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Lopez-Espada C, Linares-Palomino J, Guerra Requena M, Serrano Hernando FJ, Iborra Ortega E, Fernández-Samos R, Zanabili Al-Sibbai A, González Cañas E, Rodriguez Sánchez JM, Zaragozá García JM, García León A, Manzano Grossi S, de Benito L, Gil Sala D, Revuelta Mariño L. Multicenter Comparative Analysis of Late Open Conversion in Patients With Adherence and Nonadherence to Instructions for Use Endovascular Aneurysm Repair. J Endovasc Ther 2023; 30:867-876. [PMID: 35735201 DOI: 10.1177/15266028221102658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The widespread adoption of endovascular aneurysm repair (EVAR) as preferred treatment modality for abdominal aortic aneurysm (AAA) has enlarged the number of patients needing open surgical conversion (OSC). The relationship between adherence to Instructions For Use (IFU) and EVAR long-term outcomes remains controversial. The aim of this study is to compare preoperative differences and postoperative outcomes between EVAR patients not adjusted to IFU and adjusted to IFU who underwent OSC. METHODS This multicenter retrospective study reviewed 33 explanted EVARs between January 2003 and December 2019 at 14 Vascular Units. Patients were included if OSC occurred >30 days after implantation and excluded if explantation was performed to treat an endograft infection, aortic dissection, or traumatic transections. Variables analyzed included baseline characteristics, adherence to IFU, implant and explant procedural details, secondary reinterventions, and postoperative outcomes. RESULTS Fifteen explanted patients (15/33, 45.5%) were identified not accomplished to IFU (out-IFU) at initial EVAR vs 18 explanted patients adjusted (in-IFU). During follow-up, a mean of 1.73±1.2 secondary reinterventions were performed, with more type I endoleaks treated in the subgroup out-IFU: 16.7% vs 6.3% in-IFU patients and more type III endoleaks (8.3% vs 0%). Patients out-IFU had shorter mean interval from implant to explant: 47.60±28.8 months vs 71.17±48. Type II endoleak was the most frequent indication for explantation. Low-flow endoleaks (types II, IV, V) account for 44% of indications for OSC in subgroup of patients in-IFU, compared with 13.3% in patients out-IFU and high-flow endoleaks (types I and III) were the main indication for patients out-IFU (33.3% vs 16.7% in-IFU). Total endograft explantation was performed in 57.5% of cases (19/33) and more suprarenal clamping was required in the subgroup out-IFU. Overall, 30-day mortality rate was 12.1% (4/33): 20% for patients out-IFU and 5.6% in-IFU. CONCLUSIONS In our experience, type II endoleak is the most common indication for conversion and differences have been found between patients treated outside IFU with explantation taking place earlier during follow-up, mainly due to high-flow endoleaks and with higher mortality in comparison with patients adjusted to IFU. Ongoing research is required to delve into these differences.
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Affiliation(s)
| | - Jose Linares-Palomino
- Vascular Surgery Unit, University Hospital Virgen de las Nieves, Granada, Spain
- Department of Surgery, University of Granada, Granada, Spain
| | | | | | | | | | | | - Elena González Cañas
- Vascular Surgery Unit, Corporació Sanitaria Parc Tauli de Sabadell, Sabadell, Spain
| | | | | | - Andrés García León
- Vascular Surgery Unit, University Hospital Virgen de Valme, Sevilla, Spain
| | | | - Luis de Benito
- Vascular Surgery Unit, University Hospital Fundación Alcorcón, Madrid, Spain
| | - Daniel Gil Sala
- Vascular Surgery Unit, Vall d'Hebron University Hospital, Barcelona, Spain
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Ramirez JL, Govsyeyev N, Sorber R, Iannuzzi JC, Schanzer AS, Hicks CW, Malas MB, Zarkowsky DS. Proximal Instructions for Use Violations in Elective Endovascular Aneurysm Repair in the Vascular Quality Initiative: Retrospective Analysis. J Am Coll Surg 2023; 237:633-643. [PMID: 37288832 PMCID: PMC10788874 DOI: 10.1097/xcs.0000000000000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) is often attempted in patients with marginal anatomy. These patients' midterm outcomes are available in the Vascular Quality Initiative for analysis. STUDY DESIGN Retrospective analysis of prospectively collected data in the Vascular Quality Initiative from patients who underwent elective infrarenal EVAR between 2011 and 2018. Each EVAR was identified as either on- or off-instructions for use (IFU) based on aortic neck criteria. Multivariable logistic regression models were used to assess associations between aneurysm sac enlargement, reintervention, and type Ia endoleak with IFU status. Kaplan-Meier time-to-event models estimated reintervention, aneurysm sac enlargement, and overall survival. RESULTS We identified 5,488 patients with at least 1 follow-up recorded. Those treated off-IFU included 1,236 patients ([23%] mean follow-up 401 days) compared with 4,252 (77%) treated on-IFU (mean follow-up 406 days). There was no evidence of significant differences in crude 30-day survival (96% vs 97%; p = 0.28) or estimated 2-year survival (97% vs 97%; log-rank p = 0.28). Crude type Ia endoleak frequency was greater in patients treated off IFU (2% vs 1%; p = 0.03). Off-IFU EVAR was associated with type Ia endoleak on multivariable regression model (odds ratio 1.84 [95% CI 1.23 to 2.76]; p = 0.003). Patients treated off IFU vs on IFU experienced had increased risk of reintervention within 2 years (7% vs 5%; log-rank p = 0.02), a finding consistent with results from the Cox modeling (hazard ratio 1.38 [95% CI 1.06 to 1.81]; p = 0.02). CONCLUSIONS Patients treated off IFU were at greater risk for type Ia endoleak and reintervention, although they had similar 2-year survival compared with those treated on IFU. Patients with anatomy outside IFU should be considered for open surgery or complex endovascular repair to reduce the probability for revision.
