.4-0.7). One-year mortality rates were lower for EVAR versus OAR [hazard ratio (HR) 0.74, 95% CI, 0.6-0.9], but not statistically different after 1 year (HR: 0.95, 95% CI, 0.8-1.2). This implies additional benefits to EVAR in the short term. Reintervention rates were higher after EVAR than OAR at 2 and 5 years (rate ratio: 1.79 95% CI, 1.2-2.7 and rate ratio:2.03 95% CI, 1.4-3.0), but not within the first year. Reintervention was associated with higher mortality risk for both OAR (HR: 1.66 95% CI, 1.1-2.5) and EVAR (HR: 2.14 95% CI, 1.6-2.9). Long-term mortality was similar between repair types (HR: 0.99, 95% CI, 0.8-1.2).

CONCLUSIONS

Within VQI/Medicare patients undergoing rAAA repair, the perioperative mortality rate favors EVAR but equalizes after 1 year. Reinterventions were more common after EVAR and were associated with higher mortality regardless of treatment.

Treatment Outcomes of Patients With Ruptured Abdominal Aortic Aneurysms

BACKGROUND

Ruptured abdominal aortic aneurysm (rAAA) is a serious complication of abdominal aortic aneurysm associated with high operative mortality and morbidity rates. The present study evaluated the perioperative and long-term outcomes of Korean patients with rAAA based on national health insurance claims data.

METHODS

The National Health Insurance Service (NHIS) database was searched retrospectively to identify patients with rAAA who underwent endovascular aneurysm repair (EVAR) and open surgical repair (OSR) from 2009 to 2018. Perioperative (≤ 30 days), early postoperative (≤ 3 month), and long-term (> 3 month) survival, reinterventions, and complications were assessed.

RESULTS

The search identified 1,034 patients with rAAA, including 594 who underwent EVAR and 440 who underwent OSR. When the study period was divided into two, the total numbers of patients with rAAA, patients who underwent EVAR, and octogenarians were higher during the second half. The perioperative mortality rate was 29.8% in the EVAR and 35.0% in the OSR group (P = 0.028). Hartmann's procedure for bowel infarction was performed more frequently in the OSR than in the EVAR group (adjusted odds ratio, 6.28; 95% confidence interval [CI], 2.33-21.84; P = 0.001), but other complication rates did not differ significantly. All-cause mortality during the entire observation period did not differ significantly in the EVAR and OSR groups (adjusted hazard ratio, 1.17; 95% CI, 0.98-1.41; P = 0.087). Abdominal aortic aneurysm-related reintervention rate was significantly lower in the OSR group (adjusted hazard ratio, 0.31; 95% CI, 0.14-0.70; P = 0.005).

CONCLUSION

Although EVAR showed somewhat superior perioperative outcomes for rAAA, the long-term outcomes of EVAR after excluding initial 3 months were significantly worse than OSR. When anatomically feasible for both treatments, the perioperative mortality risk and reasonable prospects of long-term survival should be considered in rAAA.

Differences in Long-Term Outcomes in End-Stage Kidney Disease Patients with Chronic Limb-Threatening Ischemia

BACKGROUND

End-stage kidney disease (ESKD) is a risk factor for peripheral arterial disease and major adverse limb events following infra-inguinal bypass. Despite comprising an important patient population, ESKD patients are rarely analyzed as a subgroup and are underrepresented in vascular surgery guidelines. This study aims to compare the long-term outcomes of patients with and without ESKD undergoing endovascular peripheral vascular intervention (PVI) for chronic limb-threatening ischemia (CLTI).

METHODS

CLTI patients with and without ESKD from 2007-2020 were identified in the Vascular Quality Initiative PVI dataset. Patients with prior bilateral interventions were excluded. Patients undergoing femoral-popliteal and tibial interventions were included. Mortality, reintervention, amputation, and occlusion rates at 21 months following intervention were examined. Statistical analyses were completed with the t-test, chi-square, and Kaplan-Meier curves.

RESULTS

The ESKD cohort was younger (66.4 ± 11.8 vs. 71.6 ± 12.1 years, P < 0.001) with higher rates of diabetes (82.2 vs. 60.9%, P < 0.001) the non-ESKD cohort. Long-term follow-up was available for 58.4% (N = 2,128 procedures) of ESKD patients and 60.8% (N = 13,075 procedures) of non-ESKD patients. At 21 months, ESKD patients had a higher mortality (41.7 vs. 17.4%, P < 0.001) and a higher amputation rate (22.3 vs. 7.1%, P < 0.001); however, they had a lower reintervention rate (13.2 vs. 24.6%, P < 0.001).

