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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Scali ST, Stone DH. Modern management of ruptured abdominal aortic aneurysm. Front Cardiovasc Med 2023; 10:1323465. [PMID: 38149264 PMCID: PMC10749949 DOI: 10.3389/fcvm.2023.1323465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/23/2023] [Indexed: 12/28/2023] Open
Abstract
Ruptured abdominal aortic aneurysms (rAAA) remain one of the most clinically challenging and technically complex emergencies in contemporary vascular surgery practice. Over the past 30 years, a variety of changes surrounding the treatment of rAAA have evolved including improvements in diagnosis, development of coordinated referral networks to transfer patients more efficiently to higher volume centers, deliberate de-escalation of pre-hospital resuscitation, modification of patient and procedure selection, implementation of clinical pathways, as well as enhanced awareness of certain high-impact postoperative complications. Despite these advances, current postoperative outcomes remain sobering since morbidity and mortality rates ranging from 25%-50% persist among modern published series. Some of the most impactful variation in rAAA management has been fostered by the rapid proliferation of endovascular repair (EVAR) along with service alignment at selected centers to improve timely revascularization. Indeed, clinical care pathways and emergency response networks are now increasingly utilized which has led to improved outcomes contemporaneously. Moreover, evolution in pre- and post-operative physiologic resuscitation has also contributed to observed improvements in rAAA outcomes. Due to different developments in care provision over time, the purpose of this review is to describe the modern management of rAAA, while providing historical perspectives on patient, procedure and systems-based practice elements that have evolved care delivery paradigms in this complex group of patients.
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Affiliation(s)
- Salvatore T. Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, United States
| | - David H. Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
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Gjosha B, Jan Boer G, Fioole B, Buimer MG, de Bruin JL, Suman A, van der Laan L. Assessing Endovascular Aneurysm Repair Suitability According to Graft-Specific Instructions for Use in Patients With a Ruptured Abdominal Aortic Aneurysm. J Endovasc Ther 2023:15266028231169180. [PMID: 37096758 DOI: 10.1177/15266028231169180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
PURPOSE The purpose of the study is to ascertain endovascular aneurysm repair (EVAR) suitability in relation to stent-graft-specific instructions for use (IFU) in patients with a ruptured abdominal aortic aneurysm (RAAA). MATERIALS AND METHODS Using the preoperative computed tomography angiography (CTA), the aortic morphology of patients undergoing surgical repair of a RAAA in 2 Dutch hospitals between January 2014 and December 2019 was retrospectively assessed. Three-dimensional and central luminal line reconstructions were used. Anatomical suitability was defined according to the IFU of the stent graft system used. RESULTS Of 128 included patients, 112 (88%) were men and the mean age was 74.1 (SD=7.6) years. Anatomy within IFU for EVAR was present in 31 patients (24%). Overall, 94 patients (73%) were treated with open surgical repair (OSR) and 34 patients (27%) were treated with EVAR. Anatomy within IFU was present in 15 OSR patients (16%) and 16 EVAR patients (47%). In patients with anatomy outside of IFU, 90% (87/97) had unsuitable neck anatomy and 64% (62/97) had insufficient neck length. An unsuitable distal iliac landing zone was observed in 35 patients. Perioperative mortality was 27% (34/128), with no difference between OSR and EVAR (25/94 vs 9/34; p=0.989). CONCLUSION Most RAAA patients in this series did not have aortic anatomy within IFU for EVAR, mainly due to insufficient neck length. However, whether anatomy outside of IFU equates to unsuitability for EVAR in an emergency setting remains a matter of debate and warrants further research. CLINICAL IMPACT The treatment of a ruptured abdominal aortic aneurysm can consist of endovascular repair or open repair. Retrospective anatomical assessment shows that most patients do not have anatomy inside the instructions for use for endovascular aneurysm repair, mainly due to insufficient neck length. Whether anatomy outside the instructions for use equates unsuitability for endovascular aneurysm repair remains a matter of debate.
