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Khoury MK, Thornton MA, Eagleton MJ, Srivastava SD, Zacharias N, Dua A, Mohapatra A. Assessment of fitness for open repair in patients with infrarenal abdominal aortic aneurysms. J Vasc Surg 2024; 80:389-396.e2. [PMID: 38614140 DOI: 10.1016/j.jvs.2024.04.020] [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: 02/02/2024] [Revised: 04/04/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) was originally designed as a treatment modality for patients with abdominal aortic aneurysms (AAAs) deemed unfit for open repair. However, the definition of "unfit for open repair" is largely subjective and heterogenous. The purpose of this study was to compare patients deemed unfit for open repair who underwent EVAR to a matched cohort who underwent open repair for infrarenal AAAs. METHODS The Vascular Quality Initiative of the Society for Vascular Surgery was queried for patients who underwent EVAR and open infrarenal AAA repair from 2003 to 2022. Patients that underwent EVAR were included if they were deemed unfit for open repair by the operating surgeon. EVAR patients deemed unfit because of a hostile abdomen were excluded. Patients in both the open and EVAR datasets were excluded if their repair was deemed non-elective or if they had prior aortic surgery. EVAR patients were matched to a cohort of open patients. The primary outcome for this study was 1-year mortality. Secondary outcomes included 30-day mortality, major adverse cardiac events, pulmonary complications, non-home discharge, reinterventions, and 5-year survival. RESULTS A total of 5310 EVAR patients were identified who were deemed unfit for open repair. Of those, 3028 EVAR patients (57.0%) were able to be matched 1:1 to a cohort of open patients. Open patients had higher rates of major adverse cardiac events (20.2% vs 4.4%; P < .001), pulmonary complications (12.8% vs 1.6%; P < .001), non-home discharges (28.5% vs 7.9%; P < .001), and 30-day mortality (4.5% vs 1.4%; P < .001). There were no differences in early survival, but open repair had better middle and late survival compared with EVAR over the course of 5 years. A total of 74 EVAR patients (2.4%) had reinterventions during the study period. EVAR patients that required interventions had higher 1-year (40.5% vs 7.3%; P < .001) and 5-year mortality (43.2% vs 14.1%; P < .001) compared with those that did not require reinterventions. EVAR patients who had reinterventions had higher 1-year (40.5% vs 6.3%; P < .001) and 5-year (43.2% vs 20.3%; P = .006) mortality compared with their matched open cohort. CONCLUSIONS Patients undergoing EVAR for AAAs who are deemed unfit for open repair have better perioperative morbidity and mortality compared with open repair. However, patients who had an open repair had better middle and late survival over the course of 5 years. The categorization of unfitness for open surgery may be inaccurate and re-evaluation of this terminology/concept should be undertaken.
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Affiliation(s)
- Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA.
| | - Micah A Thornton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Sunita D Srivastava
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
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Bin Saif A, Summerour V, Al-Saadi N, Arif A, Newman J, Wall M. Survival and Decision-Making in Patients Turned Down for Abdominal Aortic Aneurysm Repair: A Retrospective Study with Focus on COVID-19 Impact. Ann Vasc Surg 2024; 109:522-530. [PMID: 38852773 DOI: 10.1016/j.avsg.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/08/2024] [Accepted: 03/08/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND To investigate and analyze various aspects related to patients who have been placed on a "turndown list" for elective or emergency repair of abdominal aortic aneurysms. METHODS This retrospective study analyzed data from the Black Country Vascular Network. Multidisciplinary team meetings assessed abdominal aortic aneurysm patients referred through National Abdominal Aortic Aneurysm Screening Program or directly to vascular surgery. Patients considered unfit for intervention were added to a prospectively kept turndown list. Survival and cause of death data were collected, along with cardiopulmonary exercise testing (CPET) results and British Aneurysm Repair scores for some patients. The study covered a period from January 2015 to May 2023. RESULTS After exclusions, 247 (16%) patients were placed on the turndown list with a median age of 85 years (interquartile range 8 years). The mortality of turndown cases on medical grounds was 74.1%. Survival was significantly higher for patients who completed CPET before being turned down (P = 0.004). Gender analysis revealed a higher proportion of females being turned down compared to males (P = 0.044). COVID-19 led to a notable reduction in the number of discussed cases and interventions, while the turndown rates remained consistent. Survival at 1 year in turndown patients was 66%, at 3 years it was 29%, at 4 years it was 18%, and at 7 years it was 5%. Most patients whose cause of death was known died of respiratory complications (30%) or malignancy (19%). British Aneurysm Repair scores and aneurysm size were not significant predictors of mortality. CONCLUSIONS Patients on the turndown list have a substantial mortality rate. A significant proportion of female patients were being turned down compared to men and the reasons for this are not clear. Patients who completed CPET before being turned down had a longer survival time. While COVID-19 impacted healthcare services reducing the number of interventions, it did not influence turndown decisions. The study showed that the cause of death for a significant number of patients was respiratory complications or malignancy.
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Affiliation(s)
- Anas Bin Saif
- The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | | | - Nina Al-Saadi
- The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Anum Arif
- The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Jeremy Newman
- The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
| | - Michael Wall
- The Dudley Group NHS Foundation Trust, Russells Hall Hospital, Dudley, UK
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Chellasamy RT, Krishnaswami M. Reinterventions after TEVAR. Indian J Thorac Cardiovasc Surg 2023; 39:325-332. [PMID: 38093920 PMCID: PMC10713966 DOI: 10.1007/s12055-023-01646-w] [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: 08/25/2023] [Revised: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023] Open
Abstract
Thoracic cardiovascular aortic repair is an alternative procedure to open surgery for degenerative thoracic aortic aneurysm and thoracic aortic dissection. The advancements in graft design and imaging techniques have expanded its utility. However, the long-term patency of thoracic endovascular aortic repair (TEVAR) graft is still a concern. This review delves into the literature on re-intervention following TEVAR, highlighting factors that influence the re-intervention rate.
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Affiliation(s)
| | - Murali Krishnaswami
- Department of Radiology, Institute of Cardiac and Aortic Disorders, SIMS Hospital, Chennai, 600026 India
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Li B, Aljabri B, Verma R, Beaton D, Eisenberg N, Lee DS, Wijeysundera DN, Forbes TL, Rotstein OD, de Mestral C, Mamdani M, Roche-Nagle G, Al-Omran M. Machine learning to predict outcomes following endovascular abdominal aortic aneurysm repair. Br J Surg 2023; 110:1840-1849. [PMID: 37710397 DOI: 10.1093/bjs/znad287] [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] [Received: 04/05/2023] [Revised: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) carries important perioperative risks; however, there are no widely used outcome prediction tools. The aim of this study was to apply machine learning (ML) to develop automated algorithms that predict 1-year mortality following EVAR. METHODS The Vascular Quality Initiative database was used to identify patients who underwent elective EVAR for infrarenal AAA between 2003 and 2023. Input features included 47 preoperative demographic/clinical variables. The primary outcome was 1-year all-cause mortality. Data were split into training (70 per cent) and test (30 per cent) sets. Using 10-fold cross-validation, 6 ML models were trained using preoperative features with logistic regression as the baseline comparator. The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). Model robustness was evaluated with calibration plot and Brier score. RESULTS Some 63 655 patients were included. One-year mortality occurred in 3122 (4.9 per cent) patients. The best performing prediction model for 1-year mortality was XGBoost, achieving an AUROC (95 per cent c.i.) of 0.96 (0.95-0.97). Comparatively, logistic regression had an AUROC (95 per cent c.i.) of 0.69 (0.68-0.71). The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.04. The top 3 predictive features in the algorithm were 1) unfit for open AAA repair, 2) functional status, and 3) preoperative dialysis. CONCLUSIONS In this data set, machine learning was able to predict 1-year mortality following EVAR using preoperative data and outperformed standard logistic regression models.
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Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada
| | - Badr Aljabri
- Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Derek Beaton
- Data Science & Advanced Analytics, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Douglas S Lee
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Ori D Rotstein
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Charles de Mestral
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada
- Data Science & Advanced Analytics, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
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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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Mulatti GC, Joviliano EE, Pereira AH, Fioranelli A, Pereira AA, Brito-Queiroz A, Von Ristow A, Freire LMD, Ferreira MMDV, Lourenço M, De Luccia N, Silveira PG, Yoshida RDA, Fidelis RJR, Boustany SM, de Araujo WJB, de Oliveira JCP. Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm. J Vasc Bras 2023; 22:e20230040. [PMID: 38021279 PMCID: PMC10648059 DOI: 10.1590/1677-5449.202300402] [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: 03/13/2023] [Accepted: 06/15/2023] [Indexed: 12/01/2023] Open
Abstract
The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.
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Affiliation(s)
- Grace Carvajal Mulatti
- Universidade de São Paulo - USP, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil.
| | - Edwaldo Edner Joviliano
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto - FMRP, Ribeirão Preto, SP, Brasil.
| | - Adamastor Humberto Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | | | - Alexandre Araújo Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | - André Brito-Queiroz
- Universidade Federal da Bahia - UFBA, Hospital Ana Nery, Salvador, BA, Brasil.
| | - Arno Von Ristow
- Pontifícia Universidade Católica do Rio de Janeiro - PUC-Rio, Rio de Janeiro, RJ, Brasil.
| | | | | | | | - Nelson De Luccia
- Universidade de São Paulo - USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | | | - Ricardo de Alvarenga Yoshida
- Universidade Estadual Paulista “Júlio de Mesquita Filho” - UNESP, Faculdade de Medicina de Botucatu, Botucatu, SP, Brasil.
| | | | - Sharbel Mahfuz Boustany
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
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Torabi N, Shafiee A, Heidari A, Hajizeinali M, Jalali A, Hajizeinali A. Predictors of Five-Year Survival after EVAR: 10-Year Experience of Single-Center Cohort Study. Ann Vasc Surg 2023; 96:115-124. [PMID: 37068627 DOI: 10.1016/j.avsg.2023.03.034] [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: 02/03/2023] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Endovascular abdominal aortic repair (EVAR) is the main therapeutic option for repairing abdominal aortic aneurysms (AAAs). We aimed to determine the long-term outcomes of patients who underwent EVAR at our center. METHODS In this retrospective cohort study, patients who underwent EVAR for intact isolated AAA at Tehran Heart Center between 2007 and 2017 were included. Clinical outcomes and the frequency of mortality were analyzed for follow-up periods. We calculated the 5-year survival rate and its predictors for our patients using Kaplan-Meier estimation. RESULTS We included the data of all patients (154 patients, mean age = 70.7 [± 8.0] years, 96.1% men) who successfully underwent EVAR at our center. The most common risk factors were coronary artery disease (70.1%), hypertension (68.2%), smoking (64.9%), and dyslipidemia (39.6%). There was no mortality during the procedure. The median follow-up was 65.5 months. An average decrease of 9.07 mm (95% confidence interval: 6.9-11.2) occurred in the size of the AAA. During follow-up, 12 patients developed some complications, 49 died, and 7 did not complete the follow-up. The 5-year survival rate was 75% (3.9%). The independent predictors for 5-year survival were age (hazard ratio [HR] = 1.06, P = 0.002) and anemia (HR = 1.91, P = 0.029). Despite not being statistically significant, dyslipidemia (HR = 0.573, P = 0.078) and long intensive care unit/cardiac care unit stays (HR = 1.08, P = 0.070) were borderline mortality predictors. CONCLUSIONS This study depicted an acceptable survival rate for patients who underwent EVAR at our center. Age and anemia, 2 modifiable predictors of 5-year survival, can probably prolong the survival rate of patients, which requires evaluation later.
