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Li R, Sidawy A, Nguyen BN. Acute Intraoperative Conversion from Endovascular to Open vs Planned Open Operation for Abdominal Aortic Aneurysm: A Propensity-Score Matched Study from the American College of Surgeons NSQIP-Targeted Database. J Am Coll Surg 2024; 239:162-170. [PMID: 38372301 DOI: 10.1097/xcs.0000000000001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Evaluating outcomes for acute intraoperative conversion to open surgery during endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) was difficult due to low incidence. This study aimed to compare 30-day outcomes between patients with acute intraoperative conversion during EVAR and planned open surgery, and to identify risk factors associated with acute conversion. STUDY DESIGN Patients who underwent EVAR or planned open AAA repair were identified in American College of Surgeons NSQIP-targeted databases from 2012 to 2021. Patients with acute intraoperative conversion during EVAR were selected. A 1:3 propensity-score matching was used to match demographics, baseline characteristics, surgical indications, aneurysm size and extent, and emergency cases between the conversion open and planned open groups. Thirty-day postoperative outcomes were assessed. RESULTS Of 20,566 EVAR cases, 177 (0.86%) had acute intraoperative conversion to open surgery. The conversion open group was matched to 504 of 5,249 planned open patients. Conversion open and planned open groups had comparable 30-day mortality (23.43% vs 17.46%, p = 0.09) and organ system complications, including major adverse cardiovascular event (14.86% vs 10.71%, p = 0.17), pulmonary complications (17.71% vs 24.01%, p = 0.09), and renal complications (8.57% vs 11.11%, p = 0.39). The conversion open group had lower bleeding requiring transfusion (48.57% vs 75.60%, p < 0.01), shorter operation time (p < 0.01), and shorter length of stay (p < 0.01). Other postoperative outcomes did not differ. Risk factors associated with acute intraoperative conversion included ruptured aneurysm with or without hypotension. Protective factors included hypertension and aortic distal aneurysm extent. CONCLUSIONS Although this study does not endorse a universal "EVAR first" strategy for all patients with AAA, EVAR can be attempted first in eligible patients with AAA. Even when EVAR is unsuccessful, intraoperative conversion to open surgery still appears to be safe compared with planned open repair.
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Affiliation(s)
- Renxi Li
- From The George Washington University School of Medicine and Health Sciences, Washington, DC (Li)
| | - Anton Sidawy
- Department of Surgery, The George Washington University Hospital, Washington, DC (Sidawy, Nguyen)
| | - Bao-Ngoc Nguyen
- Department of Surgery, The George Washington University Hospital, Washington, DC (Sidawy, Nguyen)
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Silva NP, Amin B, Dunne E, Hynes N, O’Halloran M, Elahi A. Implantable Pressure-Sensing Devices for Monitoring Abdominal Aortic Aneurysms in Post-Endovascular Aneurysm Repair. SENSORS (BASEL, SWITZERLAND) 2024; 24:3526. [PMID: 38894317 PMCID: PMC11175030 DOI: 10.3390/s24113526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
Over the past two decades, there has been extensive research into surveillance methods for the post-endovascular repair of abdominal aortic aneurysms, highlighting the importance of these technologies in supplementing or even replacing conventional image-screening modalities. This review aims to provide an overview of the current status of alternative surveillance solutions for endovascular aneurysm repair, while also identifying potential aneurysm features that could be used to develop novel monitoring technologies. It offers a comprehensive review of these recent clinical advances, comparing new and standard clinical practices. After introducing the clinical understanding of abdominal aortic aneurysms and exploring current treatment procedures, the paper discusses the current surveillance methods for endovascular repair, contrasting them with recent pressure-sensing technologies. The literature on three commercial pressure-sensing devices for post-endovascular repair surveillance is analyzed. Various pre-clinical and clinical studies assessing the safety and efficacy of these devices are reviewed, providing a comparative summary of their outcomes. The review of the results from pre-clinical and clinical studies suggests a consistent trend of decreased blood pressure in the excluded aneurysm sac post-repair. However, despite successful pressure readings from the aneurysm sac, no strong link has been established to translate these measurements into the presence or absence of endoleaks. Furthermore, the results do not allow for a conclusive determination of ongoing aneurysm sac growth. Consequently, a strong clinical need persists for monitoring endoleaks and aneurysm growth following endovascular repair.
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Affiliation(s)
- Nuno P. Silva
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
| | - Bilal Amin
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Eoghan Dunne
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Niamh Hynes
- Western Vascular Institute, Galway Clinic, Doughiska Road, H91 HHT0 Galway, Ireland;
| | - Martin O’Halloran
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Adnan Elahi
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
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Lim S, Pawar O, d'Audiffret A, Sarode A, Colvard BD, Cho JS. Endovascular Aneurysm Repair-First Strategy for Ruptured Abdominal Aortic Aneurysm Might Not Be Applicable to all Cases. Ann Vasc Surg 2024; 106:386-393. [PMID: 38815909 DOI: 10.1016/j.avsg.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/07/2024] [Accepted: 03/07/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND We evaluate the relationship between the hospital case volume (HCV) and mortality outcomes after open aortic repair (OAR) and endovascular aortic repair (EVAR) of intact (iEVAR) and ruptured (rEVAR) abdominal aortic aneurysm (AAA) using a contemporary administrative database. METHODS The Healthcare Cost and Utilization Project Database for New York (2016) and New Jersey/Maryland/Florida (2016-2017) were queried using International Classification of Disease-10th edition to identify patients who had undergone OAR and EVAR. The hospitals were categorized into quartiles (Q) per overall (EVAR + OAR) volume, OAR-alone volume and EVAR-alone volume. Cox regression adjusted for confounding factors was used to estimate hazard ratios (HRs) for mortality. RESULTS A total of 8,825 patients (mean age, 73.5 ± 9.5 years; 6,861 male [77.7%]) had undergone 1,355 OARs and 7,470 EVARs. Overall HCV had no impact on in-hospital mortality across quartiles after (iEVAR) (range, 0.7%-1.4%, P = 0.15), (rEVAR) (range, 20.5%-29.6%, P = 0.63) and open repair of intact AAA (iOAR) (range, 4.9%-8.8%, P = 0.63). However, the mortality rates after open repair of ruptured AAA (rOAR) in highest-volume (Q4) hospitals were significantly lower than those in the 3 lower quartile hospitals (23.1% vs. 44.7%, P < 0.001). When analyzed per OAR-alone volume, the same findings were observed (22.0% for Q4 vs. 41.6% for Q1-3, P < 0.001). Furthermore, in Q4 hospitals per the OAR-alone volume analysis, the mortality hazard was greater for rEVAR (39.0%) than for rOAR (22.0%) (HR = 2.3, 95% confidence interval, 1.02-5.34, P < 0.05). CONCLUSIONS The mortality rates for iEVAR, rEVAR and iOAR were independent of HCV. However, after rOAR, mortality rates in high OAR volume hospitals were lower than those in the lower quartile hospitals, and, at least comparable to those of rEVAR. EVAR-first strategy for ruptured AAA might not be applicable to all cases. Patent-specific, individualized treatment should be the gold standard. For patients requiring rOAR, transfer to a regional center of excellence, when clinical safe, should be encouraged.
