Short-term and long-term results of endovascular and open repair of abdominal aortic aneurysms in Germany

A computational study of artery curvature and endograft oversize influence on seal zone behavior in endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) is a minimally invasive procedure involving the placement of an endograft inside the dissection or an aneurysm to direct blood flow and prevent rupture. A significant challenge in endovascular surgery is the geometrical mismatch between the endograft and the artery, which can lead to endoleak formation, a condition where blood leaks between the endograft and the vessel wall. This study uses computational modeling to investigate the effects of artery curvature and endograft oversizing, the selection of an endograft with a larger diameter than the artery, on endoleak creation. Finite element analysis is employed to simulate the deployment of endografts in arteries with varying curvature and diameter. Numerical simulations are conducted to assess the seal zone and to quantify the potential endoleak volume as a function of curvature and oversizing. A theoretical framework is developed to explain the mechanisms of endoleak formation along with proof-of-concept experiments. Two main mechanisms of endoleak creation are identified: local buckling due to diameter mismatch and global buckling due to centerline curvature mismatch. Local buckling, characterized by excess graft material buckling and wrinkle formation, increases with higher levels of oversizing, leading to a larger potential endoleak volume. Global buckling, where the endograft bends or deforms to conform to the centerline curvature of the artery, is observed to require a certain degree of oversizing to bridge the curvature mismatch. This study highlights the importance of considering both curvature and diameter mismatch in the design and clinical use of endografts. Understanding the mechanisms of endoleak formation can provide valuable insights for optimizing endograft design and surgical planning, leading to improved clinical outcomes in endovascular aortic procedures.

Activated clotting time-guided heparinization during open AAA surgery: a pilot study

BACKGROUND

Arterial thrombo-embolic complications (TEC) are still common during and after non-cardiac arterial procedures (NCAP). While unfractionated heparin has been used during NCAP for more than 70 years to prevent TEC, there is no consensus regarding the optimal dosing strategy. The aim of this pilot study was to test the effectiveness and feasibility of an activated clotting time (ACT)-guided heparinization protocol during open abdominal aortic aneurysm (AAA) surgery, in anticipation of a randomized controlled trial (RCT) investigating if ACT-guided heparinization leads to better clinical outcomes compared to a single bolus of 5000 IU of heparin.

METHODS

A prospective multicentre pilot study was performed. All patients undergoing elective open repair for an AAA (distal of the superior mesenteric artery) between March 2017 and January 2020 were included. Two heparin dosage protocols were compared: ACT-guided heparinization with an initial dose of 100 IU/kg versus a bolus of 5000 IU. The primary outcome was the effectiveness and feasibility of an ACT-guided heparinization protocol with an initial heparin dose of 100 IU/kg during open AAA surgery. Bleeding complications, TEC, and mortality were investigated for safety purposes.

RESULTS

A total of 50 patients were included in the current study. Eighteen patients received a single dose of 5000 IU of heparin and 32 patients received 100 IU/kg of heparin with additional doses based on the ACT. All patients who received the 100 IU/kg dosing protocol reached the target ACT of > 200 s. In the 5000 IU group, TEC occurred in three patients (17%), versus three patients (9.4%) in the 100 IU/kg group. Bleeding complications were found in six patients (33%) in the 5000 IU group and in 9 patients (28%) in the 100 IU/kg group. No mortality occurred in either group.

CONCLUSIONS

This pilot study demonstrated that ACT-guided heparinization with an initial dose of 100 IU/kg appears to be feasible and leads to adequate anticoagulation levels. Further randomized studies seem feasible and warranted to determine whether ACT-guided heparinization results in better outcomes after open AAA repair.

[Recommendations for the specialist further training of nursing personnel on intensive care units in the treatment of abdominal aortic aneurysms: results of a modified Delphi procedure with experts]

INTRODUCTION

The medical development in the previous 15 years and the changes in treatment reality of the comprehensive elective treatment of abdominal aortic aneurysms necessitate a re-evaluation of the quality assurance guidelines of the Federal Joint Committee in Germany (QBAA-RL). In the current version this requires a specialist further training quota for nursing personnel in intensive care wards of 50%. The quota was determined in 2008 based on expert opinions, although a direct empirical evidence base for this does not exist.

METHODS

Representatives from the fields of patient representation, physicians, nursing personnel and other relevant interface areas were invited to participate in a modified Delphi procedure. Following a comprehensive narrative literature search, a survey and focus group discussions with national and international experts, a total of three anonymized online-based voting rounds were carried out for which previously determined key statements were assessed with a 4‑point Likert scale (totally disagree up to totally agree). In addition, the expert panel had also defined a recommendation for a minimum quota for the specialist training of nursing personnel on intensive care wards in the treatment of abdominal aortic aneurysms, whereby an a priori agreement of 80% of the participants was defined as the consensus limit.

RESULTS

Overall, 37 experts participated in the discussions and three successive voting rounds (participation rate 89%). The panel confirmed the necessity of a re-evaluation of the guideline recommendations and recommended the introduction of a shift-related minimum quota of 30% of the full-time equivalent of nursing personnel on intensive care wards and the introduction of structured promotional programs for long-term elevation of the quota.

CONCLUSION

In this national Delphi procedure with medical and nursing experts as well as representatives of patients, the fundamental benefits and needs of professional specialist qualifications in the field of intensive care medicine were confirmed. The corresponding minimum quota for specialist further training of intensive care nursing personnel should generally apply without limitations to specific groups. The expert panel stipulates a shift-related minimum quota for intensive care nursing personnel with specialist training of 30% of the nursing personnel on intensive care wards and the obligatory introduction of structured and transparent promotion programs for the long-term enhancement.

Editor's Choice - Radiation Dose Reduction During Contralateral Limb Cannulation Using Fiber Optic RealShape Technology in Endovascular Aneurysm Repair

OBJECTIVE

The increasing number of endovascular procedures has resulted in an increasing radiation burden, particularly for the treatment team. Fiber Optic RealShape (FORS) technology uses laser light instead of fluoroscopy to visualise the endovascular guidewire and catheters. These devices can be used during the navigational part of procedures, such as cannulation of the contralateral limb (CL) in endovascular aneurysm repair (EVAR). The aim of this study was to describe the effect of using FORS on radiation dose during CL cannulation in standard EVAR.

METHODS

This was a non-randomised, retrospective comparison study of prospectively collected, single centre data from FORS guided EVAR compared with a conventional fluoroscopy only guided EVAR cohort. A total of 27 FORS guided cases were matched 1:1 based on sex, age, and body mass index (BMI) with 27 regular (fluoroscopy only) EVARs. This study primarily focused on (1) technical success of FORS and (2) navigation time and radiation dose (cumulative air kerma [CAK], air kerma area product [KAP], and fluoroscopy time [FT]) during cannulation of the CL. In addition, overall procedure time and radiation dose of the complete EVAR procedure were studied.

RESULTS

In 22 (81%) of the 27 FORS guided cases the CL was successfully cannulated using FORS. All radiation dose parameters were significantly lower in the FORS group (CAK, p < .001; KAP, p = .009; and FT, p < .001) for an equal navigation time (p = .95). No significant differences were found when comparing outcomes of the complete procedure.

CONCLUSION

Use of FORS technology significantly reduces radiation doses during cannulation of the CL in standard EVAR.

Efficacy of Sac Coil Embolization in Endovascular Aortic Repair for Sac Shrinkage in Patients at a High Risk of Type II Endoleak from Lumbar Arteries

BACKGROUND

In endovascular aortic repair (EVAR), preemptive embolization of sac branch vessels is effective in preventing postoperative type II endoleak (T2EL). However, this technique has not been widely adopted especially for lumbar arteries (LAs) because of technical difficulties and time constraints. This study aimed to investigate the efficacy of nonselective sac coil embolization, which is a simpler surgical method, in postoperative sac shrinkage for patients at a high risk of T2EL from LAs.

METHODS

We retrospectively assessed 76 patients who underwent elective EVAR for abdominal aortic aneurysm with 4 or more patent LAs or at least 1 patent LA of ≥2 mm at our hospital between January 2014 and December 2022. The patients who underwent sac coil embolization were included in Group Ⅰ (n = 20), and the others were divided into 2 groups: those with an inferior mesenteric artery that was originally occluded or embolized by coils or stent graft bodies (Group Ⅱ, n = 21), and those without that (Group Ⅲ, n = 35). In Group Ⅰ, 0.035-inch coils were inserted into the sac after complete stent graft deployment. The cumulative incidence of sac shrinkage (≥5 mm) was compared between the groups. Further, univariable and multivariable Cox regression analyses were used to determine the predictors of sac shrinkage.