CONCLUSIONS

CLTI patients with ESKD have worse long-term outcomes at 2 years following PVI than non-ESKD patients. Mortality and amputation are higher with ESKD, while the reintervention rate is lower. Development of guidelines within the ESKD population has the potential to improve limb salvage.

Angiotensin II Type 1 Receptor Blocker Prevents Abdominal Aortic Aneurysm Progression in Osteoprotegerin-Deficient Mice via Upregulation of Angiotensin (1-7)

Background Angiotensin II type 1 receptor blockers (ARBs) have been shown to limit the growth of abdominal aortic aneurysm (AAA), but their efficacy is controversial. This study aimed to investigate the molecular mechanism underlying the protective effect of ARBs against AAA progression. Methods and Results Olmesartan, an ARB, was administered to wild-type and osteoprotegerin-knockout (Opg-KO) mice starting 2 weeks before direct application of CaCl₂ to aortas to induce AAA. The protective effect of olmesartan against AAA in wild-type and Opg-KO mice was compared at 6 weeks after AAA induction. Olmesartan prevented AAA progression in Opg-KO mice, including excessive aortic dilatation and collapse of tunica media, but not in wild-type mice. Deficiency of the Opg gene is known to cause excessive activation of the tumor necrosis factor-related apoptosis-inducing ligand-induced c-Jun N-terminal kinase/matrix metalloproteinase 9 pathway, resulting in prolonged AAA progression. Olmesartan attenuated the upregulation of phosphorylated c-Jun N-terminal kinase and matrix metalloproteinase 9 expression in the aortic wall of Opg-KO mice. In cultured vascular smooth muscle cells, tumor necrosis factor-related apoptosis-inducing ligand-induced c-Jun N-terminal kinase phosphorylation and matrix metalloproteinase 9 expression were inhibited by angiotensin (1-7), the circulating levels of which are increased by ARBs. Furthermore, administering an angiotensin (1-7) antagonist to Opg-KO mice diminished the protective effect of olmesartan against AAA progression. Conclusions Olmesartan prevented AAA progression in Opg-KO mice by upregulating angiotensin (1-7), suggesting that angiotensin (1-7) may be a key factor that mediates the protective effect of ARBs.

Evaluando la experiencia local: primeros 50 casos de reparo endovascular de aneurismas aórticos en Manizales, Colombia

Introducción. En las últimas décadas, la terapia endovascular en aneurismas aórticos abdominales ha ganado un papel representativo en los escenarios quirúrgicos, lo que nos motivó a conocer los resultados de este procedimiento en nuestra población. Métodos. Estudio analítico retrospectivo en el cual se incluyeron los primeros 50 casos de aneurismas aórticos abdominales con terapia endovascular, en la ciudad de Manizales, Colombia, entre los años 2015 y 2021. Se describió la población estudiada, la relación de los antecedentes prequirúrgicos con las complicaciones posoperatorias, la estancia hospitalaria y la mortalidad. Resultados. La edad promedio fue de 73 años, el sexo predominante fue el femenino (72 %), el aneurisma fusiforme fue el tipo más frecuente (63,3 %), con un diámetro promedio de 70 mm (+/- 17,3 mm). En relación con los antecedentes, el más frecuente fue hipertensión arterial (86 %), encontrándose una asociación entre la presencia de enfermedad pulmonar obstructiva crónica e hipertensión arterial con las complicaciones. Se encontró también relación entre el valor de creatinina con las complicaciones. Las complicaciones tempranas fueron de carácter leve en la mayoría de los casos (30,6 %), a diferencia de las tardías, que fueron principalmente graves (12,5 %), asociadas a una mortalidad del 10,2 % y una estancia hospitalaria promedio de 10,8 días (mediana de 5 días). Conclusiones. La población analizada tiene una alta carga de morbilidad, en la cual factores como los antecedentes médicos prequirúrgicos y la función renal, se asocian con una mayor morbilidad postquirúrgica y mortalidad.

Preoperative and ICU Scoring Models for Predicting the In-Hospital Mortality of Patients With Ruptured Abdominal Aortic Aneurysms

OBJECTIVES

This study's objective was to compare several preoperative and intensive care unit (ICU) prognostic scoring systems for predicting the in-hospital mortality of ruptured abdominal aortic aneurysms (RAAAs).