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Affiliation(s)
- Nasim Torabi
- Department of Cardiology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Akbar Shafiee
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Heidari
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Mohammadmohsen Hajizeinali
- Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Alimohammad Hajizeinali
- Interventional Cardiology Department, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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Epple J, Lingwal N, Schmitz-Rixen T, Böckler D, Grundmann RT. The Treatment of Patients With an Unruptured Abdominal Aortic Aneurysm and a Concomitant Malignancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:589-594. [PMID: 37427993 PMCID: PMC10552633 DOI: 10.3238/arztebl.m2023.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/18/2023] [Accepted: 06/18/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Having cancer adversely effects the outcome of treatment for an unruptured abdominal aortic aneurysm (AAA). METHODS A retrospective secondary analysis was performed on the basis of anonymized data from AOK, a German nationwide statutory healthinsurance carrier. Data were evaluated from all of the 20 683 patients who underwent either endovascular (EVAR, 15 792) or open surgical (OAR, 4891) treatment for an unruptured AAA in the years 2010-2016. It was determined in each case whether the patient had a known cancer at the time of the procedure to treat AAA. The analysis concerned patient characteristics, periprocedural complications, and survival after the procedure up to 31 December 2018. RESULTS 18 222 patients were free of cancer. In accordance with the known 6:1 sex ratio of AAA, 85.3% of the cancer-free patients and 92.8% of those with cancer were men. At the time of their AAA procedure, 1398 had cancer of the intestine (n = 318), lung (n = 301), prostate (n = 380), or bladder or ureter (n = 399). One-year survival after the AAA procedure was 91.5% in cancer-free patients and 84%, 74.4%, 85.8%, and 85.5% in the patients with the respective types of cancer just mentioned. Having cancer was a significant risk factor for periprocedural mortality (OR 1.326, p = 0.041) and for long-term survival (HR 1.515; p < 0.001). CONCLUSION Having cancer is a risk factor for periprocedural mortality and long-term survival in patients undergoing treatment for an unruptured AAA. This implies that the indications for surgery should be considered with care, particularly in patients with lung cancer, whose 5-year survival rate is only 37.2%.
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Affiliation(s)
- Jasmin Epple
- Department of Vascular and Endovascular Surgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Neelam Lingwal
- Department of Biostatistics and Mathematical Modeling, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | | | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Germany
| | - Reinhart T. Grundmann
- German Institute for Health Research in Vascular Medicine (DIGG gGmbH), Berlin, Germany
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10
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De Freitas S, D'Ambrosio N, Fatima J. Infrarenal Abdominal Aortic Aneurysm. Surg Clin North Am 2023; 103:595-614. [PMID: 37455027 DOI: 10.1016/j.suc.2023.05.001] [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: 07/18/2023]
Abstract
Abdominal aortic aneurysms are found in up to 6% of men and 1.7% of women over the age of 65 years and are usually asymptomatic. The natural history of aortic aneurysms is continued dilation leading to rupture, which is associated with an overall 80% mortality. Of the patients with ruptured aneurysms that undergo intervention, half will not survive their hospitalization. Reduction in aneurysm mortality is therefore achieved by prophylactic repair during the asymptomatic period. On a population-based level, this is supported by abdominal aortic aneurysm screening programs. Approximately 60% of abdominal aortic aneurysms are confined to the infrarenal portion of the aorta and are amenable to repair with off-the-shelf endovascular devices. Endovascular techniques have now replaced open surgery as the primary modality for aneurysm repair.
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Affiliation(s)
- Simon De Freitas
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Nicole D'Ambrosio
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC, USA
| | - Javairiah Fatima
- Department of Vascular Surgery, Georgetown University Hospital, MedStar Health, Washington, DC, USA.
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11
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Khoury MK, Thornton MA, Weaver FA, Ramanan B, Tsai S, Timaran CH, Modrall JG. Selection criterion for endovascular aortic repair in those with chronic kidney disease. J Vasc Surg 2023; 77:1625-1635.e3. [PMID: 36731756 DOI: 10.1016/j.jvs.2023.01.185] [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: 10/12/2022] [Revised: 01/11/2023] [Accepted: 01/14/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Endovascular aortic repair (EVAR) is the preferred method of repair for abdominal aortic aneurysms (AAAs). However, patients with advanced chronic kidney disease (CKD) are a high-risk group, and it is unknown which patients with CKD benefit from EVAR vs continued surveillance. The purpose of this study was to identify which patients with advanced CKD may benefit from EVAR. METHODS The Vascular Quality Initiative Database was utilized to identify elective EVARs for AAAs. Patients were excluded if they underwent urgent or emergent repairs. CKD stages were categorized based on preoperative estimated glomular filtration rate (eGFR) and dialysis status. Predicted 1-year mortality of untreated AAAs was calculated by modifying a validated comorbidity score that predicts 1-year mortality (Gagne Index) without repair. The primary outcome was actual 1-year mortality, which was compared with the predicted 1-year mortality without repair. RESULTS A total of 34,926 patient met study criteria. There were differences in Gagne Indices among the varying classes of CKD. Patients with CKD 4 and CKD 5 had the highest 1-year mortality rates, followed by CKD 3b, which was significantly higher than those with CKD 1 and CKD 2. Patients with CKD 4 had no differences between actual 1-year mortality with EVAR and predicted 1-year survival without EVAR across all AAA sizes. Those with CKD 5 had worse actual 1-year survival with EVAR than predicted 1-year survival without EVAR for AAAs <5.5 cm. Patients with CKD 5 only experienced an actual mortality benefit with EVAR compared with predicted 1-year mortality without EVAR for AAAs ≥7.0 cm. CONCLUSION The current data suggest that patients with CKD 3b, 4, and 5 represent a high-risk group who may not benefit from elective EVAR utilizing traditional size criteria. Patients with CKD 4 and 5 with AAAs <5.5 cm do not benefit from elective EVAR. In patients with CKD 5, elective EVAR may need to be reserved for AAAs ≥7.0 cm unless there are other concerning anatomic characteristics.
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Affiliation(s)
- Mitri K Khoury
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Micah A Thornton
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Fred A Weaver
- Division of Vascular and Endovascular Therapy, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Bala Ramanan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Surgical Service, Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Shirling Tsai
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Surgical Service, Dallas Veterans Affairs Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - J Gregory Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX; Surgical Service, Dallas Veterans Affairs Medical Center, Dallas, TX.
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12
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Iwakoshi S, Ogawa Y, Dake MD, Ono Y, Higashihara H, Ikoma A, Nakai M, Taniguchi T, Ogi T, Kawada H, Tamura A, Ieko Y, Tanaka R, Sohgawa E, Nagatomi S, Woodhams R, Ikeda O, Mori K, Nishimaki H, Koizumi J, Senokuchi T, Hagihara M, Shimohira M, Takasugi S, Imaizumi A, Higashiura W, Sakaguchi S, Ichihashi S, Inoue T, Inoue T, Kichikawa K. Outcomes of embolization procedures for type II endoleaks following endovascular abdominal aortic repair. J Vasc Surg 2023; 77:114-121.e2. [PMID: 35985566 DOI: 10.1016/j.jvs.2022.07.168] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 07/16/2022] [Accepted: 07/25/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the mid-term outcomes of embolization procedures for type II endoleak after endovascular abdominal aortic repair, and clarify the risk factors for aneurysm enlargement after embolization procedures. METHODS This was a retrospective multicenter registry study enrolling patients who underwent embolization procedures for type II endoleaks after EVAR from January 2012 to December 2018 at 19 Japanese centers. The primary end point was the rate of freedom from aneurysm enlargement, more than 5 mm in the aortic maximum diameter, after an embolization procedure. Demographic, procedural, follow-up, and laboratory data were collected. Continuous variables were summarized descriptively, and Kaplan-Meier analyses and a Cox regression model were used for statistical analyses. RESULTS A total of 315 patients (248 men and 67 women) were enrolled. The average duration from the initial embolization procedure to the last follow-up was 31.6 ± 24.6 months. The rates of freedom from aneurysm enlargement at 3 and 5 years were 55.4 ± 3.8% and 37.0 ± 5.2%, respectively. A multivariate analysis revealed that a larger aortic diameter at the initial embolization procedure and the presence of a Moyamoya endoleak, defined as heterogeneous contrast opacity with an indistinct faint border, were associated with aneurysm enlargement after embolization management. CONCLUSIONS The embolization procedures were generally ineffective in preventing further expansion of abdominal aortic aneurysms in patients with type II endoleaks after EVAR, especially in patients with a large abdominal aortic aneurysm and/or a presence of a Moyamoya endoleak.