RESULTS

Sac shrinkage (≥5 mm) was observed more frequently in Group Ⅰ (50%) than in Group Ⅱ (19%) and Group Ⅲ (17%) (P = 0.052 and 0.043, respectively). The cumulative incidence of sac shrinkage was significantly higher in Group Ⅰ than in Group Ⅱ (log-rank P = 0.039) and Group Ⅲ (log-rank P = 0.024). Multivariable Cox regression analyses revealed that sac embolization was a significant predictor of sac shrinkage (hazard ratio, 4.23; 95% confidence interval, 1.66-10.8; P = 0.003).

CONCLUSIONS

Nonselective sac coil embolization in EVAR is potentially effective for sac shrinkage in the early postoperative phase in patients at high risk of T2EL from LAs. This simple procedure may improve prognosis after EVAR.

Operation time and clinical outcomes for open infrarenal abdominal aortic aneurysms to remain stable in the endovascular era

Objective

Endovascular aortic repair (EVAR) has become a routine procedure worldwide. Ultimately, the increasing number of EVAR cases entails changing conditions for open surgical repair (OSR) regarding patient selection, complexity, and surgical volume. This study aimed to assess the time trends of open abdominal aortic aneurysm (AAA) repair in a high-volume single center in Austria over a period of 20 years, focusing on the operation time and clinical outcomes.

Materials and methods

A retrospective analysis of all patients treated for infrarenal AAAs with OSR or EVAR between January 2000 and December 2019 was performed. Infrarenal AAA was defined as the presence of a >10-mm aortic neck. Cases with ruptured or juxtarenal AAAs were excluded from the analysis. Two cohorts of patients treated with OSR at different time periods, namely, 2000-2009 and 2010-2019, were assessed regarding demographical and procedure details and clinical outcomes. The time periods were defined based on the increasing single-center trend toward the EVAR approach from 2010 onward.

Results

A total of 743 OSR and 766 EVAR procedures were performed. Of OSR cases, 589 were infrarenal AAAs. Over time, the EVAR to OSR ratio was stable at around 50:50 (p = 0.488). After 2010, history of coronary arterial bypass (13.4% vs. 7.2%, p = 0.027), coronary artery disease (38.1% vs. 25.1%, p = 0.004), peripheral vascular disease (35.1% vs. 21.3%, p = 0.001), and smoking (61.6% vs. 34.3%, p < 0.001) decreased significantly. Age decreased from 68 to 66 years (p = 0.023). The operation time for OSR remained stable (215 vs. 225 min, first vs. second time period, respectively, p = 0.354). The intraoperative (5.8% vs. 7.2%, p = 0.502) and postoperative (18.3% vs. 20.8%, p = 0.479) complication rates also remained stable. The 30-day mortality rate did not change over both time periods (3.0% vs. 2.4%, p = 0.666).

Conclusion

Balanced EVAR to OSR ratio, similar complexity of cases, and volume over the two decades in OSR showed stable OSR time without compromise in clinical outcomes.

Long-Term Outcome of Intact Abdominal Aortic Aneurysm After Endovascular or Open Repair

OBJECTIVE

Endovascular aortic aneurysm repair (EVAR) has been established as a standard treatment option for intact abdominal aortic aneurysm (iAAA) and gained importance due to a lower perioperative mortality than open repair (OAR). However, whether this survival advantage can be maintained or if OAR is beneficial in terms of long-term complications and reinterventions remains questionable.

DESIGN

In this retrospective cohort study data from patients undergoing elective EVAR or OAR for iAAAs in the years 2010-2016 was analyzed. The patients were followed through 2018.

METHODS

In the propensity score matched cohorts the perioperative and long-term outcomes of the patients were assessed. We identified 20 683 patients undergoing elective iAAA repair (76.4% EVAR). The propensity matched cohorts included 4886 pairs of patients.

RESULTS

The perioperative mortality was 1.9% for EVAR and 5.9% for OAR (P = <.001). The perioperative mortality was mainly influenced by patients age (Odds-Ratio (OR):1.073, confidence interval (CI):1.058-1.088, P ≤ .001) and OAR (OR:3.242, CI:2.552-4.119, P ≤ .001). The early survival benefit after endovascular repair persisted for approximately 3 years (estimated survival EVAR 82.3%, OAR 80.9%, P = .021). After that time the estimated survival curves were similar. After 9 years the estimated survival was 51.2% after EVAR as compared to 52.8% after OAR (P = .102). The operation method didn't influence long-term survival significantly (Hazard-Ratio (HR): 1.046, CI: .975-1.122, P = .211). The vascular reintervention rate was 17.4% in the EVAR cohort and 7.1% in the OAR cohort (P ≤ .001).

CONCLUSION

EVAR has a significantly lower perioperative mortality than OAR, a survival benefit that lasts up to 3 years after intervention. Thereafter, no significant difference in survival was observed between EVAR and OAR. The decision between EVAR or OAR may depend on patient preference, surgeons' experience, and the institutions' ability to handle complications.

Early outcomes of the Conformable endograft in severe neck angulation from the Triveneto Conformable Registry

OBJECTIVE

The study reports retrospective evaluation of early outcomes from a multicentric experience with the Excluder conformable endograft with active control system (CEXC Device) in the treatment of abdominal aortic aneurysms. Its design allows more flexibility, given by proximal unconnected stent rows and a bending wire within the delivery catheter enables control of proximal angulation. This study specifically focuses on the severe neck angulation (SNA) subgroup (≥60°).

METHODS

All patients treated with CEXC Device in nine vascular surgery centers of Triveneto area (Northeast Italy) between January 2019 and July 2022 were enrolled prospectively and analyzed retrospectively. Demographic and aortic anatomical characteristics were evaluated. Endovascular aneurysm repair in SNA were selected for analysis. Major investigated outcomes were technical success, endoleaks, morbidity, mortality, and reinterventions at 30 days and during follow-up. Endograft migration and postoperative aortic neck angulation changes were also analyzed.

RESULTS

A total of 129 patients were enrolled. An infrarenal angle of ≥60° was observed in 56 patients (43%) (SNA group) and their data analyzed. The mean patient age was 78.9 ± 5.9 years and median abdominal aortic aneurysm diameter 59 mm (range, 45-94 mm). Median aortic infrarenal neck length, angulation and diameter were 22 mm (range, 13-58 mm), 77° (range, 60°-150°), and 22.0 ± 3.5 mm respectively. Analysis revealed a technical success rate of 100% and perioperative major complication rate of 1.7%. Intraoperative and perioperative morbidity and mortality rates were 3.5% (one buttock claudication and one inguinal surgical cutdown) and 0%, respectively. No perioperative type I endoleaks were observed. The median follow-up was 13 months (range, 1-40 months). Five patients died during follow-up from aneurysm-unrelated causes. Two reinterventions occurred (3.5%): one conversion for a type IA endoleak and one sac embolization for a type II endoleak. Aneurysm sac shrinkage was observed in 15 patients (26%) and aneurysm stability in 35 patients (62%), respectively. Estimated freedom from reinterventions at 24 months was 92%. Aortic neck median postoperative angulation was 75° (range, 45°-139°).

CONCLUSIONS

The Triveneto Conformable Registry shows good early results of the CEXC device in severely angulated aortic infrarenal necks. These data need confirmation on longer follow-up and a wider cohort of patients to further increase endovascular aneurysm repair eligibility in SNA.

Long-term Mortality and Reintervention After Endovascular and Open Abdominal Aortic Aneurysm Repairs in Australia, Germany, and the United States

OBJECTIVE

To examine long-term outcomes after endovascular (EVAR) and open repairs (OAR) for intact abdominal aortic aneurysms in Australia, Germany, and the United States, using a unified study design.

BACKGROUND

Similarities and differences in long-term outcomes after EVAR versus OAR across countries remained unclear, given differences in designs across existing studies.

METHODS

We identified patients aged >65 years undergoing intact abdominal aortic aneurysm repairs during 2010-2017/2018. We compared long-term patient mortality and reintervention after EVAR and OAR using Kaplan-Meier analyses and Cox regressions. Propensity score matching was performed within each country to adjust for differences in baseline patient characteristics between procedure groups.

RESULTS

We included 3311, 4909, and 145363 patients from Australia, Germany, and the United States, respectively. The median patient age was 76 to 77 years, and most patients were males (77%-84%). Patient mortality was lower after EVAR than OAR within the first 60 days and became similar at 3-year follow-up (Australia 14.7% vs 16.5%, Germany 18.2% vs 19.7%, United States: 24.4% vs 24.4%). At the end of follow-up, patient mortality after EVAR was higher than OAR in Australia [ hazard ratio (HR) 95% CI: 1.21 (0.96-1.54)] but similar to OAR in Germany [HR 95% CI: 0.92 (0.80-1.07)] and the United States [HR 95% CI: 1.02 (0.99-1.05)]. The risk of reintervention after EVAR was more than twice that after OAR in Australia [HR 95% CI: 2.60 (1.09-6.15)], Germany [HR 95% CI: 4.79 (2.56-8.98)], and the United States [HR 95% CI: 2.67 (2.38-3.00)]. The difference in reintervention risk appeared early in German and United States patients.