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Affiliation(s)
- Bergin Gjosha
- Department of Vascular Surgery, Amphia Hospital, Breda, The Netherlands
| | - Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - M G Buimer
- Department of Vascular Surgery, Amphia Hospital, Breda, The Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Arnela Suman
- Amphia Academy, Amphia Hospital, Breda, The Netherlands
| | - Lijckle van der Laan
- Department of Vascular Surgery, Amphia Hospital, Breda, The Netherlands
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
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Jones M, Faris P, Moore R. Mortality and risk factors for ruptured abdominal aortic Aneurysm after Repair Endovascular (rARE). J Vasc Surg Cases Innov Tech 2023. [DOI: 10.1016/j.jvscit.2023.101165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
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Impact of an emergency endovascular aneurysm repair protocol on 30-day ruptured abdominal aortic aneurysm mortality. J Vasc Surg 2022; 76:663-670.e2. [PMID: 35276257 DOI: 10.1016/j.jvs.2022.02.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/10/2022] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To characterize the longstanding impact of an emergency endovascular aneurysm repair (EVAR) protocol for ruptured abdominal aortic aneurysm (rAAA) on 30-day mortality. METHODS All adult patients with an rAAA who underwent a surgical or endovascular intervention at a tertiary care center between March 2001 and December 2018 were evaluated. An emergency EVAR protocol was introduced in January 2004. The primary outcome was 30-day mortality, which was calculated using risk-adjusted logistic regression for the preprotocol and postprotocol periods. A risk-adjusted cumulative sum analysis examined changes in 30-day mortality after protocol implementation. RESULTS We identified 376 patients with rAAA between 2001 and 2018 (75 preprotocol and 301 postprotocol), with a decreasing incidence of rAAA during the study period. The introduction of the protocol in 2004 was associated with increased EVAR use (63.6% vs 6.7%; P < .001). Patients managed according to the protocol were more frequently unstable (systolic blood pressure [SBP] of ≤80 mm Hg, 46.5% postprotocol vs 22.7% preprotocol; P < 0.001), with a lower average SBP (87.4 mm Hg postprotocol vs 106 mm Hg preprotocol; P < .001) and worse renal function (estimated glomerular filtration rate 61.5 mL/min postprotocol vs 83.2 mL/min preprotocol; P < .001). The risk-adjusted 30-day mortality was 23.2% with the emergency EVAR protocol, versus 35.8% preprotocol (P = .0727). A subgroup analysis demonstrated improved the 30-day mortality for unstable patients (SBP of ≤80 mm Hg) at 38.0% (vs 62.4% preprotocol introduction; P = .0190). A cumulative sum analysis demonstrated worse than expected mortality outcomes in the preprotocol period, and stability of surgical performance over 15 years after protocol introduction. CONCLUSIONS On reflection of a 17-year experience with EVAR for rAAA, the implementation of an emergency EVAR protocol demonstrated stable surgical performance for all patients with an rAAA and evidence of improved 30-day mortality for unstable patients with an rAAA. Since the protocol introduction, EVAR has become a mainstay intervention and, despite an increase in comorbid patients, the overall incidence of rAAA is declining. EVAR should be considered the first-line intervention for the appropriate patient unstable with an rAAA.
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Maze Y, Tokui T, Murakami M, Kawaguchi T, Inoue R, Nakamura B, Hirano K, Chino S, Nakajima K, Kato N. Treatment Strategies for Improving the Surgical Outcomes of Ruptured Abdominal Aortic Aneurysm: Single-Center Experience in Japan. Ann Vasc Dis 2022; 15:8-13. [PMID: 35432648 PMCID: PMC8958394 DOI: 10.3400/avd.oa.21-00086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/20/2021] [Indexed: 12/16/2022] Open
Abstract
Objective: We aimed to examine the surgical outcomes of ruptured abdominal aortic aneurysm cases at our hospital and considered strategies for improvement. Material and Methods: We examined the preoperative characteristics of hospital mortality, postoperative complications, and long-term outcomes of 91 surgical cases of ruptured abdominal aortic aneurysm performed between January 2009 and December 2020 at our hospital. Results: Of the 91 cases, 24 died at the hospital (mortality, 26.3%). Mortality was mostly due to hemorrhage/disseminated intravascular coagulation and intestinal necrosis. Ten patients required preoperative aortic clamp by thoracotomy or insertion of intra-aortic balloon occlusion, and eight of them died. Ten patients required open abdominal management due to abdominal compartment syndrome, and five of them died. There was no significant difference between the two groups in terms of the long-term results of the open repair and abdominal endovascular aneurysm repair (EVAR). Conclusion: To improve the surgical outcomes of ruptured abdominal aortic aneurysms, it is necessary to start surgery immediately. Therefore, the choice of surgical method (open surgery or EVAR) should be based on the resources and discretion of the hospital. To prevent postoperative intestinal necrosis, risk factors for acute compartment syndrome should be considered, and open abdominal management should be introduced.