DESIGN

Retrospective cohort study.

SETTING

Single tertiary university center.

PARTICIPANTS

The study comprised 157 patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 157 patients (82% male) presented with RAAA at Charité University Hospital from January 2011 to December 2020. The mean age was 74 years (standard deviation ten years). In-hospital mortality was 29% (n = 45), of whom nine patients (6%) died en route to the operating room, 13 (8%) on the operating table, and 23 (15%) in the ICU. A total of 135 patients (86%) were admitted to the ICU. All six models demonstrated good discriminating performance between survivors and nonsurvivors. Overall, the area under the curve (AUC) for RAAA preoperative scores was greater than those for ICU scores. The largest AUC was achieved with the Vascular Study Group of New England (VSGNE) RAAA risk score (AUC = 0.87 for all patients, AUC = 0.84 for patients admitted to the ICU), followed by Hardman Index (AUC = 0.83 for all patients, AUC = 0.81 for patients admitted to the ICU), and Glasgow Aneurysm Score (AUC = 0.74 for all patients, AUC = 0.83 for patients admitted to the ICU). The largest AUC for ICU scores (only patients admitted to the ICU) was achieved with Simplified Acute Physiology Score II (0.75), followed by Sepsis-related Organ Failure Assessment (0.73), and Acute Physiology and Chronic Health Evaluation II (0.71).

CONCLUSIONS

Preoperative and ICU scores can predict the mortality of patients presenting with RAAA. In addition, the discriminatory ability of preoperative scores between survivors and nonsurvivors was larger than that for ICU scores.

Preoperative risk score accuracy confirmed in a modern ruptured abdominal aortic aneurysm experience

OBJECTIVE

Various risk score calculators used to predict 30-day mortality after treatment of ruptured abdominal aortic aneurysms (rAAAs) have produced mixed results regarding their usefulness and reproducibility. We prospectively validated the accuracy of our preoperative scoring system in a modern cohort of patients with rAAAs.

METHODS

A retrospective review of all patients wiith rAAAs who had presented to a single academic center from January 2002 to December 2018 was performed. The patients were divided into three cohorts according to when the institutional practice changes had occurred: the pre-endovascular aneurysm repair (EVAR) era (January 2002 to July 2007), the pre-Harbor View risk score era (August 2007 to October 2013), and the modern era (November 2013 to December 2018). The primary outcome measure was 30-day mortality. Our preoperative risk score assigns 1 point for each of the following: age >76 years, pH <7.2, creatinine >2 mg/dL, and any episode of hypotension (systolic blood pressure <70 mm Hg). The previously reported mortality from a retrospective analysis of the first two cohorts was 22% for 1 point, 69% for 2 points, 78% for 3 points, and 100% for 4 points. The goal of the present study was to prospectively validate the Harborview scoring system in the modern era.

RESULTS

During the 17-year study period, 417 patients with rAAAs were treated at our institution. Of the 118 patients treated in the modern era, 45 (38.1%) had undergone open aneurysm repair (OAR), 61 (51.7%) had undergone EVAR, and 12 (10.2%) had received comfort measures only. Excluding the 12 patients without aneurysm repair, we found a statistically significant linear trend between the preoperative risk score and subsequent 30-day mortality for all patients combined (P < .0001), for OAR patients alone (P = .0003), and for EVAR patients alone (P < .0001). After adjustment for the Harborview risk score, the 30-day mortality was 41.3% vs 31.6% after OAR vs EVAR, respectively (P = .2). For all repairs, the 30-day mortality was 14.6% for a score of 0, 35.7% for a score of 1, 68.4% for a score of 2, and 100% for a score of 3 or 4.

CONCLUSIONS

Our results, representing one of the largest modern series of rAAAs treated at a single institution, have confirmed the accuracy of a simple 4-point preoperative risk score in predicting 30-day mortality in the modern rAAA patient. Such tools should be used when discussing the treatment options with referring physicians, patients, and their family members to help guide transfer and treatment decision-making.

Readmission and Utilization After Repair of Ruptured Abdominal Aortic Aneurysms in the United States

OBJECTIVES

Endovascular aneurysm repair (EVAR) has emerged as a less invasive alternative to open repair for ruptured Abdominal Aortic Aneurysms (rAAA), but comparisons to traditional open rAAA repair and late complications leading to readmission are limited.

