Trends of 30-day mortality and morbidities in endovascular repair of intact abdominal aortic aneurysm during the last decade

Creation of a Shared Medical Decision Support Tool for the Management of Abdominal Aortic Aneurysms

BACKGROUND

Patients with unruptured abdominal aortic aneurysm (AAA) at the surgical threshold may benefit from aneurysmal exclusion either by open surgery or endovascular repair. A patient decision aid (PtDA) could be useful to help patients and their surgeons choose between the 2 techniques. The aim of this study was to develop a shared medical decision support tool, in french language, for the surgical treatment of AAA.

METHODS

Following the steps recommended by the International Patient Decision Aids Standards, we carried out a qualitative study using semi-structured interviews with patients and vascular surgeons and focus group with patients to identify their main points of interest. After analyzing the interviews using grounded theory with independent double coding, the verbatims were discussed at a steering committee, at the end of which a prototype of the tool was created.

RESULTS

Four surgeons and 14 patients were interviewed. No new codes emerged from the last 2 interviews. At the end of the steering committee meeting, the information selected for inclusion in the PtDA tool were the definition of an AAA, a description of the 2 surgical techniques (approach, duration of operation), the main complications, the peri-operative mortality rate, and postoperative follow-up (length of hospital stay, monitoring frequency, and risk of re-intervention). It had to be produced on a synthetic paper format, with 6 illustrations and a simple vocabulary.

CONCLUSIONS

We developed a PtDA tool for use in a sharing decision making process with the patient during consultation with the vascular surgeon and the general practitioner. Further studies are needed to validate the tool and to test it in clinical practice.

Similar Distribution between EPA-containing Phosphatidylcholine and Mesenchymal Stem Marker Positive Cells in the Aortic Wall of Abdominal Aortic Aneurysm Model Rat Fed a Low-EPA Content Diet

Abdominal aortic aneurysm (AAA) is a vascular disease characterized by progressive dilation of the abdominal aorta. Previous studies have suggested that dietary components are closely associated with AAA. Among those dietary components, eicosapentaenoic acid (EPA) is considered to have suppressive effects on AAA. In the AAA wall of AAA model animals bred under EPA-rich condition, the distribution of EPA-containing phosphatidylcholine (EPA-PC) has been reported to be similar to that of the markers of mesenchymal stem cells (MSCs) and M2 macrophages. These data suggest that the suppressive effects of EPA on AAA are related to preferential distribution of specific cells in the aortic wall. However, the distribution of EPA-PC in the AAA wall of AAA model animals fed a diet containing small amounts of EPA, which has not been reported to inhibit AAA, has not yet been explored. In the present study, we visualized the distribution of EPA-PCs in the AAA wall of AAA model animals fed a diet containing small amounts of EPA (1.5% EPA in the fatty acid composition) to elucidate the vasoprotective effects of EPA. Positive areas for markers of MSCs were significantly higher in the region where EPA-PC was abundant compared to the regions where EPA-PC was weakly detected, but not for markers of M2 macrophages, matrix metalloproteinase (MMP)-2, and MMP-9. The distribution of MSC markers was similar to that of EPA-PC but not that of M2 macrophages and MMPs. These data suggest preferential incorporation of EPA into MSCs under the conditions used in this study. The incorporation of EPA into certain cells may differ according to dietary conditions, which affect the development of AAA.

Implications and late outcomes of type II endoleaks after endovascular aneurysm repair

OBJECTIVE

Type II endoleaks (T2ELs) are the most common cause of reintervention after endovascular aneurysm repair (EVAR). Although most resolve spontaneously, the long-term implications of T2ELs remain elusive. We aim to evaluate the impact of persistent and late T2ELs on clinical outcomes after EVAR.

METHODS

This was a single-institution retrospective review of patients who underwent EVAR for degenerative infrarenal abdominal aortic aneurysm between January 2010 and June 2022 with no type I (T1EL) or III (T3EL) endoleak seen at EVAR completion. Patients were categorized based on T2EL status. Group 1 included patients with never detected or transient T2ELs (detected at EVAR completion but not after). Group 2 encompassed persistent T2ELs (seen at EVAR completion and again during follow-up) and late T2ELs (detected for the first time at any point during follow-up). Time-to-event analysis was conducted using a time-dependent approach to T2EL status. Primary outcomes included freedom from sac enlargement (SE), aneurysm-related reinterventions, and overall survival.

RESULTS

A total of 803 patients met inclusion criteria. Group 1 included 418 patients (52%), of which 85% had no T2ELs and 15% had transient T2ELs. Group 2 had 385 patients; 23% had persistent T2ELs, and 77% developed a new T2EL. Patients in group 1 had a higher prevalence of smoking (88% vs 83%; P < .001), chronic obstructive pulmonary disease (33% vs 25%; P = .008), chronic kidney disease (13% vs 8%; P = .021), and a higher mean Society for Vascular Surgery score (7 vs 6 points; P = .049). No differences were found in aneurysm diameter or morphology. Mean follow-up was 5 years for the entire cohort. In Group 2, 58 patients (15%) underwent T2EL treatment, most commonly transarterial embolization. At 10 years after EVAR, Group 2 was associated with lower freedom from SE (P < .001) and abdominal aortic aneurysm-related reinterventions (P < .001) and comparable overall survival (P = .42). More T1ELs were detected during follow-up in Group 2 (6 [1%] vs 20 [5%]; P = .004), with 15 (75%) of these detected at a median of 3 years after the T2EL. No difference between groups was observed in explant (0.7% vs 2.1%; P = .130) or aneurysm rupture (0.5% vs 1.3%; P = .269) rates.

