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Seike Y, Matsuda H, Fukuda T, Hori Y, Inoue Y, Omura A, Uehara K, Sasaki H, Kobayashi J. Is debranching thoracic endovascular aortic repair acceptable as the first choice for arch aneurysm in the elderly? Interact Cardiovasc Thorac Surg 2019; 29:101-108. [PMID: 30805619 DOI: 10.1093/icvts/ivz027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 01/16/2019] [Accepted: 01/17/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study aimed to assess differences in midterm outcomes between total arch replacement (TAR) and debranching thoracic endovascular aortic repair (d-TEVAR) and to evaluate the validity of d-TEVAR as the preferred treatment choice for aortic arch aneurysm in the elderly. METHODS We reviewed the case histories of 86 patients who had undergone TAR (64 men; mean age 78 ± 2.9 years) and 121 patients who had undergone d-TEVAR (90 men; mean age 82 ± 4.5 years) between 2007 and 2017; of these patients, 50 from each group were matched based on propensity scores to adjust for differences in patient characteristics. RESULTS Rates of freedom from all-cause mortality at 2 and 4 years were similar between the 2 groups (88% and 77% in the TAR group vs 82% and 64% in the d-TEVAR group, P = 0.11), but rates of freedom from reintervention at 2 and 4 years were significantly higher in the TAR group (100% and 96%) than in the d-TEVAR group (97% and 88%) (P = 0.004). Propensity score matching yielded similar survival rates of 88% and 85% for TAR vs 86% and 71% for d-TEVAR (P = 0.53) and comparable freedom from reintervention rates (100% and 97% in TAR, 98% and 90% in d-TEVAR, P = 0.16) at 2 and 4 years. Cox regression analysis identified previous cerebral infarction [hazard ratio (HR) 3.9; P = 0.005 in TAR/HR 3.1; P = 0.002 in d-TEVAR] as an independent positive predictor of overall mortality in both groups. CONCLUSIONS Midterm outcomes after TAR and d-TEVAR were satisfactory and propensity score matching-based evaluation revealed no significant differences in outcomes, implying that d-TEVAR is an acceptable first-choice procedure for aortic arch aneurysm in patients older than 75 years.
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Affiliation(s)
- Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshiro Hori
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Atsushi Omura
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kyokun Uehara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
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Total arch replacement versus debranching thoracic endovascular aortic repair for aortic arch aneurysm: what indicates a high-risk patient for arch repair in octogenarians? Gen Thorac Cardiovasc Surg 2018; 66:263-269. [DOI: 10.1007/s11748-018-0894-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/22/2018] [Indexed: 01/14/2023]
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3
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Patel R, Powell JT, Sweeting MJ, Epstein DM, Barrett JK, Greenhalgh RM. The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-132. [PMID: 29384470 PMCID: PMC5817412 DOI: 10.3310/hta22050] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Short-term survival benefits of endovascular aneurysm repair (EVAR) compared with open repair (OR) of intact abdominal aortic aneurysms have been shown in randomised trials, but this early survival benefit is soon lost. Survival benefit of EVAR was unclear at follow-up to 10 years. OBJECTIVE To assess the long-term efficacy of EVAR against OR in patients deemed fit and suitable for both procedures (EVAR trial 1; EVAR-1); and against no intervention in patients unfit for OR (EVAR trial 2; EVAR-2). To appraise the long-term significance of type II endoleak and define criteria for intervention. DESIGN Two national, multicentre randomised controlled trials: EVAR-1 and EVAR-2. SETTING Patients were recruited from 37 hospitals in the UK between 1 September 1999 and 31 August 2004. PARTICIPANTS Men and women aged ≥ 60 years with an aneurysm of ≥ 5.5 cm (as identified by computed tomography scanning), anatomically suitable and fit for OR were randomly assigned 1 : 1 to either EVAR (n = 626) or OR (n = 626) in EVAR-1 using computer-generated sequences at the trial hub. Patients considered unfit were randomly assigned to EVAR (n = 197) or no intervention (n = 207) in EVAR-2. There was no blinding. INTERVENTIONS EVAR, OR or no intervention. MAIN OUTCOME MEASURES The primary end points were total and aneurysm-related mortality until mid-2015 for both trials. Secondary outcomes for EVAR-1 were reinterventions, costs and cost-effectiveness. RESULTS In EVAR-1, over a mean of 12.7 years (standard deviation 1.5 years; maximum 15.8 years), we recorded 9.3 deaths per 100 person-years in the EVAR group and 8.9 deaths per 100 person-years in the OR group [adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.97 to 1.27; p = 0.14]. At 0-6 