MATERIALS AND METHODS

Hospitalizations for patients undergoing repair for rAAA were selected from the Nationwide Readmissions Database (NRD). In-hospital mortality, complications, 30-day readmission, readmission diagnoses, and charges were evaluated. Design-adjusted chi-square, Wilcoxon test, and logistic regression were used for analysis.

RESULTS

During 2014-2016, 3,629 open rAAA and 5,037 EVAR were identified. The index mortality rate was 21.4% for EVAR vs. 33.5% for open (p < .0001). Median index length of stay (LOS) was 4.9 days for EVAR vs. 8.6 days for open repair (p < 0.001). All-cause 30-day readmission after rAAA was higher following EVAR (18.9%) than open (14.3%, p = .007). Time to readmission and charges for readmission stays did not differ between procedure groups. Respiratory complications were more common following open repair than EVAR (20.4% vs 11.4%, respectively; p = .008). Patients who underwent open repair suffered more infectious complications than patients treated with EVAR during readmission (49.2% vs 39.8%, respectively; p = 0.054). In multivariable analysis, factors associated with readmission included having EVAR during the index stay (Odds ratio [OR] = 1.46, 95% confidence interval [CI] 1.14-1.88; p = .003), increased length of index stay (OR = 1.01; 95% CI 1.01-1.02; p = 0.002), chronic kidney disease (OR = 1.51; 95% CI 1.18-1.94; p = .001), and coronary artery disease (OR = 1.32; 95% CI 1.02-1.71; p = .034). Aggregate readmission charges totaled $79 million. Readmissions were most often infectious complications for both repair types.

CONCLUSIONS

EVAR was used more often than open repair for rAAA. In-hospital mortality and length of the index stay were significantly lower following EVAR. After multivariable adjustment, the odds of readmission were 1.5 times higher after EVAR, costing the health system more over time when prevalence and readmission are considered. Coronary artery disease, chronic kidney disease, and index length of stay were also associated with 30-day readmission. Further investigation into reasons why a less invasive procedure, EVAR, has a higher readmission rate and understanding post-discharge infectious complications may help lower overall health care utilization after rAAA.

Feasibility of Intraoperative Fusion Imaging Using Non-Contrast CT Scan for EVAR in Ruptured Abdominal Aortic Aneurysm

Introduction

Acute renal failure is a frequent major complication (24%) of endovascular repair for ruptured abdominal aneurysm (rAAA). Iodinated contrast media is known to be nephrotoxic. This report describes a case of endovascular aneurysm repair (EVAR) under fusion imaging guidance in a patient diagnosed with a rAAA after non-contrast CT. Written consent was obtained from the patient.

Report

A 73 year old patient with stage IV chronic kidney failure and contrast-induced nephropathy was diagnosed with rAAA using non-contrast CT. Subsequently, the patient was treated with EVAR using fusion imaging.

Discussion

EVAR with fusion imaging after non-contrast CT was safe in a patient with rAAA. It could represent an option for patients with acute renal failure in emergency settings.

Endovascular Repair of a Ruptured Thoracoabdominal Aortic Aneurysm With the Sandwich Technique: A Case Report

INTRODUCTION

aortic aneurysms involving the renal and visceral arteries are endovascular challenges, especially for emergencies. We report a case of ruptured thoracoabdominal aortic aneurysm (TAAA) in a morbidly obese 71-year-old man. The patient was admitted with a stable hemodynamic state. A computed tomography angiogram (CTA) revealed a contained ruptured TAAA with an occluded celiac trunk and left renal artery due to previous nephrectomy. Due to the emergency and his comorbidities, we performed an endovascular aortic repair with the sandwich technique and 2 chimneys. Two bridging stents (chimneys) were deployed between the aorta and the target vessels (superior mesenteric and right renal arteries) in a space created in-between 2 aortic straight endografts. Ten days postoperative, acute renal failure appeared and right renal stent occlusion was diagnosed on CTA. Unfortunately, no adequate kidney revascularization could be obtained, requiring permanent hemodialysis. At a 3-month follow-up visit, the patient did well with stable aneurysm dimensions.

CONCLUSIONS

encouraging outcomes of chimney-EVAR techniques, comparable to those in published reports of fenestrated-EVAR and branched-EVAR, support this procedure as a valid off-the-shelf available alternative in emergency situations. Nevertheless, only few midterm results achieved are actually available and long-term outcomes are actually unknown.