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Affiliation(s)
- Joel L Ramirez
- From the Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA (Ramirez, Zarkowsky)
- Chan Zuckerberg Biohub, San Francisco, CA (Rmairez)
| | | | - Rebecca Sorber
- Johns Hopkins University School of Medicine, Baltimore, MD (Sorber, Hicks)
| | | | - Andres S Schanzer
- University of Massachusetts Medical School, Worcester, MA (Schanzer)
| | - Caitlin W Hicks
- Johns Hopkins University School of Medicine, Baltimore, MD (Sorber, Hicks)
| | | | - Devin S Zarkowsky
- From the Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA (Ramirez, Zarkowsky)
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Elsayed N, Alhakim R, Al Nouri O, Baril D, Weaver F, Malas MB. Perioperative and long-term outcomes after open conversion of endovascular aneurysm repair versus primary open aortic repair. J Vasc Surg 2023; 77:89-96. [PMID: 35934217 DOI: 10.1016/j.jvs.2022.07.172] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/15/2022] [Accepted: 07/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The use of endovascular abdominal aortic aneurysm repair (EVAR) has superseded that of open aneurysm repair (OAR) as the procedure of choice for abdominal aortic aneurysm repair. However, significant rates of late reintervention and aneurysm rupture have been reported after EVAR, resulting in the need for conversion to OAR (C-OAR). To assess the relative effects of C-OAR on patients, we compared the outcomes of these patients to those of patients who had undergone P-OAR. METHODS The data from all patients who had undergone C-OAR and P-OAR in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database from 2003 to 2018 were queried. Multivariable logistic regression and Kaplan-Meier survival and Cox proportional hazard regression analyses were used to assess the perioperative long-term outcomes. RESULTS A total of 4763 patients were included (91.4%, P-OAR; 8.6%, C-OAR). C-OAR was associated with a significant increase in the odds of perioperative mortality (odds ratio, 1.7; 95% confidence interval [CI], 1.1-2.7; P = .027) and renal complications (odds ratio, 1.5; 95% CI, 1.1-2; P = .004) vs P-OAR. At 5 years, conversion was associated with a higher risk of mortality (hazard ratio [HR], 1.5; 95% CI, 1.3-1.9; P < .001), aneurysmal rupture (HR, 1.9; 95% CI, 1.2-3.1; P = .007), and reintervention (HR, 1.4; 95% CI, 1.05-1.97; P = .022) compared with P-OAR. These results also persisted at 10 years, with conversion associated with a higher risk of mortality (HR, 1.5; 95% CI, 1.2-1.8; P < .001), rupture (HR, 1.8; 95% CI, 1.1-2.8; P = .018), and reintervention (HR, 1.5; 95% CI, 1.1-2.1; P = .010). CONCLUSIONS The results from the present study have demonstrated that C-OAR is associated with a significantly higher risk of perioperative morbidity and mortality compared with P-OAR. We found a significant increase in mortality, aneurysm rupture, and reintervention at 5 and 10 years of follow-up.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Rami Alhakim
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Omar Al Nouri
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA
| | - Donald Baril
- Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Fred Weaver
- Division of Vascular and Endovascular Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California, San Diego, La Jolla, CA.
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Endovascular Repair of Abdominal Aortic Aneurysms is a Valid Alternative to Open Repair also in Patients Treated Outside of Instructions for Use Criteria. Cardiovasc Intervent Radiol 2022; 45:1765-1773. [DOI: 10.1007/s00270-022-03297-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
Abstract
Purpose
It remains unclear whether endovascular aneurysm repair, in the long term, is less effective than open surgery due to need for reinterventions and close monitoring. We aimed to evaluate this matter in a real-life cohort.
Methods
We collected consecutive patients treated with EVAR or OSR between January 2005 and December 2013. Primary outcomes were 30-day, 90-day and long-term all-cause mortality. Secondary outcomes were 30-day reintervention rate and reintervention-free survival. We evaluated also a subpopulation who did not adhere to IFU.
Results
The inclusion criteria were met by 416 patients. 258 (62%) received EVAR, while 158 (38%) underwent OSR. The 30- or 90-day mortality was similar between groups (p = 0.272 and p = 0.346), as ARM (p = 0.652). The 30-day reintervention rate was higher in the OSR group (p < 0.001), but during follow-up, it was significantly higher in the EVAR group (log-rank: 0.026).
There were 114 (44.2%) non-IFU patients in the EVAR group, and we compared them with OSR group. There was no significant difference in all-cause mortality at 30 or 90 days, nor in the long term (p = 1; p = 1 and p = 0.062). ARM was not affected by the procedure technique (p = 0.136). The short-term reintervention rate was higher in the OSR group (p = 0.003), while in the long-term EVAR, patients experienced more reinterventions (log-rank = 0.0.43).
Conclusion
No significant difference in survival was found between EVAR and OSR, independent of adherence to IFU. EVAR may be considered for surgical candidates.
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Capturing the Complexity of Open Abdominal Aortic Surgery in the Endovascular Era. J Vasc Surg 2022; 76:1520-1526. [PMID: 35714893 DOI: 10.1016/j.jvs.2022.06.007] [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: 02/13/2022] [Revised: 05/24/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Volume and quality benchmarks for open abdominal aortic surgery and particularly open aortic aneurysm repair (OAR) in the endovascular era are guided by the Society for Vascular Surgery (SVS) guidelines, but the Vascular Quality Initiative (VQI) OAR module fails to capture the full spectrum of complex OAR. We hypothesized that VQI-ineligible complex OAR is the dominant form of open repairs performed at a VQI-participating tertiary center. METHODS All OAR cases performed at a single tertiary care center from 2007 to 2020 were reviewed. The VQI OAR criteria were applied with exclusions (non-VQI) defined as concomitant renal bypass, clamping above the superior mesenteric artery (SMA) or celiac artery, repairs performed for trauma, anastomotic aneurysm, isolated iliac aneurysm, or infected aneurysms. Linear regression was used to assess temporal trends. RESULTS Among a total of 481 open abdominal aortic operations, 355 (74%) were OAR. The average annual OAR volume remained stable over 14 years (25 ± 6; P = .46). Non-VQI OAR comprised 54% of all cases and persisted over time (R2 = .047, P = .46). Supra-celiac clamping (35%) was often necessary. The proportion of endograft explantation cases significantly increased over time from 4% in 2007 to 20% in 2019 (P = .01). Infectious indications represented 20% (n = 70) of cases. Visceral branch grafts were performed in 16% of all cases. OAR for ruptured aneurysm constituted 10% of cases. Thirty-day mortality was significantly higher in non-VQI vs. VQI-eligible OAR cases (10% vs. 4%; P = .04). CONCLUSIONS Complex OAR comprises a majority of OAR cases in a contemporary tertiary referral hospital, yet these cases are not accounted for in the VQI. Creation of a "complex OAR" VQI module would capture these cases in a quality-driven national registry and help to better inform benchmarks for volume and outcomes in aortic surgery.