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Affiliation(s)
- Yasumi Maze
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Toshiya Tokui
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Masahiko Murakami
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Teruhisa Kawaguchi
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Ryosai Inoue
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Bun Nakamura
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Koji Hirano
- Department of Thoracic and Cardiovascular Surgery, Ise Red Cross Hospital
| | - Shuji Chino
- Department of Radiology, Ise Red Cross Hospital
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Arici V, Boschini S, Fellegara R, Carando S, Rossi M, Ragni F, Bozzani A. "Re: "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". Ann Vasc Surg 2021; 79:e7-e8. [PMID: 34648857 DOI: 10.1016/j.avsg.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 08/29/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Vittorio Arici
- Vascular and Endovascular Surgery, Foundation I.R.C.C.S., Pavia, Italy
| | - Stefano Boschini
- Vascular and Endovascular Surgery, Foundation I.R.C.C.S., Pavia, Italy
| | | | - Simona Carando
- Vascular and Endovascular Surgery, Foundation I.R.C.C.S., Pavia, Italy
| | - Mauro Rossi
- Vascular and Endovascular Surgery, Foundation I.R.C.C.S., Pavia, Italy
| | - Franco Ragni
- Vascular and Endovascular Surgery, Foundation I.R.C.C.S., Pavia, Italy
| | - Antonio Bozzani
- Vascular and Endovascular Surgery, Foundation I.R.C.C.S., Pavia, Italy.
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Contemporary Management of Ruptured Infrarenal Abdominal Aortic Aneurysms. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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9
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Das Gupta J, Malas MB. Reply. J Vasc Surg 2021; 73:1116. [PMID: 33632505 DOI: 10.1016/j.jvs.2020.10.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/31/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Jaideep Das Gupta
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
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Lee YH, Su TW, Su IH, Yu SY, Hsu MY, Hsin CH, Wei WC, Chu SY, Tseng JH, Ko PJ. Comparison between Totally Percutaneous Approach and Femoral Artery Cut-Down in Endovascular Aortic Repair of Ruptured Abdominal Aortic Aneurysms in a Single Hospital. Ann Vasc Surg 2021; 74:141-147. [PMID: 33508462 DOI: 10.1016/j.avsg.2020.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 12/08/2020] [Accepted: 12/13/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To evaluate the short-term outcome of totally percutaneous endovascular aortic repair (pEVAR) of ruptured abdominal aortic aneurysms (AAAs) compared with femoral cut-down endovascular aortic repair (cEVAR). MATERIALS AND METHODS The medical records of patients with ruptured AAAs that underwent EVAR between March 2010 and April 2017 were retrospectively reviewed. Demographic information, preoperative vital signs, preoperative laboratory data, method of anesthesia, procedure duration, aneurysm morphology, brand of device used, length of hospital stay, access complications, and short-term outcomes were recorded. Univariate as well as multivariate logistic regression was used to identify predictors of 30-day mortality. RESULTS Among 77 patients with ruptured AAAs, 17 (22.1%) received cEVAR and 60 (77.9%) received pEVAR. Significant differences in the procedure time (P = 0.004), method of anesthesia (P = 0.040), and 30-day mortality (P = 0.037) were detected between the cEVAR and pEVAR groups. Local anesthesia plus intravenous general anesthesia (odds ratio = 0.141, P = 0.018) was an independent factor associated with 30-day mortality and local anesthesia was better than general anesthesia for 24-hr mortality (P = 0.001) and 30-day mortality (P = 0.003). CONCLUSION In patients with ruptured AAAs, pEVAR procedures took less time than cEVAR procedures, but the length of hospital stay did not differ significantly. The 30-day mortality rate was lower with pEVAR than with cEVAR. Local anesthesia may be the key factor in EVAR to improved technical and clinical success.