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Affiliation(s)
| | - Yukihisa Ogawa
- Department of Radiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Michael D Dake
- Department of Medical Imaging, University of Arizona College of Medicine, Tucson, AZ
| | - Yusuke Ono
- Department of Radiology, Osaka University, Suita, Japan
| | | | - Akira Ikoma
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | - Motoki Nakai
- Department of Radiology, Wakayama Medical University, Wakayama, Japan
| | | | - Takahiro Ogi
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Hiroshi Kawada
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Akio Tamura
- Department of Radiology, Iwate Medical University, Morioka, Japan
| | - Yoshirou Ieko
- Department of Radiology, Iwate Medical University, Morioka, Japan
| | - Ryoichi Tanaka
- Department of Radiology, Iwate Medical University, Morioka, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Satoru Nagatomi
- Department of Radiology, Nara Medical University, Kashihara, Japan
| | - Reiko Woodhams
- Department of Radiology, Kitazato University, Tokyo, Japan
| | - Osamu Ikeda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Kensaku Mori
- Department of Radiology, Tsukuba University, Tsukuba, Japan
| | - Hiroshi Nishimaki
- Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Jun Koizumi
- Department of Radiology, Tokai University, Tokai, Japan
| | - Terutoshi Senokuchi
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Science, Kagoshima, Japan
| | - Makiyo Hagihara
- Department of Radiology, Aichi Medical University, Nagakute, Japan
| | - Masashi Shimohira
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shohei Takasugi
- Department of Radiology, Tottori University Hospital, Tottori, Japan
| | - Akira Imaizumi
- Department of Radiology, University of Yamanashi, Yamanashi, Japan
| | - Wataru Higashiura
- Department of Radiology, Okinawa Prefectural Chubu Hospital, Uruma, Japan
| | - Shoji Sakaguchi
- Department of Radiology, Matsubara Tokusyukai Hospital, Matsubara, Japan
| | - Shigeo Ichihashi
- Department of Radiology, Nara Medical University, Kashihara, Japan
| | - Takeshi Inoue
- Department of Central Radiology, Nara Medical University, Kashihara, Japan
| | - Takashi Inoue
- Institute for Clinical and Translational Science, Nara Medical University, Kashihara, Japan
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13
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Biomechanical Rupture Risk Assessment in Management of Patients with Abdominal Aortic Aneurysm in COVID-19 Pandemic. Diagnostics (Basel) 2022; 13:diagnostics13010132. [PMID: 36611424 PMCID: PMC9818825 DOI: 10.3390/diagnostics13010132] [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: 09/17/2022] [Revised: 10/18/2022] [Accepted: 12/27/2022] [Indexed: 01/04/2023] Open
Abstract
Background: The acute phase of the COVID-19 pandemic requires a redefinition of healthcare system to increase the number of available intensive care units for COVID-19 patients. This leads to the postponement of elective surgeries including the treatment of abdominal aortic aneurysm (AAA). The probabilistic rupture risk index (PRRI) recently showed its advantage over the diameter criterion in AAA rupture risk assessment. Its major improvement is in increased specificity and yet has the same sensitivity as the maximal diameter criterion. The objective of this study was to test the clinical applicability of the PRRI method in a quasi-prospective patient cohort study. Methods: Nineteen patients (fourteen males, five females) with intact AAA who were postponed due to COVID-19 pandemic were included in this study. The PRRI was calculated at the baseline via finite element method models. If a case was diagnosed as high risk (PRRI > 3%), the patient was offered priority in AAA intervention. Cases were followed until 10 September 2021 and a number of false positive and false negative cases were recorded. Results: Each case was assessed within 3 days. Priority in intervention was offered to two patients with high PRRI. There were four false positive cases and no false negative cases classified by PRRI. In three cases, the follow-up was very short to reach any conclusion. Conclusions: Integrating PRRI into clinical workflow is possible. Longitudinal validation of PRRI did not fail and may significantly decrease the false positive rate in AAA treatment.
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14
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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: 430] [Impact Index Per Article: 215.0] [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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15
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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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16
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Duan L, Xin W, Li S, Zhao L, Xin S. The treatment choices of abdominal aortic aneurysm patients in China in the era of value-based healthcare. Front Cardiovasc Med 2022; 9:961830. [DOI: 10.3389/fcvm.2022.961830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/09/2022] [Indexed: 11/30/2022] Open
Abstract
BackgroundEndovascular aneurysm repair (EVAR) is often seen as the first choice treatment for patients with abdominal aortic aneurysm (AAA), particularly high-risk patients, yet the long-term survival rate and improvement in quality of life are still unclear. In order to seek the value of EVAR to the entire healthcare field, we conducted a retrospective study to evaluate whether the improvement EVAR can truly bring to the quality of medical care in the era of value-based healthcare.MethodsWe included AAA patients who underwent surgical treatment in the Department of Vascular Surgery, First Hospital of China Medical University, from January 1, 2004, to December 31, 2019 and evaluated surgery procedure data, short-term and long-term mortality, complications, prognoses, and medical costs.ResultsWe analyzed 507 patients with AAA who underwent open repair (n = 232) or EVAR (n = 275) over a 15-year period. The operative time, blood loss, blood transfusion rate, and postoperative length of hospital stay of the EVAR group is significantly lower than which of the open repair group. Meanwhile, neither short-term nor long-term mortality rates shows significant differences between the two groups. On the other hand, the complication rate of the EVAR group was significantly higher than that of the open repair group. Lastly, the total cost of EVAR was significantly higher than that of open repair.ConclusionExisting evidence suggests that EVAR improves neither short-term nor long-term survival rate compared with open surgery. In contrast, the complication rate and the reintervention rate in the EVAR group were higher than those in the open surgery group. Moreover, the cost of EVAR and that paid by medical insurance were higher than those for open surgery. For patients with a long-life expectancy, in order to ensure that patients receive appropriate and effective care, surgeons should choose a suitable method that considers both the quality of medical care as well as the expense accordingly.
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17
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Kontopodis N, Galanakis N, Charalambous S, Matsagkas M, Giannoukas AD, Tsetis D, Ioannou CV, Antoniou GA. Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 64:461-474. [PMID: 35872342 DOI: 10.1016/j.ejvs.2022.07.009] [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: 02/11/2022] [Revised: 06/06/2022] [Accepted: 07/10/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To investigate outcomes of endovascular aneurysm repair (EVAR) in high risk patients. METHODS Bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched using combinations of thesaurus and free text terms. The review protocol was registered in PROSPERO (CRD42021287207) and reported according to PRISMA 2020. Pooled estimates were calculated using odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) applying the Mantel-Haenszel or inverse variance method. EVAR peri-operative mortality in high risk patients over time was examined with mixed effects meta-regression. The GRADE framework was used to rate the certainty of evidence. RESULTS The pooled peri-operative mortality in 18 416 high risk patients who underwent EVAR was 3% (95% CI 2.3 - 4%) and has significantly reduced over time (year of publication p = .003; median study point p = .023). The peri-operative mortality was significantly lower in high risk patients treated with EVAR compared with open repair (OR 0.64; 95% CI 0.45 - 0.92), but no significant difference was found in overall (HR 1.06; 95% CI 0.76 - 1.49) or aneurysm related mortality (HR 0.57; 95% CI 0.21 - 1.55). No significant difference was found in overall mortality between high risk patients treated with EVAR vs. no intervention (HR 0.42; 95% CI 0.14 - 1.26), but the aneurysm related mortality was significantly lower in the former (HR 0.30; 95% CI 0.14 - 0.63). The peri-operative mortality was higher in high risk than normal risk patients treated with EVAR (OR 2.33; 95% CI 1.75 - 3.10), as was the overall mortality (HR 3.50; 95% CI 2.55 - 4.80). The certainty of evidence was very low for EVAR vs. open surgery or no intervention and low for high vs. normal risk patients. CONCLUSION The EVAR peri-operative mortality in high risk patients has improved over time. Even though the aneurysm related mortality of EVAR is lower compared with no intervention, EVAR may confer no overall survival benefit.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Greece
| | - Nikolaos Galanakis
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece
| | - Stavros Charalambous
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece; Department of Radiology, Division of Interventional Radiology, Nicosia General Hospital, Nicosia, Cyprus
| | - Miltiadis Matsagkas
- Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Tsetis
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom.
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18
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Endovascular Abdominal Aortic Aneurysm Repair: Overview of Current Guidance, Strategies, and New Technologies, Perspectives from the United Kingdom. J Clin Med 2022; 11:jcm11185415. [PMID: 36143063 PMCID: PMC9506302 DOI: 10.3390/jcm11185415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/05/2022] [Accepted: 09/13/2022] [Indexed: 11/17/2022] Open
Abstract
Endovascular aortic aneurysm repair has changed the management of patients affected by this condition, offering a minimally invasive solution with satisfactory outcomes. Constant evolution of this technology has expanded the use of endovascular devices to more complex cases. The purpose of this review article is to describe the current strategies, guidance, and technologies in this field, with a particular focus on practices in the United Kingdom.
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19
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De Paulis S, Arlotta G, Calabrese M, Corsi F, Taccheri T, Antoniucci ME, Martinelli L, Bevilacqua F, Tinelli G, Cavaliere F. Postoperative Intensive Care Management of Aortic Repair. J Pers Med 2022; 12:jpm12081351. [PMID: 36013300 PMCID: PMC9410221 DOI: 10.3390/jpm12081351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/12/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.
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Affiliation(s)
- Stefano De Paulis
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | | | | | - Filippo Corsi
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
| | | | | | - Lorenzo Martinelli
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | | | - Giovanni Tinelli
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Franco Cavaliere
- Fondazione Policlinico Gemelli IRCCS, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Tseng CN, Yu SY, Chang YT, Peng WS, Lin CY, See LC. Safety of the endovascular aneurysm repair procedure: real-world evidence using interrupted-time series analysis. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 62:6649730. [PMID: 35876877 DOI: 10.1093/ejcts/ezac370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/25/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVES In Taiwan, endovascular aneurysm repair for treating abdominal aortic aneurysms (AAA) was introduced in 2004 and became reimbursable in February 2010. We evaluated the real-world practice and safety of endovascular aneurysm repair in Taiwan. METHODS Patients who underwent repair operations for AAA (open or endovascular) from 2000 to 2016 were enrolled (n = 11485). Outcome statistics (during the index hospitalization: length of stay, rate of ischaemic bowel disease and 30-day mortality; after discharge: 30-day readmission rate, 2-year mortality, 2-year reintervention rate and 2-year paraplegia rate) were calculated for each half-year cohort. Propensity score-based stabilized weights were used to balance covariates among each half-year cohort. Interrupted time-series analysis was then performed. RESULTS The elective and emergency ratio of AAA repair was 50:50 from 2000 to 2004 and became 60:40 from 2010 to 2016. The half-year rate of endovascular aneurysm repair was 0% in 2000 to 2004/06, 83.16% in 2010 and 98.1% in 2016. Interrupted time series analysis revealed that after endovascular aneurysm repair became reimbursable, both elective and emergency groups had a reduction in length of stay (-4.2 days, P < 0.0001; -1.5 days, P = 0.0928) and 30-day mortality (-5.22%, P = 0.0702; -7.76%, P = 0.0086) but a significant increase in the reintervention rate (5.05%, P = 0.0031; 4.36%, P = 0.0097). CONCLUSIONS Endovascular aneurysm repair was predominantly used in treating AAAs after it was reimbursed in Taiwan. Endovascular aneurysm repair is efficacious regarding short-term outcomes but increased the 2-year reintervention rate in both groups.
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Affiliation(s)
- Chi-Nan Tseng
- Division of Cardiac Surgery, Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.,Department of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Sheng-Yueh Yu
- Division of Vascular Surgery, Department of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
| | - Ya-Ting Chang
- Department of Pediatrics, Chang Gung Children's Hospital at Linkou, Taoyuan City, Taiwan
| | - Wei-Sheng Peng
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chun-Yu Lin
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Tucheng Branch, New Taipei City, Taiwan
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan City, Taiwan.,Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan
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21
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Trabold T, Richter GM, Rosner R, Geisbüsch P. [Endovascular aortic repair: the hostile aneurysm neck : Morphologic definition, impact on long-term outcome, and treatment options]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:563-569. [PMID: 35768584 DOI: 10.1007/s00117-022-01018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 06/15/2023]
Abstract
DEFINITION A hostile neck is defined by various anatomical conditions that describe a morphology of the proximal aneurysmal neck of infrarenal aortic aneurysms that is unfavorable for endovascular treatment (endovascular aortic repair, EVAR): proximal landing zone length ≤ 15 mm, angulation of the aortic neck > 60°, conical aortic neck, diameter of the aortic neck > 32 mm, and circumferential calcification/thrombus. EFFECTS ON OUTCOME These morphological parameters are not only associated with a higher perioperative technical failure rate (primary type 1 endoleak) but also with poorer long-term results (secondary type 1 endoleak) and thus a higher reintervention rate in standard EVAR, so that standard EVAR should be reserved for a few exceptions in these cases. TREATMENT OPTIONS Due to the rapid development of endovascular techniques in the last decade, we now have a variety of endovascular options for aneurysms with hostile necks, for both elective treatment and emergency care, in addition to conventional open surgery, which is still the standard method in many cases and is currently undergoing a renaissance: fenestrated endovascular aortic repair (FEVAR) as the method of first choice in the elective setting, EVAR with chimneys (ChEVAR), endosuture aneurysm repair (ESAR). An important option is the conservative approach, which can be a reasonable choice if the patient's preference is taken into account and a careful risk-benefit assessment is performed.