CONCLUSIONS

This multinational study demonstrated important similarities in long-term outcomes after EVAR versus OAR across 3 countries. Variation in long-term mortality and reintervention comparisons indicates possible differences in patient profiles, surveillance, and best medical therapy across countries.

Outcomes and Cost-Analysis of Open Versus Endovascular Abdominal Aortic Aneurysm Repair in a Developing Country: A 15-year Experience at a Tertiary Medical Center

BACKGROUND

Endovascular aortic aneurysm repair (EVAR) has become the most common procedure for treating abdominal aortic aneurysms based on multiple studies conducted in the western world. The implication of such findings in developing countries is not well demonstrated. The objective of this study was to compare medical outcomes and costs of EVAR and open surgical repair (OSR) in a developing country.

METHODS

This is a retrospective study of all patients undergoing elective abdominal aortic aneurysm repair between 2005 and 2020 at a tertiary medical center in a developing country. Medical records were used to retrieve demographics, comorbidities, and perioperative complications. Medical records were also used to provide data on the need of reintervention, date of last follow-up, and mortality.

RESULTS

The study included a total of 164 patients. Median follow-up time was 41 months. The mean age was 69.9 +/- 7.84 years and 90.24% (n = 148) of patients were males. Regarding long-term mortality outcomes, no significant difference was detected between both groups; OSR patients had a survival rate of 91.38% and 74.86% at 5 and 10 years, compared to 77.29% and 56.52% in the EVAR group (P value = 0.10). Both groups had comparable long-term reintervention rates (P value = 0.334). The OSR group was charged significantly less than the EVAR group ($27,666.35 vs. $44,528.04, P value = 0.008).

CONCLUSIONS

OSR and EVAR have comparable survival and reintervention outcomes. Unlike what was reported in developed countries, patients undergoing OSR in countries with low hospital stay costs incur lower treatment costs.

Cost-Effectiveness of Open Repair of Abdominal Aortic Aneurysms with a Novel Perioperative Protocol

BACKGROUND

In 2015, a novel perioperative protocol (nPOP), comprising of 19 evidence-based interventions, was adopted as a standard practice for open repair of abdominal aortic aneurysms (AAA) at the Humanitas Clinical and Research Center (Milan, Italy). Its implementation translated into lower complication rates, faster ambulation and return of bowel function, better nausea/vomiting and pain control, and, consequently, a shorter length of hospital stay. Because value of a patient's care cycle can be defined as clinical outcomes relative to costs, we aimed to analyze the cost-effectiveness of nPOP compared to the previously implemented protocols.

METHODS

Three groups were identified and retrospectively analyzed: (A) 66 patients (September 2007 to March 2009) treated according to the traditional protocol; (B) 225 patients (April 2009 to March 2015) treated in line with a transitional protocol, incorporating 5 perioperative interventions; and (C) 103 patients (April 2015 to February 2019) treated according to nPOP. For each group a monetary value of required clinical resources and the actual total cost per patient from admission to discharge were determined. The following were analyzed (including nurse and anesthesiologist time): diagnostic tests, medications, materials, operating time, surgical team time, blood transfusion, ward stay, and intensive care unit stay. Two indicators of effectiveness were determined based on the postoperative outcomes: complication-free incidents and relative shortening of hospitalization time. A cost (€) of an improvement in effectiveness (%) was calculated.

RESULTS

Alongside enhancement of clinical outcomes, nPOP constituted the cheapest approach. It consumed the least human and material resources, resulting in the direct reduction in the overall clinical cost per patient. The length-of-stay variable provided the largest reduction in total costs. The actual total clinical cost per patient in Group C was 26% lower than in Group A (4,437€ vs. 6,005€) and 39% lower than in Group B (4,437€ vs. 7,305€). Every unit of enhancement of clinical outcomes was 2.43 times more expensive for the traditional protocol and 2.23 times more costly for the transitional protocol compared to nPOP, making it the most cost-effective.

CONCLUSIONS

The nPOP for AAA open repair is not inferior to other perioperative protocols while allowing for efficient utilization of limited hospital resources, thus creating a high social value. The proposed methods for cost-effectiveness analysis are easily reproducible and therefore can be applied in future projects ranging from a micro- to a macro-economic scale.

Advancing the Real-World Evidence for Medical Devices through Coordinated Registry Networks

Objectives

Generating and using real-world evidence (RWE) is a pragmatic solution for evaluating health technologies. RWE is recognized by regulators, health technology assessors, clinicians, and manufacturers as a valid source of information to support their decision-making. Well-designed registries can provide RWE and become more powerful when linked with electronic health records and administrative databases in coordinated registry networks (CRNs). Our objective was to create a framework of maturity of CRNs and registries, so guiding their development and the prioritization of funding.

Design, setting, and participants

We invited 52 stakeholders from diverse backgrounds including patient advocacy groups, academic, clinical, industry and regulatory experts to participate on a Delphi survey. Of those invited, 42 participated in the survey to provide feedback on the maturity framework for CRNs and registries. An expert panel reviewed the responses to refine the framework until the target consensus of 80% was reached. Two rounds of the Delphi were distributed via Qualtrics online platform from July to August 2020 and from October to November 2020.

Main outcome measures

Consensus on the maturity framework for CRNs and registries consisted of seven domains (unique device identification, efficient data collection, data quality, product life cycle approach, governance and sustainability, quality improvement, and patient-reported outcomes), each presented with five levels of maturity.

Results

Of 52 invited experts, 41 (79.9%) responded to round 1; all 41 responded to round 2; and consensus was reached for most domains. The expert panel resolved the disagreements and final consensus estimates ranged from 80.5% to 92.7% for seven domains.

Conclusions

We have developed a robust framework to assess the maturity of any CRN (or registry) to provide reliable RWE. This framework will promote harmonization of approaches to RWE generation across different disciplines and health systems. The domains and their levels may evolve over time as new solutions become available.

[Perioperative lethality after endovascular and open repair of ruptured abdominal aortic aneurysms: An analysis of administrative data of the AOK health insurance fund]

OBJECTIVE

In this paper we will report the perioperative outcome after endovascular (EVAR) and open (OAR) repair of ruptured abdominal aortic aneurysms (rAAA) in Germany based on data of the AOK health insurance fund.

METHODS

Anonymised data of all patients with rAAA (n = 3,227) who were treated from 01/01/2010 to 12/31/2016 were analysed, using SPSS 27 (IBM Deutschland GmbH, Ehningen, Germany).

RESULTS

41.9% (1,353/3,227) of the patients were treated with EVAR and 58.1% (1,874/3,227) with OAR. Patients ≥80 years made up 38.4% for EVAR and 32.9% for OAR (p = 0.002). The proportion of patients undergoing surgery within 24 hours after admission was significantly higher for OAR (87.8%) than for EVAR (73.0%) (p = 0.000). The perioperative lethality rate for OAR was 42.4%, and thus almost twice as high as for EVAR with 21.3% (p = 0.000). Women had higher perioperative lethality rates for both EVAR (perioperative lethality 24.6%) and OAR (perioperative lethality 51.7%) compared to men with 20.6% (EVAR) and 40.2% (OAR), respectively. With EVAR, 35.8% of the patients showed a complication-free postoperative course, with OAR it was 17.7% (p = 0.000). Blood transfusions (whole blood, red cell concentrates, and autotransfusions) were administered in 57.6% of the patients with EVAR, but in 92.3% with OAR (p = 0.000). The highest perioperative lethality was found in EVAR and OAR patients who received both surgery within 24 hours after admission and blood transfusions (perioperative lethality EVAR 36.0%, OAR 46.0%; p = 0.000). In contrast, patients who did not require blood transfusions and were treated later than 24 hours after admission had the lowest perioperative lethality with 3.2% for EVAR vs. 5.4% for OAR (p = 0.623).

CONCLUSION

The data confirm the observation that the perioperative mortality of rAAA patients is lower with EVAR than with OAR. However, strict attention must be paid to the time of the intervention. The low perioperative lethality of patients who were treated later than 24 hours after hospital admission and who did not require blood transfusions indicates that cases of symptomatic AAA without rupture have also been recorded in this administrative database under the diagnosis rAAA. One point of criticism is that the decision not to adjust for the patient groups with EVAR and with OAR in order to be able to better analyse the properties of routine data includes a considerable risk of bias in the statements of this work due to confounding variables.

Endovascular versus open repair in patients with abdominal aortic aneurysm: a claims-based data analysis in Japan

Objectives

Endovascular aortic repair (EVAR) evolved through competition with open aortic repair (OAR) as a safe and effective treatment option for appropriately selected patients with abdominal aortic aneurysm (AAA). Although endoleaks are the most common reason for post-EVAR reintervention, compliance with lifelong regular follow-up imaging remains a challenge.