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Affiliation(s)
- Yu-Hsien Lee
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Ta-Wei Su
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - I-Hao Su
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Sheng-Yueh Yu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Ming-Yi Hsu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Chun-Hsien Hsin
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Wen-Cheng Wei
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan.
| | - Sung-Yu Chu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Jeng-Hwei Tseng
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
| | - Po-Jen Ko
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Linkou, Taiwan
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11
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Treatment of ruptured abdominal aortic aneurysm: open surgical repair versus endovascular repair. ANGIOLOGIA 2021. [DOI: 10.20960/angiologia.00256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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12
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Lin J, Nutley M, Li C, Douglas G, Du J, Zhang Z, Douville Y, Guidoin R, Wang L. Innovative textile structures designed to prevent type III endoleaks in endovascular stent-grafts. Artif Organs 2020; 45:278-288. [PMID: 32969519 DOI: 10.1111/aor.13819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/20/2020] [Accepted: 09/07/2020] [Indexed: 12/14/2022]
Abstract
The damage caused to the fabric of endovascular stent-grafts most often occurs at the contact zones between the fabrics where they are attached to the apices of Z-shaped stents as a result of normal physiologic pulsatile movement within angulated vessels in vivo. Although design improvements were made over the years, the risks were not fully eliminated even with the newer M-shaped stent reconfiguration. In this study, we proposed to create and manufacture a novel fabric for stent-grafts with specifically designed reinforced zones to enhance resistance to fabric abrasion. These reinforced zones are set at the vicinity of the apices of the Z-shaped stents and between two adjacent Z-shaped stents where folding and pleating are commonly observed to occur in angulated vessels. Three innovative weaving structures with two different types of yarns and two controls were designed and prepared. Two commonly used commercial devices supported, respectively, with ringed stents, and Z-shaped stents were selected as the references for comparison. Textile structures including thickness, water permeability, mechanical properties, (more specifically tensile and bursting stress, as well as fatigue simulation) were tested on all fabrics. Compared to commercially available plain weaves, the fabrics with locally reinforced zones showed improved mechanical characteristics and fatigue resistant properties. A fabric designed with specifically reinforced zones has now clearly been shown to effectively reduce the abrasion caused by the apices of Z-shaped stents. However, further optimization may still be possible.
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Affiliation(s)
- Jing Lin
- Key Laboratory of Textile Science and Technology of Ministry of Education, Donghua University, Shanghai, China
| | - Mark Nutley
- Division of Vascular Surgery and Department of Diagnostic Imaging, Peter Lougheed Centre, University of Calgary, Calgary, AB, Canada
| | - Chaojing Li
- Key Laboratory of Textile Science and Technology of Ministry of Education, Donghua University, Shanghai, China
| | - Graeham Douglas
- Department of Engineering, University of Cambridge, Cambridge, UK
| | - Jia Du
- Key Laboratory of Textile Science and Technology of Ministry of Education, Donghua University, Shanghai, China
| | - Ze Zhang
- Department of Surgery, Université Laval, Centre de Recherche du CHU de Québec - Université Laval, Quebec, QC, Canada
| | - Yvan Douville
- Department of Surgery, Université Laval, Centre de Recherche du CHU de Québec - Université Laval, Quebec, QC, Canada
| | - Robert Guidoin
- Department of Surgery, Université Laval, Centre de Recherche du CHU de Québec - Université Laval, Quebec, QC, Canada
| | - Lu Wang
- Key Laboratory of Textile Science and Technology of Ministry of Education, Donghua University, Shanghai, China
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13
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Blackstock CD, Jackson BM. Open Surgical Repair of Abdominal Aortic Aneurysms Maintains a Pivotal Role in the Endovascular Era. Semin Intervent Radiol 2020; 37:346-355. [PMID: 33041480 DOI: 10.1055/s-0040-1715881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Since the advent of endovascular aortic repair (EVAR) nearly three decades ago, there has been a paradigm shift in the treatment of the abdominal aortic aneurysm (AAA) to favor EVAR due to its reduced operative mortality, less invasive nature, and faster recovery times. However, more recently there has been an accumulation of data from large meta-analyses and randomized clinical trials revealing that EVAR has no survival benefit after approximately 2 years and is associated with substantially higher rates of reintervention and aneurysm rupture in the long term. These findings call into question the durability of EVAR compared with open aortic repair and emphasize the need for surgeons to remain competent with open aortic surgery in the modern era. This article will provide comprehensive review of a large body of literature comparing endovascular repair to open aortic surgery for the management of AAAs, and it will offer an overview of the open surgical repair technique for AAAs.