CONCLUSIONS

One-half of patients treated with infrarenal EVAR developed persistent/late T2ELs, which are associated with a higher risk of SE and reinterventions. No difference in overall survival or aneurysm rupture risk was seen at 10 years, based on T2EL status or T2EL intervention. A conservative approach to T2ELs may be appropriate for most patients with absent T1ELs or T3ELs.

Systematic review and meta-analysis of incidence, indications, and outcomes of early open conversions after EVAR for abdominal aortic aneurysms

INTRODUCTION

The purpose of this study is to report incidence, indications, and outcomes of early open conversions (EOC) after endovascular aortic repair (EVAR), defined as surgical conversion performed within 30 days from the initial EVAR.

EVIDENCE AQUISITION

A systematic review of the literature was performed (database searched: PubMed, Web of Science, Scopus, Cochrane Library; last search April 2023). Articles reporting EOC after EVAR comprising at least five patients were included. Meta-analyses of proportions were performed using a random-effects model.

EVIDENCE SYNTHESIS

Seventeen non-randomized studies, published between 1999 and 2022, were included. A total of 35,970 patients had previously undergone EVAR, of these 438 patients underwent EOC. Estimated incidence of EOC was 1.4% (95% CI 1.1-1.4; I2=81.66%). Specifically, in the works published before 2010 the incidence was 1.8% (95% CI 1.3-2.4; I2=74.25) while for subsequent ones it was 0.9% (95% CI 0.6-1.1; I2=69.82). Weighted mean age was 74.91 years (95% CI 72.42-77.39; I2=83.11%). Estimated rate of cause determining EOC were: access issue in 27.7% of patients (95% CI 13.8-41.6; I2=88.14%), incorrect placement of the endograft in 20.1% (95% CI 10.2-30.0; I2=76,9%), problems with "delivery system" in 9.0% (95% CI 4.9-13.1; I2=0%), aorto-iliac rupture in 8.6% (95% CI 4.5-12.6; I2=0%), endoprosthesis migration in 7.9% of cases (95% CI 3.3-12.4; I2=22.96%), failure in engaging the contralateral gate in 4.8% (95% CI 1.6-8; I2=0%), "kinking" or "twisting" of endoprosthesis in 3.3% (95% CI 0.6-5.9; I2=0%), graft thrombosis in 3.2% (95% CI 0.6-5.7; I2=0%), type Ia endoleak in 2.9% (95% CI 0.4-5.4; I2=0%), type III endoleak in 2.8% (95% CI 0.3-5.3; I2=0%) and endograft infection in 2.7% (95% CI 0.3-5.2; I2=0%). Intraoperative conversion rate was 91.1% (95% CI 85.8-96.4; I2=66.01%). Early mortality rate after EOC was 14.5% (95% CI 9.1-19.9; I2=48.31%). Mean length of stay (LOS) was 11.94 days (95% CI 6.718-17.172; I2=92.34%).

CONCLUSIONS

The incidence of EOC seems to decrease over time. Causes of EOC were mainly related to access problems and incorrect positioning of the endograft. Most of the EOC were performed intraoperatively carrying a high mortality rate.

Locoregional Anesthesia's Association With Reduced Intensive Care Unit Stay After Elective Endovascular Aneurysm Repair: Impact of Temporal Changes in Practice Patterns

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Exploiting endovascular aortic repair as a minimally invasive method - Nine years of experience in a non-university hospital

Background

At the introduction of endovascular aortic repair (EVAR) in 2013 in our non-university hospital, we established a quality registry to monitor our EVAR activity.

Purpose

To observe if we over time were able to exploit EVAR as a minimally invasive method in an elective as well as emergency setting, and to monitor our treatment quality in terms of complications, secondary interventions and mortality.

Material and methods

From November 2013 to March 2022, we treated 207 patients with EVAR, including six patients with rupture. Follow-up regimen was partly based on contrast-enhanced computer tomography, and partly on contrast-enhanced ultrasound in combination with plain radiography.

Results

During the observation period, the method of anesthesia changed from general, via spinal, to local anesthesia. The groin access changed from surgical cut down to percutaneous and the median length of postoperative stay decreased from 3 days to 1 day. EVAR on ruptured aneurysm was done for the first time in 2019. Endoleak was detected in 85 patients (42%) and 37 patients (18%) had one or more secondary interventions, of which 85% were endovascular. Estimated five-year survival was 72% in patients below 80 years of age and 45% in patients 80 years or older.

Conclusion

Nine years of experience enabled us to exploit EVAR's advantages as a minimally invasive method in an elective as well as emergency setting. Complications, secondary interventions and survival rates in our low volume non-university hospital matches results from larger vascular centers.

Management of Endoleaks After Elective Infrarenal Aortic Endovascular Aneurysm Repair: A Review

Importance

Endovascular aneurysm repair (EVAR) is the dominant treatment strategy for abdominal aortic aneurysms, encompassing 80% of all repairs in the United States. Endoleaks are ubiquitous and affect 30% of patients treated by EVAR, potentially leading to sac enlargement and increased risk of rupture. The care of EVAR patients requires long-term surveillance by a multidisciplinary team. Accordingly, physicians should be familiar with the fundamentals of endoleak management to achieve optimal outcomes, including timely referral for remediation or providing counseling and reassurance when needed.