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Affiliation(s)
- Tobias Trabold
- Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70195, Stuttgart, Deutschland.
| | - Götz M Richter
- Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70195, Stuttgart, Deutschland
| | - Rebekka Rosner
- Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70195, Stuttgart, Deutschland
| | - Philipp Geisbüsch
- Klinik für Gefäßchirurgie, Endovaskuläre Chirurgie und Transplantationschirurgie, Klinikum Stuttgart, Stuttgart, Deutschland
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22
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Alnefaie SA, Alzahrani YA, Alzahrani BS. A Comparison of Endovascular Aneurysm Repair and Open Repair for Ruptured Aortic Abdominal Aneurysms. Cureus 2022; 14:e25672. [PMID: 35812617 PMCID: PMC9255951 DOI: 10.7759/cureus.25672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
Management modalities of ruptured abdominal aortic aneurysm (AAA) include ruptured open aneurysm repair (rOAR) and ruptured endovascular aneurysm repair (rEVAR). In this study, we aim to systematically review all the previously published randomized controlled trials (RCTs) that compared rOAR and rEVAR. A systematic search was performed in the following databases: PubMed, Scopus, Web of Science, Google Scholar, Clinical trials, and others with all the potentially relevant keywords that were adjusted to meet the search strategy for each database to collect all the relevant studies that were published up to January 2021. A total of 11 studies were identified through our comprehensive search. Among these studies, seven represented the IMPROVE trial, two represented the AJAX trial, and two represented the Nottingham and ECAR trials, each, while the remaining four studies were not RCTs; however, these were included in the discussion as they obtained data from the IMPROVE trial. The IMPROVE trials preferred EVAR use due to the potential survival benefit and improved quality of life, although the EVAR and OAR had similar mortality rates. In the AJAX and ECAR, the mortality rates favored EVAR over OAR with no significance while the opposite was noticed in the Nottingham trial with no significance also. Similar rates of re-interventions and complications were also noticed and some studies reported that EVAR is cost-effective. Overall evidence slightly favors EVAR over OAR and further studies are needed.
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23
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Perissiou M, Bailey TG, Saynor ZL, Shepherd A, Harwood AE, Askew CD. The physiological and clinical importance of cardiorespiratory fitness in people with abdominal aortic aneurysm. Exp Physiol 2022; 107:283-298. [PMID: 35224790 PMCID: PMC9311837 DOI: 10.1113/ep089710] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 02/21/2022] [Indexed: 12/01/2022]
Abstract
New Findings What is the topic of this review? This review focuses on the physiological impact of abdominal aortic aneurysm (AAA) on cardiorespiratory fitness and the negative consequences of low fitness on clinical outcomes in AAA. We also discuss the efficacy of exercise training for improving cardiorespiratory fitness in AAA. What advances does it highlight? We demonstrate the negative impact of low fitness on disease progression and clinical outcomes in AAA. We highlight potential mechanistic determinants of low fitness in AAA and present evidence that exercise training can be an effective treatment strategy for improving cardiorespiratory fitness, postoperative mortality and disease progression.
Abstract An abdominal aortic aneurysm (AAA) is an abnormal enlargement of the aorta, below the level of the renal arteries, where the aorta diameter increases by >50%. As an aneurysm increases in size, there is a progressive increase in the risk of rupture, which ranges from 25 to 40% for aneurysms >5.5 cm in diameter. People with AAA are also at a heightened risk of cardiovascular events and associated mortality. Cardiorespiratory fitness is impaired in people with AAA and is associated with poor (postoperative) clinical outcomes, including increased length of hospital stay and postoperative mortality after open surgical or endovascular AAA repair. Although cardiorespiratory fitness is a well‐recognized prognostic marker of cardiovascular health and mortality, it is not assessed routinely, nor is it included in current clinical practice guidelines for the management of people with AAA. In this review, we discuss the physiological impact of AAA on cardiorespiratory fitness, in addition to the consequences of low cardiorespiratory fitness on clinical outcomes in people with AAA. Finally, we summarize current evidence for the effect of exercise training interventions on cardiorespiratory fitness in people with AAA, including the associated improvements in postoperative mortality, AAA growth and cardiovascular risk. Based on this review, we propose that cardiorespiratory fitness should be considered as part of the routine risk assessment and monitoring of people with AAA and that targeting improvements in cardiorespiratory fitness with exercise training might represent a viable adjunct treatment strategy for reducing postoperative mortality and disease progression.
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Affiliation(s)
- Maria Perissiou
- Physical Activity Health and Rehabilitation Thematic Research Group School of Sport Health and Exercise Science Faculty of Science and Health University of Portsmouth Portsmouth UK
| | - Tom G. Bailey
- Physiology and ultrasound Laboratory in Science and Exercise Centre for Research on Exercise Physical Activity and Health School of Human Movement and Nutrition Sciences University of Queensland Brisbane Australia
- School of Nursing Midwifery and Social Work University of Queensland Brisbane Australia
| | - Zoe L. Saynor
- Physical Activity Health and Rehabilitation Thematic Research Group School of Sport Health and Exercise Science Faculty of Science and Health University of Portsmouth Portsmouth UK
| | - Anthony Shepherd
- Physical Activity Health and Rehabilitation Thematic Research Group School of Sport Health and Exercise Science Faculty of Science and Health University of Portsmouth Portsmouth UK
| | - Amy E. Harwood
- Centre for Sport Exercise & Life Sciences Institute of Health and Wellbeing Coventry University Coventry UK
| | - Christopher D. Askew
- VasoActive Research Group School of Health and Behavioural Sciences University of the Sunshine Coast Sippy Downs Queensland Australia
- Sunshine Cost Health Institute Sunshine Coast Hospital and Health Service Birtinya Queensland Australia
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24
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Shovel L, Morkane C. Prehabilitation for Vascular Surgery Patients: Challenges and Opportunities. Can J Cardiol 2022; 38:645-653. [PMID: 35240251 DOI: 10.1016/j.cjca.2022.02.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/24/2022] [Accepted: 02/05/2022] [Indexed: 11/02/2022] Open
Abstract
Global demand for major surgery is rising as a consequence of a growing, ageing population and clinically applicable approaches to perioperative risk reduction have never been needed more. Prehabilitation aims to optimise aerobic capacity and address modifiable risk factors prior to surgery to improve postoperative outcomes. Given the inherently high-risk nature of vascular surgery and the frequently high-acuity, frail, vascular surgical population, the potential to introduce an intervention into the surgical pathway that may reduce postoperative complications cannot be overlooked. The aim of this article is to examine the current evidence base for prehabilitation in patients awaiting vascular surgery, and to summarise the potential benefits, pitfalls, and practicalities of this emerging perioperative intervention. There is a paucity of high-quality research specifically aimed at prehabilitation for patients undergoing vascular surgery, both peripheral and aortic, making it difficult to draw definitive conclusions upon which to base a change in practice. Currently, evidence is taken from small, often single-centre heterogenous studies that vary significantly from each other, meaning that the optimal exercise regimen for patients awaiting vascular surgery has yet to be defined. Establishing the impact of prehabilitation on outcomes for vascular patients is important as the effectiveness of preoperative exercise training is likely to vary between surgical interventions and patient populations. However, extrapolation from other cohorts is possible and indeed forms the basis of many current prehabilitation programmes. Given the success of prehabilitation in other surgical groups, it has potential to become an important future research target for patients awaiting vascular surgery.
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Affiliation(s)
- Louisa Shovel
- Royal Free Perioperative Research, Department of Anaesthesia, Royal Free Hospital, Pond Street, London, UK, NW3 2QG.
| | - Clare Morkane
- Royal Free Perioperative Research, Department of Anaesthesia, Royal Free Hospital, Pond Street, London, UK, NW3 2QG
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25
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Khoury MK, Heid CA, Rectenwald JE, Acher CW, Tsai S, Ramanan B, Timaran CH, Modrall JG. Understanding who Benefits from Endovascular Aortic Repair in those Deemed Unfit for Open Repair. J Vasc Surg 2022; 76:419-427.e3. [DOI: 10.1016/j.jvs.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/05/2022] [Indexed: 11/16/2022]
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26
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Alberga AJ, Karthaus EG, Wilschut JA, de Bruin JL, Akkersdijk GP, Geelkerken RH, Hamming JF, Wever JJ, Verhagen HJM. Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study. Eur J Vasc Endovasc Surg 2022; 63:275-283. [PMID: 35027275 DOI: 10.1016/j.ejvs.2021.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/19/2021] [Accepted: 08/15/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The Dutch Surgical Aneurysm Audit (DSAA) initiative was established in 2013 to monitor and improve nationwide outcomes of aortic aneurysm surgery. The objective of this study was to examine whether outcomes of surgery for intact abdominal aortic aneurysms (iAAA) have improved over time. METHODS Patients who underwent primary repair of an iAAA by standard endovascular (EVAR) or open surgical repair (OSR) between 2014 and 2019 were selected from the DSAA for inclusion. The primary outcome was peri-operative mortality trend per year, stratified by OSR and EVAR. Secondary outcomes were trends per year in major complications, textbook outcome (TbO), and characteristics of treated patients. The trends per year were evaluated and reported in odds ratios per year. RESULTS In this study, 11 624 patients (74.8%) underwent EVAR and 3 908 patients (25.2%) underwent OSR. For EVAR, after adjustment for confounding factors, there was no improvement in peri-operative mortality (aOR [adjusted odds ratio] 1.06, 95% CI 0.94 - 1.20), while major complications decreased (2014: 10.1%, 2019: 7.0%; aOR 0.91, 95% CI 0.88 - 0.95) and the TbO rate increased (2014: 68.1%, 2019: 80.9%; aOR 1.13, 95% CI 1.10 - 1.16). For OSR, the peri-operative mortality decreased (2014: 6.1%, 2019: 4.6%; aOR 0.89, 95% CI 0.82 - 0.98), as well as major complications (2014: 28.6%, 2019: 23.3%; aOR 0.95, 95% CI 0.91 - 0.99). Furthermore, the proportion of TbO increased (2014: 49.1%, 2019: 58.3%; aOR 1.05, 95% CI 1.01 - 1.10). In both the EVAR and OSR group, the proportion of patients with cardiac comorbidity increased. CONCLUSION Since the establishment of this nationwide quality improvement initiative (DSAA), all outcomes of iAAA repair following EVAR and OSR have improved, except for peri-operative mortality following EVAR which remained unchanged.