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Rhee R, Oderich G, Han S, Long C, Muck P, Moore E, Matsumura J. One year results of the GORE® EXCLUDER® Conformable AAA Endoprosthesis (EXCC) system in the United States regulatory trial. J Vasc Surg 2022; 76:951-959.e2. [DOI: 10.1016/j.jvs.2022.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 04/05/2022] [Indexed: 11/26/2022]
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Safir SR, Tadros RO. Endovascular Aortic Aneurysm Repair. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Yei K, Mathlouthi A, Naazie I, Elsayed N, Clary B, Malas M. Long-term Outcomes Associated With Open vs Endovascular Abdominal Aortic Aneurysm Repair in a Medicare-Matched Database. JAMA Netw Open 2022; 5:e2212081. [PMID: 35560049 PMCID: PMC9107027 DOI: 10.1001/jamanetworkopen.2022.12081] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
IMPORTANCE Endovascular aneurysm repair is associated with a significant reduction in perioperative mortality and morbidity compared with open aneurysm repair in the treatment of abdominal aortic aneurysm. However, this benefit decreases over time owing to increased reinterventions and late aneurysm rupture after endovascular repair. OBJECTIVE To compare long-term outcomes of endovascular vs open repair of abdominal aortic aneurysm. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study used deidentified data with 6-year follow-up from the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. Patients undergoing first-time elective endovascular or open abdominal aortic aneurysm repair from 2003 to 2018 were propensity score matched. Patients with ruptured abdominal aortic aneurysm, concomitant procedures, or prior history of abdominal aortic aneurysm repair, were excluded. Data were analyzed from January 1, 2003, to December 31, 2018. EXPOSURES First-time elective endovascular or open repair for abdominal aortic aneurysm. MAIN OUTCOMES AND MEASURES The primary long-term outcome of interest was 6-year all-cause mortality, rupture, and reintervention. Secondary outcomes included 30-day mortality and perioperative complications. RESULTS Among a total of 32 760 patients (median [IQR] age, 75 [70-80] years; 25 706 [78.5%] men) who underwent surgical abdominal aortic aneurysm repair, 28 281 patients underwent endovascular repair and 4479 patients underwent open repair. After propensity score matching, there were 2852 patients in each group. Open repair was associated with significantly lower 6-year mortality compared with endovascular repair (548 deaths [35.6%] vs 608 deaths [41.2%]; hazard ratio [HR], 0.83; 95% CI, 0.74-0.94; P = .002), with increases in mortality starting from 1 to 2 years (84 deaths [4.3%] vs 126 deaths [6.7%]; HR, 0.63; 95% CI, 0.48-0.83; P = .001) and 2 to 6 years (211 deaths [25.8%] vs 241 deaths [30.6%]; HR, 0.73; 95% CI, 0.61-0.88; P = .001). Open repair, compared with endovascular repair, also was associated with significantly lower rates of 6-year rupture (117 participants [5.8%] vs 149 participants [8.3%]; HR, 0.76; 95% CI, 0.60-0.97; P < .001) and reintervention (190 participants [11.6%] vs 267 participants [16.0%]; HR, 0.67; 95% CI, 0.55-0.80; P < .001). Open repair was associated with significantly higher odds of 30-day mortality (OR, 3.56; 95% CI, 2.41-5.26; P < .001) and complications. CONCLUSIONS AND RELEVANCE These findings suggest that overall mortality after elective abdominal aortic aneurysm repair was higher with endovascular repair than open repair despite reduced 30-day mortality and perioperative morbidity after endovascular repair. Endovascular repair additionally was associated with significantly higher rates of long-term rupture and reintervention. These findings emphasize the importance of careful patient selection and long-term follow-up surveillance for patients who undergo endovascular repair.
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Affiliation(s)
- Kevin Yei
- University of California, San Diego, La Jolla
| | | | | | | | - Bryan Clary
- University of California, San Diego, La Jolla
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Patel SR, Ormesher DC, Griffin R, Jackson RJ, Lip GYH, Vallabhaneni SR. Editor's Choice - Comparison of Open, Standard, and Complex Endovascular Aortic Repair Treatments for Juxtarenal/Short Neck Aneurysms: A Systematic Review and Network Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 63:696-706. [PMID: 35221243 DOI: 10.1016/j.ejvs.2021.12.042] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/07/2021] [Accepted: 12/29/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Abdominal aortic aneurysms (AAAs) with adverse morphology of the aneurysm neck are "complex". Techniques employed to repair complex aneurysms include open surgical repair (OSR) and a number of on label endovascular techniques such as fenestrated endovascular aneurysm repair (FEVAR) and endovascular aneurysm repair (EVAR) with adjuncts (including chimneys and endo-anchors), as well as off label use of standard EVAR. The aim was to conduct a network meta-analysis (NMA) of published comparative outcomes. DATA SOURCES An electronic search was performed in Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL). These databases were interrogated using the PubMed interface and the Healthcare Databases Advanced Search (HDAS) interface developed by the National Institute of Health and Care Excellence. REVIEW METHODS Online databases were interrogated up to April 2020. Studies were included if they compared outcomes between at least two methods of repair for complex aneurysms (those with at least one adverse neck feature: absent/short neck, conicality, angulation, calcification, large diameter, and thrombus). The primary outcome measure was peri-operative death. Pre-registration was done in PROSPERO (CRD42020177482). RESULTS The search identified 24 observational studies and 7854 patients who underwent OSR, FEVAR, off label EVAR, or chimney EVAR. No comparative studies included EVAR with endo-anchors. NMA was performed on 23 studies that reported outcomes of aneurysms with short/absent infrarenal neck. Compared with OSR, off label EVAR (relative risk [RR] 0.10, 95% confidence interval [CI] 0.01 - 0.41) and FEVAR (RR 0.62, 95% CI 0.32-0.94) were associated with lower peri-operative mortality. This difference was not seen at the midterm follow up (30 months). Compared with OSR, FEVAR was associated with a lower peri-operative myocardial infarction (MI) rate (RR 0.37, 95% CI 0.16 - 0.62) but a higher midterm re-intervention rate (hazard ratio 1.65, 95% CI 1.04 - 2.66). All studies had a "moderate" or "high" risk of bias. Confidence in the network findings (GRADE) was generally "low". CONCLUSION This NMA demonstrated a peri-operative survival benefit for off label EVAR and FEVAR compared with OSR, potentially due to reduced risk of MI. FEVAR carries a greater midterm re-intervention risk than OSR, with potential implications for cost effectiveness. There is paucity of comparative data for cases with adverse neck features other than short length.
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Affiliation(s)
- Shaneel R Patel
- Liverpool University Hospitals NHS Foundation Trust, Prescot Road, Liverpool, UK; Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK.
| | - David C Ormesher
- Liverpool University Hospitals NHS Foundation Trust, Prescot Road, Liverpool, UK
| | - Rebecca Griffin
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Richard J Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Srinivasa R Vallabhaneni
- Liverpool University Hospitals NHS Foundation Trust, Prescot Road, Liverpool, UK; Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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Single centre experience with Excluder ® stent graft; 17-year outcome. Radiol Oncol 2022; 56:156-163. [PMID: 35417109 PMCID: PMC9122300 DOI: 10.2478/raon-2022-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/16/2022] [Indexed: 11/21/2022] Open
Abstract
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.