Observations

PubMed and the Cochrane database were searched for articles published between January 2002 and December 2022 in English, addressing epidemiology, diagnosis, and management of endoleaks after EVAR. Endoleaks can be detected intraoperatively or years later, making lifelong surveillance mandatory. Type I and III have the highest risk of rupture (7.5% at 2 years and 8.9% at 1 year, respectively) and should be treated when identified. Intervention should be considered for other types of endoleak when associated with aneurysm sac growth larger than 5 mm based on current guidelines. Type II endoleaks are the most common, accounting for 50% of all endoleaks. Up to 90% of type II endoleaks resolve spontaneously or are not associated with sac enlargement, requiring only observation. Although the risk of rupture is less than 1%, cases that require reintervention are challenging. Recurrence is common despite endovascular treatment, and rupture can occur without evidence of sac growth. Type IV endoleaks and endotension are uncommon, are typically benign, and primarily should be observed.

Conclusions and Relevance

Endoleak management depends on the type and presence of sac expansion. Type I and III endoleaks require intervention. Type II endoleaks should be observed and treated selectively in patients with significant sac expansion. Since endoleaks can appear any time after EVAR, at least 1 contrast-enhanced computed tomographic angiogram or duplex ultrasound by an experienced laboratory is recommended every 5 years.

Safe Follow-Up after Endovascular Aortic Repair with Unenhanced MRI: The SAFEVAR Study

We aimed to investigate whether unenhanced magnetic resonance imaging (MRI) could represent a safe and highly sensitive tool for endoleak screening in patients treated with endovascular aneurysm repair (EVAR) using computed tomography angiography (CTA) as a reference standard. Patients who underwent CTA for EVAR follow-up at our institution were prospectively enrolled. All MRI examinations were performed with a 1.5 T unit. The true-FISP and HASTE sequences of the MRI scans were assessed for the presence of hyperintensity within the aneurysm sac outside the graft, whereas phase-contrast through-plane sequences were used for blood flow quantification. We included 45 patients, 5 (11%) of whom were female. The median age was 73 years (IQR 68−78 years). Among our patients, 19 (42%) were positive for endoleaks at CTA, of whom 13 (68%) had type II endoleaks and 6 (32%) had type I endoleaks. There were no significant differences in age, sex, aneurysm type, prosthesis type, or contrast-to-noise ratio between hyperintensity and thrombus between patients with and without endoleaks (p > 0.300). The combined evaluation of true-FISP and HASTE yielded 100% sensitivity (95% CI: 79−100%) and 19% specificity (95% CI: 7−40%). Patients with a positive CTA had a median thrombus flow of 0.06 L/min (IQR 0.03−0.23 L/min), significantly greater than that of patients with a negative CTA (p = 0.007). Setting a threshold at 0.01 L/min, our MRI protocol yielded 100% sensitivity, 56% specificity, and an AUC of 0.76 (95% CI 0.60−0.91). In conclusion, unenhanced MRI has perfect sensitivity for endoleak detection, although with subpar specificity that could be improved with phase-contrast flow analysis.

Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate outcomes of endovascular aneurysm repair (EVAR) in high risk patients.

METHODS

Bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched using combinations of thesaurus and free text terms. The review protocol was registered in PROSPERO (CRD42021287207) and reported according to PRISMA 2020. Pooled estimates were calculated using odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) applying the Mantel-Haenszel or inverse variance method. EVAR peri-operative mortality in high risk patients over time was examined with mixed effects meta-regression. The GRADE framework was used to rate the certainty of evidence.

RESULTS

The pooled peri-operative mortality in 18 416 high risk patients who underwent EVAR was 3% (95% CI 2.3 - 4%) and has significantly reduced over time (year of publication p = .003; median study point p = .023). The peri-operative mortality was significantly lower in high risk patients treated with EVAR compared with open repair (OR 0.64; 95% CI 0.45 - 0.92), but no significant difference was found in overall (HR 1.06; 95% CI 0.76 - 1.49) or aneurysm related mortality (HR 0.57; 95% CI 0.21 - 1.55). No significant difference was found in overall mortality between high risk patients treated with EVAR vs. no intervention (HR 0.42; 95% CI 0.14 - 1.26), but the aneurysm related mortality was significantly lower in the former (HR 0.30; 95% CI 0.14 - 0.63). The peri-operative mortality was higher in high risk than normal risk patients treated with EVAR (OR 2.33; 95% CI 1.75 - 3.10), as was the overall mortality (HR 3.50; 95% CI 2.55 - 4.80). The certainty of evidence was very low for EVAR vs. open surgery or no intervention and low for high vs. normal risk patients.

CONCLUSION

The EVAR peri-operative mortality in high risk patients has improved over time. Even though the aneurysm related mortality of EVAR is lower compared with no intervention, EVAR may confer no overall survival benefit.

Migration of High Cardiac Risk Patients from Open to Endovascular Procedures is Evident within the Society for Vascular Surgery Vascular Quality Initiative

BACKGROUND

In this study, pre-operative medical complexity is estimated by the independently validated Vascular Quality Initiative VQI Cardiac Risk Index (CRI). This study aims to identify and correlate trends of CRI for open abdominal aortic aneurysm (OAR) with trends in the CRI for corresponding endovascular aortic repair (EVAR). This assessment of differences in estimated procedural risks will be used to support the theory that, patient migration is an important factor contributing to decreased POMI following open vascular procedures.