A meta-analysis of locoregional anesthesia versus general anesthesia in endovascular repair of ruptured abdominal aortic aneurysm

OBJECTIVE

To conduct a meta-analytic review of studies investigating the effect of the anesthesia modality on perioperative mortality in endovascular repair of ruptured abdominal aortic aneurysms (REVAR).

METHODS

The present meta-analysis was performed in accordance with the PRISMA guidelines. Multiple electronic databases were comprehensively searched from database inception to January 2020. Eligible studies included cohort studies that reported the 30-day/in-hospital mortality rate or the multivariate adjusted odds ratio (OR) or hazard ratio of the mortality risk for patients who underwent emergency REVAR under locoregional anesthesia (LA) vs general anesthesia (GA). A random effects model was used to estimate the ORs by pooling the related data from individual studies.

RESULTS

A total of eight studies were included in this analysis. The first meta-analysis of seven studies that reported the 30-day/in-hospital mortality with a total of 3116 patients (867 in the LA group and 2249 in the GA group) revealed that LA was associated with a lower 30-day/in-hospital mortality than GA (16.4% vs 25.4%; unadjusted OR, 0.47; 95% confidence interval [CI], 0.32-0.68). The second meta-analysis of three of these seven studies (including 586 patients in the LA group and 1945 in the GA group) that reported the perioperative variables revealed comparable baseline characteristics but a lower 30-day/in-hospital mortality in the LA group (unadjusted OR, 0.55; 95% CI, 0.42-0.71). The third meta-analysis of the adjusted ORs or hazard ratios that were reported from four studies (including 501 patients in the LA group and 1136 in the GA group) showed a similar trend (adjusted OR,0.37; 95% CI, 0.19-0.75).

CONCLUSIONS

REVAR under LA is associated with a lower 30-day/in-hospital mortality than REVAR under GA. However, because the included studies may have had some observation bias, further randomized controlled trials are warranted to validate the present results.

Modern mortality risk stratification scores accurately and equally predict real-world postoperative mortality after ruptured abdominal aortic aneurysm

OBJECTIVE

It is often unclear which patients presenting with a ruptured abdominal aortic aneurysm (rAAA) are likely to survive after surgery. The Harborview Medical Center (HMC), Dutch Aneurysm Score (DAS), and Vascular Study Group of New England (VSGNE) risk scores have been recent attempts at predicting mortality in this setting. We compared the prognostic value of these scoring systems for patients at our institution with rAAA.

METHODS

A retrospective chart review was performed for all patients who received surgery at our institution for rAAA between January 1, 2011, and November 27, 2019. The χ², Fisher's exact, and t-tests were used to screen preoperative variables against in-hospital mortality. HMC, DAS, and VSGNE scores were calculated for each patient and tested against in-hospital mortality. Logistic regression and receiver operating characteristic curves were used to assess performance of each scoring system.

RESULTS

Sixty-four patients were identified during the study period. Fifteen patients were excluded because 4 patients chose comfort care and an additional 11 patients were missing key variables. The final cohort for analysis included 49 patients who underwent surgery, including 33 patients receiving endovascular repair and 16 patients receiving open repair. The in-hospital mortality was 37% (24% for endovascular repair vs 63% for open repair). Individual variables associated with in-hospital mortality were lowest preoperative systolic blood pressure (P = .036), creatinine greater than 2.0 mg/dL (P = .020), first recorded intraoperative pH (P = .007), and use of suprarenal aortic control (P = .025), and preoperative cardiac arrest approached significance (P = .051). Plots of the HMC and VSGNE scores vs in-hospital mortality rate produced linear relationships (R² = 0.97 and R² = 0.93, respectively), in which a higher score was associated with a greater likelihood of mortality. On logistic regression analysis using HMC score components, creatinine greater than 2.0 mg/dL produced a significant association with in-hospital mortality (odds ratio, 12.3; 95% confidence interval [CI], 1.1-131.7). Similar analysis using VSGNE components produced a significant association between suprarenal aortic control and in-hospital mortality (odds ratio, 5.5; 95% CI, 1.2-25.5). receiver operating characteristic curves produced an area under the curve of 0.74 (95% CI, 0.60-0.88), 0.73 (95% CI, 0.58-0.87), and 0.67 (95% CI, 0.51-0.83) for the HMC, VSGNE, and DAS, respectively.

CONCLUSIONS

The HMC, VSGNE, and DAS scores performed similarly and adequately predicted in-hospital mortality after rAAA. The HMC score holds the added benefit of using preoperative variables, setting it apart as a valid prognostic indicator in the preoperative setting.