Design

Retrospective data analysis.

Setting

The Japan Medical Data Center (JMDC), a claims database with anonymous data linkage across hospitals, consists of corporate employees and their families of ≤75 years of age.

Participants

The analysis included participants in the JMDC who underwent EVAR or OAR for intact (iAAA) or ruptured (rAAA) AAA. Patients with less than 6 months of records before the aortic repair were excluded.

Main outcome measures

Overall survival and reintervention rates.

Results

We identified 986 cases (837 iAAA and 149 rAAA) from JMDC with first aortic repairs between January 2015 and December 2020. The number of patients, median age (years (IQR)), follow-up (months) and post-procedure CT scan (times per year) were as follows: iAAA (OAR: n=593, 62.0 (57.0–67.0), 26.0, 1.6, EVAR: n=244, 65.0 (31.0–69.0), 17.0, 2.2), rAAA (OAR: n=110, 59.0 (53.0–59.0), 16.0, 2.1, EVAR: n=39, 62.0 (31.0–67.0), 18.0, 2.4). Reintervention rate was significantly higher among EVAR than OAR in rAAA (15.4% vs 8.2%, p=0.04). In iAAA, there were no group difference after 5 years (7.8% vs 11.0%, p=0.28), even though EVAR had initial advantage. There were no differences in mortality rate between EVAR and OAR for either rAAA or iAAA.

Conclusions

Claims-based analysis in Japan showed no statistically significant difference in 5-year survival rates of the OAR and EVAR groups. However, the reintervention rate of EVAR in rAAA was significantly higher, suggesting the need for regular post-EVAR follow-up with imaging. Therefore, international collaborations for long-term outcome studies with real-world data are warranted.

New tools to reduce radiation exposure during aortic endovascular procedures

INTRODUCTION

The evolution of endovascular surgery over the past 30 years has made it possible to treat increasingly complex vascular pathologies with an endovascular method. Although this generally speeds up the patient's recovery, the risks of health problems caused by long-term exposure to radioactive radiation increase. This warrants the demand for radiation-reducing tools to reduce radiation exposure during these procedures.

AREAS COVERED

For this systematic review Pubmed, Embase and Cochrane library databases were searched on 28 December 2021 to provide an overview of tools that are currently used or have the potential to contribute to reducing radiation exposure during endovascular aortic procedures. In addition, an overview is presented of radiation characteristics of clinical studies comparing a (potential) radiation-reducing device with conventional fluoroscopy use.

EXPERT OPINION

Radiation-reducing instruments such as fiber optic shape sensing or electromagnetic tracking devices offer the possibility to further reduce or even eliminate the use of radiation during endovascular procedures. In an era of increasing endovascular interventional complexity and awareness of the health risks of long-term radiation exposure, the use of these technologies could have a major impact on an ongoing challenge to move toward radiation-free endovascular surgery.

Endovascular Treatment of Abdominal Aortic Aneurysm With Severe Angulation of Infrarenal Aortic Neck by Gore Conformable Endograft

INTRODUCTION

The aim of the study is to report a single-center experience with the Gore Excluder conformable endograft with active control system (CEXC Device, W.L. Gore and Associates, Flagstaff, AZ, USA) in abdominal aortic aneurysms (AAAs) with severe infrarenal neck angulation.

METHODS

All patients underwent EVAR with CEXC Device between September 2018 and 2020, were prospectively enrolled, and retrospectively analyzed. Anatomical details of the proximal aortic neck were evaluated. Early endpoints were the use of repositionability and angulation system, intraoperative unplanned cuff, technical success (TS), 30-day morbidity/mortality, and reintervention. Follow-up endpoints were type-I endoleaks, endograft migration, aortic neck dilatation, aneurismal sac shrinkage, survival (S), and freedom from reintervention (FFR).

RESULTS

Twenty-five patients were enrolled (median age: 80 [range = 60-90] years, median AAA diameter: 60 [range = 52-90] mm). All patients had severe infrarenal neck angulation (beta angle ≧ 60°), and 11 (44%) of those had neck beta angle ≧ 90°. Median infrarenal neck angle, length, and diameter were 70° (range = 60°-90°), 22 (range = 13-42) mm and 22 (range = 18-31) mm, respectively. Endograft repositioning system was employed in 15 (60%) cases and the median number of repositioning maneuvers was 1 (range:0-4). Active angulation system was used in 17 (68%) patients. The median proximal diameter of the main-body and oversize were 28 (range = 23-36) mm and 28% (range = 21%-38%), respectively. Proximal cuff was positioned in 1 (4%) patient. Technical success was achieved in all cases. Intraoperative and perioperative morbidity and mortality were 12% and 0%, respectively. Perioperative type-I/III and II endoleaks were observed in 0 and 4 (16%) patients, respectively. The median follow-up was 12 months (range: 3-30). One patient died at 12-month for AAA-unrelated causes. Abdominal aortic aneurysm-sac shrinkage and stability were observed in 9 (36%) and 15 (60%) cases, respectively. No type-I/III endoleak and reintervention occurred during the follow-up. One persistent type-II endoleak was observed. Estimated survival at 24 months was 92%.

CONCLUSION

According to the present data, the CEXC Device allows an excellent rate of TS in severe angulated aortic neck. This preliminary data, could increase the rate of patients eligible for EVAR.

Association of neutrophils, lymphocytes, and neutrophil-lymphocyte ratio to overall mortality after endovascular abdominal aortic aneurysm repair

BACKGROUND

The purpose of this study was to determine the predictive ability of neutrophilia, lymphocytopenia, and neutrophil-lymphocyte ratio (NLR) for overall mortality after EVAR for AAA.

METHODS

Data on patients with AAA treated by EVAR between March 2012 and December 2016 were obtained from a prospectively maintained EVAR database at Tokyo Medical University Hospital. The NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. A cut-off value of total WBC count, neutrophil count, lymphocyte count, and NLR was determined according to a receiver operating characteristic (ROC) curve. Univariate and multivariate analyses were performed using the Cox proportional hazard analyses to account for the time at risk.

RESULTS

178 patients were included in this study after selection based on the exclusion criteria. The subjects consisted of 150 men and 28 women with a mean age of 77.5 years (range, 51-89 years). A ROC curve analysis determined the optimal cut-off values of preoperative total WBC, neutrophils, lymphocytes, and NLR for predicting overall mortality with 7,050 /μL, 4,012 /μL, 1,312 /μL, and 3.19, respectively. On univariate analysis and multivariate analyses, octogenarian, obesity, COPD, active cancer, and lymphocytopenia or NLR were detected as independent predictors for overall mortality.

CONCLUSIONS

Specific leukocyte populations, such as lymphocyte count and NLR, are useful biomarkers to predict overall mortality in patients undergoing EVAR for AAA, suggesting that WBC count and its subsets, which are easy to perform a test, may be used to stratify patients at risk for poor prognosis following EVAR.

The survival rate among endovascular and open surgical repair of abdominal aortic aneurysms

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients with Infrarenal abdominal aortic aneurysm (AAA), Does endovascular abdominal aortic repair (EVAR), AS compared to open surgical repair (OSR), has higher Survival rates? The outcomes assessed were the overall survival rates in both techniques. The best evidence showed that there is no statistically significant difference between EVAR and OSR in survival rates.

ACTION-1: study protocol for a randomised controlled trial on ACT-guided heparinization during open abdominal aortic aneurysm repair

BACKGROUND

Heparin is used worldwide for 70 years during all non-cardiac arterial procedures (NCAP) to reduce thrombo-embolic complications (TEC). But heparin also increases blood loss causing possible harm for the patient. Heparin has an unpredictable effect in the individual patient. The activated clotting time (ACT) can measure the effect of heparin. Currently, this ACT is not measured during NCAP as the standard of care, contrary to during cardiac interventions, open and endovascular. A RCT will evaluate if ACT-guided heparinization results in less TEC than the current standard: a single bolus of 5000 IU of heparin and no measurements at all. A goal ACT of 200-220 s should be reached during ACT-guided heparinization and this should decrease (mortality caused by) TEC, while not increasing major bleeding complications. This RCT will be executed during open abdominal aortic aneurysm (AAA) surgery, as this is a standardized procedure throughout Europe.

METHODS

Seven hundred fifty patients, who will undergo open AAA repair of an aneurysm originating below the superior mesenteric artery, will be randomised in 2 treatment arms: 5000 IU of heparin and no ACT measurements and no additional doses of heparin, or a protocol of 100 IU/kg bolus of heparin and ACT measurements after 5 min, and then every 30 min. The goal ACT is 200-220 s. If the ACT after 5 min is < 180 s, 60 IU/kg will be administered; if the ACT is between 180 and 200 s, 30 IU/kg. If the ACT is > 220 s, no extra heparin is given, and the ACT is measured after 30 min and then the same protocol is applied. The expected incidence for the combined endpoint of TEC and mortality is 19% for the 5000 IU group and 11% for the ACT-guided group.