METHODS

A retrospective review of VQI data from 2003 to 2020 for all patients undergoing elective aortic repairs (OAR and EVAR) was conducted. The CRI scoring developed for the open repair (oCRI) was applied to both the OAR and EVAR cohorts, with variables specific to EVAR translated from similar open repair factors in the model where feasible. To evaluate for changes across time, patients were grouped into Eras based on year of procedure, subsequently, univariate analysis of post-operative myocardial infarction (POMI) rates and CRI scores were perfomed between each era.

RESULTS

A total of 56,067 elective aortic repairs were identified (83% EVAR, 17% OAR). Within the OAR cohort, the average oCRI estimate was 7.1% with significant decrease across the studied timeframe (8% ± 4.6%→6.9% ± 4.4%, P < 0.001), which corresponded to a significant decrease in observed clinical myocardial infarction (MI) rate (4.1%→1.4%, P < 0.001). Over that same time period, the open CRI was applied to the EVAR cohort, and the average oCRI estimate was 7.2% and showed a significant increase (6.6% ± 2.8%→7.2% ± 4.4%, P < 0.001). Within the EVAR cohort, the eCRI estimate did not show any significant changes over time (average 0.48%), while the actual rate of clinical MI showed a significant decrease (1.1%→0.3%, P = 0.002). Gap analysis was conducted within the EVAR cohort between CRI estimates of procedural risks from an open operation versus an EVAR, which demonstrated that patients within the EVAR cohort would, on an average, has had 6.7% higher risk of POMI had they undergone an open procedure.

CONCLUSIONS

Paradigm shifts with regard to patient selection for aortic repair is evident within this large national cohort. Over time, OAR patients had fewer preoperative estimated cardiac comorbidities and there is a corresponding decrease in POMI rates. As high-risk patients migrate from OAR to EVAR, there has been a subsequent increase in EVAR estimated pre-operative risks as the patients become more medically high-risk. Despite increasing complexity, rates of POMI in EVAR significantly decreased, potentially explained by improved operative technique and peri-operative care.

Predictive factors for major adverse cardiac and cerebrovascular events in octogenarians after elective endovascular aneurysm repair

OBJECTIVES

The aim of this study was to identify risk factors of major adverse cardiac and cerebrovascular events (MACCE) in octogenarians who received elective endovascular aneurysm repair (EVAR).

METHODS

Consecutive patients aged ≥ 80 years undergoing elective EVAR from 2009 to 2020 were retrospectively evaluated. The primary outcome was long-term MACCE. All independent risk factors for outcomes were determined by multivariate logistic analysis or Cox regression analysis.

RESULTS

A total of 163 patients were enrolled in this study. The median age was 81 (interquartile range, IQR, 80-84) years and 85.9% (140/163) of them were male. MACCE happened in 2.5% (4/163) patients within 30 days. With median follow-up of 28 (IQR, 15-46) months, the incidence of long-term MACCE was 26.4% (43/163). Arrythmia was significantly associated with long-term MACCE (hazard ratio, HR = 2.64, 95% confidence interval, CI, 1.16-6.03, P = .021). Carotid artery disease was found a significant association with 2-year MACCE (odd ratio, OR = 6.50, 95% CI, 1.07-39.51, P = .042). Besides, we found that arrythmia and congestive heart failure (CHF) were predictors for overall survival (arrythmia, HR = 2.56, 95% CI, 1.05-6.28, P = .039; CHF, HR = 8.96, 95% CI, 2.12-37.79, P = .003).

CONCLUSIONS

EVAR in octogenarians had acceptable perioperative risk and long-term outcome. Considering high risk of 2-year MACCE, intervention strategy should be more cautious for patients with carotid artery disease. Octogenarians with arrythmia and CHF should receive stricter postoperative management in case of MACCE.

Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned

Objectives

We aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation.

Methods

We performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV).

Results

Forty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure.

Conclusions

Our re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma.

Single centre experience with Excluder® stent graft; 17-year outcome

BACKGROUND

Endovascular abdominal aortic aneurysm repair (EVAR) has become a mainstay of abdominal aorta aneurysm treatment. Long term follow-up on specific stent grafts is needed.

PATIENTS AND METHODS

This study included 123 patients (104 men; mean age 73.0 years, range 51-89) with abdominal aorta aneurysm, treated with Excluder^® stent graft between October 2002 and June 2008. Periprocedural and follow-up data were retrieved by reviewing the records of our institution, while time and cause of death were retrieved from the National Institute of Public Health. If an abdominal aortic aneurysm rupture was listed as the cause of death, records were retrieved from the institution that issued the death certificate. Our primary goal was to assess the primary technical success rate, type 1 and type 2 endoleak, reintervention free survival, 30-day mortality, the overall survival and aneurysm rupture-free survival.

RESULTS

The median follow-up was 9.7 years (interquartile range, 4.6-13.8). The primary technical success was 98.4% and the 30-day mortality accounted for 0.8%. Secondary procedures were performed in 29 (23.6%) patients during the follow-up period. The one-, five-, ten-, fifteen- and seventeen-year overall survival accounted for 94.3%, 74.0%, 47.2%, 35.8% and 35.8%, while the aneurysm-related survival was 98.4%, 96.3%, 92.6%, 92.6%, 92.6%. In seven (5.7%) patients, abdominal aortic rupture was found as the primary cause of death during follow-up.