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11
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De Guerre LEVM, O'Donnell TFX, Varkevisser RRB, Swerdlow NJ, Li C, Dansey K, van Herwaarden JA, Schermerhorn ML, Patel VI. The Association between Device Instructions for Use Adherence and Outcomes after Elective Endovascular Aortic Abdominal Aneurysm Repair. J Vasc Surg 2022; 76:690-698.e2. [PMID: 35276256 DOI: 10.1016/j.jvs.2022.02.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/14/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Aortic neck anatomy has a significant impact on the complexity of endovascular aortic aneurysm repair (EVAR), with concern that neck characteristics outside of instructions for use (IFU) may result in worse outcomes. Therefore, this study determined the impact of neck characteristics outside of IFU on perioperative and one-year outcomes and mid-term survival after EVAR. METHODS We identified all patients undergoing elective infrarenal EVAR from December 2014 to May 2020 in the Vascular Quality Initiative database. Neck characteristics outside of IFU were determined based the specific device IFU neck characteristics (Neck diameter, length, and angulation). Patients without one-year follow-up were excluded for the 1-year outcomes analyses (n=6,138 (40%)). We used multivariable adjusted logistic regression and Cox proportional hazard models to identify the independent associations between neck characteristics outside of IFU and our outcomes. RESULTS Of the 15,448 patients identified, 22.1% had neck characteristics outside of IFU, including 6.6% with a infrarenal angle, 6.8% with a neck length, 10.4% with a neck diameter, and 1.1% with a suprarenal angulation outside of IFU. Of these, 2.4% had more than one neck characteristic outside of IFU. Patients with neck characteristics outside of IFU were more often female (27.9% vs. 15.0%, P<.001) and were older (median age 75 vs. 73, P<.001). EVAR patients with neck characteristics outside of IFU had higher rates of type Ia endoleaks at completion (4.8% vs. 2.5%, P<.001), perioperative mortality (1.2% vs. 0.6%, P<.001), one-year sac expansion (7.1% vs. 5.3%, P=.017), and one-year reinterventions (4.4% vs. 3.2%, P=.03). In multivariable adjusted analyses, neck characteristics outside of IFU were independently associated with type Ia completion endoleaks (OR 1.6, [1.3-2.0], P<.001), perioperative mortality (OR 1.8; [1.2-2.7]; P=.005), one-year sac expansion (OR 1.4; [1.0-1.8]; P=.025) and one-year reinterventions (OR 1.4; [1.0-1.9]; P=.039). Unadjusted mid-term survival was lower for patients with neck characteristics outside of IFU than for patients without (5-year survival 84.0% vs. 86.7%, log-rank<.001). However, after adjustment, survival was similar for patients with neck characteristics outside of IFU to those within (HR: 1.1; [1.0-1.3]; P=.22). CONCLUSION Neck characteristics outside of IFU are independently associated with completion type Ia endoleaks, perioperative mortality, one-year sac expansion and one-year reinterventions among patients undergoing elective EVAR. These results indicate that continued effort is needed to improve the proximal seal in patients with neck characteristics outside of IFU undergoing EVAR. Also, in patients with severe hostile neck characteristics, alternative approaches such as open repair, use of a fenestrated or branched device, or endoanchors should be considered.
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Affiliation(s)
- Livia E V M De Guerre
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Thomas F X O'Donnell
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Rens R B Varkevisser
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nicholas J Swerdlow
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Chun Li
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kirsten Dansey
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Marc L Schermerhorn
- Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Virendra I Patel
- Division of Vascular and Endovascular Surgery, New York Presbyterian/Columbia University Irving Medical Center/ Columbia University Vagelos College of Physicians & Surgeons, New York, NY 10032.
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12
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Gibello L, Verzini F, Spalla F, Frola E, Porro L, Peluttiero I, Ripepi M, Boero M, Varetto G. Long-term outcomes of open and endovascular abdominal aortic repair in younger patients. Ann Vasc Surg 2022; 85:323-330. [PMID: 35271964 DOI: 10.1016/j.avsg.2022.02.021] [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: 11/10/2021] [Revised: 02/13/2022] [Accepted: 02/18/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES To evaluate long-term results in abdominal aortic aneurysm (AAA) surgery by either open (OAR) or endovascular (EVAR) repair in patients under 70 years of age. METHODS A retrospective analysis of a prospectively collected database of patients with age under 70 years old undergoing elective infrarenal AAA surgery between 2010 and 2018 was performed. The study population was divided into two groups: OAR and EVAR. The primary end-points were overall survival and aneurysm-related death, while secondary outcomes were need for reintervention and development of minor and major complications. RESULTS 191 patients younger than 70 years old treated for elective AAA surgery were enrolled: 157 OAR (98% males, mean age 65 ± 4 years) and 34 EVAR (94% males, mean age 66 ± 4 years). Hospital stay, 30-day mortality and need for reintervention were similar; OAR population presented higher incidence of postoperative major complications (18% vs 2.9%; p .01) while minor complications were 32% in OAR vs 21% in EVAR group (p .08). Median follow-up was 69 months for OAR (IQR 53 months) vs. 79 months (IQR 51 months) for EVAR (p .9): long-term AAA-related reinterventions were more frequent after EVAR (1.9% OAR vs. 17% EVAR; p .01) while AAA-related long-term mortality was similar in both sugroups (1.3% OAR and 3% EVAR; p .8). At univariate analysis a higher risk of reintervention was reported for conical necks in EVAR group (p .03) and for the concomitant presence of iliac aneurysms in both groups (p .01). CONCLUSIONS In our population, the presence of a conical neck is an independent predictor of EVAR failure and late reintervention, while it does not play a significant role in OAR group. For this reason, in such cases, open surgery must be considered as the first option in younger patients with a long-life expectancy.
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Affiliation(s)
- Lorenzo Gibello
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy.
| | - Fabio Verzini
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Flavia Spalla
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Edoardo Frola
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Luca Porro
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Ilaria Peluttiero
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Matteo Ripepi
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Michele Boero
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
| | - Gianfranco Varetto
- Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, A.O.U. Città della Salute e della Scienza, Molinette Hospital; Turin, Italy
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13
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Park JK, Kang J, Kim YW, Kim DI, Heo SH, Gil E, Woo SY, Park YJ. Outcomes after Elective Open Abdominal Aortic Aneurysm Repair in Octogenarians Compared to Younger Patients in Korea. J Korean Med Sci 2021; 36:e314. [PMID: 34873883 PMCID: PMC8648610 DOI: 10.3346/jkms.2021.36.e314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although the first choice of treatment for abdominal aortic aneurysm (AAA) is endovascular aneurysm repair, especially in elderly patients, some patients require open surgical repair. The purpose of this study was to compare the mortality outcomes of open AAA repair between octogenarians and younger counterparts and to identify the risk factors associated with mortality. METHODS All consecutive patients who underwent elective open AAA repair due to degenerative etiology at a single tertiary medical center between 1996 and June 2020 were included in this retrospective review. Medical records and imaging studies were reviewed to collect the following information: demographics, comorbid medical conditions, clinical presentations, radiologic findings, surgical details, and morbidity and mortality rates. For analysis, patients were divided into two groups: older and younger than 80 years of age. Multivariate analysis was performed to identify factors associated with mortality after elective open AAA repair. RESULTS Among a total of 650 patients who underwent elective open AAA repair due to degenerative AAA during the study period, 58 (8.9%) were octogenarians and 595 (91.1%) were non-octogenarians. Patients in the octogenarian group were predominantly female and more likely to have lower body weight and body mass index (BMI), hypertension, chronic kidney disease, and lower preoperative serum hemoglobin and albumin compared with patients in the non-octogenarian group. Maximal aneurysm diameter was larger in octogenarians. During the median follow-up duration of 34.4 months for 650 patients, the median length of total hospital and intensive care unit stay was longer in octogenarians. The 30-day (1.7% vs. 0.7%, P = 0.374) and 1-year (6.9% vs. 2.9%, P = 0.108) mortality rates were not statistically significantly different between the two groups. Multivariate analysis showed that low BMI was associated with increased 30-day (odds ratio [OR], 16.339; 95% confidence interval [CI], 1.192-224.052; P = 0.037) and 1-year (OR, 8.236; CI, 2.301-29.477; P = 0.001) mortality in all patients. CONCLUSION Because the mortality rate of octogenarians after elective open AAA repair was not significantly different compared with their younger counterparts, being elderly is not a contraindication for open AAA repair. Low BMI might be associated with increased postoperative mortality.