Trends in management and outcomes of vascular emergencies in the nationwide inpatient sample

Summary: Background: To evaluate trends in frequency, mortality and treatment for non-traumatic vascular emergencies (VE) in the US. Methods: VE in the Nationwide Inpatient Sample (2005–2014) were identified. ICD-9 CM diagnosis and procedures codes captured six common VE. Results: 228,210,504 emergency admissions with 317,396 procedures for VE were estimated. Mean age was 67.8 years and were primarily men (56.1 %; p < 0.0001). The commonest VE was Acute Limb Ischemia (ALI) (82.4 %) followed by ruptured AAA (10.8 %) and Acute Mesenteric Ischemia (4.71 %). VE increased from 132.8 per 100,000 admissions in 2005 to 153.6 in 2014 (p < 0.001), with mortality decrease for all VE (13.8 % vs. 9.1 %; p < 0.0001). Length of stay decreased (median 8 vs. 7 days; p < 0.0001) but cost of care increased (median $ 25,443 vs. $ 29,353; p < 0.0001). Endovascular treatment increased overall for VE from 23.7 % in 2005 to 37.2 % in 2014 (p < 0.0001). Hospital mortality for VE decreased overall, except ruptured thoracoabdominal aortic aneurysm with mortality decrease with endovascular treatment (34.3 vs. 11.1; p = 0.04) and mortality increase with open treatment (44.7 vs. 47.6; p = 0.06). ALI overall mortality decreased from 8.1 % to 5.7 % (p < 0.0001) due to reduced open surgical mortality from 9.6 % to 7.4 % (p < 0.0001); endovascular mortality did not improve over time (4.0 % vs. 3.4 %; p = 0.45). Hospital mortality also increased for endovascular treatment of ruptured thoracic aortic aneurysm (rTAA) from 14.9 % to 27.4 % (p = 0.0003) during this period. Conclusions: VE frequency increased with a decrease in overall mortality over time. Overall hospital stay has decreased but with an increase in the cost of care. Open surgical mortality for VE has also decreased overall, suggesting perioperative care improvements, with the exception of ruptured thoracoabdominal aortic aneurysm. Endovascular utilization for VE has significantly increased; associated with lower mortality for most VE, although an increase in hospital mortality after endovascular repair of rTAA was seen. This may be due to an increased implementation of endovascular repair for patients not previously eligible for surgery due to high risk. We recommend careful selection of patients for rTAA treatment as mortality has increased despite endovascular therapy and at an increased cost of care.

Outcomes and Risk Factors Associated with Prolonged Intubation after EVAR

BACKGROUND

Time to discharge has decreased for aortic surgery since the advent of endovascular aortic aneurysm repair (EVAR), partially due to improved perioperative management. We aimed to investigate outcomes and risk factors associated with prolonged intubation following EVAR.

METHODS

The Vascular Study Group of New England (VSGNE) database was queried to select all patients who underwent elective EVAR between January 2003 and December 2014. Patients who were not extubated in the operating room were classified as having prolonged intubation. Patients requiring prolonged intubation were compared with those extubated in the operating room using t-test and chi-square statistics. Kaplan-Meier survival analyses estimated all-cause mortality. Independent predictors associated with prolonged intubation, including postoperative pneumonia or respiratory failure, were examined using multivariable logistic regression.

RESULTS

A total of 3,979 patients were identified within the elective EVAR VSGNE data set, among whom 5.2% required prolonged intubation. Patients with prolonged intubation were older, more frequently female, non-Hispanic, had larger aneurysms, and had a more frequent diagnoses of diabetes, congestive heart failure, coronary artery disease, ejection fraction < 50%, and chronic obstructive pulmonary disease (all P < 0.05). Respiratory complications occurred in 25.5% of patients with prolonged intubation vs. 1.8% of patients who were extubated in the operating room (P < 0.001). Kaplan-Meier survival estimates suggested patients requiring prolonged intubation after EVAR had significantly lower survivals than those who extubated in the operating room (P < 0.05). On multivariable analysis, independent risk factors associated with prolonged intubation included subjective lack of fitness for open procedure (OR: 4.8, 95% confidence interval [CI]: 3.5-8.7), ejection fraction < 50% (1.8, 1.3-2.8), and ASA class >3 (1.5, 1.1-1.7).