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Affiliation(s)
- Anna J Alberga
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.
| | - Eleonora G Karthaus
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Janneke A Wilschut
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Robert H Geelkerken
- Department of Surgery, Hospital Medisch Spectrum Twente, Enschede, The Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jan J Wever
- Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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27
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Dorweiler B, Mylonas S, Salem O. [Debate on Infrarenal AAA in Young and Fit Patients ('Fit for Open Repair'): Open Repair is Safe and Long-term Results are Better]. Zentralbl Chir 2021; 146:458-463. [PMID: 34666358 DOI: 10.1055/a-1611-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Endovascular aortic repair, initially developed for patients at prohibitively high risk for an open repair, has undergone significant technical evolution and refinement and has emerged as the preferred treatment option for patients with an infrarenal aortic aneurysm. However, analysis of long-term data of the randomised studies revealed inferior results with regards to survival and freedom-from-reintervention after eight years. Open aortic repair has been performed for more than seven decades and especially for the younger patients with few comorbidities, results are excellent. Potential drawbacks of open repair like incisional hernias, erectile dysfunction and quality of life can either be effectively prevented (mesh reinforcement) or actually failed to show a significant difference compared to open repair in recent studies. Therefore, meticulous assessment of patient comorbidites using validated parameters is the key element for decision-making and parameters such as young age, low comorbidity profile, large aneurysm and presence of atopic renal arteries or a dominant inferior mesenteric artery should prompt a recommendation of open repair.
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Affiliation(s)
- Bernhard Dorweiler
- Department of Vascular and Endovascular Surgery, Uniklinik Köln, Koln, Deutschland
| | - Spyridon Mylonas
- Department of Vascular and Endovascular Surgery, Uniklinik Köln, Koln, Deutschland
| | - Oroa Salem
- Department of Vascular and Endovascular Surgery, Uniklinik Köln, Köln, Deutschland
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28
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Bulder RMA, Hamming JF, van Schaik J, Lindeman JHN. Towards Patient Centred Outcomes for Elective Abdominal Aortic Aneurysm Repair: A Scoping Review of Quality of Life Scales. Eur J Vasc Endovasc Surg 2021; 62:630-641. [PMID: 34479768 DOI: 10.1016/j.ejvs.2021.06.026] [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] [Received: 02/15/2021] [Revised: 05/17/2021] [Accepted: 06/20/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE In order to better incorporate the patient's perspective in medical decision making, core outcome sets (COS) are being defined. In the field of abdominal aortic aneurysm (AAA), efforts to capture the patient's perspective focus on generic quantitative quality of life (QoL) scales. The question arises whether these quantitative scales adequately reflect the patient's perspective on QoL, and whether they can be included in the QoL aspect of COS. A scoping review of QoL assessment in the context of elective AAA repair was undertaken. DATA SOURCES PubMed, Embase, Web of Science, and the Cochrane Library. REVIEW METHODS A scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Articles reporting QoL assessment in the context of elective AAA repair were identified. Quantitative studies (i.e., traditional QoL scales) were aligned (triangulation approach) with qualitative studies (i.e., patient perspective) to identify parallels and discrepancies. Mean Short Form 36 item survey (SF-36) scores were pooled using a random effects model to evaluate sensitivity to change. RESULTS Thirty-three studies were identified, of which 29 (88%) were quantitative and four (12%) qualitative. The 33 studies reported a total of 54 quantitative QoL scales; the most frequently used were the generic SF-36 (16 studies) and five dimension EuroQol (EQ-5D; eight studies). Aneurysm specific scales were reported by one study. The generic quantitative scales showed poor alignment with the patient's perspective. The aneurysm specific scales better aligned but missed "concerns regarding symptoms" and "the impact of possible outcomes/complications". "Self control and decision making", which was brought forward by patients in qualitative studies, was not captured in any of the current scales. CONCLUSION There is no established tool that fully captures all aspects of the patient's perspective appropriate for a COS for elective AAA repair. In order to fulfil the need for a COS for the management of, AAA disease, a more comprehensive overview of the patient's perspective is required.
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Affiliation(s)
- Ruth M A Bulder
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jan van Schaik
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jan H N Lindeman
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands.
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29
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Warmerdam BWCM, van Holstein Y, Eefting D, van Rijswijk CSP, van der Meer RW, Mooijaart SP, Hamming JF, van der Vorst JR, van Schaik J. Functional Performance After Complex Endovascular Aortic Repair: A Single-Center Retrospective Cohort Study. J Endovasc Ther 2021; 28:852-859. [PMID: 34190633 PMCID: PMC8573623 DOI: 10.1177/15266028211028222] [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] [Indexed: 11/17/2022]
Abstract
Purpose Complex endovascular aortic repair (EVAR) procedures provide a treatment option for patients with aortic aneurysms involving visceral branches. Good technical results and short-term outcomes have been reported. Whether complex EVAR provides acceptable functional outcomes is not clear. The current study aims to describe postoperative functional outcomes in complex EVAR patients—an older and relatively frail patient group. Materials and Methods A single-center retrospective cohort study was performed, using data from a computerized database of consecutive patients who underwent complex EVAR in the Leiden University Medical Center (LUMC, The Netherlands) between July 2013 and September 2020. As of May 2017, patients scheduled for complex EVAR were referred to a geriatric care pathway to determine (Instrumental) Activities of Daily Living ((I)ADL) scores at baseline and, if informed consent was given, after 12 months. For the total patient group, adverse functional performance outcomes were: discharge to a nursing home and 12-month mortality. For the patients included in geriatric follow-up, the additional outcome was the incidence of functional decline (defined by a ≥2 point increase in (I)ADL-score) at 12-month follow-up Results Eighty-two patients underwent complex EVAR, of which 68 (82.9%) were male. Mean age was 73.3 years (SD=6.3). Within 30 days postsurgery, 6 patients (7.3%) died. Mortality within 12 months for the total patient group was 14.6% (n=12). After surgery, no patients had to be discharged to a nursing home. Fifteen patients (18.3%) were discharged to a rehabilitation center. Twenty-three patients gave informed consent and were included in geriatric follow-up. Five patients (21.7%) presented functional decline 12 months postsurgery and 4 patients had died (17.4%) by that time. This means that 39.1% of the patients in the care pathway suffered an adverse outcome. Conclusion To our knowledge, this is the only study that examined functional performance after complex EVAR, using a prospectively maintained database. No patients were newly discharged to a nursing home and functional performance results at 12 months are promising. Future multidisciplinary research should focus on determining which patients are most prone to deterioration of function, so that efforts can be directed toward preventing postoperative functional decline.
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Affiliation(s)
| | - Yara van Holstein
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Daniël Eefting
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jan van Schaik
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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30
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Vega de Ceniga M, Blanco Larizgoitia J, Barba Vélez Á, González Fernández A, Laliena LE. Outcomes of Small Incidental Abdominal Aortic Aneurysms in Octogenarian and Nonagenarian Patients in Northern Spain. Eur J Vasc Endovasc Surg 2021; 62:46-53. [PMID: 34088613 DOI: 10.1016/j.ejvs.2021.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 03/11/2021] [Accepted: 03/21/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Greater population life expectancy and consistent improvement in diagnostic techniques have increased the diagnosis of abdominal aortic aneurysms (AAAs) in the elderly population. The aim was to study the natural history of small (< 55 mm) incidental AAAs in octogenarian and nonagenarian patients to assess the need for follow up and/or invasive treatment. METHODS This was a retrospective analysis of a prospective registry. Patients ≥ 80 years old at the time of diagnosis of a < 55 mm AAA in 1988-2018 were selected. Clinical and anatomical characteristics were registered. Patients were divided in three groups: 30 - 39 mm, 40 - 49 mm, and 50 - 54 mm AAA. The outcome variables were aorto-iliac rupture, AAA reaching a surgical threshold (≥ 55 mm), and death. A descriptive statistical analysis was performed and life tables, Kaplan-Meier curves, and uni- and multivariable Cox regression were used. RESULTS Three hundred and ten patients were included, 256 (82.6%) men, with mean index age of 84.5 years (standard deviation [SD] 3.5), and median follow up of 37.9 months (interquartile range [IQR] 18.2 - 65.4). Eighteen (5.8%) AAAs ruptured; four of these patients were operated on and only one survived. Sixty-two (20%) AAA reached a surgical size; eight were repaired electively, with 0% early mortality. The survival rates were 81%, 70%, and 38% at one, two, and five years. The rupture rates were 1%, 2%, and 6% and the AAAs reaching surgical threshold were 1%, 4%, and 19% for the same time periods. AAA size < 40 mm was an independent protective factor from rupture (0.13; 95% confidence interval [CI] 0.03 - 0.48), reaching surgical threshold (0.08; 95% CI 0.04 - 0.16) and death (0.63; 95% CI 0.42 - 0.95). CONCLUSION The risk of late rupture of small incidental AAA diagnosed in octogenarian and nonagenarian patients is very small, especially when the AAA is < 40 mm in diameter. In contrast, global mortality is high. Conservative management seems sensible, with strict selection of the patients who would benefit from follow up and eventual repair.
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Affiliation(s)
- Melina Vega de Ceniga
- Department of Angiology and Vascular Surgery, Hospital de Galdakao-Usansolo, Bizkaia, Spain.
| | | | - Ángel Barba Vélez
- Department of Angiology and Vascular Surgery, Hospital de Galdakao-Usansolo, Bizkaia, Spain
| | | | - Luis Estallo Laliena
- Department of Angiology and Vascular Surgery, Hospital de Galdakao-Usansolo, Bizkaia, Spain
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31
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Ahmed A, Heyes A, Pandher J, Rajagopalan S. Abdominal aortic aneurysms. Br J Hosp Med (Lond) 2021; 82:1-7. [PMID: 34076526 DOI: 10.12968/hmed.2019.0351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Vascular surgery is a relatively new surgical sub-speciality in the UK, with treatment of abdominal aortic aneurysms forming a substantial proportion of the emergency and elective caseload. This article summarises the guidance from the National Institute of Health and Care Excellence and the European Society for Vascular Surgery that outlines the epidemiology, diagnosis and management of abdominal aortic aneurysms. This is important for both vascular and non-vascular trainees to understand because of the critical nature of the disease, which can cause catastrophic haemorrhage, limb loss and mortality. However, if discovered in time, abdominal aortic aneurysms are a very treatable condition.