CONCLUSIONS

Our data showed that EVAR with Excluder^® stent graft offers good long-term results. More than 75% of patients can be treated completely percutaneously. Late ruptures do occur in the first ten years, raising awareness about regular medical controls.

Report on the nature, characteristics, and outcomes of the Japanese healthcare system

In Japan, healthcare takes a "patient-centeredness" approach to prioritize providing rational medicine for patients under the initiative of medical doctors. This approach to healthcare is based on the concept that patients should receive the correct diagnosis and optimal treatment. The present report aims to provide an overview of the specific characteristics of healthcare in Japan to healthcare management professionals in other countries. We introduce the systems within Japan's healthcare framework, particularly "medical team approach", "nutrition management", and "infection controls", as well as treatment results in Japan using objective data to inform medical doctors in management positions in other parts of the world. Collectively, these three healthcare systems comprise the "patient-centeredness" philosophy through which Japanese healthcare professionals perceive ideal patient care and act accordingly. These healthcare systems are unique to Japan and were developed in accordance with the specific framework of Japanese history, systems, and culture. This report presents the effects of "patient-centeredness" healthcare based on treatment results and performance data by making a quantitative and qualitative comparison with healthcare in Europe and the USA. Further objective evaluation revealed that Japan demonstrates positive treatment results that are comparable to those of Europe and the USA due to its "patient-centeredness" rational medical system and the availability of the "correct diagnosis and optimal treatment". These findings introduce Japan's "patient-centeredness" medical and healthcare system with a view of informing and guiding improvements in the healthcare quality of other countries and promoting future international collaborations.

Low Volume Hospitals Are Not Associated with Inferior Outcomes After Thoracic Endovascular Aortic Repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has been used increasingly to treat complex thoracic aortic pathology. This study aimed to assess hospital volume's impact on outcomes in patients undergoing TEVAR.

STUDY DESIGN

Patients undergoing TEVAR between January 2015 and December 2019 were identified in the Vascular Quality Initiative (VQI) database. The participating centers were grouped into either low-volume hospitals (LVH) or high-volume hospitals (HVH). We assessed the impact of hospital volume on 30-day mortality and major postoperative complications using a multivariable logistic regression analysis.

RESULTS

A total of 3,584 TEVAR patients (asymptomatic = 1,720; symptomatic/ruptured =1,864) were identified at 147 centers. The median average annual number of TEVAR cases at LVH and HVH was 6 and 17 cases, respectively. There was no significant difference in 30-day mortality between LVH and HVH (asymptomatic: 3.7% vs. 3.7%, p = 0.98; symptomatic/rupture: 9.3% vs. 7.3%, p = 0.13). After adjusting for multiple clinical and anatomical factors, being treated in LVH was not associated with increased 30-day mortality (asymptomatic: OR = 0.98, 95% CI: 0.52, 1.87, p = 0.96; symptomatic/rupture: OR = 1.15, 95%CI: 0.75, 1.77, p = 0.53) nor an increased risk of major complications, including renal, neurological, cardiac, pulmonary, and femoral artery access complication (all p > 0.05).

CONCLUSION

Using a large national database, we demonstrate that LVH is not associated with inferior TEVAR outcomes than HVH. The technical aspect of the procedure might play a role in the similarity of outcomes across the different institutional experiences.

[Case load and quality indicators in the treatment of abdominal aortic aneurysms]

BACKGROUND

The MTL30 (mortality, transfer, length of stay) was proposed as a surrogate parameter for evaluating the quality of large and potentially complication-prone visceral surgical interventions.

OBJECTIVE

The aim of this study was to find out to what extent the MTL30 can be correlated with the results of the abdominal aortic aneurysm (AAA) registry of the German Institute for Vascular Health Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine (DGG) and with the case volume of the participating hospitals.

MATERIAL AND METHODS

Elective endovascular abdominal aortic aneurysm repair (EVAR) was performed in 14,282 patients and open repair (OAR) in 3923 patients. Case volume of the treating hospitals, hospital mortality, length of stay and transfer to another acute care hospital were determined 30 days after the index intervention.

RESULTS

The hospital mortality was 1.3% for EVAR and 4.9% for OAR (p = 0.000), the MTL30 was 5.0% and 14.4%, respectively (p = 0.000). For EVAR, no relationship between case volume and hospital mortality (quintile 1: 1.0%; quintile 5: 1.3%) as well as case volume and MTL30 (quintile 1: 5.3%; quintile 5: 5.3%) could be demonstrated. Also in OAR there was no significant relationship between case volume and hospital mortality (quintile 1: 5.8%, quintile 5: 3.5%; p = 0.505) and case volume and MTL30 (quintile 1: 16.4%, quintile 5: 12.2%, p = 0.110). With a hospital mortality rate of 7.2% (5-10%) the MTL30 for OAR was 17.6%. In both EVAR and OAR, the length of stay correlated significantly with hospital mortality and MTL30.

DISCUSSION

A clear relationship between hospital case volume and hospital mortality could not be shown in the AAA registry of the DIGG. The same was true for the MTL30. It remains to be seen whether the MTL30 offers an additional benefit compared to the recording of hospital mortality and inpatient length of stay as a quality parameter.

Is Mini-Invasive Surgery an Alternative for the Treatment of Juxtarenal Aortic Aneurysms?