DISCUSSION

The ACTION-1 trial is an international RCT during open AAA surgery, designed to show superiority of ACT-guided heparinization compared to the current standard of a single bolus of 5000 IU of heparin. A significant reduction in TEC and mortality, without more major bleeding complications, must be proven with a relevant economic benefit. TRIAL REGISTRATION {2A}: NTR NL8421 ClinicalTrials.gov NCT04061798 . Registered on 20 August 2019 EudraCT 2018-003393-27 TRIAL REGISTRATION: DATA SET {2B}: Data category Information Primary registry and trial identifying number ClinicalTrials.gov : NCT04061798 Date of registration in primary registry 20-08-2019 Secondary identifying numbers NTR: NL8421 EudraCT: 2018-003393-27 Source(s) of monetary or material support ZonMw: The Netherlands Organisation for Health Research and Development Dijklander Ziekenhuis Amsterdam UMC Primary sponsor Dijklander Ziekenhuis Secondary sponsor(s) N/A Contact for public queries A.M. Wiersema, MD, PhD Arno@wiersema.nu 0031-229 208 206 Contact for scientific queries A.M. Wiersema, MD, PhD Arno@wiersema.nu 0031-229 208 206 Public title ACT Guided Heparinization During Open Abdominal Aortic Aneurysm Repair (ACTION-1) Scientific title ACTION-1: ACT Guided Heparinization During Open Abdominal Aortic Aneurysm Repair, a Randomised Trial Countries of recruitment The Netherlands. Soon the recruitment will start in Germany Health condition(s) or problem(s) studied Abdominal aortic aneurysm, arterial disease, surgery Intervention(s) ACT-guided heparinization 5000 IU of heparin Key inclusion and exclusion criteria Ages eligible for the study: ≥18 years Sexes eligible for the study: both Accepts healthy volunteers: no Inclusion criteria: Study type Interventional Allocation: randomized Intervention model: parallel assignment Masking: single blind (patient) Primary purpose: treatment Phase IV Date of first enrolment March 2020 Target sample size 750 Recruitment status Recruiting Primary outcome(s) The primary efficacy endpoint is 30-day mortality and in-hospital mortality during the same admission. The primary safety endpoint is the incidence of bleeding complications according to E-CABG classification, grade 1 and higher. Key secondary outcomes Serious complications as depicted in the Suggested Standards for Reports on Aneurysmal disease: all complications requiring re-operation, longer hospital stay, all complications.

Re-intervention rate in endovascular vs open surgical repair for abdominal aortic aneurysms

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients with Infrarenal abdominal aortic aneurysm (AAA), Does endovascular abdominal aortic repair (EVAR), AS compared to open surgical repair (OSR), has lower re-intervention rates? The outcomes assessed were the re-interventional rates in both techniques. The best evidence showed that the OSR has lower statistically significant difference rates in re-intervention rates than the EVAR.

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Endovascular abdominal aortic aneurysm repair is inferior to the open surgical repair regarding the re-intervention rates.

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Long term outcomes of the open surgical repair are better than the Endovascular repair.

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Secondary procedures are more in endovascular repair than the open surgical repair of abdominal aortic aneurysm.

Outcomes and predictors of mortality in a Belgian population of patients admitted with ruptured abdominal aortic aneurysm and treated by open repair in the contemporary era

BACKGROUND

Abdominal aortic aneurysm (AAA) rupture is a serious condition that results in extremely high mortality rates. Some improvements in outcome have been reported during the last 2 decades. The objective of the present study was to determine the overall and operative (by open repair) mortality related to ruptured AAA in the contemporary era and to identify preoperative, intraoperative, and early postoperative parameters associated with poor outcomes.

METHODS

We performed a retrospective review of all consecutive patients admitted to our single institution with a diagnosis of ruptured AAA between 2004 and 2013. A total of 103 parameters, including demographic characteristics, medical history, clinical and biological parameters, cardiovascular risk factors, emergency level, diagnostic modalities, time from symptoms to diagnosis and treatment, type of operative procedure and postoperative complications, were analyzed. The primary endpoint considered in this study was the cumulative incidence rate of mortality. The secondary endpoint was the identification, by logistic regression methods, of risk factors for overall mortality as well as for operative, and postoperative mortality.

RESULTS

Within our study period, 104 patients were admitted for a ruptured AAA. The majority of patients (84.6%) were male, and the AAA was known in 34.6% of the patients. Rupture occurred for a maximal diameter lower than 55 mm in 25% of the female population, compared to 5.7% of the male population (P = 0.030). The proportions of admitted patients who died before (preoperative mortality), during (intraoperative mortality) or after (postoperative hospital mortality) surgery was 17.3%, 16.3%, and 18.3%, respectively, yielding a cumulative in-hospital mortality of 51.9%. In the multivariate analysis, age ≥ 80 (P = 0.001), myocardial ischemia on the admission ECG (P = 0.046), and management by the physician response unit (P = 0.002) were the only preoperative parameters associated with a higher risk of hospital mortality. Four risk factors were found to be associated with a higher risk of postoperative mortality in the multivariate analysis, and all patients presenting with 3 or more of these risk factors (n = 5) died.

CONCLUSIONS

The overall mortality of ruptured AAA in a contemporary cohort of patients who underwent open repair remains high and does not seem to have decreased during recent decades. Ruptures occur at smaller diameters in women than in men, supporting a lower threshold for intervention in women with known AAA. We developed risk scores to predict the mortality of patients with rAAA at different times of their hospital course. The validity of these scores should be assessed in prospective clinical studies.

Evaluation of Survival Outcomes of Endovascular Versus Open Aortic Repair for Abdominal Aortic Aneurysms with a Big Data Approach

Abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta. Once ruptured AAA (rAAA) happens, repairing procedures need to be applied immediately, for which there are two main options: open aortic repair (OAR) and endovascular aortic repair (EVAR). It is of great clinical significance to objectively compare the survival outcomes of OAR versus EVAR using randomized clinical trials; however, this has serious feasibility issues. In this study, with the Medicare data, we conduct an emulation analysis and explicitly "assemble" a clinical trial with rigorously defined inclusion/exclusion criteria. A total of 7826 patients are "recruited", with 3866 and 3960 in the OAR and EVAR arms, respectively. Mimicking but significantly advancing from the regression-based literature, we adopt a deep learning-based analysis strategy, which consists of a propensity score step, a weighted survival analysis step, and a bootstrap step. The key finding is that for both short- and long-term mortality, EVAR has survival advantages. This study delivers a new big data strategy for addressing critical clinical problems and provides valuable insights into treating rAAA using OAR and EVAR.

Predictive Factors and Strategies to Prevent the Development of Type 2 Endoleaks following Endovascular Aneurysm Repair

Type 2 endoleaks are a potential complication of endovascular aortic repair for abdominal aortic aneurysms. They are caused by vessels that have been excluded from the aorta lumen, but may still fill the aneurysm sac due to collateral filling. Type 2 endoleaks may lead to increased morbidity and need for additional procedures. Being able to identify patients at risk for Type 2 endoleaks and prevent them is important for any physician who is performing endovascular aortic repair.

Contemporary outcomes of endovascular abdominal aortic aneurysm repair in patients deemed unfit for open surgical repair

OBJECTIVE

Endovascular abdominal aortic aneurysm repair (EVAR) has been preferred to open surgical repair (OSR) for the treatment of abdominal aortic aneurysms (AAAs) in high-risk patients. We compared the perioperative and long-term outcomes of EVAR for patients designated as unfit for OSR using a large national dataset.

METHODS

The Vascular Quality Initiative database was queried for patients who had undergone elective EVAR for AAAs >5 cm from 2013 to 2019. The patients were stratified into two cohorts according to their suitability for OSR (fit vs unfit). The primary outcomes included perioperative (in-hospital) major adverse events, perioperative mortality, and mortality at 1 and 5 years. Patient demographics and postoperative outcomes were analyzed to identify the predictors of perioperative and long-term mortality.