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Affiliation(s)
- Sungho Lim
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, Rush Medical College/Rush University Medical Center, Chicago, IL
| | - Omkar Pawar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine/University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Alexandre d'Audiffret
- Division of Vascular and Endovascular Surgery, Department of Cardiovascular and Thoracic Surgery, Rush Medical College/Rush University Medical Center, Chicago, IL
| | - Anuja Sarode
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine/University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Benjamin D Colvard
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine/University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Case Western Reserve University School of Medicine/University Hospitals, Cleveland Medical Center, Cleveland, OH.
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Jo EA, Ahn S, Mo H, Jung IM, Kim HK, Ko H, Han A, Min S, Ha J, Min SK. A 20-Year Analysis of Ruptured Abdominal Aortic Aneurysm Outcomes and Associated Factors in Korea. Ann Vasc Surg 2024; 102:152-159. [PMID: 38307230 DOI: 10.1016/j.avsg.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/09/2023] [Accepted: 10/30/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Unlike western countries, which have reported distinct decreases in incidence of ruptured abdominal aortic aneurysm (rAAA) over the last few decades, epidemiologic studies in Korea have not shown significant changes in incidence or mortality of rAAA. The purpose of this study was to analyze the changes in rAAA treatment outcomes and various associated risk factors over the past 2 decades. METHODS A 20-year retrospective multicenter review for rAAA cases from the period of January 2000 to December 2020 was undertaken. Preoperative, intraoperative and postoperative clinical data were extracted for patients diagnosed with rAAA. For analysis, outcomes from the early era, defined as patients treated between January 1, 2000, and December 31, 2010, were compared with outcomes from the late era, defined as patients treated between January 1, 2011, and December 31, 2020. RESULTS The total in-hospital mortality was 34.1% in the early era compared to 44.8% in the late era. Patients in the late era were older than those in the early era (75.2 ± 10.3 years vs. 70.3 ± 8.9 years; P = 0.009). Treatment with rAAA endovascular aneurysm repair increased from 2.3% in early to 13.8% in late era (P = 0.031). In the early era, more patients were operated by experienced surgeons than the late era (78.1% vs. 45.9%; P = 0.002). The emergency room to operating room time did not show improvement over the 20 years. CONCLUSIONS The results indicate that mortality rate of rAAA in Korea has not changed over the last 2 decades. The study suggests the need for national preventive strategies, improved systemic coordination, and potential centralization of vascular services to enhance survival rates for rAAA.
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Affiliation(s)
- Eun-Ah Jo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea; Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Sanghyun Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
| | - Hyejin Mo
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - In-Mok Jung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hyo Kee Kim
- Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Hyunmin Ko
- Department of Surgery, Kyung Hee University Medical Center, Seoul, Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sangil Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Duran M, Arnautovic A, Kilic C, Rembe JD, Mulorz J, Schelzig H, Wagenhäuser MU, Garabet W. The Comparison of Endovascular and Open Surgical Treatment for Ruptured Abdominal Aortic Aneurysm in Terms of Safety and Efficacy on the Basis of a Single-Center 30-Year Experience. J Clin Med 2023; 12:7186. [PMID: 38002798 PMCID: PMC10672125 DOI: 10.3390/jcm12227186] [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: 10/08/2023] [Revised: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE Ruptured abdominal aortic aneurysm (rAAA) is a critical condition with a high mortality rate. Over the years, endovascular aortic repair (EVAR) has evolved as a viable treatment option in addition to open repair (OR). The primary objective of this study was to compare the safety and efficacy of EVAR and OR for the treatment of rAAA based on a comprehensive analysis of our single-centre 30-year experience. METHODS Patients treated for rAAA at the Department of Vascular and Endovascular Surgery, University Hospital Düsseldorf, Germany from 1 January 1993 to 31 December 2022 were included. Relevant information was retrieved from archived medical records. Patient survival and surgery-related complications were analysed. RESULTS None of the patient-specific markers, emergency department-associated parameters, and co-morbidities were associated with patient survival. The 30-day and in-hospital mortality was higher in the OR group vs. in the EVAR group (50% vs. 8.7% and 57.1% vs. 13%, respectively). OR was associated with more frequent occurrence of more severe complications when compared to EVAR. Overall patient survival was 56 ± 5% at 12 months post-surgery (52 ± 6% for OR vs. 73 ± 11% for EVAR, respectively) (p < 0.05). Patients ≥70 years of age showed poorer survival in the OR group, with a 12-month survival of 42 ± 7% vs. 70 ± 10% for patients <70 years of age (p < 0.05). In the EVAR group, this age-related survival advantage was not found (12-month survival: ≥70 years: 67 ± 14%, <70 years: 86 ± 13%). Gender-specific survival was similar regardless of the applied method of care. CONCLUSION OR was associated with more severe complications in our study. EVAR initially outperformed OR for rAAA regarding patient survival while re-interventions following EVAR negatively affect survival in the long-term. Elderly patients should be treated with EVAR. Gender does not seem to have a significant impact on survival.