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Affiliation(s)
- Aadil Ahmed
- Department of Vascular Surgery, Royal Stoke University Hospital, University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Adam Heyes
- School of Medicine, Keele University, Keele, UK
| | - Jagraj Pandher
- Department of Vascular Surgery, Royal Stoke University Hospital, University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Sriram Rajagopalan
- Department of Vascular Surgery, Royal Stoke University Hospital, University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK.,School of Medicine, Keele University, Keele, UK
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Nadeswaran P, Ding L, Singh N, Plotkin A, Magee GA, Han SM, Garg PK. Functional performance status and risk of cardiovascular events and mortality following endovascular repair of thoracic and abdominal aortic pathology. Vascular 2021; 30:206-216. [PMID: 33900842 DOI: 10.1177/17085381211010545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize the association of preoperative functional performance status based on Eastern Cooperative Oncology Group (ECOG) scoring with the risk of adverse cardiovascular events, vascular events, and mortality in patients undergoing EVAR and TEVAR. METHODS Retrospective review of the Society for Vascular Surgery Vascular Quality Initiative, a large, multi-center, registry database was performed. All individuals undergoing EVAR (n = 18,730) and TEVAR (n = 6595) for non-ruptured aortic pathologies between 2014 and 2018 were eligible for analysis. Multivariable logistic regression was used to determine the association of pre-procedure ECOG functional performance status on risk of in-hospital adverse cardiovascular events, vascular events, and mortality. RESULTS The number of operations complicated by adverse cardiovascular and vascular events was 480 (2.6%) and 190 (1.0%) for EVAR and 733 (11.1%) and 219 (3.3%) for TEVAR, respectively. There were 118 (0.6%) and 240 (3.6%) in-hospital deaths following EVAR and TEVAR, respectively. Patients with ECOG grades 3 or 4 undergoing EVAR were at increased risk of cardiovascular events (OR = 1.62; 95% CI = 1.09, 2.41) and one-year mortality (HR = 2.62; 95% CI = 1.92, 3.57) compared to those with ECOG grade 0. Patients undergoing TEVAR with ECOG grade 3 or 4 were at increased risk for both inpatient death (OR = 2.77; 95% CI = 1.56, 4.9) and one-year mortality (HR = 3.27, 95% CI = 2.06, 5.21). ECOG status was not associated with an increased risk of adverse vascular events following either EVAR or TEVAR. CONCLUSIONS Poor preoperative functional status as assessed by ECOG score is associated with an increased risk of adverse postoperative cardiovascular events following EVAR and a higher mortality risk following both EVAR and TEVAR. Functional status assessment may be useful for risk stratification and determining procedural candidacy prior to EVAR and TEVAR.
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Affiliation(s)
- Pradeep Nadeswaran
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Li Ding
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Nikhil Singh
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Anastasia Plotkin
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Parveen K Garg
- Division of Cardiology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Youssef S, Elkawafi M, Peysner R, Popplewell MA, Rajagopalan S. A Review of UK-based National and International Scientific Meeting Published Abstracts in Response to the Draft NICE Aortic Aneurysm Guidelines. Ann Vasc Surg 2021; 75:358-367. [PMID: 33831527 DOI: 10.1016/j.avsg.2021.01.120] [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: 11/17/2020] [Revised: 01/23/2021] [Accepted: 01/26/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND UK National Institute for Health and Care Excellence (NICE) draft clinical guidelines (CG) (2018) regarding aortic aneurysm repair were disputed internationally. We aim to appraise the academic response to the draft CG in terms of quantity and scientific quality by reviewing published conference abstracts from three major national and international, UK meetings. METHODS Abstracts related to aortic practice from The Vascular Societies Annual Scientific Meeting, British Society for Endovascular Therapy (BSET) & Charing Cross (CX) meetings from 2019 were reviewed for methodology, sample size, data collection period, scientific quality and conclusions that supported or conflicted the draft guideline. RESULTS A total of 549 abstracts were identified from VSGBI, BSET and CX abstract books of which, 226 (41.2%) were related to aortic practices. Of these, 115 (50.9%) were related to EVAR. Twenty-two of these abstracts (19.1%) were identified as having findings relevant to the draft guidelines. Eighteen (15.7%) were identified as findings that potentially conflict the draft CG and 4 (3.5%) that could support the initial recommendations. Six abstracts (5.2%) made direct reference to or challenged the draft CG. The median data collection period was 4 years. The median sample size was 102 patients. In general, scientific quality was poor, with 82% of selected abstracts were graded at level 2b. CONCLUSION We have demonstrated a concerted response to the draft NICE clinical guidelines relating to the treatment of abdominal aortic aneurysms at three large scientific meetings. As a result of which and other factors, significant changes were made to the finalized NG156. There is still paucity in evidence regarding the long-term safety and cost-effectiveness of EVAR.
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Affiliation(s)
- Sofian Youssef
- University of Nottingham, Nottingham, UK; Department of Vascular Surgery, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK.
| | - Mohamed Elkawafi
- Department of Vascular Surgery, Countess of Chester Hospital NHS Trust, Chester, UK
| | - Ryan Peysner
- Keele University School of Medicine, Newcastle-under-Lyme, UK
| | | | - Sriram Rajagopalan
- Department of Vascular Surgery, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
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Agle CG, Neves CAP, Abbehusen FDC, Andrade TL, de Cerqueira FM, Amorim DS. Immediate outcome of endovascular treatment of ruptured juxtarenal aneurysm with parallel stents. J Vasc Bras 2021; 20:e20200120. [PMID: 34093683 PMCID: PMC8147893 DOI: 10.1590/1677-5449.200120] [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] [Indexed: 11/25/2022] Open
Abstract
Rupture of an abdominal aortic aneurysm is an event with a high mortality rate and treatment is a medical emergency. Endovascular treatment of these aneurysms has become established as a minimally invasive alternative to classical open surgery and is now the first-choice option. However, 20 to 50% of patients with abdominal aortic aneurysms do not have anatomy favorable for endovascular treatment because of a short aneurysm neck or because visceral branches are involved by the aneurysm. We report the case of a 70-year-old patient who underwent endovascular repair of a ruptured juxtarenal aneurysm with deployment of parallel stents in the renal arteries (in a chimney technique). Clinical data and details of the procedure are reported. Technical success was achieved and there were no postoperative complications.
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Gambardella I, Lau C, Gaudino MFL, Worku B, Rahouma M, Tranbaugh RF, Girardi LN. Splanchnic occlusive disease predicts for spinal cord injury after open descending thoracic and thoracoabdominal aneurysm repair. J Vasc Surg 2021; 74:1099-1108.e4. [PMID: 33677031 DOI: 10.1016/j.jvs.2021.02.030] [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: 07/30/2020] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In the present study, we sought to discern the effects of splanchnic occlusive disease (SOD; renal, superior mesenteric, and/or celiac axis arteries) on spinal cord injury (SCI; paraparesis or paraplegia) and major adverse events (MAE) after descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) open repair. METHODS Patients who had undergone DTA/TAAA repair at our institution were dichotomized according to the presence of SOD, which was investigated as a predictive factor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, tracheostomy, de novo dialysis, MAE, survival) endpoints. Risk adjustment used both propensity score matching and multivariable logistic regression. RESULTS From July 1997 to October 2019, 888 patients had undergone DTA/TAAA repair, of whom 19 were excluded from our analysis for missing data. SOD was absent in 712 patients and present in 157 patients. The patients with SOD had presented with a greater incidence of preoperative renal impairment (61 [38.9%] vs 175 [24.6%]; P < .01) and peripheral arterial disease (60 [38.2%] vs 162 [22.8%]; P < .01] and decreased left ventricular ejection fraction (45%; interquartile range, 10%; vs 50%; interquartile range, 4%; P < .01). The etiology of aortic disease was more frequently dissection in the SOD group (56.1% vs 43.7%) and more frequently nondissecting aneurysm in the non-SOD group (56.3% vs 43.9%; P < .01). Patients without SOD had presented with aneurysms more cranially located (DTA, 34.0% vs 7.6%; extent I TAAA, 44.0% vs 7.6%). In contrast, patients with SOD had presented with aneurysms more caudally located (extent II TAAA, 36.9% vs 8.6%; extent III TAAA, 30.6% vs 11.0%; extent IV TAAA, 17.2% vs 2.5%; P < .01). Propensity score matching led to 144 pairs, with SOD significantly associated with SCI (10 [6.9%] vs 2 [1.4%]; P = .03) and MAE (47 [32.6%] vs 26 [15%]; P < .01). Ten-year survival was reduced in those with SOD (31.5% vs 45.2%; P < .01). Conditional multivariable regression confirmed SOD to be a predictor of SCI in the matched sample (odds ratio, 6.60; P = .02). CONCLUSIONS Our results have shown that SOD is a significant predictor of SCI in patients undergoing open DTA/TAAA repair. The investigation of measures to prolong neuronal ischemia tolerance (eg, hypothermia) is warranted for such patients.
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Affiliation(s)
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Berhane Worku
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mohamad Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Robert F Tranbaugh
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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Montelione N, Sirignano P, d'Adamo A, Stilo F, Mansour W, Capoccia L, Nenna A, Spinelli F, Speziale F. Comparison of Outcomes Following EVAR Based on Aneurysm Diameter and Volume and Their Postoperative Variations. Ann Vasc Surg 2021; 74:183-193. [PMID: 33549787 DOI: 10.1016/j.avsg.2020.12.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE to evaluate the impact of bi- and 3-dimensional preoperative aortic morphological features and their immediate postoperative variations on the outcome of abdominal aortic aneurysms (AAA) treated by endovascular exclusion with standard devices (EVAR). MATERIALS AND METHODS Double centre retrospective analysis of prospectively collected registry data of EVAR patients. For all patients, preoperative and 30-day computed tomographic angiography images (CTA) were reviewed. Preoperative maximum AAA diameter >59 mm and volume >159 cm3, and any 30-day postoperative increasing at CTA, were considered as potentially influencing the outcome. The outcome measures were: primary technical success; 30-day, 1-year, and mean follow-up reintervention, all-cause and AAA-related mortality rates, and also endoleak-related reinterventions. RESULTS Three hundred and thrity-three patients were enrolled. Mean preoperative and 30-day AAA diameter and volume were 50.4 mm ± 11.8 vs. 49.1 mm ± 12.1, and 112.9 cm3 ± 79.5 vs. 112.1 cm3 ± 80.5, respectively. Primary technical success was achieved in all cases. At 34.9 months follow-up, cumulative reintervention rate was 12.0%, mortality rates 7.2%, without AAA-related deaths. Endoleak-related reintervention rate was 7.5%. At uni- and multi-variate analysis, preoperative AAA diameter >59 mm, and AAA volume >159 cm3 were significantly associated to reintervention (P = 0.012; P = 0.002), and reintervention and death (P = 0.002; P = 0.001) during follow-up. Additionally, any increase in postoperative AAA diameter or volume was significantly associated with reintervention (P = 0.001, P = 0.001) and reintervention and death (P = 0.006, P = 0.001). Endoleak-related reintervention were also significantly associated with all of the analysed morphological parameters (P = 0.019, P = 0.005, P = 0.005, and P = 0.002, respectively). CONCLUSIONS Patients with larger baseline AAA size and volume as well as unfavourable early remodelling of the sac are associated to worse long-term EVAR outcome.
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Affiliation(s)
- Nunzio Montelione
- Vascular Surgery Division, University of Campus Bio-Medico, Rome, Italy.
