1
|
Peeters M, Oosterveld R, Decraemer G, Wong C, Salemans P, Nouwens R, Bouwman L, Yazar O. Clinical outcomes of MANTA closure device in percutaneous endovascular aortic aneurysm repair. J Vasc Surg 2024; 79:569-576. [PMID: 37923021 DOI: 10.1016/j.jvs.2023.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/15/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The MANTA device is a plug-based vascular closure device (VCD) designed for large bore femoral arterial access site closure. It showed promising results in transcatheter aortic valve replacement cases. In this study, we report our results and evaluate the MANTA VCD in percutaneous endovascular aortic aneurysm repair (pEVAR). METHODS All data of consecutive patients who underwent an elective pEVAR between October 2018 and December 2022 were retrospectively reviewed. In all patients at least one common femoral artery was intended to close with the MANTA VCD. Depending on the sheath size, the 14Fr or 18Fr MANTA VCD was used. On the preoperative computed tomography scan, the diameter of the common femoral artery (CFA) was measured and the amount of calcification based on the Peripheral Arterial Calcium Scoring System (PACSS) was scored. Primary outcome was procedural technical success. Procedural technical success was defined as placement of the MANTA closure device resulting in vascular closure with patent CFA, without requiring immediate open or endovascular surgery. The secondary outcomes were access site complications requiring reintervention and all-cause mortality at 30-day follow-up. RESULTS In total, 152 consecutive patients underwent pEVAR with 291 common femoral artery closure procedures with the Manta VCD. Mean age was 74.1 ± 6.4 years, with a mean body mass index of 27.7 ± 4.4 kg/m2. The mean diameter of the CFA was 10.5 ± 1.9 mm. In 52.6% of the cases, there were no calcification on the preoperative computed tomography scan. The 18Fr and 14Fr Manta VCD were used 169 and 122 times, respectively. The technical success rate was 96.6%. Major vascular complications were reported in 4.5% of the cases, without any death-related events. CONCLUSIONS This single-center retrospective cohort study analyzed the procedural technical success, major vascular complications and all-cause mortality at 30-day follow-up of the MANTA vascular closure device in 152 pEVAR patients with 291 common femoral artery closure procedures. The technical success rate was 96,6%. Major vascular complications were reported in 4.5% of the cases, without any death related events. We concluded that the MANTA device is a safe and feasible option with a high rate of technical success in patients undergoing pEVAR.
Collapse
Affiliation(s)
- Maxim Peeters
- Department of Surgery, Division of Vascular Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands.
| | - Rens Oosterveld
- Department of Surgery, Division of Vascular Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands; Faculty of Medicine, Maastricht University, Maastricht, The Netherlands
| | - Gilles Decraemer
- Department of Surgery, Division of Vascular Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - ChunYu Wong
- Department of Surgery, Division of Vascular Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Pieter Salemans
- Department of Surgery, Division of Vascular Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Ruben Nouwens
- Procurement Department, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Lee Bouwman
- Department of Surgery, Division of Vascular Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands; Faculty of Science and Engineering, Maastricht University, Maastricht, The Netherlands
| | - Ozan Yazar
- Department of Surgery, Division of Vascular Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| |
Collapse
|
2
|
Zottola ZR, Lehane DJ, Geiger JT, Kruger JL, Kong DS, Newhall KA, Doyle AJ, Mix DS, Stoner MC. Locoregional Anesthesia's Association With Reduced Intensive Care Unit Stay After Elective Endovascular Aneurysm Repair: Impact of Temporal Changes in Practice Patterns. J Surg Res 2024; 295:827-836. [PMID: 38168643 DOI: 10.1016/j.jss.2023.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 10/05/2023] [Accepted: 11/12/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Elective endovascular aneurysm repair (EVAR) can be performed via local anesthetics and/or regional (epidural or spinal) anesthesia (locoregional [LR]), versus general anesthesia (GA), conferring reduced intensive care unit (ICU) and hospital stays. Current analyses fail to account for temporal changes in vascular practice. Therefore, this study aimed to confirm reductions in ICU and hospital stays among LR patients while accounting for changes in practice patterns. MATERIALS AND METHODS Using the Society for Vascular Surgery's Vascular Quality Initiative, elective EVARs from August 2003 to June 2021 were grouped into LR or GA. Outcomes included ICU admission and prolonged hospital stay (>2 d). Procedures were stratified into groups of 2 y periods, and outcomes were analyzed within each time period. Univariable and multivariate analyses were used to assess outcomes. RESULTS LR was associated with reduced ICU admissions (22.3% versus 32.1%, P < 0.001) and prolonged hospital stays (14.3% versus 7.9%, P < 0.001) overall. When stratified by year, LR maintained its association with reduced ICU admissions in 2014-2015 (21.8% versus 34.0%, P < 0.001), 2016-2017 (23.6% versus 31.6%, P < 0.001), 2018-2019 (18.5% versus 30.2%, P < 0.001), and 2020-2021 (15.8% versus 28.8%, P < 0.001), although this was highly facility dependent. LR was associated with fewer prolonged hospital stays in 2014-2015 (15.6% versus 20.4%, P = 0.001) and 2016-2017 (13.3% versus 16.6%, P = 0.006) but not after 2017. CONCLUSIONS GA and LR have similar rates of prolonged hospital stays after 2017, while LR anesthesia was associated with reduced rates of ICU admissions, although this is facility-dependent, providing a potential avenue for resource preservation in patients suitable for LR.
Collapse
Affiliation(s)
- Zachary R Zottola
- University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Daniel J Lehane
- University of Rochester School of Medicine & Dentistry, Rochester, New York
| | - Josh T Geiger
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Joel L Kruger
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel S Kong
- Division of Vascular Surgery, Department of Surgery, MedStar Georgetown Hospital Center, Washington, District of Columbia
| | - Karina A Newhall
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Adam J Doyle
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Doran S Mix
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Michael C Stoner
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York.