INTRODUCTION

Aim of our study is to evaluate the outcomes of mini-laparotomy, suprarenal cross-clamping, and enhanced recovery after elective open surgical repair for juxta-renal abdominal aortic aneurysms (JAAA) in a tertiary referral center.

METHODS

Data of all consecutive patients with abdominal aortic aneurysms (AAA) electively treated with left sub-costal mini-laparotomy requiring infrarenal or suprarenal cross-clamping between 2013 and 2018 were retrospectively collected. Patients were divided into two groups: infra-renal cross-clamping (group A) and JAAA requiring supra-renal cross-clamping (group B). Early and mid-term mortality, postoperative renal dysfunction according to RIFLE criteria and factors affecting postoperative outcome were analysed.

RESULTS

Four hundred one patients, 356 (88.8%) men, mean age 70.8 yrs, underwent open surgical repair (OSR), 343 (85.5%) AAA in group A, 58 (14.5%) JAAA in group B. Mean diameter of the aneurysms was 54 ± 11.4 mm vs. 52 ± 9 mm and mean time of intervention 154.9 ± 56.3 min vs. 180.1 ± 65.7 min respectively. Total clamp time was 72.27 ± 31.4 vs. 75 ± 33.1 and suprarenal clamp time in group B 27.82 ± 14.1 min. Mean hospital length of stay was 5.1 ± 2.8 vs. 5.37 ± 3.4 days respectively. At 30 days, 3 (0.9%) patients died in group A and no one in group B; at 24 months 7 (2%) deaths in group A and 4 (6.9%) in group B. Preoperative, postoperative and discharge serum creatinine mean value, in group B, were 1.07 ± 0.32, 1.31 ± 0.36 and 1.83 ± 1.24 respectively. Based on RIFLE criteria for renal function, we observed Risk in 14.2% and Injury in 12.7% of patients after suprarenal cross clamping.

CONCLUSIONS

Our results show that mini-invasive open repair for JAAA with a suprarenal cross-clamping can be performed with acceptable morbidity and mortality rates similar to traditional surgical approach without significant modifications of renal functions.

ERA OF ENDOVASCULAR AORTIC ANEURYSM REPAIR IS LINKED TO PREOPERATIVE ANATOMIC SEVERITY AND PERIOPERATIVE PATIENT OUTCOMES

OBJECTIVE

Varying opinions on optimal elective and emergent surgical management of infrarenal AAAs are expressed by the most recent Society for Vascular Surgery (SVS), European Society for Vascular Surgery (ESVS), versus NICE (National Institutes for Health and Care Excellence, UK) guidelines. The NICE guidelines propose that open surgical repair (OSR) serve as the default treatment for infrarenal AAA. The rationale for this approach relied on data from the early era of endovascular aneurysm repair (EVAR), and are in contrast to the more balanced approaches of the SVS and ESVS. We hypothesize that significant differences in patient selection, management, and postoperative outcome are related to the era in which treatment was undertaken, contextualizing the outcomes reported in early era EVAR RCTs.

METHODS

Retrospectively, two cohorts representing all EVAR patients from "early", n= 167 (2008-2010) and "late" n=129 (2015-2017) periods at a single treating institution, were assembled. Primary outcomes of era-related changes in preoperative demographics, anatomy, and intraoperative events were assessed; anatomy was compared using the Society for Vascular Surgery Anatomic Severity Grading (ASG) system. These era-related differences were then placed in the context of early perioperative outcomes and at follow-up to one year.

RESULTS

Choice of surgical strategy differed by era, despite the same patient preoperative comorbidities between EVAR groups. Preoperative anatomic severity was significantly worse in the early cohort (p<.001), with adverse proximal and distal seal zone features (p<·001). Technical success was 16·2% higher in the late cohort, with significantly fewer type 1A/B endoleaks perioperatively (p<.001). In-hospital complications, driven by higher acute kidney injury and surgical site complications in the early cohort, resulted in a 16·5% difference between cohorts (p<0·05). At one year of follow-up, outcome differences persisted; late era patients had fewer 1A endoleaks, fewer graft complications, and better reintervention-free survival.

CONCLUSIONS

From a granular dataset of EVAR patients, we found an impact of EVAR repair era on early clinical outcome; late cohort infrarenal (IR) EVAR patients had less severe preoperative anatomy, and improved perioperative and follow-up outcomes to one year, suggesting that the results of early EVAR RCTs may no longer be generalizable to modern practice.

Functional Performance After Complex Endovascular Aortic Repair: A Single-Center Retrospective Cohort Study

Purpose

Complex endovascular aortic repair (EVAR) procedures provide a treatment option for patients with aortic aneurysms involving visceral branches. Good technical results and short-term outcomes have been reported. Whether complex EVAR provides acceptable functional outcomes is not clear. The current study aims to describe postoperative functional outcomes in complex EVAR patients—an older and relatively frail patient group.