months after randomisation, patients in the EVAR group had a lower mortality (adjusted HR 0.61, 95% CI 0.37 to 1.02 for total mortality; HR 0.47, 95% CI 0.23 to 0.93 for aneurysm-related mortality; p = 0.031), but beyond 8 years of follow-up patients in the OR group had a significantly lower mortality (adjusted HR 1.25, 95% CI 1.00 to 1.56, p = 0.048 for total mortality; HR 5.82, 95% CI 1.64 to 20.65, p = 0.0064 for aneurysm-related mortality). The increased aneurysm-related mortality in the EVAR group after 8 years was mainly attributable to secondary aneurysm sac rupture, with increased cancer mortality also observed in the EVAR group. Overall, aneurysm reintervention rates were higher in the EVAR group than in the OR group, 4.1 and 1.7 per 100 person-years, respectively (p < 0.001), with reinterventions occurring throughout follow-up. The mean difference in costs over 14 years was £3798 (95% CI £2338 to £5258). Economic modelling based on the outcomes of the EVAR-1 trial showed that the cost per quality-adjusted life-year gained over the patient's lifetime exceeds conventional thresholds used in the UK. In EVAR-2, patients died at the same rate in both groups, but there was suggestion of lower aneurysm mortality in those who actually underwent EVAR. Type II endoleak itself is not associated with a higher rate of mortality. LIMITATIONS Devices used were implanted between 1999 and 2004. Newer devices might have better results. Later follow-up imaging declined, particularly for OR patients. Methodology to capture reinterventions changed mainly to record linkage through the Hospital Episode Statistics administrative data set from 2009. CONCLUSIONS EVAR has an early survival benefit but an inferior late survival benefit compared with OR, which needs to be addressed by lifelong surveillance of EVAR and reintervention if necessary. EVAR does not prolong life in patients unfit for OR. Type II endoleak alone is relatively benign. FUTURE WORK To find easier ways to monitor sac expansion to trigger timely reintervention. TRIAL REGISTRATION Current Controlled Trials ISRCTN55703451. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and the results will be published in full in Health Technology Assessment; Vol. 22, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rajesh Patel
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Michael J Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - David M Epstein
- Centre for Health Economics, University of York, York, UK.,Department of Applied Economics, University of Granada, Granada, Spain
| | - Jessica K Barrett
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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4
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Powell JT, Sweeting MJ, Ulug P, Blankensteijn JD, Lederle FA, Becquemin J, Greenhalgh RM. Meta-analysis of individual-patient data from EVAR-1, DREAM, OVER and ACE trials comparing outcomes of endovascular or open repair for abdominal aortic aneurysm over 5 years. Br J Surg 2017; 104:166-178. [PMID: 28160528 PMCID: PMC5299468 DOI: 10.1002/bjs.10430] [Citation(s) in RCA: 267] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/01/2016] [Accepted: 09/26/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND The erosion of the early mortality advantage of elective endovascular aneurysm repair (EVAR) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation. METHODS An individual-patient data meta-analysis of four multicentre randomized trials of EVAR versus open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm-related mortality and reintervention. RESULTS The analysis included 2783 patients, with 14 245 person-years of follow-up (median 5·5 years). Early (0-6 months after randomization) mortality was lower in the EVAR groups (46 of 1393 versus 73 of 1390 deaths; pooled hazard ratio 0·61, 95 per cent c.i. 0·42 to 0·89; P = 0·010), primarily because 30-day operative mortality was lower in the EVAR groups (16 deaths versus 40 for open repair; pooled odds ratio 0·40, 95 per cent c.i. 0·22 to 0·74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths versus 3 for open repair; pooled hazard ratio 5·16, 1·49 to 17·89; P = 0·010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under EVAR. Those with peripheral artery disease had lower mortality under open repair (39 deaths versus 62 for EVAR; P = 0·022) in the period from 6 months to 4 years after randomization. CONCLUSION The early survival advantage in the EVAR group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from EVAR compared with open repair. Aneurysm-related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the EVAR group. Trial registration numbers: EVAR-1, ISRCTN55703451; DREAM (Dutch Randomized Endovascular Aneurysm Management), NCT00421330; ACE (Anévrysme de l'aorte abdominale, Chirurgie versus Endoprothèse), NCT00224718; OVER (Open Versus Endovascular Repair Trial for Abdominal Aortic Aneurysms), NCT00094575.