| |
Collapse
|
3
|
Brahmandam A, Huttler J, Bellamkonda K, Setia O, Cardella JA, Stewart W, Guzman RJ, Ochoa Chaar CI. The radiographic relationship of the femoral head, inguinal ligament, and common femoral artery bifurcation for optimal vascular access. JVS Vasc Sci 2024; 5:100196. [PMID: 38633882 PMCID: PMC11022081 DOI: 10.1016/j.jvssci.2024.100196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 02/15/2024] [Indexed: 04/19/2024] Open
Abstract
Objective Common femoral artery (CFA) access is commonly used for endovascular interventions. Access site complications contribute to significant morbidity and mortality. This study characterizes the radiographic variability in the relationship of the femoral head, the inguinal ligament, and the CFA bifurcation, to identify the zone of optimal CFA access. Methods Human cadaver dissection of the inguinal ligament and CFA bifurcation was performed. The inguinal ligament and CFA bifurcation were marked with radiopaque pins and plain anteroposterior radiographs were obtained. Radiographic measurements of the femoral head length, the distance of the top of the femoral head to the inguinal ligament, and to the CFA bifurcation were obtained. Results were reported as percentage of femoral head covered by the inguinal ligament or the CFA bifurcation relative to the top of the femoral head. A heatmap was derived to determine a safe access zone between the inguinal ligament and CFA bifurcation. Results Forty-five groin dissections (male, n = 20; female, n = 25) were performed in 26 cadavers. The mean overlap of the inguinal ligament with the femoral head was 11.2 mm (range, -19.4 to 27.4 mm). There were no age (<85 vs ≥85 years) or sex-related differences. In 82.6% of cadaveric CFA exposures, there was overlap between the inguinal ligament and femoral head (mean, 27.7%; range, -85.7% to 70.1%), with 55.6% having a >25% overlap. In 11.1%, there was an overlap between the lower one-third of the femoral head and the CFA bifurcation. Cumulatively, heatmap analysis depicted a >80% likelihood of avoiding the inguinal ligament and CFA bifurcation below the midpoint of the femoral head. Conclusions Significant variability exists in the relationship between the inguinal ligament, CFA bifurcation, and the femoral head, suggesting the lack of a consistently safe access zone. The safest access zone in >80% of patients lies below the radiographic midpoint of the femoral head and the inferior aspect of the femoral head.
Collapse
Affiliation(s)
- Anand Brahmandam
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Kirthi Bellamkonda
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Ocean Setia
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Jonathan A. Cardella
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - William Stewart
- Section of Anatomy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Raul J. Guzman
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
4
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
5
|
MELANI C, BASTIANON M, MOZZETTA G, DI GREGORIO S, DI BARTOLO M, CAPONE A, PRATESI C, PULLI R, MAURI F, PIFFARETTI G, PALERMO D, ANGILETTA D, PRATESI G. Multicenter real-life study on access-related outcomes after EVAR: percutaneous is the way. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2023. [DOI: 10.23736/s1824-4777.22.01559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
6
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 397] [Impact Index Per Article: 198.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
| |
Collapse
|
7
|
Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
8
|
Marone EM, Brioschi C, Pallini M, Marazzi G, Chierico S, Rinaldi LF. Mini-surgical access prevents local complications and reduces costs in endovascular aortic repair. Ann Vasc Surg 2022; 86:111-116. [PMID: 35717007 DOI: 10.1016/j.avsg.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 04/28/2022] [Accepted: 05/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study aims to propose a minimally invasive surgical approach to the common femoral artery in endovascular aortic repair and assess its value by a single-center retrospective study including 118 patients. MATERIALS AND METHODS Between 2017 and 2022, all patients receiving endovascular treatment for thoracic and abdominal aortic aneurysms in our Center had the anterior wall of the common femoral artery exposed, through a 2- 3cm transverse groin incision, instead of a complete surgical cut-down. We access the artery with a purse-string suture, held tight with a tourniquet. After procedure completion, we tie the purse-string closing the arteriotomy. We retrospectively analyzed the cohort of all consecutive patients treated with endovascular aortic repair in this period and recorded primary and assisted technical success, operative time, in-hospital length of stay, access failure, and access-related complications, comparing the results with the current literature. RESULTS All procedures were successful, with no perioperative mortality. Primary technical success was achieved in 116 patients: two required adjunctive procedures. No access failure or access-related complications (thrombosis, groin hematoma, lymphocele, wound dehiscence, or infection) occurred. Two accesses required conversion to complete femoral artery exposure and endarterectomy. Operatory time and length of in-hospital stay were comparable to the outcomes of the major studies reporting on percutaneous access, saving the costs of the closure devices. CONCLUSION Minimally invasive surgical access is safe and feasible for endovascular aortic procedures. Compared to the costs of percutaneous access found in literature, it is cost-effective. It can be chosen whenever the percutaneous approach is not feasible or at high risk of complications.
Collapse
Affiliation(s)
- Enrico Maria Marone
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy.
| | - Chiara Brioschi
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy
| | - Maura Pallini
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Giulia Marazzi
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Simona Chierico
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Luigi Federico Rinaldi
- Department of Vascular Surgery, Policlinico di Monza, Monza, Italy; Vascular Surgery, Department of Integrated Surgical and Diagnostic Sciences, University of Genoa, Genoa, Italy
| |
Collapse
|
9
|
Gontarz B, Majeed R, Staff I, DeMartino R, Jain A, Aitcheson E, Shah P, Divinagracia T, Gallagher J, Healy L, Ayach M, Gifford E. Female sex is associated with worse outcomes following complex fenestrated or branched endovascular aortic repair. Ann Vasc Surg 2022; 87:113-123. [PMID: 35339593 DOI: 10.1016/j.avsg.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Sex-related discrepancies after standard endovascular aneurysm repair (EVAR) are noted to disproportionally affect females. A growing body of literature suggests similar disparities may extend to complex fenestrated or branched endovascular aneurysm repair (FBEVAR). However, recent examination of complex FBEVAR by a consortium of high-volume centers noted equivalent mortality among sexes. Whether similar results extend to non-trial data is unknown. METHODS We examined all juxta-renal through type IV thoraco-abdominal aneurysms (sealing zones 6-8) who underwent elective FBEVAR within the Vascular Quality Initiative (VQI) database from January 2012 to December 2020. Urgent, symptomatic, ruptured, and staged cases were excluded, as were parallel stent grafts. Demographics, comorbid conditions, and technical factors were compared between sexes. Univariate analysis with Wilcoxon ranked sum tests and Chi-square tests of proportion were performed, followed by multivariate logistic regression for failure of target vessel technical success, reintervention, complications, and in-hospital mortality. RESULTS Our analysis included 1521 patients, 1180 males (77.6%) and 341 females (22.4%). There were noted differences in pre-operative demographics, medical optimization, and technical aspects of the procedure. However, no difference was noted in proximal or distal sealing stents, number of fenestrations, or immediate endoleaks. On multi variate logistic regression, female sex was an independent predictor of failure of target vessel technical success (OR 3.339, 95% CI: 2.173-5.132, p<.001), reintervention (OR 2.192, 95% CI: 1.304-3.683, p=.003), complications (OR 1.747, 95% CI: 1.282-2.381, p<.001), and in-hospital mortality (OR 2.836, 95% CI: 1.510-5.328, p=.001). CONCLUSION Females suffer worse outcomes after FBEVAR despite similar extent of disease, number of fenestrations, and incidence of immediate endoleak. Notable discrepancies were higher rates of COPD and lower rates of pre-operative aspirin, statin, and beta blocker therapy in females. Controlling for pre-operative demographics, female sex remained an independent predictor of worse outcomes. These discrepancies warrant further examination and should impact case planning for female patients undergoing complex aortic aneurysm repair.