RESULTS

Of 16,183 EVARs, 1782 patients had been deemed unfit for OSR. The unfit cohort was more likely to be older and female, with a greater proportion of hypertension, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and larger aneurysm diameters. Postoperatively, the unfit cohort was more likely to have experienced cardiopulmonary complications (6.5% vs 3%; P < .001), with greater perioperative mortality (1.7% vs 0.6%; P < .001) and 1- and 5-year mortality (13% and 29% for the unfit vs 5% and 14% for the fit cohorts, respectively; P < .001). A subgroup analysis of the unfit cohort revealed that those deemed unfit because of a hostile abdomen had significantly lower 1- and 5-year mortality (6% and 20%, respectively) compared with those considered unfit because of cardiopulmonary compromise and frailty (14% and 30%, respectively; P = .451). Reintervention-free survival at 1 and 5 years was significantly greater in the fit cohort (93% and 82%, respectively) compared with that for the unfit cohort (85% and 68%, respectively; P < .001). The designation as unfit for OSR was an independent predictor of both perioperative (odds ratio, 1.59; 95% confidence interval [CI], 1.03-2.46; P = .038) and long-term mortality (hazard ratio [HR], 1.92; 95% CI, 1.69-2.17; P < .001). Advanced age (odds ratio, 2.91; 95% CI, 1.28-6.66; P = .011) was the strongest determinant of perioperative mortality, and end-stage renal disease (HR, 2.51; 95% CI, 1.78-3.55; P < .001) was the strongest predictor of long-term mortality. Statin use (HR, 0.77; 95% CI, 0.69-0.87; P < .001) and angiotensin-converting enzyme inhibitor use (HR, 0.83; 95% CI, 0.75-0.93; P < .001) were protective of long-term mortality.

CONCLUSIONS

Despite low perioperative mortality, the long-term mortality of those designated by operating surgeons as unfit for OSR was rather high for patients undergoing elective EVAR, likely owing to the competing risk of death from medical frailty. An unfit designation because of a hostile abdomen did not confer any additional risks after EVAR. Judicious estimation of the patient's life expectancy is essential when considering the treatment options for this subset of patients deemed unfit for OSR.

Management of Abdominal Aortic Aneurysm Disease: Similarities and Differences Among Cardiovascular Guidelines and NICE Guidance

The development of endovascular techniques has improved abdominal aortic aneurysm (AAA) management over the past 2 decades. Different cardiovascular societies worldwide have recommended the endovascular approach as the standard of care in their currently available guidelines. While endovascular treatment has established its role in daily clinical practice, a new debate has arisen regarding the indications, appropriateness, limitations, and role of open surgery. To inform this debate, the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched from 2010 to May 2020; the systematic search identified 5 articles published between 2011 and 2020 by 4 cardiovascular societies and the National Institute of Health and Care Excellence (NICE). Four debatable domains were assessed and analyzed: diagnostic methods and screening, preoperative management, indications and treatment modalities, and postoperative follow-up and endoleak management. The review addresses controversial proposals as well as widely accepted recommendations and "gray zone" issues that need to be further investigated and analyzed, such as screening in women, medical management, and follow-up imaging. While the recommendations for AAA management have significant overlap and agreement among international cardiovascular societies, the NICE guidelines diverge regarding the role of open repair in aortic disease, recommending conventional surgery in most elective cases.

Comparison of the Short and Long-Term Outcomes of Endovascular Repair and Open Surgical Repair in the Treatment of Unruptured Abdominal Aortic Aneurysms: Meta-Analysis and Systematic Review

Background

Although the initial results of endovascular repair (EVAR) were promising, a comparison of its long-term efficacy against open surgical repair (OSR) remains largely elusive, and late-onset adverse events have not been systematically evaluated. Since OSR and EVAR are currently the only treatment options available in the management of abdominal aortic aneurysms (AAAs), the main question arising in clinical practice is whether EVAR or OSR confers more favourable short and long-term outcomes for patients presenting with unruptured AAAs.

Aims

The present meta-analysis aims to draw a head-to-head comparison between EVAR and OSR and facilitate the formulation of an evidence-based approach to the clinical management of unruptured AAAs.

Methods

A systematic review was conducted using three databases to identify all relevant studies with comparative data on EVAR vs. OSR. All-cause mortality was the primary outcome. Procedural outcomes, such as stroke, myocardial infarction, renal complications, rupture, and reintervention rates, were determined as secondary outcomes.

Results

Sixteen studies were included for comparative analysis, including four randomised-controlled trials and six non-randomised comparative clinical trials. EVAR conferred a clear perioperative survival advantage as compared to OSR (P < 0.00001). However, this survival advantage did not persist beyond two years post-procedure; all-cause mortality rates were comparable between the two treatment groups at two years (P = 0.09), four years (P = 0.58), and six years (P = 0.88) post-procedure. Although no statistically significant differences in aneurysm-related mortality, postoperative stroke, or myocardial infarction were identified, the OSR group had a statistically significant higher rate of postoperative renal complications. On the other hand, there was a statistically significant higher rate of rupture and reintervention following EVAR.

Conclusion

Whether the initial survival advantage afforded by EVAR is sufficient to justify the long-term risk of rupture, reintervention, and long-term mortality should be determined on a case-by-case basis by the multidisciplinary team overseeing the clinical care of the patient. Currently, it is reasonable to conclude that EVAR is as efficacious as OSR, but it would be invalid to claim it as superior. Ultimately, longer follow-up data must be presented before any definitive conclusions can be established for this potentially revolutionary technique. Presently, one can neither advocate nor refute EVAR over OSR.

Impact of Gradual Adoption of EVAR in Elective Repair of Abdominal Aortic Aneurysm: A Retrospective Cohort Study from 2009 to 2015

INTRODUCTION

The recommendations about the preferred type of elective repair of abdominal aortic aneurysm (AAA) still divides guidelines committees, even nowadays. The aim is to assess outcomes after AAA repair focusing on differences between endovascular aneurysm repair (EVAR) and open surgical repair (OSR).

METHODS

The observational retrospective cohort study of consecutive patients submitted to elective AAA repair at a tertiary center, 2009-2015. Exclusion criteria were as follows: nonelective cases or complex aortic aneurysms. Primary outcomes were postoperative complications, length of hospital stay, survival, freedom from aortic-related mortality, and vascular reintervention. Time trends were assessed along the period under analysis.

RESULTS

From a total of 211 included patients, those submitted to EVAR were older (74 ± 7 vs. 67 ± 9 years; P < 0.001), presented a higher prevalence of hypertension (83.5% vs. 68.5%, P = 0.004), obesity (28.7% vs. 14.3%, P = 0.029), previous cardiac revascularization (30.5% vs. 14.7%, P = 0.005), heart failure (17.2% vs. 5.2%, P = 0.013), and chronic obstructive pulmonary disease (32.8% vs. 13.3%, P = 0.002). Patients were followed during a median of 49 months. EVAR resulted in a significantly shorter length of hospital stay (median 4 and interquartile range 3 vs. 8 (9); P < 0.001), lower 30-day complications (10.6% vs. 22.8%, P = 0.017), lower aortic-related mortality, and similar reintervention after adjustment with a propensity score. Along the time under analysis, EVAR became the predominate type of repair (P = 0.024), the proportion of complications decreased (P = 0.014), and the 30-day mortality (P = 0.035).

CONCLUSIONS

Although EVAR was offered to patients with more comorbidities, better and durable outcomes were achieved after EVAR, favoring its adoption for elective AAA repair.

Influence of patient-specific rehearsal on operative metrics and technical success for endovascular aneurysm repair

INTRODUCTION

Patient-specific rehearsal (PsR) is a recent technology within virtual reality (VR) simulation that lets the operators train on patient-specific data in a simulated environment prior to the procedure. Endovascular aneurysm repair (EVAR) is a complex procedure where operative metrics and technical success might improve after PsR.

MATERIAL AND METHODS

We compared technical success and operative metrics (endovascular procedure time, contralateral gate cannulation time, fluoroscopy time, total radiation dose, number of angiograms and contrast medium use) between 30 patients, where the operators performed PsR (the PsR group), and 30 patients without PsR (the control group).

RESULTS

The endovascular procedure time was significantly shorter in the PsR group than in the control group (median 44 versus 55 min, p = .017). The other operative metrics were similar. Technical success rates were higher in the PsR group, 96.7% primary and assisted primary outcome versus 90.0% in the control group. The differences were not significant (p = .076).

CONCLUSIONS

PsR before EVAR reduced endovascular procedure time, and our results indicate that it might improve technical success, but further studies are needed to confirm those results.

Outcomes of Elective Endovascular Aneurysmal Repair for Abdominal Aortic Aneurysms in Jordan

Purpose

The outcomes of endovascular aneurysmal repair (EVAR) for infrarenal abdominal aortic aneurysms (AAAs) in the Middle East have rarely been reported. We analyzed the outcomes of EVAR in a Jordanian population.

Materials and Methods

We conducted a retrospective review of the medical records of patients with infrarenal AAA who were treated with elective EVAR between January 2004 and January 2017 at a single center in Jordan. Patient characteristics, anatomical characteristics, procedural details, and early and late postoperative outcomes were analyzed.