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Affiliation(s)
- Mansur Duran
- Department of Vascular and Endovascular Surgery, Marienhospital Gelsenkirchen, Teaching Hospital of Ruhr-University Bochum, Virchowstraße 135, 45886 Gelsenkirchen, Germany;
| | - Amir Arnautovic
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Cem Kilic
- Department of Vascular and Endovascular Surgery, KLINIKUM Westfalen GmbH, Am Knappschaftskrankenhaus 1, 44309 Dortmund, Germany;
| | - Julian-Dario Rembe
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Joscha Mulorz
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Markus Udo Wagenhäuser
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
| | - Waseem Garabet
- Department of Vascular and Endovascular Surgery, University Hospital of Dusseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany; (A.A.); (J.-D.R.); (H.S.); (W.G.)
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Viitala H, Laukontaus S, Aho P, Venermo M. Treatment of Abdominal Aortic Aneurysm Ruptures in a Well-defined Geographical Area during 2012-2020-A Paradigm Shift. Ann Vasc Surg 2023; 96:140-146. [PMID: 37023921 DOI: 10.1016/j.avsg.2023.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/22/2023] [Accepted: 03/19/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The treatment of abdominal aortic aneurysm ruptures (rAAA) has changed from open to endovascular repair (rEVAR) during the last decade. The immediate survival benefit after endovascular treatment method is well-known, yet without conclusive support from randomized controlled studies. The aim of this study is to report the survival benefit of rEVAR during the transition between 2 treatment methods and to highlight the in-hospital protocol for rAAA patients, with continuous simulation training and a designated team. METHODS This study is a retrospective review of rAAA patients diagnosed at Helsinki University Hospital during 2012-2020, including a total of 263 patients. Patients were divided by treatment method, and the primary end point was 30-day mortality. The secondary end points were 90-days mortality, one year mortality, and the length of stay in intensive care. RESULTS Patients were divided into the rEVAR group (n = 119) and open repair group (rOR n = 119). The turndown rate was 9.5% (n = 25). The 30-day short-term survival favored endovascular treatment (rEVAR 83.2% vs. rOR 68.9%, P = 0.015). The 90-day postdischarge survival was higher in the rEVAR group (rEVAR 80.7% vs. rOR 67.2%, P = 0.026). One-year survival was also higher in the rEVAR group, however with less statistical significance (rEVAR 74.8% vs. rOR 64.7%, P = 0.120). The effect of the revised rAAA protocol was seen in improved survival, when comparing the first 3 years of the cohort (2012-2014) to the last 3 years of the cohort (2018-2020). Survival rates were higher at 30 days, 90 days, and one year in the late cohort (74% vs. 84%, 72% vs. 81%, and 70% vs. 77%). CONCLUSIONS The rEVAR has its place as a first-line treatment option for most patients and reduces short-term and midterm mortality at least to 1-year follow-up compared to rOR. Dedicated vascular surgeons for rEVAR and continuous simulation training for the operating room staff are key elements of a low turndown and successful rAAA treatment. The use of an occlusive aortic balloon reduces overall mortality in both operative methods.
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Affiliation(s)
- Herman Viitala
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Sani Laukontaus
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pekka Aho
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Nana P, Spanos K, Jakimowicz T, Torrealba JI, Jama K, Panuccio G, Rohlffs F, Kölbel T. Urgent and emergent repair of complex aortic aneurysms using an off-the-shelf branched device. Front Cardiovasc Med 2023; 10:1277459. [PMID: 37808886 PMCID: PMC10556233 DOI: 10.3389/fcvm.2023.1277459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/11/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Endovascular repair using off-the-shelf endografts is a viable solution in patients with ruptured or symptomatic complex aortic aneurysms. This analysis aimed to present the peri-operative and follow-up outcomes in urgent and emergent cases managed with the t-Branch multibranched thoracoabdominal endograft. Methods Prospectively collected data from all consecutive urgent and emergent cases managed in two aortic centers between January 1st, 2014, to November 30th, 2022, using the t-Branch device (Cook Medical Inc., Bjaeverskov, Denmark) were analyzed. Patients presenting with ruptured aortic complex aneurysms were characterized as emergent and patients with aneurysms >90 mm of diameter, or symptomatic aneurysms were characterized as urgent. Technical success, 30-day mortality, major adverse events (MAE) and spinal cord ischemia (SCI) rates were assessed. Results 225 patients (36.5% females, 72.5 ± 2.8 years) were included; 73.0% were urgent. The mean aneurysm diameter was 109 ± 3.9 mm and 44.4% were type I-III TAAAs. Females (p = .03), para-renal aneurysms (p = .02) and ASA score IV (p < .001) were more common in emergent cases. Technical success was 97.8%. Thirty-day mortality and MAE rates were 17.8% and 30.6%, respectively. SCI rate was 14.7%, (4.8% paraplegia rate) with 22.2% of patients receiving prophylactic cerebrospinal drainage. Thirty-day mortality (13.3% vs. 26.7%, p = .04) and MAE (26.0% vs. 43.0%, p = .02) were more common among emergent cases while technical success (97.6% vs. 98.3%, p = .9), and SCI (13.3% vs. 18.3%, p = .4) were similar. Survival at 12-months was 83.5% (SE 5.9%) for the urgent and 77.1% (SE 8.2%) for the emergent group (log rank, p = 0.96). Conclusion T-Branch represents an effective and safe solution for the management of urgent and emergent cases with complex aortic aneurysms, with high technical success, promising early mortality and SCI rates.