Collapse
Affiliation(s)
- Brendan Gontarz
- Department of Surgery, University of Connecticut Health Center, Farmington, CT
| | - Rashad Majeed
- Department of Surgery, University of Connecticut Health Center, Farmington, CT; Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Ilene Staff
- Department of Clinical Research, Hartford Hospital, Hartford, CT
| | | | - Akhilesh Jain
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - Parth Shah
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - James Gallagher
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Laura Healy
- Department of Surgery, University of Connecticut Health Center, Farmington, CT; Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Mouhanad Ayach
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Edward Gifford
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT.
| |
Collapse
|
10
|
Sideman MJ, Hui DS. A standardized approach to access in patients requiring complex endovascular aortic therapy. Ann Cardiothorac Surg 2021; 10:790-792. [PMID: 34926183 DOI: 10.21037/acs-2021-taes-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/13/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Matthew J Sideman
- Division of Vascular Surgery, Department of Surgery, Joe R. and Teresa Long Lozano School of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, Joe R. and Teresa Long Lozano School of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA
| |
Collapse
|
11
|
Bi G, Wang Q, Xiong G, Chen J, Luo D, Deng J, Qin X. Is percutaneous access superior to cutdown access for endovascular abdominal aortic aneurysm repair? A meta-analysis. Vascular 2021; 30:825-833. [PMID: 34259113 DOI: 10.1177/17085381211032765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective is to investigate whether percutaneous access (pEVAR) is superior to cutdown access (cEVAR) in terms of safety and efficacy during endovascular repair of abdominal aortic aneurysms (AAAs). METHODS We searched PubMed, Embase, and Cochrane Library from January 1999 to December 2020 for studies reporting on the comparison between percutaneous and cutdown techniques for endovascular repair of AAAs. Outcomes evaluated were technical success rates, access site-related complications and operative time, and hospital stay. RESULTS Four randomized controlled trials and nine observational studies with a total of 1683 patients comprising 2715 groin accesses were eligible for the meta-analysis. pEVAR was associated with a lower risk of overall complications (odds ratio (OR) = 0.63; p = .005) and seroma/lymphorrhea (OR, 0.18; p = .0001) and shortened operation time (MD = -39.04; p = .002) and the length of hospital stay (MD = -0.75; p < .00001) compared with cEVAR. The technical success rate for pEVAR was 95.1% (694/729), with an overall OR of 0.27 (95% CI 0.14-0.55, p = .0003) comparing pEVAR with cEVAR. Furthermore, pEVAR did not increase the risk of site infection, femoral artery thrombosis, postoperative hematoma, nerve injury, dissection, and bleeding. CONCLUSION Percutaneous endovascular aneurysm repair is a safe and effective method for the treatment of AAA. It reduces the risk of overall complications and shortens the operation time and hospital stay. The technical success rate of pEVAR is lower than that of cEVAR, which may be linked to the selection of patients, operator experience, and the use of ultrasound. Large definitive trials are required to draw robust conclusions.
Collapse
Affiliation(s)
- Guoshan Bi
- Department of Vascular Surgery, 117742The First Affiliated Hospital of Guangxi Medical University, Guangxi, China.,Department of Vascular Surgery, 575432The Second Affiliated Hospital of University of South China, Hunan Province, China
| | - Quanwen Wang
- Department of Vascular Surgery, 575432The Second Affiliated Hospital of University of South China, Hunan Province, China
| | - Guozuo Xiong
- Department of Vascular Surgery, 575432The Second Affiliated Hospital of University of South China, Hunan Province, China
| | - Jie Chen
- Department of Vascular Surgery, 575432The Second Affiliated Hospital of University of South China, Hunan Province, China
| | - Dongyang Luo
- Department of Vascular Surgery, 117742The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Jiangbei Deng
- Department of Vascular Surgery, 117742The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| | - Xiao Qin
- Department of Vascular Surgery, 117742The First Affiliated Hospital of Guangxi Medical University, Guangxi, China
| |
Collapse
|
12
|
Kronenfeld JP, Ryon EL, Lall A, Kang N, Kenel-Pierre S, DeAmorim H, Rey J, Karwowski J, Bornak A. Percutaneous endovascular abdominal aortic aneurysm repair with monitored anesthesia care decreases operative time but not pulmonary complications. Vascular 2021; 30:418-426. [PMID: 33940997 DOI: 10.1177/17085381211012908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To report our experience and compare the results of percutaneous endovascular aortic aneurysm repair (PEVAR) performed under monitored anesthesia care (MAC) to PEVAR under general anesthesia (GA). METHODS A retrospective review of patients who underwent non-emergency endovascular abdominal aortic aneurysm repair (EVAR) was completed. Patients were excluded if they had a complex repair, including fenestrated, branched, or parallel endografting. Demographics, operative data, 30-day mortality/morbidity and postoperative outcomes were analyzed. RESULTS A total of 159 patients were identified with a median age of 69. 115 patients had PEVAR, 45 (39.1%) PEVAR MAC and 70 (60.9%) PEVAR GA. PEVAR MAC compared to PEVAR GA had decreased operative time (106 vs. 134 min, P < 0.001), time in the operating room (163 vs. 245 min, P = 0.016), and estimated blood loss (EBL) (115 vs. 176 mL P = 0.012). There was no statistically significant difference in the hospital length of stay (LOS) (1.9 vs. 2.7 days, P = 0.133), and post-operative complications including pulmonary (2.2 vs. 2.9%, P = 0.835). Forty-four patients had EVAR with a femoral cutdown (FC), including 14 PEVAR conversions. PEVAR conversion was associated with higher EBL (543 vs. 323 mL, P = 0.03), operative time (230 vs. 178 min, P = 0.01), and operating room time (307 vs. 275 min, P = 0.01) compared to planned EVAR with FC. CONCLUSIONS PEVAR under MAC is associated with shorter time in the operating room compared to PEVAR under GA. PEVAR under MAC does however not decrease overall morbidities, including postoperative pulmonary complications.