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Affiliation(s)
- Joon-Kee Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jihee Kang
- Division of Vascular Surgery, Department of Surgery, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seon-Hee Heo
- Department of Surgery, Yonsei University School of Medicine, Seoul, Korea
| | - Eunmi Gil
- Department of Critical Care Medicine and Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shin-Young Woo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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O'Donnell TF, McElroy IE, Mohebali J, Boitano LT, Lamuraglia GM, Kwolek CJ, Conrad MF. Late Type 1A Endoleaks: Associated Factors, Prognosis and Management Strategies. Ann Vasc Surg 2021; 80:273-282. [PMID: 34752856 DOI: 10.1016/j.avsg.2021.08.057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Unlike periprocedural Type 1A endoleaks, late appearing proximal endoleaks have been poorly described. METHODS We studied all elective EVAR from 2010 -2018 in a single institution. Late endoleaks were defined as those appearing after 1 year. We used Cox regression to study factors associated with late Type 1A endoleaks and survival. RESULTS Of 477 EVAR during the study period, 411 (86%) had follow-up imaging, revealing 24 Type 1A endoleaks; 4 early and 20 late. Freedom from Type 1A endoleaks was 99%, 92-81% at 1, 5 and 8 years with a median time to occurrence of 2.5 years (.01-8.2 years). On completion angiogram, only 10% of patients with a late Type 1A had a proximal endoleak, and 60% had no endoleak. Only 21% of late Type 1As were diagnosed on routine 1-year CT angiogram, but 79% had stable or expanding sacs. Two thirds (65%) of the patients eventually diagnosed with late Type 1A endoleaks had previously been treated for other endoleaks, mostly Type 2 (10/13). Age (HR 1.07/year [1.02-1.12], P = 0.01), neck diameter >28mm (HR 3.5 [1.2-10.3], P = 0.02), neck length <20mm (HR 3.0 [1.1-8.6], P = 0.04), and neck angle>60 degrees (HR 3.4 [1.5-7.9], P = 0.004) were associated with higher rates of Type 1A endoleak, but not female sex, endograft, or the use of suprarenal fixation. 2 patients had proximal degeneration and 5 experienced graft migration. There were 2 ruptures (10%), and 13 patients underwent repair with 5 open conversions. Median survival after late Type 1A repair was 6.6 years (0-8.4 years). CONCLUSION Late appearing Type 1A endoleaks have a high rate of rupture and present significant diagnostic and management challenges. Careful surveillance is needed in patients with hostile neck anatomy and those who undergo intervention for other endoleaks. Adverse neck anatomy may be better suited for open repair or fenestrated/branched devices rather than conventional EVAR.
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Affiliation(s)
- Thomas Fx O'Donnell
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Imani E McElroy
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Glenn M Lamuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Christopher J Kwolek
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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15
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Li B, Rizkallah P, Eisenberg N, Forbes TL, Roche-Nagle G. Thresholds for abdominal aortic aneurysm repair in Canada and United States. J Vasc Surg 2021; 75:894-905. [PMID: 34597785 DOI: 10.1016/j.jvs.2021.08.091] [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] [Received: 07/09/2021] [Accepted: 08/23/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Previous studies have demonstrated significant geographic variations in the management of abdominal aortic aneurysms (AAA) despite standard guidelines. Differences in patient selection, operative technique, and outcomes for AAA repair in Canada versus United States were assessed. METHODS The Vascular Quality Initiative was used to identify all patients who underwent elective endovascular or open AAA repair between 2010 and 2019 in Canada and the United States. Demographic, clinical, and procedural characteristics were recorded and differences between countries were assessed using independent t test and χ2 test. The primary outcome was the percentage of AAA repaired below recommended diameter thresholds (men, <5.5 cm; women, <5.0 cm). The secondary outcomes were in-hospital and 1-year mortality rates. Associations between region and outcomes were assessed using univariate/multivariate logistic regression and Cox proportional hazards analysis. RESULTS There were 51,455 US patients and 1451 Canadian patients who underwent AAA repair in Vascular Quality Initiative sites during the study period. There was a higher proportion of endovascular repairs in the United States (83.7% vs 68.4%; odds ratio [OR], 2.38; 95% confidence interval [CI], 2.13-2.63; P < .001). US patients had more comorbidities, including hypertension, congestive heart failure, chronic kidney disease, and prior revascularization. The percentage of AAA repaired below recommended thresholds was significantly higher in the United States (38.8% vs 15.2%; OR, 3.57; 95% CI, 3.03-4.17; P < .001). This difference persisted after controlling for demographic, clinical, and procedural characteristics (adjusted OR, 3.57; 95% CI, 2.63-4.17; P < .001). Factors that predicted AAA repair below recommended thresholds were US region (adjusted OR, 3.57; 95% CI, 3.03-4.17), male sex (adjusted OR, 2.89; 95% CI, 2.72-3.07), and endovascular repair (adjusted OR, 2.08; 95% CI, 1.95-2.21). The in-hospital mortality rate was low (1.0% vs 0.8%) and the 1-year rate mortality was similar between countries (hazard ratio, 0.96; 95% CI, 0.70-1.31; P = .79). CONCLUSIONS There are significant variations in AAA management between Canada and the United States. A greater proportion of US patients underwent AAA repair below the recommended diameter thresholds. This finding is partly driven by a higher percentage of endovascular repairs. Despite these differences, the perioperative and 1-year mortality rates are similar. Future studies should investigate reasons for these variations and quality improvement projects are needed to standardize care.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Philippe Rizkallah
- Division of Vascular Surgery, Peter Munk Cardiac Centre & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre & University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre & University Health Network, University of Toronto, Toronto, Ontario, Canada.