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Affiliation(s)
- Petroula Nana
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Konstantinos Spanos
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Jose I. Torrealba
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Giuseppe Panuccio
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Fiona Rohlffs
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- German Aortic Center, Department of Vascular Medicine, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
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Takei Y, Tezuka M, Saito S, Ogasawara T, Seki M, Kato T, Kanno Y, Hirota S, Shibasaki I, Fukuda H. A protocol-based treatment for ruptured abdominal aortic aneurysm contributed to improving aorta-related mortality: a retrospective cohort study. BMC Cardiovasc Disord 2023; 23:436. [PMID: 37658328 PMCID: PMC10474727 DOI: 10.1186/s12872-023-03473-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/25/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Recent guidelines state that improving the survival rate of patients with ruptured abdominal aortic aneurysm (rAAA) requires a protocol or algorithm for the emergency management of these patients. We aimed to investigate whether introducing a protocol treatment for rAAA improves clinical outcomes compared with the pre-protocol strategy. METHODS At our institution, 92 patients treated for rAAA between June 2008 and August 2022 were retrospectively analyzed. In 2014, the protocol-based treatment was introduced comprising a transfer algorithm to shorten the time to proximal control, use of an endovascular occlusion balloon, strict indications for endovascular aortic aneurysm repair (EVAR) or open surgical repair, and perioperative care, including for abdominal compartment syndrome (ACS). Clinical outcomes were compared between the protocol and pre-protocol group, including operative status, all-cause mortality, and rAAA-related death at 30-day, in-hospital, and 1-year postoperative follow-ups. RESULTS Overall, 52 and 40 patients received the protocol-based and pre-protocol treatments, respectively. EVAR was more frequently performed in the protocol group. The rate of achieving time to proximal control was significantly faster, and the transfusion volume was lower in the protocol group. ACS occurred more frequently in the protocol group with a higher EVAR. No difference was found in all-cause mortality between the two groups. The protocol group exhibited fewer rAAA-related deaths than the pre-protocol group during the following time points: 30 days (9.6% vs. 22.5%), during the hospital stay (11.5% vs. 30.0%), and 1 year (14.5% vs. 31.5%). CONCLUSIONS The protocol-based treatment improved the survival rate of patients with rAAA.
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Affiliation(s)
- Yusuke Takei
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan.
| | - Masahiro Tezuka
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Shunsuke Saito
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Takeshi Ogasawara
- Mathematics and Statistics Section, Department of Fundamental Education, Dokkyo Medical University, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Masahiro Seki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Takashi Kato
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Yasuyuki Kanno
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Shotaro Hirota
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Ikuko Shibasaki
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
| | - Hirotsugu Fukuda
- Department of Cardiac and Vascular Surgery, Dokkyo Medical University Graduate School of Medicine, 880 Kitakobayashi, Mibu-Machi, Simotuga-gun, Tochigi, 321-0293, Japan
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11
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Gjosha B, Jan Boer G, Fioole B, Buimer MG, de Bruin JL, Suman A, van der Laan L. Assessing Endovascular Aneurysm Repair Suitability According to Graft-Specific Instructions for Use in Patients With a Ruptured Abdominal Aortic Aneurysm. J Endovasc Ther 2023:15266028231169180. [PMID: 37096758 DOI: 10.1177/15266028231169180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
PURPOSE The purpose of the study is to ascertain endovascular aneurysm repair (EVAR) suitability in relation to stent-graft-specific instructions for use (IFU) in patients with a ruptured abdominal aortic aneurysm (RAAA). MATERIALS AND METHODS Using the preoperative computed tomography angiography (CTA), the aortic morphology of patients undergoing surgical repair of a RAAA in 2 Dutch hospitals between January 2014 and December 2019 was retrospectively assessed. Three-dimensional and central luminal line reconstructions were used. Anatomical suitability was defined according to the IFU of the stent graft system used. RESULTS Of 128 included patients, 112 (88%) were men and the mean age was 74.1 (SD=7.6) years. Anatomy within IFU for EVAR was present in 31 patients (24%). Overall, 94 patients (73%) were treated with open surgical repair (OSR) and 34 patients (27%) were treated with EVAR. Anatomy within IFU was present in 15 OSR patients (16%) and 16 EVAR patients (47%). In patients with anatomy outside of IFU, 90% (87/97) had unsuitable neck anatomy and 64% (62/97) had insufficient neck length. An unsuitable distal iliac landing zone was observed in 35 patients. Perioperative mortality was 27% (34/128), with no difference between OSR and EVAR (25/94 vs 9/34; p=0.989). CONCLUSION Most RAAA patients in this series did not have aortic anatomy within IFU for EVAR, mainly due to insufficient neck length. However, whether anatomy outside of IFU equates to unsuitability for EVAR in an emergency setting remains a matter of debate and warrants further research. CLINICAL IMPACT The treatment of a ruptured abdominal aortic aneurysm can consist of endovascular repair or open repair. Retrospective anatomical assessment shows that most patients do not have anatomy inside the instructions for use for endovascular aneurysm repair, mainly due to insufficient neck length. Whether anatomy outside the instructions for use equates unsuitability for endovascular aneurysm repair remains a matter of debate.
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Affiliation(s)
- Bergin Gjosha
- Department of Vascular Surgery, Amphia Hospital, Breda, The Netherlands
| | - Gert Jan Boer
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - M G Buimer
- Department of Vascular Surgery, Amphia Hospital, Breda, The Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Arnela Suman
- Amphia Academy, Amphia Hospital, Breda, The Netherlands
| | - Lijckle van der Laan
- Department of Vascular Surgery, Amphia Hospital, Breda, The Netherlands
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
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12
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Rokosh RS, Chang H, Lui A, Rockman CB, Patel VI, Johnson W, Siracuse JJ, Cayne NS, Jacobowitz GR, Garg K. The impact of aorto-uni-iliac graft configuration on outcomes of endovascular repair for ruptured abdominal aortic aneurysms. J Vasc Surg 2023; 77:1054-1060.e1. [PMID: 36368646 PMCID: PMC10038827 DOI: 10.1016/j.jvs.2022.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Endovascular aneurysm repair has improved outcomes for ruptured abdominal aortic aneurysms (rAAA) compared with open repair. We examined the impact of aorto-uni-iliac (AUI) vs standard bifurcated endograft configuration on outcomes in rAAA. METHODS Patients 18 years or older in the Vascular Quality Initiative database who underwent endovascular aneurysm repair for rAAA from January 2011 to April 2020 were included. Patient characteristics were analyzed by graft configuration: AUI or standard bifurcated. Primary and secondary outcomes included 30-day mortality, postoperative major adverse events (myocardial infarction, stroke, heart failure, mesenteric ischemia, lower extremity embolization, dialysis requirement, reoperation, pneumonia, or reintubation), and 1-year mortality. A subset propensity-score matched cohort was also analyzed. RESULTS We included 2717 patients: 151 had AUI and 2566 had standard bifurcated repair. There was no significant difference between the groups in terms of age, major medical comorbidities, anatomic aortic neck characteristics, or rates of conversion to open repair. Patients who underwent AUI were more commonly female (30% vs 22%, P = .011) and had a history of congestive heart failure (19% vs 12%, P = .013). Perioperatively, patients who underwent AUI had a significantly higher incidence of cardiac arrest (15% vs 7%, P < .001), greater intraoperative blood loss (1.3 L vs 0.6 L, P < .001), longer operative duration (218 minutes vs 138 minutes, P < .0001), higher incidence of major adverse events (46.3% vs 33.3%, P = .001), and prolonged intensive care unit (7 vs 4.7 days, P = .0006) and overall hospital length of stay (11.4 vs 8.1 days, P = .0003). Kaplan-Meier survival analyses demonstrated significant differences in 30-day (31.1% vs 20.2%, log-rank P = .001) and 1-year mortality (41.7% vs 27.7%, log-rank P = .001). The propensity-score matched cohort demonstrated similar results. CONCLUSIONS The AUI configuration for rAAA appears to be implemented in a sicker cohort of patients and is associated with worse perioperative and 1-year outcomes compared with a bifurcated graft configuration, which was also seen on propensity-matched analysis. Standard bifurcated graft configuration may be the preferred approach in the management of rAAA unless AUI configuration is mandated by patient anatomy or other extenuating circumstances.