Collapse
Affiliation(s)
- Joshua P Kronenfeld
- Vascular & Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL, USA
| | - Emily L Ryon
- Vascular & Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL, USA
| | - Alex Lall
- Vascular & Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL, USA
| | - Naixin Kang
- Vascular & Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL, USA
| | - Stefan Kenel-Pierre
- Vascular & Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL, USA
| | - Hilene DeAmorim
- Vascular & Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL, USA
| | - Jorge Rey
- Vascular & Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL, USA
| | - John Karwowski
- Vascular & Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL, USA
| | - Arash Bornak
- Vascular & Endovascular Surgery, University of Miami & Miami VAMC, Miami, FL, USA
| |
Collapse
|
13
|
Cheng TW, Farber A, Levin SR, Malas MB, Garg K, Patel VI, Kayssi A, Rybin D, Hasley RB, Siracuse JJ. Perioperative Outcomes for Centers Routinely Admitting Postoperative Endovascular Aortic Aneurysm Repair to the ICU. J Am Coll Surg 2021; 232:856-863. [PMID: 33887484 DOI: 10.1016/j.jamcollsurg.2021.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Intensive care unit (ICU) admission after endovascular aortic aneurysm repair (EVAR) varies across medical centers. We evaluated the association of postoperative ICU use with perioperative and long-term outcomes after EVAR. STUDY DESIGN The Vascular Quality Initiative (2003-2019) was queried for index elective EVARs. Included centers were categorized by percentage of patients with EVARs postoperatively admitted to the ICU; routine ICU (rICU) centers as ≥80% ICU admissions and nonroutine ICU (nrICU) centers as ≤20% ICU admissions. Patients admitted preoperatively or with same day discharge were excluded. Perioperative outcomes and survival were compared between rICU and nrICU centers. RESULTS Of 45,310 EVARs in the database, 35,617 were performed at rICU or nrICU centers - 5,443 (15.3%) at 71 rICU centers and 30,174 (84.7%) at 200 nrICU centers. Overall, mean age was 73.4 years and 81.6% were male. Postoperative myocardial infarction, pulmonary complications, stroke, leg ischemia, and in-hospital mortality were similar between rICU and nrICU centers (all p > 0.05). Postoperative length of stay (LOS) was prolonged at rICU centers (mean) (2.2 ± 3.6 vs 2 ± 4.2 days, p < 0.001). One-year survival was similar between rICU and nrICU centers, respectively, (94.9% vs 95.4%, p = 0.085). When compared with nrICU centers, rICU centers had similar 1-year mortality risk (hazard ratio [HR] 1.15, 95% CI 0.99-1.34, p = 0.076), but were associated with longer postoperative LOS (means ratio 1.1, 95% CI 1.08-1.13, p < 0.001). CONCLUSIONS Routine ICU use after EVAR was associated with prolonged postoperative LOS, without improved perioperative/long-term morbidity or mortality. Updated care pathways to include postoperative admission to lower acuity care units may reduce costs without compromising care.
Collapse
Affiliation(s)
- Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Karan Garg
- NYU Langone Medical Center, Division of Vascular Surgery, New York, NY
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, New York-Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Ahmed Kayssi
- Division of Vascular Surgery, University of Toronto, Toronto, ON
| | - Denis Rybin
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Rebecca B Hasley
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
| |
Collapse
|
14
|
Liu Y, Wang T, Zhao J, Kang L, Ma Y, Huang B, Yuan D, Yang Y. Influence of Anesthetic Techniques on Perioperative Outcomes after Endovascular Aneurysm Repair. Ann Vasc Surg 2020; 73:375-384. [PMID: 33383135 DOI: 10.1016/j.avsg.2020.11.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/04/2019] [Accepted: 11/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The purpose of the study was to explore the influence of anesthetic techniques on perioperative outcomes after endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) in a Chinese population. METHODS A retrospective review was performed in patients after elective EVAR for infrarenal AAA at our single center. Patients were classified into general anesthesia (GA), regional anesthesia (RA), and local anesthesia (LA) groups. The primary outcomes (30-day mortality and morbidity) and secondary outcomes [procedure time, mean arterial pressure (MAP), and length of hospital stay (LOS)] were collected and analyzed. RESULTS From January 2006 to December 2015, 486 consecutive patients underwent elective EVAR at our center. GA was used in 155 patients (31.9%), RA in 56 (11.5%), and LA in 275 (56.6%). The GA patients had fewer respiratory comorbidities, shorter and more angulated proximal necks, and more concomitant iliac aneurysms. LA during EVAR was significantly associated with a shorter procedure time (GA, P < 0.001; RA, P < 0.001) and shorter LOS (GA, P = 0.002; RA, P = 0.001), but a higher MAP (GA, P < 0.001; RA, P < 0.001) compared with GA and RA. LA was associated with a significantly lower risk of cardiac (odds ratio (OR) 4.27, 95% confidence interval (CI) 1.21-15.04), pulmonary (OR 5.37, 95% CI 1.58-18.23), and systemic complications (OR 4.15, 95% CI 1.85-9.33) compared with GA. RA was also associated with a decreased risk of systemic complications (OR 4.74, 95% CI 1.19-18.92) compared with GA. There was no difference in the 30-day mortality, neurologic complications, renal complications, and intraoperative extra procedures among the 3 groups. CONCLUSIONS Anesthetic techniques for EVAR have no influence on the 30-day mortality. LA for EVAR appears to be beneficial concerning the procedure time, LOS, and 30-day systemic complications for patients after elective EVAR for infrarenal AAA in the Chinese population.
Collapse
Affiliation(s)
- Yang Liu
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Tiehao Wang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
| | - Limei Kang
- West China School of Medicine, Sichuan University, Chengdu, Sichuan Province, China
| | - Yukui Ma
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yi Yang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
| |
Collapse
|
15
|
Ng JJ, Tan JKH, Lee JWK, Choong AMTL. Longitudinal versus transverse incision for common femoral artery exposure: a systematic review and meta-analysis. ANZ J Surg 2020; 91:822-831. [PMID: 33205574 DOI: 10.1111/ans.16448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND A longitudinal or a transverse incision is routinely used for common femoral artery (CFA) exposure. Some believe a transverse incision is associated with a lower incidence of postoperative complications. We performed a systematic review and meta-analysis to evaluate the risk of postoperative surgical site infection, lymphatic complications, wound dehiscence and haematoma formation when using a longitudinal or transverse incision for CFA exposure. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were adhered to. We searched various databases such as MEDLINE via PubMed and Embase for relevant studies from inception till 31 May 2020. Relevant search terms such as 'longitudinal', 'transverse', 'vertical', 'horizontal', 'femoral', 'incision' were used. We included both randomized controlled trials and case-controlled studies, and extracted data related to study characteristics and postoperative complications. We assessed risk of bias using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. A random-effects meta-analysis was performed to obtain the pooled proportions and risk ratios (RR) for our study outcomes. RESULTS We included seven studies with a total of 5922 groin incisions. A longitudinal incision was associated with a significantly higher incidence of wound infection (RR 2.93, 95% confidence interval (CI) 1.12-7.70, P = 0.03) and wound dehiscence (RR 2.87, 95% CI 1.06-7.77, P = 0.04). The risk of lymphatic complications (RR 1.09, 95% CI 0.39-3.05, P = 0.87) and wound haematoma (RR 2.85, 95% CI 0.88-9.21, P = 0.08) were similar. CONCLUSIONS A longitudinal incision may be associated with a higher incidence of wound infection and wound dehiscence, as compared to using a transverse incision for CFA exposure.