CONCLUSIONS

Prolonged intubation following EVAR is associated with increased risk of postoperative respiratory complications, as well as decreased long-term survival. High-risk patients for prolonged intubation, including those deemed subjectively unfit for an open procedure, ejection fraction < 50% and ASA class >3, may not benefit from an elective EVAR.

A Majority of Admitted Patients With Ruptured Abdominal Aortic Aneurysm Undergo and Survive Corrective Treatment: A Population-Based Retrospective Cohort Study

Background

Abdominal aortic aneurysm (AAA) is an asymptomatic, potentially lethal condition predominantly found in elderly. The mortality is 100 % if rupture occurs and left untreated, but even in treated patients the mortality is substantial. Female sex and treatment with open repair rather than endovascular aortic repair (EVAR) have been reported to negatively affect outcome. The objective was to describe the contemporary care and outcome of all treated and untreated patients with ruptured AAA (rAAA) admitted to hospital.

Method

Population-based retrospective investigation, including all patients admitted to the emergency departments within Stockholm County diagnosed with rAAA 2009–2013. All identified patients’ charts (n = 297) were analyzed; the study cohort includes 283 verified patients.

Results

Men were in majority [214 (76 %), 69 (24 %) women] and were younger than women (78 vs 82 years, p < 0.001). A majority of patients were treated (212/283, 75 %), a similar proportion of women and men. Untreated patients had a higher mean age (84 vs 77 years, p < 0.001). The proportion treated with EVAR was 27 %, and they were older than OR treated (79 vs 76 years, p = 0.043). Forty-seven percentage of patients admitted with rAAA survived 30 days, and 62 % of treated patients survived 30 days. The 30-day mortality for women and men was similar.

Conclusions

Our results and other contemporary series show a shift toward a higher rate of treated patients with rAAA, and improving outcomes, similar for women and men. The increased use of EVAR contributes to this improvement in short-term outcome. High age influences the willingness to treat patients with rAAA.

Open versus endovascular repair of ruptured abdominal aortic aneurysms: What have we learned after more than 2 decades of ruptured endovascular aneurysm repair?

BACKGROUND

Ruptured abdominal aortic aneurysm is one of the most difficult clinical problems in surgical practice, with extraordinarily high morbidity and mortality. During the past 23 years, the literature has become replete with reports regarding ruptured endovascular aneurysm repair.

METHODS

A variety of study designs and databases have been utilized to compare ruptured endovascular aneurysm repair and open surgical repair for ruptured abdominal aortic aneurysm and studies of various designs from different databases have yielded vastly different conclusions. It therefore remains controversial whether ruptured endovascular aneurysm repair improves outcomes after ruptured abdominal aortic aneurysm in comparison to open surgical repair.

RESULTS

The purpose of this article is to review the best available evidence comparing ruptured endovascular aneurysm repair and open surgical repair of ruptured abdominal aortic aneurysm, including single institution and multi-institutional retrospective observational studies, large national population-based studies, large national registries of prospectively collected data, and randomized controlled clinical trials.

CONCLUSION

This article will analyze the study designs and databases utilized with their attendant strengths and weaknesses to understand the sometimes vastly different conclusions the studies have reached. This article will attempt to integrate the data to distill some of the lessons that have been learned regarding ruptured endovascular aneurysm repair and identify ongoing needs in this field.

A primer on infrarenal abdominal aortic aneurysms

Ruptured abdominal aortic aneurysms have an alarmingly high mortality rate that often exceeds 50%, even when patients survive long enough to be transported to hospitals. Historical data have shown that ruptures are especially likely to occur with aneurysms measuring ≥6 cm in diameter, but there are so many exceptions to this that several randomized clinical trials have been done in an attempt to determine whether smaller aneurysms should be repaired electively as soon as they are discovered. More recently, further trials have been conducted in order to compare the relative benefits and disadvantages of modern endovascular aneurysm repair to those of traditional open surgery. This review summarizes current evidence from randomized trials and large population-based datasets regarding two questions that are uppermost in the mind of virtually every patient who is found to have an abdominal aortic aneurysm. Should it be fixed? What are the risks?