Materials and Methods

A single-center retrospective cohort study was performed, using data from a computerized database of consecutive patients who underwent complex EVAR in the Leiden University Medical Center (LUMC, The Netherlands) between July 2013 and September 2020. As of May 2017, patients scheduled for complex EVAR were referred to a geriatric care pathway to determine (Instrumental) Activities of Daily Living ((I)ADL) scores at baseline and, if informed consent was given, after 12 months. For the total patient group, adverse functional performance outcomes were: discharge to a nursing home and 12-month mortality. For the patients included in geriatric follow-up, the additional outcome was the incidence of functional decline (defined by a ≥2 point increase in (I)ADL-score) at 12-month follow-up

Results

Eighty-two patients underwent complex EVAR, of which 68 (82.9%) were male. Mean age was 73.3 years (SD=6.3). Within 30 days postsurgery, 6 patients (7.3%) died. Mortality within 12 months for the total patient group was 14.6% (n=12). After surgery, no patients had to be discharged to a nursing home. Fifteen patients (18.3%) were discharged to a rehabilitation center. Twenty-three patients gave informed consent and were included in geriatric follow-up. Five patients (21.7%) presented functional decline 12 months postsurgery and 4 patients had died (17.4%) by that time. This means that 39.1% of the patients in the care pathway suffered an adverse outcome.

Conclusion

To our knowledge, this is the only study that examined functional performance after complex EVAR, using a prospectively maintained database. No patients were newly discharged to a nursing home and functional performance results at 12 months are promising. Future multidisciplinary research should focus on determining which patients are most prone to deterioration of function, so that efforts can be directed toward preventing postoperative functional decline.

Association of Medicaid Expansion with In-Hospital Outcomes After Abdominal Aortic Aneurysm Repair

OBJECTIVES

Multiple studies have shown improved outcomes and higher utilization of care with the increase of insurance coverage. This study aims to assess whether Medicaid expansion (ME) has changed the utilization and outcomes of abdominal aortic aneurysm (AAA) repair in the United States.

DESIGN

Retrospective observational study.

MATERIALS

Data of patients undergoing AAA repair in the Vascular Quality Initiative (2010-2017).

METHODS

Interrupted time-series (ITS) analysis was utilized to evaluate changes in annual trends of postoperative outcomes after elective AAA repair before and after 2014. We also assessed if these trend changes were significant by comparing the changes in states which adopted ME in 2014 versus nonexpansion states (NME), and conducting a difference-in-difference analysis. Primary outcomes included in-hospital mortality and adverse events (bowel and leg ischemia, cardiac, renal, respiratory, stroke and return to the OR).

RESULTS

A total of 19,143 procedures were included (Endovascular: 85.8% and open: 14.2%), of which 40.9% were performed in ME States. Compared to preexpansion trends (P1), there was a 2% annual increase in elective AAA repair in ME states (P1: -1.8% versus P2: +0.2%, P< 0.01) with no significant change in NME (P1: +0.3% versus P2: +0.2%, P = 0.97). Among elective cases, annual trends in the use of EVAR increased by 2% in ME states (95% confidence interval (CI) = -0.1, 4.1, P = 0.06), compared to a 3% decrease in NME States [95%CI = -5.8, -0.6, P = 0.01) (P_MEversusNME < 0.01]. There was no association between ME and in-hospital mortality. Nonetheless, it was associated with a decrease in the annual trends of in-hospital complications (ME: -1.4% (-2.1,-0.8) versus NME: +0.2% (-0.2, +0.8), P < 0.01).

CONCLUSIONS

While no association between ME and increased survival was noted in states which adopted ME, there was a significant increase of elective AAA cases and EVAR utilization and a decrease in in-hospital complications in ME States.

Nineteen-year outcomes with the Anaconda stent graft system from two tertiary centers

OBJECTIVE

The Anaconda stent graft device presents peculiar and unique features in its design and deployment sequence, available on the market for many years with minor modifications, among different generations. The aim of this study was to assess the long-term, real-life, outcomes obtained in two high-volume centers with this endograft for infrarenal aortic aneurysms treatment over a period of 19 years.

METHODS

All patients treated with the investigated device between 2000 and 2019, with at least 1 year of follow-up, were entered into a prospective database and data were reviewed retrospectively. The long-term results were assessed according to the Kaplan-Meier method. Primary outcomes were overall survival, freedom from AAA rupture, and freedom from AAA-related death. Secondary outcomes were freedom from late reintervention, freedom from late conversion to open repair, freedom from late limb occlusion, and freedom from late EVAR failure.

RESULTS

A total of 260 consecutive patients were treated during the study period. Technical success was achieved in 98.5% (256/260) of the cases. Two perioperative deaths (0.8%) and four major complications (1.5%) were recorded. At a mean follow-up of 54 ± 38 months (summary follow-up index = 0.86), the late survival estimate was 94.8% at 1 year, 75.2% at 5 years, 50.5% at 10 years, and 43.3% at 13 years, with no case of late AAA rupture or late AAA-related death. Late freedom from conversion was 99.2% at 1 year, 96.9% at 5 years, 94.0% at 10 years, and 94.0% at 13 years. Freedom from late limb thrombosis was 96.8% at 1 year and 91.0% at 5, 10, and 13 years. Estimates of freedom from late reintervention was 95.6% at 1 year, 87.0% at 5 years, 77.4% at 10 years, and 77.4% at 13 years. Estimates of limb thrombosis at 11 years were significantly different in patients receiving or not intraoperative iliac kissing balloon maneuver with noncompliant angioplasty catheters (98.0% vs 88.4%; P = .029).