Collapse
Affiliation(s)
- Jun Jie Ng
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Vascular and Endovascular Surgery, National University Heart Centre, Singapore
| | - Jarrod K H Tan
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James W K Lee
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew M T L Choong
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Vascular and Endovascular Surgery, National University Heart Centre, Singapore.,Cardiovascular Research Institute, National University Health System, Singapore
| |
Collapse
|
16
|
Chang H, Rockman CB, Jacobowitz GR, Ramkhelawon B, Cayne NS, Veith FJ, Patel VI, Garg K. Contemporary outcomes of endovascular abdominal aortic aneurysm repair in patients deemed unfit for open surgical repair. J Vasc Surg 2020; 73:1583-1592.e2. [PMID: 33035595 DOI: 10.1016/j.jvs.2020.08.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/22/2020] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Bhama Ramkhelawon
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
| |
Collapse
|
17
|
Montross BC, O’Brien-Irr MS, Koudoumas D, Khan SZ, Rivero M, Harris LM, Dosluoglu HH, Cherr GS, Dryjski ML. The selection of patients for ambulatory endovascular aneurysm repair of elective asymptomatic abdominal aortic aneurysm. J Vasc Surg 2020; 72:1347-1353. [DOI: 10.1016/j.jvs.2020.01.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 01/17/2020] [Indexed: 11/27/2022]
|
18
|
O'Donnell TFX, Deery SE, Boitano LT, Schermerhorn ML, Siracuse JJ, Clouse WD, Malas MB, Takayama H, Patel VI. The long-term implications of access complications during endovascular aneurysm repair. J Vasc Surg 2020; 73:1253-1260. [PMID: 32889076 DOI: 10.1016/j.jvs.2020.08.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 08/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Access issues are one of the most common complications of endovascular aneurysm repair (EVAR). However, contemporary rates as well as risk factors for complications and the subsequent impact of access complications on mortality are poorly described. METHODS We studied all EVAR for intact abdominal aortic aneurysms without prior aortic surgery in the Vascular Quality Initiative between 2011 and 2018. We studied factors associated with access complications (thrombosis, embolus, wound infection, hematoma, and conversion to cutdown), as well as the interaction with female sex and the impact on survival using multilevel logistic regression and propensity weighting. Multiple imputation was used for missing data. RESULTS There were 33,951 EVAR during the study period (91% elective, 9% symptomatic); most cases (70%) involved an attempt at percutaneous access on at least one side, with 30% bilateral cutdowns and 0.1% iliac conduits. There were 1553 patients (4.6%) who experienced at least one access complication. Access complications were almost twice as common in female patients (7.5% vs 3.9%; P < .001). The factors associated with access complications included female sex (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.0-3.6; P < .001), age (OR, 1.05 per 5 years; 95% CI, 1.02-1.1; P < .01), aortouni-iliac device (OR, 1.6; 95% CI, 1.1-2.3; P < .01), smoking (OR, 1.4; 95% CI, 1.1-1.7; P < .01), body mass index of less than 16 (OR, 1.8; 95% CI, 1.3-2.5; P = .001), dual antiplatelet therapy (1.3; 95% CI, 1.02-1.6 P = .03), prior infrainguinal bypass (OR, 1.8; 95% CI, 1.3-2.7; P < .01), and beta blocker use (OR, 1.2; 95% CI, 1.03-1.4; P = .02). Conversion from percutaneous access to open cutdown was associated with higher rates of complications than planned open cutdown (8.6% vs 2.9%; P < .001). In propensity-weighted analysis, percutaneous access was associated with significantly lower odds of access complications in women (OR, 0.6; 95% CI, 0.4-0.96; P = .03). Patients who experienced an access complication had more than four times the odds of perioperative death (OR, 4.2; 95% CI, 2.5-7.1; P < .001), and a 60% higher risk of long-term mortality (hazard ratio, 1.6; 95% CI, 1.2-2.1; P = .001). In addition to death, patients with access site complications had higher rates of other major complications, including reoperation during the index hospitalization (19% vs 1.2%; P < .001), myocardial infarction (3.5% vs 0.7%; P < .001), stroke (0.8% vs 0.2%; P < .001), acute kidney injury (12% vs 3%; P < .001), and reintubation (5.7% vs 0.8%). CONCLUSIONS Although access complications are infrequent in the current era, they are associated with both perioperative and long-term morbidity and mortality. Female patients in particular are at high risk of access complications, but may benefit from percutaneous access.
Collapse
Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Hospital, Baltimore, Md
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, Va
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California, San Diego, Calif
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians & Surgeons, New York, NY.
| |
Collapse
|
19
|
Sen I, Tenorio ER, Mirza AK, Kärkkäinen JM, Mendes BC, DeMartino RR, Cha S, Oderich GS. Effect of Blood Loss and Transfusion Requirements on Clinical Outcomes of Fenestrated-Branched Endovascular Aortic Repair. Cardiovasc Intervent Radiol 2020; 43:1600-1607. [PMID: 32864718 DOI: 10.1007/s00270-020-02573-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/22/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of blood loss and transfusion requirements on clinical outcomes of patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs). METHODS We reviewed the clinical data of 370 consecutive patients (277 male, mean age 74 ± 10 years) treated by F-BEVAR between 2007 and 2017. Outcomes were estimated blood loss (EBL), use of intraoperative blood salvage (IOBS), transfusion of packed red blood cells (PRBCs), mortality, and major adverse events (MAEs). RESULTS There were 189 patients (51%) treated for PRAs and 181 patients (49%) treated for TAAAs. IOBS was used in 194 patients (52%) and transfusion of PRBCs was needed in 137 (37%). Thirty-day mortality was 2.2% (8/370) and MAEs occurred in 123 patients (33%), including 74 patients (20%) who had EBL > 1L. EBL > 1L and transfusion of PRBCs were significantly higher (P < 0.05) in patients treated in the first half of clinical experience and in those with larger aneurysms, iliofemoral conduits, bilateral open surgical femoral access and Extent I-III TAAAs. Use of DrySeal® sheaths (WL Gore, Flagstaff AZ) was associated with significantly lower (P < .05) EBL volume and with less transfusion of PRBCs. On multivariate analysis PRBCs > 1L, male gender and the last half of clinical experience were associated with MAEs/mortality. CONCLUSIONS F-BEVAR was associated with significantly higher volume of blood loss and transfusion requirements in patients treated in the early experience and in those who had iliofemoral conduits, open femoral surgical exposure or Extent I-III TAAAs.