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Affiliation(s)
- Rae S Rokosh
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Heepeel Chang
- Department of Vascular Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Aiden Lui
- Department of Vascular Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Caron B Rockman
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Virendra I Patel
- Division of Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - William Johnson
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Neal S Cayne
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, NYU Langone Health, New York, NY.
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13
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Long-term Survival After Repair of Ruptured Abdominal Aortic Aneurysms Is Improving Over Time: Nationwide Analysis During Twenty-four Years in Sweden (1994-2017). Ann Surg 2023; 277:e670-e677. [PMID: 34183511 DOI: 10.1097/sla.0000000000005030] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate long-term survival after ruptured abdominal aortic aneurysms (rAAA) repair in Sweden during twenty-four years (1994-2017). SUMMARY BACKGROUND DATA Management of rAAA has seen significant changes in the past decades, with the shifting from open (OAR) to endovascular (EVAR) being the most striking, thereby enabling treatment of elderly patients with multiple comorbidities. METHODS A registry-based nationwide cohort study was performed, and three 8-year periods (1994-2001, 2002-2009, 2010-2017) were compared for crude long-term survival with Kaplan-Meier and multivariable Cox proportional hazards analyses. Relative survival compared to matched general population referents was estimated. RESULTS Overall, 8928 rAAA repair subjects were identified (1994-2001 N = 3368; 2002-2009 N = 3405; 2010-2017 N = 2155). The proportion of octogenarians (20.6%; 27.5%; 34.0%; P < 0.001), women (14.3%; 18.5%; 20.6%; P < 0.001), and EVAR procedures (1.5%; 14.9%; 35.5%; P < 0.001) increased over time. The crude 5-year survival was 36%; 44%; 43% (P < 0.0001). Multivariable Cox proportional hazard analysis displayed a decreasing mortality hazard ratio (HR) over time (1.00; 0.80; 0.72; P < 0.001). Use of EVAR was associated with reduced hazards of crude long-term mortality (HR = 0.80, P < 0.001). Relative survival for patients surviving the perioperative period (ie, 90 days) was lower than matched general population referents, and was stable over time (relative 5-year survival: 86% vs 88%, vs 86% P < 0.001). CONCLUSIONS Nationwide analysis of long-term outcomes after repair of rAAA in Sweden during 24 years (1994-2017) has revealed that, despite changes in the baseline population characteristics as well as in the treatment strategy, long-term survival improved over time.
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14
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The Impact of Endovascular Repair of Abdominal Aortic Aneurysms on Vascular Surgery Training in Open Aneurysm Repair. Ann Vasc Surg 2023; 92:1-8. [PMID: 36754163 DOI: 10.1016/j.avsg.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Since the introduction of endovascular aneurysm repair (EVAR) in 1992, the number of open AAA repair (OAR) cases continue to decline. The consequence of reduced OAR cases raises valid concerns related to patient safety and the future training of vascular surgeons that need to be appropriately addressed. Our objective is to analyze trends in OAR and EVAR cases and to assess their implications on the quality of vascular surgery training. METHODS We analyzed the Accreditation Council for Graduate Medical Education (ACGME) case log database for total clinical experience in OAR and EVAR for graduating vascular surgery fellows (VSFs) finishing 5 + 2 programs between 2002 and 2019 and vascular surgery integrated residents (VSRs) between 2013 and 2019. VSF case totals were calculated by combining average total cases of open and endovascular supra- and infrarenal AAA repair during fellowship years combined with total cases performed during their general surgery residency. VSR case totals included only the cases performed during the 5-year residency period. Isolated Iliac and thoracic aortic aneurysms were excluded from our analysis. RESULTS The average number of OAR cases per trainee has decreased by 60% (from 36.9 to 14.7) with a rate of 1.4 cases per year (P < 0.001) for VSF. Meanwhile, EVAR average cases have increased by 102% (from 22 to 44.4). However, there were 2 different trends exhibited with EVAR over the study period. Between 2002 and 2007, EVAR cases tended to increase by 5.9 cases per year (P < 0.001). Whereas, between 2007 and 2019, there was a slightly decreased trend in EVAR cases by 0.3 cases per year (P = 0.01). For VSR, while no significant trend was observed in the mean number of OAR cases (Coef. -0.3, P = 0.2) due to the limited time frame, the proportion of open cases was significantly lower compared to endovascular cases. Additionally, there were 2 different trends exhibited with EVAR over the study period. Between 2013 and 2015, EVAR cases tended to increase by 1.7 cases per year (P = 0.1). Whereas, between 2015 and 2019, there was a slightly decreased trend in EVAR cases by 0.2 cases per year (P = 0.007). CONCLUSIONS A significant reduction in average OAR cases and an increase in EVAR cases were observed over the study period. Vascular surgery training programs may need to introduce further training programs in open surgical repair to ensure vascular surgery trainees have the required technical skills and expertize to perform such a high-risk procedure safely and independently.