CONCLUSIONS

The Anaconda stent graft demonstrated effective and durable outcomes for AAA treatment over a 19-year period, with no case of late AAA rupture or AAA related death in the studied population. Late limb occlusion was the leading cause of reintervention; however, a positive prevention strategy was found in intraoperative kissing balloon, which was associated with significant reduced rate of iliac thrombosis over time.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Open surgical repair of juxtarenal abdominal aortic aneurysms in the elderly is not associated with increased thirty-day mortality compared with fenestrated endovascular grafting

OBJECTIVE

Endovascular repair of juxtarenal abdominal aortic aneurysms (JAAAs) with fenestrated grafts (fenestrated endovascular aneurysm repair [FEVAR]) has been reported to decrease operative mortality and morbidity compared with open surgical repair (OSR). However, previous comparisons of OSR and FEVAR have not necessarily included patients with comparable clinical profiles and aneurysm extent. Although FEVAR has often been chosen as the first-line therapy for high-risk patients such as the elderly, many patients will not have anatomy favorable for FEVAR. At present, a paucity of data has examined the operative outcomes of OSR in elderly patients for JAAAs relative to FEVAR. Therefore, we chose to perform a propensity-matched comparison of OSR and FEVAR for JAAA repair in patients aged ≥70 years.

METHODS

Patients aged ≥70 years who had undergone elective nonruptured JAAA repairs from 2012 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted endovascular aneurysm repair (EVAR) and AAA databases. Patients who had undergone FEVAR were identified in the targeted EVAR database as those who had received the Cook Zenith Fenestrated endograft (Cook Medical, Bloomington, Ind). Because our study specifically examined JAAAs, those patients who had undergone OSR with supraceliac proximal clamping or concomitant renal/visceral revascularization were excluded. A 1:1 propensity-match algorithm matched the OSR and FEVAR patients by preoperative clinical and demographic characteristics, operative indications, and aneurysm extent. The 30-day outcomes, including mortality, major adverse cardiovascular events, and pulmonary and renal complications, were compared between the propensity-matched OSR and FEVAR groups.

RESULTS

A 1:1 propensity match was achieved, and the final analysis included 136 OSR patients and 136 FEVAR patients. No significant differences were found in 30-day mortality (4.4% vs 3.7%; odds ratio [OR], 1.21; 95% confidence interval [CI], 0.36-4.06; P = .759) between the OSR and FEVAR groups. OSR was associated with a higher incidence of major adverse cardiovascular events compared with FEVAR; however, the trend was not statistically significant (8.1% vs 3.7%; OR, 2.31; 95% CI, 0.78-6.82; P = .131). Compared with FEVAR, the OSR group had significantly greater rates of pulmonary complications (19.1% vs 3.7%; OR, 6.19; 95% CI, 2.30-16.67; P < .001) and renal complications (8.1% vs 2.2%; OR, 3.90; 95% CI, 1.06-14.31; P = .040).

CONCLUSIONS

In the samples assessed in the present study, the results with OSR of JAAAs in the elderly did not differ from those of FEVAR with respect to 30-day mortality despite a greater incidence of pulmonary and renal complications. Although FEVAR should remain the first-line therapy for JAAAs in elderly patients, OSR might be an acceptable alternative for select patients with anatomy unfavorable for FEVAR.

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review

More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.

The effect of Endovascular Aneurysm Repair on Renal Function in Patients Treated for Abdominal Aortic Aneurysm

Aim:

The effect of endovascular aneurysm repair in patients treated for abdominal aortic aneurysm has not been clearly defined. The objective of the present article was to provide a contemporary literature review and perform an analysis to determine the effect of EVAR on renal function in the early post-operative period and during follow-up.

Methods:

A systematic review of the literature was undertaken to identify all studies reporting the effect of EVAR on renal function. Outcome data were pooled and combined overall effect sizes were calculated using fixed or random-effects models.

Results:

Thirty-two studies reporting on 24846 patients were included. Acute renal failure after EVAR occurred with an estimated frequency of 9% (95%CI: 5-16%; I2=97%). Median follow-up period was 19.5 months (range 1-60 months). The estimated frequency of chronic renal failure during follow-up was 7% (95%CI: 3-17%; I2=98%). Hemodialysis was required in 2% (1-3%; I2=97%) of the cases.

Conclusion:

High-level evidence demonstrating the effect of EVAR on the incidence of acute and chronic renal failure is lacking. Based on the current available data, nearly 10% of patients undergoing EVAR for AAA have an increased risk for renal dysfunction after the procedure. Whether this deterioration may lead to a worse outcome has not been adequately proved.

GRADE-Based Recommendations for Surgical Repair of Nonruptured Abdominal Aortic Aneurysm

The objective of this study was to provide evidence-based recommendations for endovascular aneurysm repair (EVAR) versus open surgical repair (OSR) for patients with a nonruptured abdominal aortic aneurysm (AAA). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement and adhered to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Both low- and high surgical risk patients treated with EVAR showed decreased 30-day mortality, but the low-risk group had no differences in 4-year mortality. Compared with friendly anatomy, patients with hostile anatomy had an increased risk of type I endoleak. Young patients may prefer OSR. Endovascular aneurysm repair was not cost-effective in Europe. Four conditional recommendations were formulated: (1) OSR for low-risk patients up to 80 years old, (2) EVAR for low-risk patients older than 80 years, (3) EVAR for high-risk patients as long as is anatomically feasible, and (4) OSR in patients in whom it is not anatomically feasible to perform EVAR. Based on GRADE criteria, either OSR or EVAR can be suggested to patients with nonruptured AAA taking into account their surgical risk, hostile anatomy, and age. Given the weakness of the recommendations, personal preferences are determinant.