Collapse
Affiliation(s)
- Indrani Sen
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Emanuel R Tenorio
- Advanced Aortic Research Program, University of Texas Health Science at Houston, McGoven Medical School, Houston, TX, USA
| | - Aleem K Mirza
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Jussi M Kärkkäinen
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Bernardo C Mendes
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Randall R DeMartino
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Stephen Cha
- Advanced Endovascular Aortic Research Program, Mayo Clinic, Rochester, MN, USA
| | - Gustavo S Oderich
- Advanced Aortic Research Program, University of Texas Health Science at Houston, McGoven Medical School, Houston, TX, USA. .,Memorial Hermann Medical Plaza, University of Texas Health Science, Houston, TX, USA.
| |
Collapse
|
20
|
Effect of obesity on radiation exposure, quality of life scores, and outcomes of fenestrated-branched endovascular aortic repair of pararenal and thoracoabdominal aortic aneurysms. J Vasc Surg 2020; 73:1156-1166.e2. [PMID: 32853700 DOI: 10.1016/j.jvs.2020.07.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/16/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND The aim of the present study was to assess the effect of obesity on procedural metrics, radiation exposure, quality of life (QOL), and clinical outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of pararenal and thoracoabdominal aortic aneurysms. METHODS We reviewed the clinical data from 334 patients (236 men; mean age, 75 ± 8 years) enrolled in a prospective nonrandomized study to evaluate FB-EVAR from 2013 to 2019. The patients were classified using the body mass index (BMI) as obese (BMI ≥30 kg/m2) or nonobese (BMI <30 kg/m2). QOL questionnaires (short-form 36-item questionnaire) and imaging studies were obtained preoperatively and at 2 months and 6 months postoperatively, and annually thereafter. The procedures were performed using two different fixed imaging systems. The end points included procedural metrics (ie, total operative time, fluoroscopic time, contrast volume), radiation exposure, technical success, 30-day mortality, and major adverse events, QOL changes, freedom from target vessel instability, freedom from reintervention, and patient survival. RESULTS The aneurysm extent was a pararenal aortic aneurysm in 117 patients (35%) and a thoracoabdominal aortic aneurysm in 217 patients (65%). Both groups had similar demographics, cardiovascular risk factors, and aneurysm extent, except for a greater incidence of hyperlipidemia and diabetes among the obese patients (P < .05). No significant differences were found in the procedural metrics or intraprocedural complications between the groups, except that the obese patients had greater radiation exposure than the nonobese patients (mean, 2.5 vs 1.6 Gy; P < .001), with the highest radiation exposure in those obese patients who had undergone the procedure using system 1 (fusion alone) instead of system 2 (fusion and digital zoom; mean, 4.1 vs 1.5 Gy; P < .001). Three patients had died within 30 days (0.8%), with no difference in mortality or major adverse events between the groups. The mental QOL scores had improved in the obese group at 2 and 12 months compared with the nonobese patients, with persistently higher scores up to 3 years. At 3 years, the obese and nonobese patients had a similar incidence of freedom from target vessel instability (74% ± 6% vs 80% ± 3%; P = .99, log-rank test), freedom from reintervention (66% ± 6% vs 73% ± 4%; P = .77, log-rank test), and patient survival (83% ± 5% vs 75% ± 4%; P = .16, log-rank test). CONCLUSIONS FB-EVAR was performed with high technical success and low mortality and morbidity, with no significant differences between the obese and nonobese patients. The procedural metrics and outcomes were similar, with the exception of greater radiation exposure among obese patients, especially for the procedures performed using system 1 with fusion alone compared with system 2 (fusion and digital zoom). Obese patients had higher QOL mental scores at 2 and 12 months, with a similar reintervention rate, target vessel outcomes, and survival compared with nonobese patients.
Collapse
|
21
|
Melloni A, Grandi A, Melissano G, Chiesa R, Bertoglio L. Safety and Feasibility of Percutaneous Purse-String-Like Downsizing for Femoral Access During Complex Endovascular Aortic Repair. Cardiovasc Intervent Radiol 2020; 43:1084-1090. [DOI: 10.1007/s00270-020-02508-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/25/2020] [Indexed: 12/17/2022]
|
22
|
Canteras M, Baptista‐Silva JCC, do Carmo Novaes F, Cacione DG. Transverse versus vertical groin incision for femoral artery approach. Cochrane Database Syst Rev 2020; 4:CD013153. [PMID: 32319682 PMCID: PMC7175778 DOI: 10.1002/14651858.cd013153.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Access to the femoral vessels is necessary for a wide range of vascular procedures, including treatment of thromboembolic disease, arterial grafts (i.e. bifemoral aortic bypass or infrainguinal bypass), endovascular repair of abdominal aortic aneurysm (EVAR), thoracic endovascular aneurysm repair (TEVAR) and transcatheter aortic valve implantation (TAVI). The surgical technique used to access the femoral artery may be a factor in the occurrence of postoperative complications; this will be the focus of our review. We will compare the transverse surgical technique-a cut made parallel to the groin crease-versus the vertical groin incision surgical technique-classic technique: a surgical cut made across the groin crease-to access the femoral artery, in an attempt to determine which technique has the lower rate of complications, is safer and is more effective. OBJECTIVES To evaluate the efficacy and safety of transverse groin incision compared with vertical groin incision for accessing the femoral artery in endovascular surgical procedures and open surgery. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to 17 February 2020. The review authors searched the IBECS database to 26 March 2020 and reference lists of relevant studies/papers. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-randomized trials (qRCTs) that compare transverse and vertical groin incision, during either endovascular or open surgery procedures. DATA COLLECTION AND ANALYSIS Two review authors (MVCRC, FCN) independently selected the studies, assessed risk of bias, extracted data, performed data analysis and graded the certainty of evidence according to GRADE. MAIN RESULTS We included one RCT and one qRCT in this review. These two studies had a combined total of 237 participants (283 groins). Infection of the surgical wound was the only outcome that was similar in both studies, and that could therefore be submitted to a combined analysis. Meta-analysis of the two studies showed low-certainty evidence that transverse groin incision resulted in a lower risk of surgical wound infection in the 10- to 28-day period following surgery (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.08 to 0.76; 2 studies; 283 groin incisions). There was low heterogeneity between the studies. We downgraded the certainty of the evidence for surgical wound infection by one level due to serious limitations in the design (there was a high risk of bias in critical domains). The confidence interval for surgical wound infection is relatively wide, further indicating that the certainty of the effect estimate is low. This is likely due to the small number of studies and participants. We observed no evidence of a difference between the two surgical techniques for the other evaluated primary outcome 'lymphatic complications': lymphocele (RR 0.46, 95% CI 0.20 to 1.02; 1 study; 116 groins); and lymphorrhea (RR 2.77, 95% CI 0.92 to 8.34; 1 study; 116 groins). We downgraded the certainty of evidence for lymphatic complications by one level due to serious limitations in the design (there was a high risk of bias in critical domains); and by two further levels because of imprecision (small number of participants and only one study included). High-quality studies are needed to enable a comparison of the two surgical techniques with respect to other outcomes, such as infection of the vascular graft (endoprosthesis/prosthesis), prolonged hospitalization, reoperative surgery, death, neurological deficit (e.g. paresthesia), amputation, graft patency, and postoperative pain. AUTHORS' CONCLUSIONS In this systematic review, we found low-certainty evidence that performing transverse groin incision to access the femoral artery resulted in fewer surgical wound infections compared with performing vertical groin incision. We observed no evidence of a difference between the two surgical techniques for the other evaluated outcomes (lymphocele and lymphorrhea). Other outcomes were not evaluated in these studies. Limitations of this systematic review are, however, the small sample size, short clinical follow-up period and high risk of bias in critical domains. For this reason, the applicability of the results is limited.