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Alessandro d'Adamo
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, University of Campus Bio-Medico, Rome, Italy
| | - Wassim Mansour
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Surgery, University of Campus Bio-Medico, Rome, Italy
| | | | - Francesco Speziale
- Vascular and Endovascular Surgery Division, Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Italy
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Failure properties of abdominal aortic aneurysm tissue are orientation dependent. J Mech Behav Biomed Mater 2020; 114:104181. [PMID: 33153925 DOI: 10.1016/j.jmbbm.2020.104181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 08/12/2020] [Accepted: 10/23/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Biomechanical rupture risk assessment of abdominal aortic aneurysm (AAA) requires information about failure properties of aneurysmal tissue. There are large differences between reported values. Among others, studies vary in using either axially or circumferentially oriented samples. This study investigates the effect of sample orientation on failure properties. METHODS Aneurysmal tissues from 45 patients (11 females) were harvested during open AAA repair, cut into uniaxial samples (90) and tested mechanically within 3 h. If possible, the samples were cut in both axial (49 samples) and circumferential (41 samples) directions. Wall thickness, First Piola-Kirchhoff strength Pult and ultimate tension Tult were recorded. Influence of sample orientation and other clinical parameters were investigated using non parametric tests. RESULTS Medians of Pult (values 1100 kPa for circumferential vs. 715 kPa for axial direction, p < 10-4) and Tult (17.4 N/cm in circumferential vs. 11.2 N/cm in axial direction, p < 10-4) were significantly higher in circumferential direction. For paired data, the median of difference was 411 kPa (p < 10-3) in Pult and 7.4 N/cm (p < 10-4) in Tult in favor of circumferential direction. CONCLUSIONS In this first study of anisotropy in AAA wall failure properties using paired comparisons, the strength in circumferential orientation was found to be higher than in axial orientation.
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Seike Y, Fukuda T, Yokawa K, Inoue Y, Shijo T, Uehara K, Sasaki H, Matsuda H. Preoperative Neck Angulation is Associated with Aneurysm Sac Growth Due to Persistent Type Ia Endoleak after Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Dis 2020; 13:261-268. [PMID: 33384728 PMCID: PMC7751068 DOI: 10.3400/avd.oa.20-00057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aims to determine how instructions for use affect the occurrence of aneurysm sac growth and endoleaks after an endovascular aneurysm repair (EVAR). Materials and Methods: We reviewed 302 patients who underwent EVAR for abdominal aortic aneurysm between 2007 and 2013, and we were able to enroll 159 patients (74% men, mean age 78±7 years) with adequate data (mean follow-up; 48±20 months). Results: The angle of the proximal landing zone (LZ) (hazard ratio: 1.02, 95% confidence interval: 1.00–1.03, p=0.01) was recognized as an independent risk factor of sac growth (≥5 mm). The receiver operating characteristics curve (area under the curve: 0.72) showed a cutoff value of 47° of the minimum angle of the proximal LZ to predict sac growth. Freedom rates for persistent type Ia endoleaks were also found to be lower in the angulated group than those in the other groups (p=0.0095, log-rank). Conclusion: The angle of the proximal LZ was identified as an independent risk factor for sac growth post-EVAR. The incidence of persistent type Ia endoleaks was significantly higher in the angulated group.
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Affiliation(s)
- Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center
| | - Koki Yokawa
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Takayuki Shijo
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kyokun Uehara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
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Wu CC, Chou AH, Lin YS, Wu VCC, Chang SH, Chu PH, Cheng YT, Ko PJ, Liu KS, Chen SW. Late outcomes of endovascular aortic stent graft therapy in patients with chronic kidney disease. Medicine (Baltimore) 2020; 99:e22157. [PMID: 32925775 PMCID: PMC7489716 DOI: 10.1097/md.0000000000022157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Endovascular aneurysm repair (EVAR) and thoracic endovascular aortic repair (TEVAR) are effective and minimally invasive treatment options for high-risk surgical candidates. Nevertheless, knowledge about the management of aortic stent graft therapy in chronic kidney disease (CKD) is scarce. This study aimed to examine outcomes after EVAR and TEVAR in patients with CKD.Utilizing data from the Taiwan National Health Insurance Research Database, we retrospectively assessed patients who underwent EVAR and TEVAR therapy between January 1, 2006, and December 31, 2013. Patients were divided into CKD and non-CKD groups. Outcomes were in-hospital mortality, all-cause mortality, readmission, heart failure, and major adverse cardiac and cerebrovascular events.There were 1019 patients in either group after matching. The CKD group had a higher in-hospital mortality rate than the non-CKD group (15.2% vs 8.3%, respectively; odds ratio, 1.92; 95% confidence interval [CI], 1.46-2.54). Patients with CKD had higher risks of all-cause mortality including in-hospital death (46.1% vs 33.1%; hazard ratio [HR], 1.61; 95% CI, 1.35-1.92), readmission rate (62.6% vs 55.0%; subdistribution HR [SHR], 1.61; 95% CI, 1.32-1.69), redo stent (7.8% vs 6.2%; SHR, 1.50; 95% CI, 1.09-2.07), and major adverse cardiac and cerebrovascular events (13.3% vs 8.8%; SHR, 1.50; 95% CI, 1.15-1.95). The subgroup analysis did not demonstrate a variation in mortality between the TEVAR and EVAR cohorts (P for interaction = .725). The dialysis group had higher risks of all-cause mortality and readmission than the CKD without dialysis and non-CKD groups.Among EVAR/TEVAR recipients, CKD was independently associated with higher in-hospital mortality, postoperative complication, and all-cause mortality rates. Patients with end-stage renal disease on dialysis had worse outcomes than those in the CKD non-dialysis and non-CKD groups.
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Affiliation(s)
- Chung-Cheng Wu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery
| | - An-Hsun Chou
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City
- Department of Medicine, Chang Gung University, Linkou, Taipei
| | - Yu-Sheng Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi branch, Chiayi City
| | | | | | | | - Yu-Ting Cheng
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery
| | - Po-Jen Ko
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery
| | - Kuo-Sheng Liu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
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Wanken ZJ, Barnes JA, Trooboff SW, Columbo JA, Jella TK, Kim DJ, Khoshgowari A, Riblet NB, Goodney PP. A systematic review and meta-analysis of long-term reintervention after endovascular abdominal aortic aneurysm repair. J Vasc Surg 2020; 72:1122-1131. [DOI: 10.1016/j.jvs.2020.02.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/03/2020] [Indexed: 01/12/2023]
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Çekmecelioglu D, Orozco-Sevilla V, Coselli JS. Open vs. endovascular thoracoabdominal aortic aneurysm repair: tale of the tape. Asian Cardiovasc Thorac Ann 2020; 29:643-653. [PMID: 32772547 DOI: 10.1177/0218492320949073] [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: 11/16/2022]
Abstract
Open surgical repair persists as the gold-standard operation for thoracoabdominal aortic aneurysm; however, endovascular repair has become commonplace. Technical considerations in thoracoabdominal aortic aneurysm treatment are particularly complex, insofar as it involves critical branching arteries feeding the visceral organs. Newer, low-profile devices make total endovascular thoracoabdominal aortic aneurysm repair more feasible and, thus, appealing. For younger and low-risk patients, the choice between open and endovascular therapy remains controversial. Despite the advantages of a minimally invasive procedure, data suggest that endovascular aortic repair incurs a greater risk of spinal cord deficit, and the durability of endovascular aortic repair remains unclear. It is difficult to compare outcomes between endovascular and open thoracoabdominal aortic aneurysm repair, primarily because of the current investigational status of endovascular devices, the variety of approaches to endovascular repair, differing patient populations, lack of prospective randomized studies, and minimal medium- and long-tern follow-up data on endovascular repair. When deciding between open and endovascular approaches, one should consider which is more suitable for each patient. Older patients generally benefit from a less invasive approach. Open repair should be considered for young patients and those with heritable thoracic aortic disease. Infection and fistulae are best treated by open repair, although endovascular intervention as a lifesaving bridge to definitive repair has evolved to become a critical component of initial treatment. It is crucial to have technical expertise in both open and endovascular procedures to provide the best aortic repair for the patient. This may require dedicated aortic programs at tertiary institutions.
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Affiliation(s)
- Davut Çekmecelioglu
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Vicente Orozco-Sevilla
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Joseph S Coselli
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Cardiovascular Surgery, CHI St. Luke's Health, Baylor St. Luke's Medical Center, Houston, Texas, USA.,Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA
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Kinio A, Ramsay T, Jetty P, Nagpal S. Declining institutional memory of open abdominal aortic aneurysm repair. J Vasc Surg 2020; 73:889-895. [PMID: 32712346 DOI: 10.1016/j.jvs.2020.06.125] [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: 01/19/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Since its introduction, endovascular aneurysm repair (EVAR) has become a mainstay in the treatment of abdominal aortic aneurysms (AAAs), resulting in the decline of open aneurysm repairs. The objective of this study was to determine whether reduced open aneurysm repair frequency has led to a reduction in perioperative efficiency and increase in postsurgical complications. METHODS A retrospective cohort study compared perioperative data and complications of 49 consecutive juxtarenal AAA (<1-cm neck) open repairs performed between 2014 and 2017 and 53 consecutive juxtarenal AAA controls (2005-2007) at The Ottawa Hospital. There was no change in surgical personnel during this 10-year comparison. RESULTS The Ottawa Hospital experienced a 61% decline in the number of open AAA repairs between the two time periods examined; 541 open AAA repairs and 86 EVARs were performed between 2005 and 2007, whereas 358 open AAA repairs and 385 EVARs were performed between 2014 and 2017. Age of participants significantly decreased in the 2014 to 2017 group (P = .01), as did the number of women undergoing open juxtarenal AAA repair (P = .05). Total operating room time and anesthesia time were longer in the 2014-2017 group (P = .02; P = .01), whereas surgical times remained consistent (P = .13). Suprarenal clamp time and blood loss during the procedure were decreased in the 2014-2017 group (P < .01; P < .01). Intensive care unit stay and overall hospital stay were not significantly different between groups (P = .77; P = .87); however, there were large standard deviations observed for the 2014-2017 group. As well, 18.4% of patients in the 2014-2017 group experienced postsurgical complications of Clavien-Dindo grade IIIa or higher compared with 11.3% of patients in the historical control group (P = .07). Mortality also trended toward an increase in the 2014-2017 group (P = .43). CONCLUSIONS The reduced rate of open repair performance at The Ottawa Hospital reflects the global trend toward EVAR. Anesthesia and operating room times increased during the period examined, reflecting a possible loss of expertise in the last decade. Complications also increased during this time for anatomically similar patients. Taken together, these findings may reflect a decreased institutional familiarity with open aneurysm repair and postsurgical care.
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Affiliation(s)
- Anna Kinio
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Prasad Jetty
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Vascular and Endovascular Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sudhir Nagpal
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Vascular and Endovascular Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada.