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Affiliation(s)
- Christopher D Blackstock
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Jackson
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
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Wang LJ, Locham S, Al-Nouri O, Eagleton MJ, Clouse WD, Malas MB. Endovascular repair of ruptured abdominal aortic aneurysm is superior to open repair: Propensity-matched analysis in the Vascular Quality Initiative. J Vasc Surg 2020; 72:498-507. [DOI: 10.1016/j.jvs.2019.11.063] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/13/2019] [Indexed: 11/29/2022]
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15
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Five-year survival following endovascular repair of ruptured abdominal aortic aneurysms is improving. J Vasc Surg 2020; 72:105-113.e4. [DOI: 10.1016/j.jvs.2019.10.074] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/14/2019] [Indexed: 01/01/2023]
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16
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Paraskevas KI, Eckstein HH, Veith FJ. Prevention and Treatment of Ruptured Abdominal Aortic Aneurysms. Angiology 2020; 71:586-588. [DOI: 10.1177/0003319720923808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Kosmas I. Paraskevas
- Department of General and Vascular Surgery, Central Clinic of Athens, Athens, Greece
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Frank J. Veith
- Divisions of Vascular Surgery, New York University Langone Medical Center, New York, NY, USA
- The Cleveland Clinic, Cleveland, OH, USA
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Arici V, Bozzani A, Rossi M, Corbetta R, Brunetto MB, Scudeller L, Ticozzelli G, Rossini R, Rota M, Ragni F. Contemporary Early and Long-Term Results of Open Repair for Ruptured and Symptomatic Unruptured Infrarenal AAA. Single Center Experience. Ann Vasc Surg 2020; 64:99-108. [DOI: 10.1016/j.avsg.2019.10.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
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18
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Melillo AM, Trani JL, Gaughan JP, Carpenter JP, Lombardi JV. Assessing trends, morbidity, and mortality in ruptured abdominal aortic aneurysm repair with 9 years of data from the National Surgical Quality Improvement Program. J Vasc Surg 2020; 71:423-431. [DOI: 10.1016/j.jvs.2019.04.462] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 04/04/2019] [Indexed: 10/26/2022]
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19
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ANARCYL SCALE (ANeurisma de Aorta Roto Castilla y León) FOR PREDICTING MORTALITY IN RUPTURED ABDOMINAL AORTIC ANEURYSMS. ANGIOLOGIA 2020. [DOI: 10.20960/angiologia.00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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20
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Ito H. Operative Strategy of Ruptured Abdominal Aortic Aneurysms and Management of Postoperative Complications. Ann Vasc Dis 2019; 12:323-328. [PMID: 31636741 PMCID: PMC6766759 DOI: 10.3400/avd.ra.19-00074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In addition to traditional open surgical repair (OSR), endovascular aneurysm repair (EVAR) is currently another strong option to treat RAAA. All vascular surgeons who try to save RAAA patients must be deeply versed in both OSR and EVAR. In this article, current trend of RAAA treatment and abdominal compartment syndrome, which has been most important postoperative complication, are reviewed. (This is a translation of Jpn J Vasc Surg 2019; 28: 127–132.)
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Affiliation(s)
- Hiroyuki Ito
- Division of Vascular Surgery, Cardiovascular and Aortic Center, Saiseikai Fukuoka General Hospital, Fukuoka, Fukuoka, Japan
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Risk factors and outcomes for bowel ischemia after open and endovascular abdominal aortic aneurysm repair. J Vasc Surg 2019; 70:869-881. [DOI: 10.1016/j.jvs.2018.11.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 11/20/2018] [Indexed: 12/17/2022]
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Pires Coelho A, Lobo M, Brandão JP, Nogueira C, Tournoij E, Jongkind V, Wikkeling O, Fernández AM, Noya JF, Campos J, Augusto R, Coelho N, Semião AC, Ribeiro JP, Canedo A. Prediction of Survival after 48 Hours of Intensive Unit Care following Repair of Ruptured Abdominal Aortic Aneurysm-Multicentric Study for External Validation of a New Prediction Score for 30-Day Mortality. Ann Vasc Surg 2019; 60:95-102. [PMID: 31075455 DOI: 10.1016/j.avsg.2019.