Collapse
Affiliation(s)
- Marcus Canteras
- UNIFESP – Escola Paulista de MedicinaDepartment of SurgeryRua Borges Lagoa, cj 564, CJ 124Vila ClementinoSão PauloSão PauloBrazil04038000
| | - Jose CC Baptista‐Silva
- Universidade Federal de São PauloEvidence Based Medicine, Cochrane BrazilRua Borges Lagoa, 564, cj 124São PauloSão PauloBrazil04038‐000
| | - Frederico do Carmo Novaes
- UNIFESP – Escola Paulista de MedicinaDepartment of SurgeryRua Borges Lagoa, cj 564, CJ 124Vila ClementinoSão PauloSão PauloBrazil04038000
| | - Daniel G Cacione
- UNIFESP – Escola Paulista de MedicinaDivision of Vascular and Endovascular Surgery, Department of SurgeryRua Borges Lagoa, 564 cj 124Vila ClementinoSão PauloBrazil04038000
| | | |
Collapse
|
23
|
Pivotal Clinical Study to Evaluate the Safety and Effectiveness of the MANTA Vascular Closure Device During Percutaneous EVAR and TEVAR Procedures. J Endovasc Ther 2020; 27:414-420. [DOI: 10.1177/1526602820912224] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose: To evaluate the safety and effectiveness of the MANTA percutaneous vascular closure device in patients undergoing percutaneous endovascular aneurysm repair (PEVAR) or thoracic endovascular aortic repair (TEVAR). Materials and Methods: The SAFE MANTA Study ( ClinicalTrials.gov identifier NCT02908880) was a prospective, single-arm, multicenter trial in patients undergoing endovascular interventions using large-bore sheaths (transcatheter aortic valve replacement, PEVAR, or TEVAR) at 20 sites in North America. Patient selection intended to test the MANTA device in populations without morbid obesity, severe calcification, or a severely scarred femoral access area. Of the 263 patients enrolled in the primary analysis cohort, 53 (20.2%) patients (mean age 74.9±8.9 years; 41 men) underwent PEVAR (n=51) or TEVAR (n=2) procedures and form the cohort for this subgroup analysis. Per protocol a single MANTA device was deployed in all PEVAR/TEVAR cases. Results: The mean time to hemostasis in the PEVAR/TEVAR cohort was 35±91 seconds, with a median time of 19 seconds vs 24 seconds in the overall SAFE MANTA population. The MANTA device met the definition for technical success in 52 (98%) of 53 PEVAR/TEVAR cases compared with 97.7% in the overall SAFE MANTA population. One (1.9%) major complication (access-site stenosis) occurred in this subgroup compared to 14 (5.3%) events in the SAFE population. In the PEVAR/TEVAR group, 1 pseudoaneurysm was noted prior to discharge, another at 30-day follow-up, and one at 60 days. One (1.9%) of the 3 minor pseudoaneurysms was treated with ultrasound-guided compression and the other 2 required no treatment. Conclusion: The MANTA device demonstrated a short time to hemostasis and low complication rates compared with published literature results of other percutaneous closure devices. Time to hemostasis and complication rates were comparable between the PEVAR/TEVAR patients and the full SAFE MANTA study cohort. The MANTA device provides reliable closure with a single percutaneous device for PEVAR/TEVAR procedures.
Collapse
|
24
|
D’Oria M, Oderich GS, Tenorio ER, Kärkkäinen JM, Mendes BC, DeMartino RR. Safety and Efficacy of Totally Percutaneous Femoral Access for Fenestrated–Branched Endovascular Aortic Repair of Pararenal–Thoracoabdominal Aortic Aneurysms. Cardiovasc Intervent Radiol 2020; 43:547-555. [DOI: 10.1007/s00270-020-02414-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/09/2020] [Indexed: 12/17/2022]
|
25
|
Varkevisser RRB, Swerdlow NJ, Verhagen HJM, Lyden SP, Schermerhorn ML. Similar 5-year outcomes between female and male patients undergoing elective endovascular abdominal aortic aneurysm repair with the Ovation stent graft. J Vasc Surg 2019; 72:114-121. [PMID: 31843301 DOI: 10.1016/j.jvs.2019.08.275] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/21/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Female patients undergoing endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysms present with more challenging anatomy and historically have worse outcomes compared with men. The Ovation Abdominal Stent Graft platform (Endologix, Irving, Calif) contains a polymer-filled proximal sealing ring and has a low-profile delivery system, potentially beneficial in female patients. We therefore investigated differences in long-term outcomes between men and women treated with this device. METHODS We used data collected prospectively in the Effectiveness of Custom Seal with Ovation: Review of the Evidence (ENCORE) database, comprising five trials and the European Post-Market Registry. Anatomic characteristics of the proximal aneurysm neck and iliac arteries were compared between male and female patients. Outcomes were 5-year freedom from type IA and type I/III endoleaks, abdominal aortic aneurysm-related reinterventions, and overall survival. We used Kaplan-Meier analysis to estimate survival proportions and tested univariate differences in survival using log-rank tests. Cox proportional hazards modeling was used to adjust for baseline differences. RESULTS We identified 1045 (81%) male and 251 (19%) female patients undergoing EVAR. Female patients were older (mean age, 75 ± 8.4 years vs 73 ± 8.1 years; P < .006). Aneurysm diameter (52 ± 7.5 mm vs 55 ± 9.2 mm; P < .001) and proximal neck diameter (21 ± 3.3 mm vs 23 ± 2.9 mm; P < .001) were smaller in female patients, but adjusted for body surface area, female patients had relatively larger aneurysms and aneurysm necks. Furthermore, female patients presented with shorter proximal necks, smaller iliac artery diameters, more angulated necks, and higher rates of reverse-tapered necks. Five-year freedom from type IA endoleak was similar between men and women (97% vs 96%; P = .38), as was freedom from type I/III endoleaks (91% vs 94%; P = .37) and reinterventions (91% vs 93%; P = .67). Five-year survival was 81% for female patients, similar to the 79% in male patients (P = .55), with one aneurysm-related death in female patients (0.4%) and five in male patients (0.8%; P = .76). Risk-adjusted analyses showed no association between sex and type IA endoleak (hazard ratio [HR], 1.4; 95% confidence interval [CI], 0.6-3.1; P = .41), type I/III endoleak (HR, 1.4; 95% CI, 0.7-2.8; P = .33), reintervention (HR, 1.0; 95% CI, 0.6-2.0; P = .77), and overall mortality (HR, 0.7; 95% CI, 0.4-1.1; P = .14). CONCLUSIONS Female patients undergoing EVAR with the Ovation platform presented with substantially more adverse proximal neck characteristics. Despite these differences, 5-year freedom from endoleaks and overall survival did not differ between sexes.