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15
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 397] [Impact Index Per Article: 198.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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16
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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17
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Center Volume and Failure to Rescue after Open or Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. J Vasc Surg 2022; 76:1565-1576.e4. [PMID: 35872329 DOI: 10.1016/j.jvs.2022.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 04/26/2022] [Accepted: 05/05/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The correlation between center volume and elective abdominal aortic aneurysm(AAA) repair outcomes is well established; however, these effects for either endovascular(EVAR) or open(OAR) repair of ruptured AAA(rAAA) remains unclear. Notably, the capacity to either avert or manage complications associated with postoperative mortality is an important cause of outcome disparities following elective procedures; however, there is a paucity of data surrounding non-elective presentations. Therefore, the purpose of this analysis was to describe the association between annual center volume, complications, and failure to rescue(FtR) after EVAR and OAR of rAAA. METHODS All consecutive endovascular and open rAAA repairs from 2010-2020 in the Vascular Quality Initiative were examined. Annual center volume(procedures/year per center) was grouped into quartiles: EVAR-Q1[<14](3.4%), Q2[14-23](12.8%), Q3[24-37](24.7%), Q4[>38](59.1%); OAR-Q1[<3](5.4%), Q2[4-6](12.8%), Q3[7-10](22.7%), Q4[>10](59.1%). The primary end-point was FtR, defined as in-hospital death after experiencing one of six major complications(cardiac, renal, respiratory, stroke, bleeding, colonic ischemia). Risk-adjusted analyses for inter-group comparisons was completed using multivariable logistic regression. RESULTS The unadjusted in-hospital death rate was 16.5% and 28.9% for EVAR and OAR, respectively. Complications occurred in 45% of EVAR(n=1,439/3,188) and 70% of OAR(n=1,366/1,961) patients with corresponding FtR rates of 14%(EVAR) and 26%(OAR). For OAR, Q4-centers had a 43% lower FtR risk(OR 0.57, 95%CI 0.4-0.9;p=.017) compared to Q1 centers. Centers performing >5 OARs/year had a 43% lower risk(OR 0.57, 95%CI 0.4-0.7;p<.001) of FtR and this decreased 4% for each additional 5 procedures performed annually(95%CI .93-.991;p=.013). However, there was no significant relationship between center volume and FtR after EVAR. The risk of FtR was strongly associated with a greater number of complications for both procedures(OR multiplied by 6.5 for EVAR and 1.5 for OAR for each additional complication;p<.0001). Among OAR patients with a single recorded complication, return to the operating room for bleeding had highest risk of in-hospital mortality(OR 4.1, 95%CI 1.1-4.8;p=.034), while no specific type of complication increased FtR risk after EVAR. CONCLUSIONS FtR occurs commonly after EVAR and OAR of rAAA within VQI centers. Importantly, increasing center volume was associated with reduced FtR risk after OAR but not EVAR. Complication pattern and frequency predicted FTR after either repair strategy. For stable patients, especially those deemed anatomically ineligible for EVAR, these findings emphasize the need to improve coordination of regional referral networks that centralize rAAAs to high-volume centers. Moreover, hospitals that treat rAAA should invest resources that develop protocols targeting specific complications to mitigate risk of preventable postoperative death.
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Pratesi C, Esposito D, Apostolou D, Attisani L, Bellosta R, Benedetto F, Blangetti I, Bonardelli S, Casini A, Fargion AT, Favaretto E, Freyrie A, Frola E, Miele V, Niola R, Novali C, Panzera C, Pegorer M, Perini P, Piffaretti G, Pini R, Robaldo A, Sartori M, Stigliano A, Taurino M, Veroux P, Verzini F, Zaninelli E, Orso M. Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE). THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:328-352. [PMID: 35658387 DOI: 10.23736/s0021-9509.22.12330-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.
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Affiliation(s)
- Carlo Pratesi
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Davide Esposito
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy -
| | | | - Luca Attisani
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Raffaello Bellosta
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Filippo Benedetto
- Department of Vascular Surgery, AOU Policlinico Martino, Messina, Italy
| | | | | | - Andrea Casini
- Department of Intensive Care, Careggi University Hospital, Florence, Italy
| | - Aaron T Fargion
- Department of Vascular Surgery, Careggi University Hospital, Florence, Italy
| | - Elisabetta Favaretto
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Antonio Freyrie
- Department of Vascular Surgery, Parma University Hospital, Parma, Italy
| | - Edoardo Frola
- Department of Vascular Surgery, AO S. Croce e Carle, Cuneo, Italy
| | - Vittorio Miele
- Department of Diagnostic Imaging, Careggi University Hospital, Florence, Italy
| | - Raffaella Niola
- Department of Vascular and Interventional Radiology, AORN Cardarelli, Naples, Italy
| | - Claudio Novali
- Department of Vascular Surgery, GVM Maria Pia Hospital, Turin, Italy
| | - Chiara Panzera
- Department of Vascular Surgery, AOU Sant'Andrea, Rome, Italy
| | - Matteo Pegorer
- Department of Vascular Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Paolo Perini
- Department of Vascular Surgery, Parma University Hospital, Parma, Italy
| | | | - Rodolfo Pini
- Department of Vascular Surgery, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Alessandro Robaldo
- Department of Vascular Surgery, Ticino Vascular Center - Lugano Regional Hospital, Lugano, Switzerland
| | - Michelangelo Sartori
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | | | | | - Fabio Verzini
- Department of Vascular Surgery, AOU Città della Salute e della Scienza, Turin, Italy
| | - Erica Zaninelli
- Department of General Medical Practice, ATS Bergamo - ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Massimiliano Orso
- Istituto Zooprofilattico Sperimentale dell'Umbria e delle Marche, Perugia, Italy
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Menges AL, Meuli L, Dueppers P, Stoklasa K, Kopp R, Reutersberg B, Zimmermann A. Relevance of Type II Endoleak After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Retrospective Single-Center Cohort Study. J Endovasc Ther 2022:15266028221086476. [PMID: 35352969 DOI: 10.1177/15266028221086476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Endovascular aortic repair (EVAR) is widely used as an alternative to open repair in elective and even in emergent cases of ruptured abdominal aortic aneurysm (rAAA). One of the most frequent complications after EVAR is type II endoleak (T2EL). In elective therapy, evidence-based therapeutic recommendations for T2EL are limited. Completely unclear is the role of T2EL after EVAR for rAAA (rEVAR). This study aims to investigate the significance of T2ELs after rEVAR. PATIENTS AND METHODS This is a retrospective single-center data analysis of all patients who underwent rEVAR between January 2010 and December 2020 with primary T2EL. The outcome criteria were overall and T2EL-related mortality and reintervention rate as well as development of aneurysm diameter over follow-up (FU). RESULTS During the study period between January 2010 and December 