Open and endovascular aneurysm repair in the Society for Vascular Surgery Vascular Quality Initiative

The Society for Vascular Surgery Vascular Quality Initiative is a patient safety organization and a collection of procedure-based registries that can be utilized for quality improvement initiatives and clinical outcomes research. The Vascular Quality Initiative consists of voluntary participation by centers to collect data prospectively on all consecutive cases within specific registries which physicians and centers elect to participate. The data capture extends from preoperative demographics and risk factors (including indications for operation), through the perioperative period, to outcomes data at up to 1-year of follow-up. Additionally, longer-term follow-up can be achieved by matching with Medicare claims data, providing long-term longitudinal follow-up for a majority of patients within the Vascular Quality Initiative registries. We present the unique characteristics of the Vascular Quality Initiative registries and highlight important insights gained specific to open and endovascular abdominal aortic aneurysm repair.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk stratification for the development of respiratory adverse events following vascular surgery using the Society of Vascular Surgery's Vascular Quality Initiative

OBJECTIVE

Postoperative respiratory adverse events (RAEs) are associated with high rates of morbidity and mortality in general surgery, however, little is known about these complications in the vascular surgery population, a frail subset with multiple comorbidities. The objective of this study was to describe the contemporary incidence of RAEs in vascular surgery patients, the risk factors for this complication, and the overall impact of RAEs on patient outcomes.

METHODS

The Vascular Quality Initiative was queried (2003-2014) for patients who underwent endovascular abdominal aortic repair, open abdominal aortic aneurysm repair, thoracic endovascular aortic repair, suprainguinal bypass, or infrainguinal bypass. A mixed-effects logistic regression model determined the independent risk factors for RAEs. Using a random 85% of the cohort, a risk prediction score for RAEs was created, and the score was validated using the remaining 15% of the cohort, comparing the predicted to the actual incidence of RAE and determining the area under the receiver operating characteristic curve. The independent risk of in-hospital mortality and discharge to a nursing facility associated with RAEs was determined using a mixed-effects logistic regression to control for baseline patient characteristics, operative variables, and other postoperative adverse events.

RESULTS

The cohort consisted of 52,562 patients, with a 5.4% incidence of RAEs. The highest rates of RAEs were seen in current smokers (6.1%), recent acute myocardial infarction (10.1%), symptomatic congestive heart failure (9.9%), chronic obstructive pulmonary disease requiring oxygen therapy (11.0%), urgent and emergent procedures (6.4% and 25.9%, respectively), open abdominal aortic aneurysm repairs (17.6%), in situ suprainguinal bypasses (9.68%), and thoracic endovascular aortic repairs (9.6%). The variables included in the risk prediction score were age, body mass index, smoking status, congestive heart failure severity, chronic obstructive pulmonary disease severity, degree of renal insufficiency, ambulatory status, transfer status, urgency, and operative type. The predicted compared with the actual RAE incidence were highly correlated, with a correlation coefficient of 0.943 (P < .0001) and a c-statistic = 0.818. RAEs had a significantly higher rates of in-hospital mortality (25.4% vs 1.2%; P < .0001; adjusted odds ratio, 5.85; P < .0001), and discharge to a nursing facility (57.8% vs 19.0%; P < .0001; adjusted odds ratio, 3.14; P < .0001).

CONCLUSIONS

RAEs are frequent and one of the strongest risk factors for in-hospital mortality and inability to be discharged home. Our risk prediction score accurately stratifies patients based on key demographics, comorbidities, presentation, and operative type that can be used to guide patient counseling, preoperative optimization, and postoperative management. Furthermore, it may be useful in developing quality benchmarks for RAE following major vascular surgery.

Current treatment strategies for ruptured abdominal aortic aneurysm

BACKGROUND

Ruptured abdominal aortic aneurysm (rAAA) represents one of the most challenging emergencies in surgery. Open repair (OR) is associated with relevant morbidity and mortality and has not been reduced significantly over the last decade. The introduction of endovascular aneurysm repair (EVAR) and its meanwhile common use in the treatment of rAAA has raised the demand for randomised controlled trials (RCTs) in order to resolve a potential superiority of either OR or EVAR.

PURPOSE

This review discusses the current treatment strategies in rAAA repair including diagnostics, peri-operative management and results of OR and EVAR, focussing on RCTs comparing both modalities.

RESULTS

Thirty-day mortality after OR and EVAR shows no significant difference in published RCTs. In particular with respect to OR, 30-day mortality was much lower than anticipated throughout all RCTs ranging from 18 to 37 %. EVAR for rAAA resulted in reduced in-hospital stay. Limitations of all except one RCT are low patient recruitment and exclusion of haemodynamically unstable patients.

CONCLUSIONS

OR and EVAR need to be provided for rAAA. Despite lacking evidence, EVAR is the first choice treatment in experienced high-volume vascular centres. Low mortality rates in all RCTs raise the question if aortic surgery should be centralised.