Results

A total of 288 patients (mean age, 70 years; 77.8% males) underwent EVAR for infrarenal AAA (median aneurysm size, 64 mm). Bifurcated endografts were used in 265 patients, and aorto-uni-iliac devices were used in 22 patients. Successful endograft deployment was achieved in all patients with no open conversion. Early complications included localized groin hematoma in 15, femoral artery dissection in 4, wound infection in 3, and seroma in 3 patients. With a mean follow-up of 60 months, 50 endoleaks were detected, including 9 type I, 38 type II, and 3 type III. Seven patients had unilateral graft limb occlusion. The 30-day mortality was 1.7%, and long-term mortality was 7.0%, mostly due to non-AAA-related causes.

Conclusion

EVAR was safely performed in Jordanian patients with minimal complications. However, long-term surveillance is important due to the risk of endoleaks and consequent intervention.

Editor's Choice - Endovascular vs. Open Repair for Abdominal Aortic Aneurysm: Systematic Review and Meta-analysis of Updated Peri-operative and Long Term Data of Randomised Controlled Trials

OBJECTIVE

The objective was to investigate whether endovascular aneurysm repair (EVAR) has better peri-operative and late clinical outcomes than open repair for non-ruptured abdominal aortic aneurysm.

METHODS

Electronic bibliographic sources (MEDLINE, EMBASE, and CENTRAL) were searched up to July 2019 using a combination of thesaurus and free text terms to identify randomised controlled trials (RCTs) comparing the outcomes of EVAR and open repair. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI). A time to event data meta-analysis was performed using the inverse variance method and the results were reported as summary hazard ratio (HR) and 95% CI.

RESULTS

Seven RCTs reporting a total of 2 983 patients were included in quantitative synthesis. Three of the trials reported long term follow up that extended to 15.8 years, 14.2 years, and 12.5 years. Meta-analysis found significantly lower odds of 30 day (OR, 0.36; 95% CI 0.20-0.66) and in hospital mortality with EVAR (RD -0.03; 95% CI -0.04 to -0.02). Meta-analysis of the three trials reporting long term follow up found no significant difference in all cause mortality at any time between EVAR and open repair (HR 1.02; 95% CI 0.93-1.13; p = .62). The hazard of all cause (HR 0.62; 95% CI 0.42-0.91) and aneurysm related death within six months (HR 0.42; 95% CI 0.24-0.75) was significantly lower in patients who underwent EVAR, but with further follow up, the pooled hazard estimate moved in favour of open surgery; in the long term (>8 years) the hazard of aneurysm related mortality was significantly higher after EVAR (HR 5.12; 95% CI 1.59-16.44). The risk of secondary intervention (HR 2.13; 95% CI 1.69-2.68), aneurysm rupture (OR, 5.08; 95% CI 1.11-23.31), and death due to rupture (OR, 3.57; 95% CI 1.87-6.80) was significantly higher after EVAR, but the risk of death due to cancer was not significantly different between EVAR and open repair (OR, 1.03; 95% CI 0.84-1.25).

CONCLUSION

Compared with open surgery, EVAR results in a better outcome during the first six months but carries an increased risk of aneurysm related mortality after eight years.

Ten Years of Urgent Care of Ruptured Abdominal Aortic Aneurysms in a High-Volume-Center

BACKGROUND

The urgent treatment of ruptured abdominal aortic aneurysms (rAAA) remains a challenging condition with devastating morbidity and mortality. Available studies are often limited due to a significant selection bias. This study aims to illuminate real-world evidence using comprehensive data from electronic health records, registries, postmortem findings, and administrative data on all consecutively treated patients presenting with rAAA at a tertiary care center.

METHODS

This is a retrospective cross-sectional cohort study covering consecutively treated patients with rAAA between 2009 and 2018. All noninvasive treatments, fatalities, and invasive repairs were included. Information on patient's characteristics, prehospital, and inpatient care was gathered. Short-term outcomes and long-term survival were analyzed for relevant subgroups.

RESULTS

In total, 139 patients with rAAA (median age 75 years and 20.9% females, 79.9% infrarenal) were treated increasingly frequent by endovascular aortic repair (EVAR) when compared to open-surgical aortic repair (OSR) during the study period (16.7% in 2009 to 33.3% in 2018, P < 0.05). The rate of patients who had been turned down for rAAA repair was 10.8%, and the overall in-hospital mortality was 43.2%. Perioperative morbidity and mortality were similar for EVAR and OSR, although patients treated by OSR presented with a lower mean Glasgow Coma Scale during the prehospital (12.7 vs. 14.3) and inpatient care (12.7 vs. 14.4) (both P < 0.001), higher rates of intubation (12.8% vs. 10.9%, P < 0.001), lower systolic blood pressure (115 mm Hg vs. 127 mm Hg, P = 0.042), and more often had a cardiac arrest before the operation (14.1% vs. 2.3%, P < 0.001). Higher patient's age (Odds Ratio, OR 1.09; Hazard Ratio, HR 1.06), history of stroke or transient ischemic attack (OR 5.30; HR 2.64), higher serum creatinine (OR 1.81; HR 1.31), and occurrence of colonic ischemia (OR 11.31; HR 2.82) were significantly associated with higher odds of dying in hospital and in the longer term, respectively.

CONCLUSIONS

We observed comparable outcomes following OSR and EVAR, although hemodynamically unstable patients were more likely to be treated by OSR. This study also confirmed the impact of colonic ischemia as a devastating complication following rAAA repair emphasizing the need for further reflection by the vascular community.

Inferior Mid-term Durability with Comparable Survival for Younger Patients Undergoing Elective Endovascular Infrarenal versus Open Abdominal Aortic Aneurysm Repair

BACKGROUND

The durability of endovascular aneurysm repair (EVAR) when compared to open surgical repair (OSR) in younger patients for elective, infrarenal abdominal aortic aneurysms (AAA) remains unclear due to limited follow-up.

METHODS

We identified all patients <70 years of age who underwent elective, de novo EVAR or OSR for infrarenal AAA from 2003 to 2013 in a multihospital, single institution. Baseline patient clinical and aneurysmal characteristics were adjusted for using multivariable Cox proportional hazards models and negative binomial regression.

RESULTS

We identified 253 patients: 204 underwent EVAR (80.6%) and 49 OSR (19.4%). Baseline demographics and comorbidities were similar across groups. There were no deaths in the immediate perioperative period. The rate of new arrhythmia (EVAR: 1.0%, OSR: 10.2%; P = 0.004), median hospital length of stay (EVAR: 1 day, OSR: 5 days; P < 0.001), and discharge to a facility (EVAR: 2.9%, OSR: 12.2%; P = 0.016) were significantly increased for OSR. In both groups, median follow-up time was 4.5 years, in which survival did not differ between groups. The hazard of composite of freedom from death and any reinterventions (hazard ratio [HR] 4.3, P = 0.009), freedom from any reintervention (relative risk [RR] 4.08, P = 0.030), and freedom from any endovascular reintervention (RR 4.83, P = 0.038) were each higher for OSR when compared to EVAR. EVAR of the standard instruction for use (IFU) for neck length was more likely to die or undergo a reintervention (HR 4.90, P = 0.001).

CONCLUSIONS

Our retrospective review of younger patients undergoing elective AAA repair demonstrated no significant differences in perioperative mortality or survival over time between EVAR and OSR. EVAR required more total reinterventions and endovascular reintervention when compared to OSR.

Predictors of bleeding or anemia requiring transfusion in complex endovascular aortic repair and its impact on outcomes in health insurance claims

OBJECTIVE

This study aimed to determine predictors and outcomes associated with bleeding or anemia requiring transfusion (BAT) after fenestrated or branched endovascular aneurysm repair (FB-EVAR).

METHODS

Health insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate BAT in elective FB-EVAR performed between 2008 and 2017. International Classification of Diseases and German Operations and Procedure Key codes were used.

RESULTS

A total of 959 patients (24.8% with BAT) matching the inclusion criteria were identified during the study period. Compared with patients without BAT, patients with BAT were older (74.4 vs 73.0 years; P = .015) and suffered more frequently from congestive heart failure (18.5% vs 9.4%), cardiac arrhythmias (26.9% vs 14.7%), and hereditary or acquired coagulopathy (31.9% vs 6.2%; all P < .001). Coagulopathy (odds ratio [OR], 3.65; 95% confidence interval [CI], 2.29-5.84), female sex (OR, 2.67; 95% CI, 1.78-4.00), and multiple comorbidities (OR, 1.10; 95% CI, 1.07-1.14) were independent predictors of BAT (all P < .001). BAT was associated with higher in-hospital (11.3% vs 2.6%), 30-day (12.2% vs 3.1%), and 90-day (18.5% vs 4.4%) mortality (all P < .001). Furthermore, myocardial infarction (23.9% vs 2.8%) and paraplegia (9.7% vs 0.7%) were more frequent in the BAT group (all P < .001). In multivariable analyses, BAT was associated with worse short-term (OR, 3.19; 95% CI, 1.63-6.33; P = .001) and long-term survival (hazard ratio, 1.62; 95% CI, 1.24-2.11; P < .001).