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16
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Zarkowsky DS, Sorber R, Ramirez JL, Goodney PP, Iannuzzi JC, Wohlauer M, Hicks CW. Aortic Neck IFU Violations During EVAR for Ruptured Infrarenal Aortic Aneurysms are Associated with Increased In-Hospital Mortality. Ann Vasc Surg 2021; 75:12-21. [PMID: 33951521 PMCID: PMC9843606 DOI: 10.1016/j.avsg.2021.04.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Vascular surgeons treating patients with ruptured abdominal aortic aneurysm must make rapid treatment decisions and sometimes lack immediate access to endovascular devices meeting the anatomic specifications of the patient at hand. We hypothesized that endovascular treatment of ruptured abdominal aortic aneurysm (rEVAR) outside manufacturer instructions-for-use (IFU) guidelines would have similar in-hospital mortality compared to patients treated on-IFU or with an infrarenal clamp during open repair (ruptured open aortic aneurysm repair [rOAR]). METHODS Vascular Quality Initiative datasets for endovascular and open aortic repair were queried for patients presenting with ruptured infrarenal AAA between 2013-2018. Graft-specific IFU criteria were correlated with case-specific proximal neck dimension data to classify rEVAR cases as on- or off-IFU. Univariate comparisons between the on- and off-IFU groups were performed for demographic, operative and in-hospital outcome variables. To investigate mortality differences between rEVAR and rOAR approaches, coarsened exact matching was used to match patients receiving off-IFU rEVAR with those receiving complex rEVAR (requiring at least one visceral stent or scallop) or rOAR with infrarenal, suprarenal or supraceliac clamps. A multivariable logistic regression was used to identify factors independently associated with in-hospital mortality. RESULTS 621 patients were treated with rEVAR, with 65% classified as on-IFU and 35% off-IFU. The off-IFU group was more frequently female (25% vs. 18%, P = 0.05) and had larger aneurysms (76 vs. 72 mm, P= 0.01) but otherwise was not statistically different from the on-IFU cohort. In-hospital mortality was significantly higher in patients treated off-IFU vs. on-IFU (22% vs. 14%, P= 0.02). Off-IFU rEVAR was associated with longer operative times (135 min vs. 120 min, P= 0.004) and increased intraoperative blood product utilization (2 units vs. 1 unit, P= 0.002). When off-IFU patients were matched to complex rEVAR and rOAR patients, no baseline differences were found between the groups. Overall in-hospital complications associated with off-IFU were reduced compared to more complex strategies (43% vs. 60-81%, P< 0.001) and in-hospital mortality was significantly lower for off-IFU rEVAR patients compared to the supraceliac clamp group (18% vs. 38%, P= 0.006). However, there was no significantly increased mortality associated with complex rEVAR, infrarenal rOAR or suprarenal rOAR compared to off-IFU rEVAR (all P> 0.05). This finding persisted in a multivariate logistic regression. CONCLUSIONS Off-IFU rEVAR yields inferior in-hospital survival compared to on-IFU rEVAR but remains associated with reduced in-hospital complications when compared with more complex repair strategies. When compared with matched patients undergoing rOAR with an infrarenal or suprarenal clamp, survival was no different from off-IFU rEVAR. Taken together with the growing available evidence suggesting reduced long-term durability of off-IFU EVAR, these data suggest that a patient's comorbidity burden should be key in making the decision to pursue off-IFU rEVAR over a more complex repair when proximal neck violations are anticipated preoperatively.
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Affiliation(s)
- Devin S. Zarkowsky
- Divison of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Joel L. Ramirez
- Division of Vascular Surgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Philip P. Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - James C. Iannuzzi
- Division of Vascular Surgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Max Wohlauer
- Divison of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
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17
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O'Donnell TFX, McElroy IE, Boitano LT, Mohebali J, Lamuraglia GM, Kwolek CJ, Conrad MF. Comparison of treatment options for aortic necks outside standard endovascular aneurysm repair instructions for use. J Vasc Surg 2021; 74:1548-1557. [PMID: 34019983 DOI: 10.1016/j.jvs.2021.04.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/16/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE/BACKGROUND Endovascular aneurysm repair (EVAR) is associated with worse outcomes in patients whose anatomy does not meet the device instructions for use (IFU). However, whether open surgical repair (OSR) and commercially available fenestrated EVAR (Zenith Fenestrated [ZFEN]) represent better options for these patients is unknown. METHODS We identified all patients without prior aortic surgery undergoing elective repair of abdominal aortic aneurysms with neck length ≥4 mm at a single institution with EVAR, OSR, and ZFEN. We applied device-specific aneurysm neck-related IFU to EVAR patients, and a generic EVAR IFU to ZFEN and OSR patients. Long-term outcomes were studied using propensity scores with inverse probability weighting. We compared outcomes in patients undergoing EVAR by adherence to IFU and outcomes by repair types in the subset of patients not meeting IFU. RESULTS Of 652 patients (474 EVAR, 34 ZFEN, 143 OSR), 211 had measurements outside of standard EVAR IFU (109 EVAR [23%], 27 ZFEN [80%], and 74 OSR [52%]). Perioperative mortality was 0.5% overall. For EVAR, treatment outside the IFU was associated with significantly higher adjusted rates of long-term type IA endoleak (22% at 5 years compared to 2% within IFU, hazard ratio [HR]: 5.8 [3.1-10.9], P < .001), and lower survival (5- and 10-year survival: 56% and 34% vs 81% and 53%, HR: 2.3 [1.2-4.3], P = .01). There was no difference in reinterventions or open conversion. In patients not meeting IFU, ZFEN was associated with higher adjusted rates of reinterventions (EVAR as referent: HR: 2.6 [1.5-4.4, P < .001), whereas OSR and EVAR patients experienced similar reintervention rates (HR: 0.7 [0.4-1.1], P = .13). Patients outside the IFU experienced lower mortality with OSR compared with either EVAR (HR: 0.4 [0.2-0.9], P = .005) or ZFEN (HR: 0.3 [0.1-0.7], P = .002). When restricted to patients outside the IFU deemed fit for open repair, OSR patients remained associated with lower adjusted mortality compared with ZFEN (HR: 0.2 [0.1-0.5], P < .001), but statistical significance was lost in the comparison to EVAR (HR: 0.6 [0.3-1.1], P = .1). CONCLUSIONS Treatment outside device-specific IFU is associated with adverse long-term outcomes. Open surgical repair is associated with higher long-term survival in patients who fall outside of the EVAR IFU and should be favored over EVAR or ZFEN in suitable patients. A three-vessel-based fenestrated strategy may not be a durable solution for difficult aortic necks, but more data are needed to evaluate the performance of newer, four-vessel devices.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Imani E McElroy
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Jahan Mohebali
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Glenn M Lamuraglia
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Christopher J Kwolek
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Mark F Conrad
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
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18
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Charlton-Ouw KM, Ikeno Y, Bokamper M, Zakhary E, Smeds MR. Aortic endograft sizing and endoleak, reintervention, and mortality following endovascular aneurysm repair. J Vasc Surg 2021; 74:1519-1526.e2. [PMID: 33940075 DOI: 10.1016/j.jvs.2021.04.045] [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: 11/05/2020] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Endograft sizing for endovascular abdominal aortic aneurysm repair (EVAR) is not consistent despite published instructions for use (IFU). We sought to identify factors associated with over/undersizing, determine sex influence on sizing, and examine sizing effects on endoleak, reintervention, and mortality by analyzing data obtained from the W.L. Gore & Associates Global Registry for Endovascular Aortic Treatment (GREAT). METHODS All patients enrolled in GREAT undergoing EVAR were included for analysis. Proximal/distal aortic landing zones were compared with device implanted to assess sizing as related to IFU. χ2/Fisher exact tests were used to evaluate associations between IFU sizing and demographics. Logistic regression modeling was used to identify predictors of outside IFU sizing. Cox proportional hazards regression analyzed the relationship between sizing and endoleak, device-related reinterventions, and all-cause/aortic mortality. RESULTS There were 3607 EVAR subjects enrolled in GREAT as of March 2020. Of them, 1896 (53%) were within IFU for sizing, 791 (22%) were oversized, 540 (15%) were undersized, and 380 (10%) had both over- and undersized components. Factors predictive of use outside of IFU included female sex (P = .001), non-white race (P = .0003), decreased proximal neck length (P < .061), or larger iliac diameters (P < .0001). Women were more likely than men to have proximal neck undersizing and iliac limb oversizing, and men were more likely to have iliac limb undersizing. On multivariate analysis, undersizing of the proximal graft was associated with endoleak (hazard ratio [HR], 1.8) and aortic (HR, 60.5) and all-cause (HR, 18.0) mortality. Undersizing of iliac limbs was associated with endoleak (HR, 1.5) and device-related reintervention (HR, 1.4). Iliac limb outside IFU sizing was associated with aortic (HR, 2.6) and all-cause (HR, 1.3) mortality. Proximal and distal oversizing was not associated with adverse outcomes. Female sex was associated with mortality on univariate but not multivariate analysis. CONCLUSIONS Women undergoing EVAR with GORE EXCLUDER abdominal aortic aneurysm Endoprosthesis (W.L. Gore & Associates Inc, Flagstaff, Ariz) are more likely to have proximal stent-graft undersizing and iliac limb oversizing, whereas men are more likely to have undersized iliac limbs. Proximal aortic graft undersizing is associated with endoleak and all-cause/aortic mortality, whereas undersizing of iliac limbs is associated with endoleak and device-related reintervention. Oversizing was not associated with adverse outcomes.