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/03/2019] [Accepted: 02/10/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ruptured abdominal aortic aneurysm (rAAA) remains a critical life-threatening condition. We aimed to evaluate rAAA management in our center focusing on predictors of mortality at 48 hr of intensive care unit (ICU) and to develop a new mortality prediction score considering data at 48 hr postprocedure. External validation of the modified score with patient data from independent vascular surgery centers was subsequently pursued. METHODS Clinical data of all patients admitted in our center from January 2010 to December 2017 with the diagnosis of rAAA were retrospectively reviewed for the development of the mortality prediction score. Subsequently, clinical data from patients admitted at independent centers from January 2010 to December 2017 were reviewed for external validation of the score. Statistical analysis was performed with SPSS Version 25. RESULTS A total of 78 patients were included in the first part of the study: 21 endovascular aneurysm repairs (EVARs), 56 open repairs (ORs), and 1 case of conservative management. Intraoperative mortality in EVAR and OR groups was 0% vs. 24.6%, respectively (P = 0.012). Thirty-day mortality reached 50% and 33% in the OR and EVAR groups. For patients alive at 48 hr, 30-day mortality diminished to 27.6%. Several preoperative predictors of outcome were identified: smoking (P = 0.004), hemodynamic instability(P = 0.004), and elevated international normalized ratio (P < 0.0001). Dutch Aneurysm Score and Vascular Study Group of New England Score (VSGNE) were also significant predictors of outcome (area under the receiver operating characteristic curve [ROC AUC] 0.89 and 0.79, respectively; P < 0.0001). At 48 hr of ICU stay, high lactate level, high Sequential Organ Failure Assessment score, need for hemodyalitic technique, and hemodynamic instability were significant risk predictors for 30-day mortality (P < 0.05). VSGNE score was modified with the inclusion of 2 variables: hemodynamic instability and lactate level at 48 hr and a new score was attained-Postoperative Aneurysm Score (PAS). Comparing AUC for VSGNE and PAS for patients alive at 48 hr, the latter was significantly better (AUC 0.775 vs. 0.852, P = 0.039). The PAS was applied and validated in 3 independent vascular surgery centers (AUC VSGNE 0.782 vs. AUC PAS 0.820, P = 0.027). CONCLUSIONS Despite recent evidence on preoperative predictors of survival in an era when both EVAR and OR are available, emergent decision to withhold life-saving treatment will always be extremely difficult. Therefore, the policy in our department is to try surgical repair in all cases. It remains important, however, to identify whether late deaths can be predicted, so that unnecessary prolonged treatment can be avoided. A PAS was delineated predicting 30-day mortality significantly better in patients alive at 48 hr. The score was externally applied and validated in independent centers, corroborating the score's usefulness.
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Affiliation(s)
- Andreia Pires Coelho
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal; Department of Vascular Surgery, Faculdade de Medicina Universidade Porto, Porto, Portugal.
| | - Miguel Lobo
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - J Pedro Brandão
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Clara Nogueira
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Erik Tournoij
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | - Otmar Wikkeling
- Department of Vascular Surgery, Heelkunde Friesland, Nij Smellinghe Ziekenhuis, Drachten, The Netherlands
| | - Alba Mendez Fernández
- Department of Vascular Surgery, Centro Hospitalario Universitario Santiago de Compostela, Santiago de Compostela, Spain
| | - Jorge Fernández Noya
- Department of Vascular Surgery, Centro Hospitalario Universitario Santiago de Compostela, Santiago de Compostela, Spain
| | - Jacinta Campos
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal; Department of Vascular Surgery, Faculdade de Medicina Universidade Porto, Porto, Portugal
| | - Rita Augusto
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal; Department of Vascular Surgery, Faculdade de Medicina Universidade Porto, Porto, Portugal
| | - Nuno Coelho
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal; Department of Vascular Surgery, Faculdade de Medicina Universidade Porto, Porto, Portugal
| | - Ana Carolina Semião
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - João Pedro Ribeiro
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal
| | - Alexandra Canedo
- Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal; Department of Vascular Surgery, Faculdade de Medicina Universidade Porto, Porto, Portugal
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Yin K, Locham SS, Schermerhorn ML, Malas MB. Trends of 30-day mortality and morbidities in endovascular repair of intact abdominal aortic aneurysm during the last decade. J Vasc Surg 2019; 69:64-73. [DOI: 10.1016/j.jvs.2018.04.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/08/2018] [Indexed: 12/17/2022]
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Paraskevas KI, Gloviczki P. Emerging evidence to support endovascular over open repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2018; 68:1593-1594. [PMID: 30360848 DOI: 10.1016/j.jvs.2018.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Affiliation(s)
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minn.
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