CONCLUSIONS

Patients with hereditary or acquired coagulopathy, patients with multiple comorbidities, and women are at higher risk for development of BAT after FB-EVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of patient blood management in FB-EVAR.

Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm

BACKGROUND

Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective repair of abdominal aortic aneurysm (AAA) for many patients. However, the superiority of the endovascular procedure has recently been challenged by reports of impaired long-term survival in patients who underwent EVAR. A systematic review of long-term survival following AAA repair was therefore undertaken.

METHODS

A systematic review was performed according to PRISMA guidelines. Articles reporting short- and/or long-term mortality of EVAR and open surgical repair (OSR) of AAA were identified. Pooled overall survival estimates (hazard ratios (HRs) with corresponding 95 per cent c.i. for EVAR versus OSR) were calculated using a random-effects model. Possible confounding owing to age differences between patients receiving EVAR or OSR was addressed by estimating relative survival.

RESULTS

Some 53 studies were identified. The 30-day mortality rate was lower for EVAR compared with OSR: 1·16 (95 per cent c.i. 0·92 to 1·39) versus 3·27 (2·71 to 3·83) per cent. Long-term survival rates were similar for EVAR versus OSR (HRs 1·01, 1·00 and 0·98 for 3, 5 and 10 years respectively; P = 0·721, P = 0·912 and P = 0·777). Correction of age inequality by means of relative survival analysis showed equal long-term survival: 0·94, 0·91 and 0·76 at 3, 5 and 10 years for EVAR, and 0·96, 0·91 and 0·76 respectively for OSR.

CONCLUSION

Long-term overall survival rates were similar for EVAR and OSR. Available data do not allow extension beyond the 10-year survival window or analysis of specific subgroups.

Sarcopenia predicts mortality and adverse outcomes after endovascular aneurysm repair and can be used to risk stratify patients

BACKGROUND

Endovascular aneurysm repair (EVAR) is currently the most common treatment of abdominal aortic aneurysms. Potential predictors of long-term survival after EVAR include physiologic, functional, and cognitive status, but assessments of these conditions have been difficult to standardize. Objective radiographic findings, such as skeletal muscle atrophy, or sarcopenia, may provide an additional means for selection of patients. This study investigates sarcopenia as a method to predict 1-year survival in patients undergoing EVAR.

METHODS

A single-institution retrospective review was conducted of all patients who underwent elective EVAR from September 2002 to June 2014. Patients with an available periprocedural computed tomography (CT) scan and clinical data were included in the analysis. Normalized total psoas cross-sectional area (nTPA) was measured on axial CT images using the area of the bilateral psoas muscle at the third lumbar vertebral level normalized to the square of patient height. A threshold for optimal estimate of sarcopenia based on nTPA was determined using a receiver operating characteristic curve. Sarcopenia was evaluated as an independent risk predictor using univariate, multivariate, and survival analysis.

RESULTS

A total of 272 EVAR-treated patients were evaluated, including 237 men and 35 women with a median age of 72 years and mean body mass index of 28.6 kg/m². There was a significant increase in overall mortality in patients in the lowest quartile of nTPA (Q1, 23.53%; Q2, 13.24%; Q3, 7.35%; Q4, 5.88%; P = .01). The estimated nTPA threshold for increased mortality after EVAR was 500 mm²/m². Using this threshold, sarcopenia accounted for 57% of the risk effect in our 1-year survival model.

CONCLUSIONS

Sarcopenia can assist in identifying EVAR candidates who are less likely to benefit from surgery. It can be readily evaluated from preoperative CT scans and may be a useful tool in evaluation of abdominal aortic aneurysm patients with applications in risk evaluation and telemedicine.

Pharmacologic Management of Aneurysms

Current management of aortic aneurysms relies exclusively on prophylactic operative repair of larger aneurysms. Great potential exists for successful medical therapy that halts or reduces aneurysm progression and hence alleviates or postpones the need for surgical repair. Preclinical studies in the context of abdominal aortic aneurysm identified hundreds of candidate strategies for stabilization, and data from preoperative clinical intervention studies show that interventions in the pathways of the activated inflammatory and proteolytic cascades in enlarging abdominal aortic aneurysm are feasible. Similarly, the concept of pharmaceutical aorta stabilization in Marfan syndrome is supported by a wealth of promising studies in the murine models of Marfan syndrome-related aortapathy. Although some clinical studies report successful medical stabilization of growing aortic aneurysms and aortic root stabilization in Marfan syndrome, these claims are not consistently confirmed in larger and controlled studies. Consequently, no medical therapy can be recommended for the stabilization of aortic aneurysms. The discrepancy between preclinical successes and clinical trial failures implies shortcomings in the available models of aneurysm disease and perhaps incomplete understanding of the pathological processes involved in later stages of aortic aneurysm progression. Preclinical models more reflective of human pathophysiology, identification of biomarkers to predict severity of disease progression, and improved design of clinical trials may more rapidly advance the opportunities in this important field.

Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair

OBJECTIVE

Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR).

METHODS

This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis.

RESULTS

A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias.

CONCLUSIONS

The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.

Incidence, Predictors, and Outcomes of Colonic Ischaemia in Abdominal Aortic Aneurysm Repair

OBJECTIVE/BACKGROUND

Colonic ischaemia (CI) is a severe complication following abdominal aortic aneurysm (AAA) repair, leading to high morbidity and mortality. The aim of the study was to determine the incidence, predictors, and outcomes of CI following AAA repair.

METHODS

National claims from Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate CI after intact (iAAA) and ruptured (rAAA) AAA repairs. Patients undergoing endovascular (EVAR) or open surgical (OSR) repairs between January 2008 and December 2017 were included in the study.

RESULTS

There were 9145 patients (8248 iAAA and 897 rAAA) undergoing EVAR or OSR procedures and the median follow up was 2.28 years. Most patients were male (79.2% iAAA, 79.3% rAAA); the median age was 73.0 years (iAAA group) and 76.0 years (rAAA group). Overall, CI occurred 97 (1.2%) times after iAAA and 95 (10.6%) after rAAA. In univariable analyses CI occurred less often after EVAR than after OSR (0.6% vs. 3.7%; p < .001). Acute post-operative renal and respiratory insufficiencies were also related to the occurrence of CI (p < .001). CI was associated with greater in hospital mortality (42.2% vs. 2.7% for iAAA, 64.2% vs. 36.3% for rAAA; p < .001) and lower long-term survival for iAAA (Kaplan-Meier analysis). In multivariable analyses, rAAA (odds ratio [OR] 5.59), and higher van Walraven comorbidity score (OR 1.09) were independently associated with greater risk of CI occurrence. EVAR use (OR 0.30) was protective. EVAR use remained protective in stratified analyses within iAAA (OR 0.32) and rAAA (OR 0.26).

CONCLUSION

Post-operative CI after AAA repair is not common but is associated with worse in hospital outcomes and lower long-term survival. EVAR was protective after both rAAA and iAAA repairs. When discussing the treatment of AAA with patients the protective effect of EVAR should be considered. Future studies should validate predictive scores and advance preventive strategies.

Complex endovascular treatment of intact aortic aneurysms: An analysis of health insurance claims data

Background

The complex endovascular repair of aortic aneurysms and dissections with fenestrated or branched stent grafts (FB-EVAR) remains challenging for interventional vascular surgery. To date, the evidence regarding treatment patterns and outcome measures consists of single center studies; however, it might be reasonable to validate results with multicenter real-world evidence.

Methods

Health insurance claims data from Germany’s third largest insurance provider, DAK-Gesundheit, were used to determine outcomes following FB-EVAR of non-ruptured thoracic aorta (TA) or thoracoabdominal including pararenal abdominal (TAA) aorta. The study included patients operated between January 2008 and April 2017.

Results

Included were 984 patients (18.1% female) who underwent FB-EVAR. Patients with treatment of the TA were younger (71.7 vs. 73.2 years, p < 0.001) and more often female (38.5% vs. 17.0%, p < 0.001) as compared to patients with treatment of TAA. In the TA group peripheral arterial disease was less frequent compared to the TAA group (67.3% vs. 80.4%, p = 0.036). Mortality was significantly (p < 0.001) higher following repair of the TAA compared to the TA at discharge (17.3% vs. 4.6%), at 30 days (26.9% vs. 8.2%) and at 90 days (34.6% vs. 10.1%). Patients with treatment of the TAA suffered more often from stroke as compared to the TA group (7.7% vs. 1.2%, p = 0.002).

Conclusion

In this large-scale German analysis of claims data, multicenter real-world evidence was different from single center studies regarding patient risk-factors and outcome measures. Validated multicenter registry studies could help to further investigate this topic in times of increasing procedures.