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Affiliation(s)
- Kristofer M Charlton-Ouw
- HCA Houston Healthcare, Gulf Coast Division, Department of Clinical Sciences, University of Houston College of Medicine, Houston, Tex; Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Yuki Ikeno
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center at Houston (UTHealth), Houston, Tex
| | - Matthew Bokamper
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University School of Medicine, St. Louis, Mo
| | - Emad Zakhary
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, St. Louis, Mo
| | - Matthew R Smeds
- Division of Vascular and Endovascular Surgery, Department of Surgery, Saint Louis University, St. Louis, Mo.
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19
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Sato H, Fukada J, Tamiya Y. Impact of Instructions for Use and Endoleaks On Long-Term Mortality After Treatment for Abdominal Aortic Aneurysm. Ann Vasc Surg 2021; 76:309-317. [PMID: 33905857 DOI: 10.1016/j.avsg.2021.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/16/2021] [Accepted: 03/25/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We reported the clinical outcomes after open repair and endovascular aortic repair for abdominal aortic aneurysm and analyzed the risk factors for all-cause mortality and endoleak after endovascular aortic repair. METHODS Patients who underwent elective treatment for abdominal aortic aneurysm from January 2009 to March 2020 were included in this study. The treatment was according to a procedure selection algorithm based on the Society for Vascular Surgery comorbidity scores and instructions for use. All patients were divided into open repair and endovascular aortic repair groups, and the clinical results were compared between the groups. RESULTS Of the 278 patients, 116 patients (41.9%) underwent open repair, and 161 patients (58.1%) underwent endovascular aortic repair. The cumulative survival rate with endovascular aortic repair was 78.6%. In the Cox proportional hazard analysis, hemodialysis (hazard ratio = 4.56; 95% confidence interval = 1.5-14.0) and the presence of type I or III endoleak (hazard ratio = 5.7; 95% confidence interval = 1.50-14.5) were independent risk factors for all-cause mortality. The Society for Vascular Surgery comorbidity score was not an independent risk factor (hazard ratio = 1.11; 95% confidence interval = 1.0-1.2). In the multivariate logistic regression analysis to identify the risk factors for type I or III endoleak after endovascular aortic repair, anticoagulation drug therapy (odds ratio = 3.99; 95% confidence interval = 1.8-8.9), untreated thoracic aortic aneurysm (odds ratio = 4.8; 95% confidence interval = 1.8-17.3), and outside instruction for use for the proximal neck (odds ratio = 5.8; 95% confidence interval = 2.3-9.8) were independent risk factors. CONCLUSIONS We analyzed the risk factors for all-cause mortality after treatment and endoleak after endovascular aortic repair. The results indicated that the instructions for use should be respected to reduce the frequency of endoleaks and that open repair should be chosen more often to improve late survival.
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Affiliation(s)
- Hiroshi Sato
- Department of Cardiovascular Surgery, Otaru General Hospital, Otaru, Hokkaido, Japan.
| | - Joji Fukada
- Department of Cardiovascular Surgery, Otaru General Hospital, Otaru, Hokkaido, Japan
| | - Yukihiko Tamiya
- Department of Cardiovascular Surgery, Otaru General Hospital, Otaru, Hokkaido, Japan
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20
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Rosenfeld ES, Macsata RA, Lala S, Lee KB, Pomy BJ, Ricotta JJ, Sparks AD, Amdur RL, Sidawy AN, Nguyen BN. Open surgical repair of juxtarenal abdominal aortic aneurysms in the elderly is not associated with increased thirty-day mortality compared with fenestrated endovascular grafting. J Vasc Surg 2020; 73:1139-1147. [PMID: 32919026 DOI: 10.1016/j.jvs.2020.08.121] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 08/04/2020] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Ethan S Rosenfeld
- Department of Surgery, The George Washington University, Washington, D.C..
| | - Robyn A Macsata
- Department of Surgery, The George Washington University, Washington, D.C
| | - Salim Lala
- Department of Surgery, The George Washington University, Washington, D.C
| | - K Benjamin Lee
- Department of Surgery, The George Washington University, Washington, D.C
| | - Benjamin J Pomy
- Department of Surgery, The George Washington University, Washington, D.C
| | - John J Ricotta
- Department of Surgery, The George Washington University, Washington, D.C
| | - Andrew D Sparks
- Department of Surgery, The George Washington University, Washington, D.C
| | - Richard L Amdur
- Department of Surgery, The George Washington University, Washington, D.C
| | - Anton N Sidawy
- Department of Surgery, The George Washington University, Washington, D.C
| | - Bao-Ngoc Nguyen
- Department of Surgery, The George Washington University, Washington, D.C
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21
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Dias-Neto M, Mani K, Leite-Moreira A, Freitas A, Sampaio S. Nationwide Analysis of Intact Abdominal Aortic Aneurysm Repair in Portugal from 2000 to 2015. Ann Vasc Surg 2020; 66:54-64.e1. [DOI: 10.1016/j.avsg.2019.12.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/09/2019] [Accepted: 12/13/2019] [Indexed: 10/25/2022]
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22
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Impact of Gradual Adoption of EVAR in Elective Repair of Abdominal Aortic Aneurysm: A Retrospective Cohort Study from 2009 to 2015. Ann Vasc Surg 2020; 70:411-424. [PMID: 32615203 DOI: 10.1016/j.avsg.2020.06.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The recommendations about the preferred type of elective repair of abdominal aortic aneurysm (AAA) still divides guidelines committees, even nowadays. The aim is to assess outcomes after AAA repair focusing on differences between endovascular aneurysm repair (EVAR) and open surgical repair (OSR). METHODS The observational retrospective cohort study of consecutive patients submitted to elective AAA repair at a tertiary center, 2009-2015. Exclusion criteria were as follows: nonelective cases or complex aortic aneurysms. Primary outcomes were postoperative complications, length of hospital stay, survival, freedom from aortic-related mortality, and vascular reintervention. Time trends were assessed along the period under analysis. RESULTS From a total of 211 included patients, those submitted to EVAR were older (74 ± 7 vs. 67 ± 9 years; P < 0.001), presented a higher prevalence of hypertension (83.5% vs. 68.5%, P = 0.004), obesity (28.7% vs. 14.3%, P = 0.029), previous cardiac revascularization (30.5% vs. 14.7%, P = 0.005), heart failure (17.2% vs. 5.2%, P = 0.013), and chronic obstructive pulmonary disease (32.8% vs. 13.3%, P = 0.002). Patients were followed during a median of 49 months. EVAR resulted in a significantly shorter length of hospital stay (median 4 and interquartile range 3 vs. 8 (9); P < 0.001), lower 30-day complications (10.6% vs. 22.8%, P = 0.017), lower aortic-related mortality, and similar reintervention after adjustment with a propensity score. Along the time under analysis, EVAR became the predominate type of repair (P = 0.024), the proportion of complications decreased (P = 0.014), and the 30-day mortality (P = 0.035). CONCLUSIONS Although EVAR was offered to patients with more comorbidities, better and durable outcomes were achieved after EVAR, favoring its adoption for elective AAA repair.