Collapse
Affiliation(s)
- Rens R B Varkevisser
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
| |
Collapse
|
26
|
Swerdlow NJ, Lyden SP, Verhagen HJM, Schermerhorn ML. Five-year results of endovascular abdominal aortic aneurysm repair with the Ovation abdominal stent graft. J Vasc Surg 2019; 71:1528-1537.e2. [PMID: 31515176 DOI: 10.1016/j.jvs.2019.06.196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 06/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Endovascular abdominal aortic aneurysm repair (EVAR) has been rigorously compared with open repair for the treatment of abdominal aortic aneurysms in randomized trials and observational studies, but a comparison of individual devices is lacking, and single-device registries and trials are limited by small sample size. Here we report a descriptive analysis of the Effectiveness of Custom Seal with Ovation: Review of the Evidence (ENCORE) database, pooled results of multiple studies evaluating the midterm results of EVAR with the Ovation Abdominal Stent Graft Platform. METHODS This is a retrospective analysis of the ENCORE database, a cohort of patients undergoing EVAR with the Ovation platform composed of pooled, prospectively collected data from 1296 patients from five clinical trials and the prospectively maintained European Union Post-Market Registry. The primary outcomes were 5-year rates of type IA and type I or III endoleak. Secondary outcomes included were 30-day mortality, 30-day major adverse event, technical success (successful deployment of the aortic body and iliac limbs), as well as 5-year survival, and freedom from aneurysm-related mortality, type II endoleak, device-related intervention, aneurysm rupture, sac expansion, and conversion to open repair. RESULTS A total of 1296 patients were included in the analysis. The average age was 73 ± 8 years and 81% of patients were male. Fifty percent of patients had complex aortic anatomy, (neck length <10 mm, neck diameter >28 mm, neck angle >60°, reverse neck taper >10%, distal common iliac artery diameter <10 mm, or external iliac artery diameter <6 mm). Technical success was 99.7%. Thirty-day mortality was 0.3%, 30-day rate of major adverse event was 1.6%, and polymer leak rate was 0.2%. Freedom from type IA endoleak at 1, 3, and 5 years was 97.6%, 97.1%, and 95.8%, respectively; type I or III endoleak at 1, 3, and 5 years was 96.9%, 95.7%, and 94.0%, respectively. Freedom from device-related reintervention at 1, 3, and 5 years was 96.2%, 94.4%, and 92.4% and primary freedom from sac expansion was 97.0% at 1 year, 90.3% at 3 years, and 84.9% at 5 years. Freedom from all-cause mortality and aneurysm-related mortality at 5 years were 78.9% and 99.3%, respectively. CONCLUSIONS This analysis of the ENCORE database demonstrates that EVAR with the Ovation platform has favorable midterm durability evidenced by successful aneurysm exclusion and 5-year freedom from aneurysm-related mortality.
Collapse
Affiliation(s)
- Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Sean P Lyden
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
| |
Collapse
|
27
|
Roberts L, Farber A, Jones DW, Woo K, Eslami MH, Simons J, Malas M, Tan TW, Rybin D, Siracuse JJ. Tapered arteriovenous grafts do not provide significant advantage over nontapered grafts in upper extremity dialysis access. J Vasc Surg 2019; 69:1552-1558. [DOI: 10.1016/j.jvs.2018.08.181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 08/23/2018] [Indexed: 11/29/2022]
|
28
|
Liang P, O'Donnell TFX, Swerdlow NJ, Li C, Lee A, Wyers MC, Hamdan AD, Schermerhorn ML. Preoperative risk score for access site failure in ultrasound-guided percutaneous aortic procedures. J Vasc Surg 2019; 70:1254-1262.e1. [PMID: 30852039 DOI: 10.1016/j.jvs.2018.12.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/12/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The factors associated with access site failure after ultrasound-guided percutaneous access for aortic endograft procedures remain poorly characterized. We developed a prediction model to risk stratify patients for access site failure. METHODS We performed a retrospective institutional review of consecutive patients who underwent endovascular aneurysm repair (EVAR), fenestrated EVAR (FEVAR), or thoracic endovascular aortic repair (TEVAR) from 2014 to 2016. We excluded patients undergoing direct aortic access through sternotomy and patients treated with physician-modified endografts, given reporting restrictions. Our primary outcome was groin access site failure, which included bleeding and thrombosis. An 8-point risk model was created for access site failure using multivariable fractional polynomials and internally validated using bootstrapping. RESULTS We identified 469 femoral arteries from 247 patients undergoing endovascular aortic repair procedures (EVAR, 75%; FEVAR, 8.0%; TEVAR, 17%). Surgeons performed percutaneous access in 97.2% of the femoral arteries, with 99.6% ultrasound use. Twenty-seven (5.9%) access site failures occurred (17 bleeding, 10 thrombosis), all treated with groin cutdown, for a successful percutaneous femoral artery access rate of 94%. Of the 215 patients with attempted bilateral percutaneous access, 90% had successful bilateral access. However, FEVAR had lower rates of successful bilateral access (FEVAR, 78%; EVAR, 91%; TEVAR, 94%; P = .03). Factors independently associated with percutaneous access site failure were femoral artery outer wall diameter (per millimeter increase: odds ratio [OR], 0.003 [0.0002-0.1]; P < .001), femoral artery stenosis >50% (OR, 22.3 [2.7-183.2]; P < .01), and urgent/emergent intervention (OR, 3.6 [1.2-11.0]; P = .03). A risk prediction model based on these criteria produced a C statistic of 0.89, a Hosmer-Lemeshow goodness of fit of 0.99, and a Brier score of 0.04. Excluding treatment for ruptured aneurysms, cutdown for access failure and planned initial groin cutdown resulted in longer postoperative lengths of stay and higher rates of access-related readmission, return to operating room, groin infection, and myocardial infarction compared with successful percutaneous access. There was no difference in major adverse events between planned initial groin cutdown and cutdown after failure; however, the small number of patients in these two comparison groups limits the statistical power to detect a difference. CONCLUSIONS Percutaneous ultrasound-guided access can be safely performed in almost all patients undergoing endovascular aortic procedures, but access site failures do occur. This risk score can help users select patients with high likelihood of success, identify patients who need close scrutiny with postclosure femoral duplex ultrasound, and provide patient guidance about risk of unplanned groin cutdown.
Collapse
Affiliation(s)
- Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Andy Lee
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Allen D Hamdan
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
| |
Collapse
|
29
|
Affiliation(s)
- Nicholas J. Swerdlow
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Winona W. Wu
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Marc L. Schermerhorn
- From the Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| |
Collapse
|
30
|
Gloviczki P. Journal of Vascular Surgery – July 2018 Audiovisual Summary. J Vasc Surg 2018. [DOI: 10.1016/j.jvs.2018.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|