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Davidovic LB, Palombo D, Treska V, Sladojevic M, Koncar IB, Houdek K, Spinella G, Zlatanovic P, Pane B. Late open conversion after endovascular abdominal aortic aneurysm repair: experience of three-high volume centers. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:183-190. [DOI: 10.23736/s0021-9509.19.10972-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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King AH, Schmaier AH, Harth KC, Kumins NH, Wong VL, Zidar DA, Kashyap VS, Cho JS. Elevated neutrophil-lymphocyte ratio predicts mortality following elective endovascular aneurysm repair. J Vasc Surg 2020; 72:129-137. [PMID: 32037083 DOI: 10.1016/j.jvs.2019.10.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 10/06/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The neutrophil-lymphocyte ratio (NLR) is an inexpensive and useful inflammatory marker that incorporates the balance of the innate (neutrophil) and adaptive (lymphocyte) immune responses. Data exist on the association between NLR and mortality in various coronary diseases and in cancer surgery, but there is a paucity of data on the impact of preoperative NLR on vascular surgical outcomes. The aim of this study was to evaluate the relationship between preoperative NLR and elective endovascular aortic aneurysm repair (EVAR) outcome. METHODS A retrospective review of all patients who underwent elective EVAR at a single institution between 2010 and 2018 was conducted (n = 373). Only patients who had a preoperative complete blood count with differential within 30 days of their operation were included. The NLR was computed by dividing the absolute neutrophil count by the absolute lymphocyte count. A receiver operating characteristic curve was used to determine the optimal cutoff value of NLR with the strongest association with mortality. NLR was dichotomized so that patients with NLR above the threshold were at increased risk of mortality compared with those below it. Continuous variables were analyzed using Wilcoxon nonparametric signed-rank test and categorical variables with the Fisher exact test. A comparison of NLR and mortality was completed using Kaplan-Meier survival analysis. Cox regression analysis was used to evaluate factors associated with mortality through 5-year follow-up. RESULTS Overall, 108 patients were included in this study. An NLR ≥ 4.0 was found to be associated with mortality (P < .0001). Thirty-two patients composed the High-NLR (NLR ≥ 4.0) group and the remaining 76 patients formed the Low-NLR (NLR < 4.0) group. Baseline characteristics were similar between groups, except that the High-NLR group was older (77.9 vs 74.4; P = .047). At a mean of 36.4 months follow-up, the overall mortality rate was 32.4%. Although there were no differences in the perioperative period, the Kaplan-Meier estimates of mortality were significantly greater in the High-NLR group at 1, 2, and 5 years postoperatively (P < .0001). The mean preoperative NLR of the deceased was higher (5.94 ± 5.20; median, 4.75; interquartile range, 3.17-7.83) than those who survived (2.87 ± 1.61; median, 2.53; interquartile range, 1.97-3.49) (P < .0001). Secondary interventions and sac enlargement rates were similar between groups. On univariable analysis, NLR (hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.10-1.23; P < .0001), age (HR, 1.06; 95% CI, 1.02-1.11; P = .004), and aneurysm diameter (HR, 1.04; 95% CI, 1.01-1.07; P = .003) were associated with mortality. On multivariable analysis, NLR (HR, 1.19; 95% CI, 1.12-1.27; P < .0001), age (HR, 1.06; 95% CI, 1.01-1.11; P = .026), and aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.07; P = .003) were associated with mortality. CONCLUSIONS Patients with an elevated preoperative NLR, irrespective of other comorbidities, may represent a previously unrecognized subset of patients who are at heightened risk of mortality after elective EVAR. A complete blood count with differential is an inexpensive test that may be used as a prognostic indicator for outcome after EVAR. Further research is warranted to identify clinical, pathological, or anatomical factors associated with an elevated NLR and to determine modifiable factors, which may help improve long-term survival.
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Affiliation(s)
- Alexander H King
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Alvin H Schmaier
- Division of Hematology/Oncology, Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Karem C Harth
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Norman H Kumins
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Virginia L Wong
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - David A Zidar
- Division of Cardiology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vikram S Kashyap
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jae S Cho
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
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Janho KE, Rashaideh MA, Shishani J, Jalokh M, Haboub H. Outcomes of Elective Endovascular Aneurysmal Repair for Abdominal Aortic Aneurysms in Jordan. Vasc Specialist Int 2019; 35:202-208. [PMID: 31915664 PMCID: PMC6941770 DOI: 10.5758/vsi.2019.35.4.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/28/2019] [Accepted: 11/28/2019] [Indexed: 11/20/2022] Open
Abstract
Purpose The outcomes of endovascular aneurysmal repair (EVAR) for infrarenal abdominal aortic aneurysms (AAAs) in the Middle East have rarely been reported. We analyzed the outcomes of EVAR in a Jordanian population. Materials and Methods We conducted a retrospective review of the medical records of patients with infrarenal AAA who were treated with elective EVAR between January 2004 and January 2017 at a single center in Jordan. Patient characteristics, anatomical characteristics, procedural details, and early and late postoperative outcomes were analyzed. Results A total of 288 patients (mean age, 70 years; 77.8% males) underwent EVAR for infrarenal AAA (median aneurysm size, 64 mm). Bifurcated endografts were used in 265 patients, and aorto-uni-iliac devices were used in 22 patients. Successful endograft deployment was achieved in all patients with no open conversion. Early complications included localized groin hematoma in 15, femoral artery dissection in 4, wound infection in 3, and seroma in 3 patients. With a mean follow-up of 60 months, 50 endoleaks were detected, including 9 type I, 38 type II, and 3 type III. Seven patients had unilateral graft limb occlusion. The 30-day mortality was 1.7%, and long-term mortality was 7.0%, mostly due to non-AAA-related causes. Conclusion EVAR was safely performed in Jordanian patients with minimal complications. However, long-term surveillance is important due to the risk of endoleaks and consequent intervention.
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Affiliation(s)
- Kristi E. Janho
- Vascular Surgery Department, King Hussin Medical Center at Royal Medical Services, Amman, Jordan
| | - Mohammed A. Rashaideh
- Vascular Surgery Department, King Hussin Medical Center at Royal Medical Services, Amman, Jordan
| | - Jan Shishani
- Vascular Surgery Department, King Hussin Medical Center at Royal Medical Services, Amman, Jordan
| | - Muhannad Jalokh
- Vascular Surgery Department, King Hussin Medical Center at Royal Medical Services, Amman, Jordan
| | - Hazem Haboub
- Interventional Radiology Department, King Hussin Medical Center at Royal Medical Services, Amman, Jordan
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Choi C, Ahn S, Min SI, Ahn M, Ha J, Yoon HJ, So R, Choi SH, Min SK. Nationwide Epidemiologic Study of Abdominal Aortic Aneurysms in Korea: A Cross-Sectional Study Using National Health Insurance Review and Assessment Service Data. Vasc Specialist Int 2019; 35:193-201. [PMID: 31915663 PMCID: PMC6941766 DOI: 10.5758/vsi.2019.35.4.193] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/03/2019] [Accepted: 12/06/2019] [Indexed: 11/20/2022] Open
Abstract
Purpose The prevalence and treatment patterns of abdominal aortic aneurysm (AAA) vary according to ethnicity and region. This study analyzed nationwide data on the epidemiology, practice patterns, and mortality rates of AAA in Korea. Materials and Methods Data from patients treated for AAA from 2012 to 2016 were extracted from the Korean Health Insurance Review and Assessment (HIRA) database. Results A total of 30,766 patients in Korea had treatment codes for AAA and 2,618 patients were treated for ruptured AAA. Of the 6,356 patients treated surgically, 1,849 and 4,507 underwent open surgical aneurysmal repairs (OSAR) or endovascular aneurysmal repairs (EVAR), respectively. The number of surgical treatments performed annually for AAA increased from 1,129 cases in 2012 to 1,501 cases in 2016. The number of EVAR cases increased from 753 to 1,109 during these five years, while the number of OSAR cases remained similar, at 376 and 392, respectively. The 30-day mortality rates after EVAR and OSAR were 4.2% and 10.6%, respectively. The mortality rates were significantly higher in patients with hypertension, dyslipidemia, chronic renal disease, diabetes mellitus, and congestive heart failure. There were significant differences in the prevalence, proportion of EVAR, and mortality rates according to the regional area. Conclusion The prevalence of AAA and the proportion of EVAR in Korea increased in the past 5 years, while the rupture rate and the proportion of OSAR remained similar. To minimize mortality and regional discrepancies, nationwide registry and treatment standardization are needed.
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Affiliation(s)
- Chanjoong Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Sanghyun Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-il Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Moonsang Ahn
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Jin Yoon
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Rina So
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Hyouk Choi
- Department of Biomedical Engineering, 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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Bennett KM, McAninch CM, Scarborough JE. Locoregional anesthesia is associated with lower 30-day mortality than general anesthesia in patients undergoing endovascular repair of ruptured abdominal aortic aneurysm. J Vasc Surg 2019; 70:1862-1867.e1. [DOI: 10.1016/j.jvs.2019.01.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/11/2019] [Indexed: 12/19/2022]
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Gambardella I, Gaudino MFL, Rahouma M, Farrington WJ, Khan FM, Hameed I, Lau C, Iannacone E, Girardi LN. Impact of left ventricular ejection fraction on the outcomes of open repair of descending thoracic and thoracoabdominal aneurysms. J Thorac Cardiovasc Surg 2019; 161:534-541.e5. [PMID: 31924362 DOI: 10.1016/j.jtcvs.2019.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To discern the impact of depressed left ventricular ejection fraction (LVEF) on the outcomes of open descending thoracic aneurysm (DTA) and thoracoabdominal aneurysms (TAAA) repair. METHODS Restricted cubic spline analysis was used to identify a threshold of LVEF, which corresponded to an increase in operative mortality and major adverse events (MAE: operative death, myocardial infarction, stroke, spinal cord injury, need for tracheostomy or dialysis). Logistic and Cox regression were performed to identify independent predictors of MAE, operative mortality, and survival. RESULTS DTA/TAAA repair was performed in 833 patients between 1997 and 2018. Restricted cubic spline analysis showed that patients with LVEF <40% (n = 66) had an increased risk of MAE (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.22-3.87; P < .01) and operative mortality (OR, 2.72; 95% CI, 1.21-6.12; P = .02) compared with the group with LVEF ≥40% (n = 767). The group with LVEF <40% had a worse preoperative profile (eg, coronary revascularization, 48.5% vs 17.3% [P < .01]; valvular disease, 82.8% vs 49.39% [P < .01]; renal insufficiency, 45.5% vs 26.1% [P < .01]; respiratory insufficiency, 36.4% vs 21.2% [P = .01]) and worse long-term survival (35.5% vs 44.7% at 10 years; P = .01). Nonetheless, on multivariate regression, depressed LVEF was not an independent predictor of operative mortality, MAE, or survival. CONCLUSIONS LVEF is not an independent predictor of adverse events in surgery for DTA.
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Affiliation(s)
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mohamad Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | | | - Faiza M Khan
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Erin Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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Abdul Jabbar A, Chanda A, White CJ, Jenkins JS. Percutaneous endovascular abdominal aneurysm repair: State‐of‐the art. Catheter Cardiovasc Interv 2019; 95:767-782. [DOI: 10.1002/ccd.28576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/27/2019] [Accepted: 10/25/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Ali Abdul Jabbar
- Interventional CardiologyOchsner Clinic Foundation New Orleans Louisiana
| | - Arijit Chanda
- Interventional CardiologyOchsner Clinic Foundation New Orleans Louisiana
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