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Edman NI, Bartek MA, Kang PC, Sweet MP. Anatomic Eligibility for Commercial Branched Endograft Repair of Thoracoabdominal Aortic Aneurysms. Ann Vasc Surg 2020; 70:481-490. [PMID: 32603844 DOI: 10.1016/j.avsg.2020.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND First-generation "off-the-shelf" branched endovascular stent grafts are in development for treatment of thoracoabdominal aortic aneurysms (TAAAs). Prior studies have assessed eligibility rates among highly selected cohorts of patients referred for endovascular treatment, and the broader applicability of these devices to all patients with TAAA is unknown. The aims of this study were to assess the overall suitability of the 3 commercial 4-branched devices with or without adjunct procedure(s) in an unselected cohort of patients with TAAA and to identify areas for improvement in the next generation of devices. METHODS A retrospective review of three-dimensional centerline reconstructions of contrast-enhanced computed tomography (CT) imaging was performed in consecutive patients with TAAA seen between 2013 and 2017. All patients with contrast-enhanced CT imaging were included, regardless of prior evaluation for suitability for endovascular repair. Eligibility for a device was assessed based on instructions for use (IFU) from the device manufacturer along with prespecified anatomic criteria. Adjunct procedures were defined as carotid-subclavian revascularization, target vessel endovascular intervention, and iliac conduit/revascularization. RESULTS Of 165 patients with TAAA, 122 had CT scans adequate for study inclusion. Eighteen patients (14.8%) were eligible for at least 1 device by IFU, and 41 (33.6%) could have been made eligible for at least 1 device by an adjunct procedure. Sixty-three (51.6%) were not eligible for any device within IFU even with adjunct procedures, including 31 of 32 patients with TAAA due to dissection. The most common reasons for ineligibility were perivisceral flow channel diameter <20 mm (n = 43) and an inadequate proximal seal zone (n = 29). Women were significantly less likely to be eligible for an off-the-shelf device (P = 0.03) and were more likely to require an iliac procedure to become eligible (P = 0.006). Almost none of the patients with dissection could receive a device even if adjunct procedures were used. CONCLUSIONS Over half of patients with TAAA could not be made eligible for an off-the-shelf device based on manufacturers' criteria, even with adjunct procedures. Women and patients with TAAA due to dissection had higher rates of ineligibility. These data demonstrate that custom fenestrated devices and low-profile devices are needed to expand eligibility for endovascular repair of TAAA.
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Affiliation(s)
- Natasha I Edman
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Matthew A Bartek
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - P Chulhi Kang
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA.
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Steinmetz OK, Gill HL, Herman CR. Reply. J Vasc Surg 2020; 71:2188. [PMID: 32446527 DOI: 10.1016/j.jvs.2020.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/07/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Oren K Steinmetz
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Heather L Gill
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Christine R Herman
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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25
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Khoury MK, Matsumura JS, DiMusto PD. Regarding "Long-term survival after endovascular and open repair in patients with anatomy outside instructions for use criteria for endovascular repair". J Vasc Surg 2020; 71:2187. [PMID: 32446526 DOI: 10.1016/j.jvs.2020.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/15/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Mitri K Khoury
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Jon S Matsumura
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
| | - Paul D DiMusto
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc
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Yokoyama Y, Kuno T, Takagi H. Meta-analysis of phase-specific survival after elective endovascular versus surgical repair of abdominal aortic aneurysm from randomized controlled trials and propensity score-matched studies. J Vasc Surg 2020; 72:1464-1472.e6. [PMID: 32330598 DOI: 10.1016/j.jvs.2020.03.041] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/18/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Although endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) significantly decreases perioperative mortality compared with open surgical repair (OSR), we have not concluded superiority between EVAR and OSR beyond the perioperative period. The aim of this study was to compare phase-specific survival after EVAR vs OSR. METHODS The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Embase and MEDLINE were searched up to November 2019 to identify randomized controlled trials and propensity score-matched studies that investigated ≥2-year all-cause mortality (primary outcome) after EVAR vs OSR for intact infrarenal AAA. For each study, the hazard ratio (HR) with 95% confidence interval (CI) of mortality for EVAR vs OSR was calculated using survival curves for the following specific phases: early term (0-2 years after repair), midterm (2-6 years after repair), long term (6-10 years after repair), and very long term (≥10 years after repair). The risk ratio (RR) in the perioperative (in-hospital or 30-day) period was also extracted. Phase-specific HRs or RRs were separately pooled using the random effects model. Sensitivity analyses were performed by removing one study at a time to confirm that our findings were not derived from any single study. Funnel plot asymmetry was also examined using the linear regression test. RESULTS Our search identified four randomized controlled trials and seven propensity score-matched studies enrolling a total of 106,243 AAA patients assigned to EVAR (n = 53,123) or OSR (n = 53,120). The mortality after EVAR compared with OSR was significantly lower in the perioperative period (RR, 0.39; 95% CI, 0.29-0.51; P < .00001) and similar in the early-term period (HR, 0.93; 95% CI, 0.84-1.03; P = .16). Notably, significantly higher mortality was observed in the EVAR group compared with the OSR group in the midterm period (HR, 1.15; 95% CI, 1.03-1.29; P = .01). However, similar mortality was observed between the EVAR group and the OSR group in the long-term (HR, 1.06; 95% CI, 0.96-1.17; P = .27) and very-long-term (HR, 1.17; 95% CI, 0.93-1.47; P = .19) periods. In sensitivity analyses, the significant benefit of EVAR in the perioperative period and that of OSR in the midterm period were not changed. No funnel plot asymmetry was identified in all analyses. CONCLUSIONS Compared with OSR, EVAR was associated with lower perioperative mortality and higher mortality in the midterm period for intact infrarenal AAA. The superiority of EVAR was absent in the early-term period, and the inferiority of EVAR in the midterm period disappeared in the long-term and very-long-term periods.
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Affiliation(s)
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY.
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
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Journal of Vascular Surgery – December 2019 Audiovisual Summary. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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