2020, 35 (25%) out of 138 patients with rEVAR presented a primary postoperative T2EL (age 74±11 years, 34 males). At rupture, mean aneurysm diameter was 73±12 mm. Follow-up was 26 (0-172) months. The reintervention-free survival was 69% (95% confidence interval [CI]: 55%-86%) at 30 days, 58% (95% CI: 43%-78%) at 1 year, and 52% (95% CI: 36%-75%) at 3 years. In 40% (n=14), T2ELs resolved spontaneously within a median time of 3.4 (0.03-85.6) months. The overall and T2EL reintervention rates were 43% (n=15) and 9% (n=3), respectively. Within 30 days, 11 patients (31%) required reintervention, of which 2 were T2EL related. Aneurysm sac growth by ≥5 mm was seen in 3 patients (9%), and aneurysm shrinkage rate was significantly higher in sealed T2EL group (86% vs 5%, p<0.0001). The overall survival was 85% (95% CI: 74%-98%) at 30 days, 75% (95% CI: 61%-92%) at 1 year, and 67% (95% CI: 51%-87%) at 3 years. Six deaths were aneurysm related, while 1 was T2EL related within the first 30 days due to persistent hemorrhage. During FU, one more patient died due to a T2EL-related secondary rupture (T2EL-related mortality, 5.7%, n=2). Multivariable analysis revealed that arterial hypertension was associated with an increased risk for reintervention (hazard ratio [HR]: 27.8, 95% CI: 1.48-521, p=0.026) and age was associated with an increased risk for mortality (HR 1.14, 95% CI: 1.04-1.26, p=0.005). CONCLUSION T2ELs after rEVAR showed a benign course in most cases. In the short term, the possibility of persistent bleeding should be considered. In the mid term, a consequent FU protocol is required to detect known late complications after EVAR at an early stage and to prevent secondary rupture and death.
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Affiliation(s)
- Anna-Leonie Menges
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Philip Dueppers
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Kerstin Stoklasa
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Reinhard Kopp
- Department of Vascular Surgery, University Hospital Zurich, Zurich, Switzerland
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de Boer M, Shiraev T, Waller J, Qasabian R. Has EVAR changed the outcomes of ruptured abdominal aortic aneurysms? A decades worth of experience in an Australian Teaching Hospital. ANZ J Surg 2022; 92:730-735. [PMID: 35170179 DOI: 10.1111/ans.17554] [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: 09/23/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ruptured abdominal aortic aneurysms (rAAA) are associated with significant mortality, and equipoise remains as to whether patients managed with endovascular stent grafts (rEVAR) demonstrate better outcomes when compared to traditional open repair (OR). This study sought to examine the outcomes of patients presenting with rAAA to our institution and assess the perioperative outcomes and outpatient mortality of patients over the past decade. METHODS A retrospective analysis was conducted. Patients treated for rAAA between 2010 and 2019 were identified from a search of the hospital database for ACHI and ICD-10 codes for repair of AAA. Demographic, operative and post-operative variables were collected from electronic medical records of identified patients. RESULTS Eighty patients were identified, 51 of whom presented with a rAAA. The majority of repairs were rEVARs (59%). Median age was 76 years. Median length of admission to ICU was 3 days, and median length of hospital admission was 10 days. Overall in-patient mortality was 26%, with rates of 39% at 3 years and 47% at 5 years. No significant difference in outpatient mortality was found in patients undergoing rEVAR compared to OR, with rates of 61% at 5 years compared to 65% at 5 years, respectively (p = 0.8). CONCLUSION Perioperative outcomes of our cohort of patients undergoing endovascular repair compared to open repair for ruptured and symptomatic AAAs are comparable over the past decade. Given equipoise remains between repair methods, further observational studies are required to quantify benefits of OR and endovascular repairs for ruptured and symptomatic AAAs.
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Affiliation(s)
- Madeleine de Boer
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Timothy Shiraev
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Jacob Waller
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Raffi Qasabian
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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21
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Controversies in Vascular Surgery. Surg Clin North Am 2021; 101:1097-1110. [PMID: 34774271 DOI: 10.1016/j.suc.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
There have been significant advances in vascular surgery in recent years. These advances include procedural techniques, choice of procedure, and application of nonoperative management. Endovascular techniques have expanded greatly over the past decade. As a result, for many clinical scenarios there is more than 1 option for management, which has given rise to controversies in the choice of best management. This article reviews current controversies in the management of carotid artery disease, abdominal aortic aneurysms, acute deep venous thrombosis, and inferior vena cava filter placement.
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22
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Alsusa H, Shahid A, Antoniou GA. A comparison of endovascular versus open repair for ruptured abdominal aortic aneurysm - Meta-analysis of propensity score-matched data. Vascular 2021; 30:628-638. [PMID: 34126813 DOI: 10.1177/17085381211025168] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Optimal management of ruptured abdominal aortic aneurysms (rAAA) has been heavily debated in the literature. The aim of this review is to assess comparative outcomes from propensity-matched studies of endovascular versus open for rAAA. METHODS Electronic databases (MEDLINE and Embase) were searched in January 2021 using the Healthcare Databases Advanced Search interface. Eligible studies compared endovascular versus open repair for rAAA using propensity-matched cohorts. Pooled estimates of perioperative outcomes were calculated using odds ratio (OR) or mean difference (MD) and 95% confidence interval (CI) using the random-effects model. Time-to-event data meta-analysis was conducted using the inverse-variance method and reported as summary hazard ratio (HR) and associated 95% CI. The quality of evidence was graded using a system developed by the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) working group. RESULTS Six studies published between 2010 and 2020 were selected for qualitative and quantitative synthesis, reporting a total of 6731 patients. The odds of perioperative mortality after endovascular aneurysm repair (EVAR) were significantly lower than after open surgical repair (OSR) (OR 0.52, 95% CI 0.41-0.65). The hazard of overall mortality during follow-up was lower, although not significantly, after EVAR than after OSR (HR 0.79, 95% CI 0.62-1.01). The odds of acute kidney injury and early aneurysm-related reintervention were both significantly lower after EVAR than after OSR (OR 0.34, 95% CI 0.14-0.78 and OR 0.57, 95% CI 0.33-0.98, respectively). Patients treated with EVAR stayed in hospital for significantly less time than those treated with OSR (MD -5.13, 95% CI -7.94 to -2.32). The certainty of the body of evidence for perioperative mortality was low and for overall mortality was very low. CONCLUSION The evidence suggests that EVAR confers a significant benefit on perioperative mortality.
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Affiliation(s)
- Hatim Alsusa
- Department of Vascular and Endovascular Surgery,523611 Manchester University NHS Foundation Trust, Manchester, UK
| | - Abbas Shahid
- Department of Vascular and Endovascular Surgery,523611 Manchester University NHS Foundation Trust, Manchester, UK
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery,523611 Manchester University NHS Foundation Trust, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, 574497The University of Manchester, Manchester, UK
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23
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Contemporary Management of Ruptured Infrarenal Abdominal Aortic Aneurysms. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ng JJ, Choong AMTL. Important covariates such as perioperative cardiac arrest or hemodynamic instability to reduce confounding. J Vasc Surg 2021; 73:1115-1116. [PMID: 33632503 DOI: 10.1016/j.jvs.2020.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/11/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Jun Jie Ng
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore; Division of Endovascular and Vascular Surgery, National University Heart Centre, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew M T L Choong
- SingVaSC, Singapore Vascular Surgical Collaborative, Singapore; Division of Endovascular and Vascular Surgery, National University Heart Centre, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Research Institute, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Das Gupta J, Malas MB. Reply. J Vasc Surg 2021; 73:1116. [PMID: 33632505 DOI: 10.1016/j.jvs.2020.10.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/31/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Jaideep Das Gupta
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
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Rokosh RS, Starnes BW, Chaikof EL. Society for Vascular Surgery implementation of clinical practice guidelines for patients with an abdominal aortic aneurysm: Repair of an abdominal aortic aneurysm. J Vasc Surg 2021; 73:1485-1487. [PMID: 33548428 DOI: 10.1016/j.jvs.2020.12.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Rae S Rokosh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Division of Vascular and Endovascular Surgery, Department of Surgery, NYU Langone Health, New York, NY
| | - Benjamin W Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Elliot L Chaikof
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Blackstock CD, Jackson BM. Open Surgical Repair of Abdominal Aortic Aneurysms Maintains a Pivotal Role in the Endovascular Era. Semin Intervent Radiol 2020; 37:346-355. [PMID: 33041480 DOI: 10.1055/s-0040-1715881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Since the advent of endovascular aortic repair (EVAR) nearly three decades ago, there has been a paradigm shift in the treatment of the abdominal aortic aneurysm (AAA) to favor EVAR due to its reduced operative mortality, less invasive nature, and faster recovery times. However, more recently there has been an accumulation of data from large meta-analyses and randomized clinical trials revealing that EVAR has no survival benefit after approximately 2 years and is associated with substantially higher rates of reintervention and aneurysm rupture in the long term. These findings call into question the durability of EVAR compared with open aortic repair and emphasize the need for surgeons to remain competent with open aortic surgery in the modern era. This article will provide comprehensive review of a large body of literature comparing endovascular repair to open aortic surgery for the management of AAAs, and it will offer an overview of the open surgical repair technique for AAAs.
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Affiliation(s)
- Christopher D Blackstock
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Jackson
- Division of Vascular Surgery and Endovascular Therapy, University of Pennsylvania, Philadelphia, Pennsylvania
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Deng J, Liu J, Rong D, Ge Y, Zhang H, Liu X, Guo W. A meta-analysis of locoregional anesthesia versus general anesthesia in endovascular repair of ruptured abdominal aortic aneurysm. J Vasc Surg 2020; 73:700-710. [PMID: 32882348 DOI: 10.1016/j.jvs.2020.08.112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/04/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To conduct a meta-analytic review of studies investigating the effect of the anesthesia modality on perioperative mortality in endovascular repair of ruptured abdominal aortic aneurysms (REVAR). METHODS The present meta-analysis was performed in accordance with the PRISMA guidelines. Multiple electronic databases were comprehensively searched from database inception to January 2020. Eligible studies included cohort studies that reported the 30-day/in-hospital mortality rate or the multivariate adjusted odds ratio (OR) or hazard ratio of the mortality risk for patients who underwent emergency REVAR under locoregional anesthesia (LA) vs general anesthesia (GA). A random effects model was used to estimate the ORs by pooling the related data from individual studies. RESULTS A total of eight studies were included in this analysis. The first meta-analysis of seven studies that reported the 30-day/in-hospital mortality with a total of 3116 patients (867 in the LA group and 2249 in the GA group) revealed that LA was associated with a lower 30-day/in-hospital mortality than GA (16.4% vs 25.4%; unadjusted OR, 0.47; 95% confidence interval [CI], 0.32-0.68). The second meta-analysis of three of these seven studies (including 586 patients in the LA group and 1945 in the GA group) that reported the perioperative variables revealed comparable baseline characteristics but a lower 30-day/in-hospital mortality in the LA group (unadjusted OR, 0.55; 95% CI, 0.42-0.71). The third meta-analysis of the adjusted ORs or hazard ratios that were reported from four studies (including 501 patients in the LA group and 1136 in the GA group) showed a similar trend (adjusted OR,0.37; 95% CI, 0.19-0.75). CONCLUSIONS REVAR under LA is associated with a lower 30-day/in-hospital mortality than REVAR under GA. However, because the included studies may have had some observation bias, further randomized controlled trials are warranted to validate the present results.
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Affiliation(s)
- Jianqing Deng
- Department of Vascular and Endovascular Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Jie Liu
- Department of Vascular and Endovascular Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Dan Rong
- Department of Vascular and Endovascular Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yangyang Ge
- Department of Vascular and Endovascular Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Hongpeng Zhang
- Department of Vascular and Endovascular Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiaoping Liu
- Department of Vascular and Endovascular Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Wei Guo
- Department of Vascular and Endovascular Surgery, the First Medical Centre, Chinese PLA General Hospital, Beijing, China.
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Lawrence P. Journal of Vascular Surgery – August 2020 Audiovisual Summary. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Inferring causality. J Vasc Surg 2020; 72:387-388. [PMID: 32711903 DOI: 10.1016/j.jvs.2020.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 01/17/2020] [Indexed: 11/20/2022]
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