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Affiliation(s)
- J. T. Powell
- Vascular Surgery Research GroupImperial College LondonLondonUK
| | - M. J. Sweeting
- Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
| | - P. Ulug
- Vascular Surgery Research GroupImperial College LondonLondonUK
| | | | - F. A. Lederle
- Department of MedicineVA Medical Centre, MinneapolisMinnesotaUSA
| | - J.‐P. Becquemin
- Vascular Institute of Paris East, Hôpital Privé Paul d'Egine, Champigny, Université, Paris-Est CréteilCréteilFrance
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5
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Treatment of uncomplicated type B aortic dissection. Gen Thorac Cardiovasc Surg 2016; 65:74-79. [DOI: 10.1007/s11748-016-0734-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 11/25/2016] [Indexed: 10/20/2022]
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6
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Kataja J, Chrapek W, Kaukinen S, Pimenoff G, Salenius JP. Hormonal Stress Response and Hemodynamic Stability in Patients Undergoing Endovascular vs. Conventional Abdominal Aortic Aneurysm Repair. Scand J Surg 2016; 96:236-42. [DOI: 10.1177/145749690709600309] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aims: To investigate the effect of two different surgical techniques with different anesthetic modes on intraoperative and postoperative hormonal stress response, hemodynamic stability, fluid loading and renal function in patients scheduled for elective infrarenal abdominal aortic aneurysm (AAA) repair. Materials and Methods: Forty consecutive patients scheduled for elective infrarenal AAA repair were allocated without randomizing into two groups: an endovascular (EVAR, n=20) and a conventional (CAR, n=20) aneurysm repair group according to aneurysm morphology as determined by pre-operative computed tomography and angiography. The EVAR group were operated under spinal anesthesia and the CAR group using general anesthesia with epidural blockade. Results: Patients undergoing CAR showed lower intraoperative mean arterial pressure and significantly higher plasma norepinephrine before aortic cross-clamping and significantly higher lactate after aortic declamping and postoperatively than patients in the EVAR group. Postoperatively, vasopressin and serum cortisol were also significantly higher in the CAR group. Fluid loading and estimated blood loss were more excessive in the CAR group. Conclusions: Stress response was lower and hemodynamic stability and lower body perfusion superior and renal function also better maintained in patients undergoing EVAR under spinal anesthesia as compared to those undergoing CAR using general anesthesia with epidural blockade.
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Affiliation(s)
- J. Kataja
- Department of Anesthesia and Intensive Care, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - W. Chrapek
- Department of Anesthesia and Intensive Care, Tampere University Hospital and Medical School, Tampere, Finland
| | - S. Kaukinen
- Department of Anesthesia and Intensive Care, Tampere University Hospital and Medical School, Tampere, Finland
| | - G. Pimenoff
- Department of Radiology, Tampere University Hospital and Medical School, Tampere, Finland
| | - J.-P. Salenius
- Department of Surgery, Tampere University Hospital and Medical School, Tampere, Finland
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Parkinson F, Ferguson S, Lewis P, Williams IM, Twine CP. Rupture rates of untreated large abdominal aortic aneurysms in patients unfit for elective repair. J Vasc Surg 2015; 61:1606-12. [PMID: 25661721 DOI: 10.1016/j.jvs.2014.10.023] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 10/15/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Elective abdominal aortic aneurysm (AAA) surgery relies on balancing the risk of the intervention against the risk of the aneurysm causing death. Although much is known about intervention at 5.5 cm, little is known about the fate of the patient unfit for elective surgery at this threshold. Medical therapy and endovascular surgery have revolutionized management of aortic aneurysms in the last 20 years and are thought to have affected rupture rates. METHODS MEDLINE via PubMed, EMBASE, and the Cochrane Library Database were searched for studies reporting follow-up of untreated large AAA approach from inception to January 2014. Data were pooled using random-effects analysis with standardized mean differences and 95% confidence intervals (CIs) reported. The primary end points were rupture rates and all-cause mortality per year by AAA size. RESULTS The search strategy identified 1892 citations, of which 11 studies comprising 1514 patients experiencing 347 ruptured AAA were included. The overall incidence of ruptured AAA in patients with AAA >5.5 cm was 5.3% (95% CI, 3.1%-7.5%) per year. This represented cumulative yearly rupture rates of 3.5% (95% CI, -1.6% to 8.7%) in AAAs 5.5 to 6.0 cm, 4.1% (95% CI, -0.7% to 9.0%) in AAAs 6.1 to 7.0 cm, and 6.3% (95% CI, -1.8% to 14.3%) in AAAs >7.0 cm. There was no heterogeneity between studies (I(2) = 0%). Only 32% of these patients were offered repair on rupturing an AAA, with a perioperative mortality of 58% (95% CI, 32%-83%). The risk of death from causes other than AAA was higher than the risk of death from rupture. CONCLUSIONS Rupture rates of untreated AAA were lower than those currently quoted in the literature. Non-AAA-related mortality in this group of patients is high.
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Affiliation(s)
- Fran Parkinson
- Department of Vascular Surgery, Royal Gwent Hospital, Newport, United Kingdom
| | - Stuart Ferguson
- Department of Vascular Surgery, Royal Gwent Hospital, Newport, United Kingdom
| | - Peter Lewis
- Department of Vascular Surgery, Royal Gwent Hospital, Newport, United Kingdom
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Christopher P Twine
- Department of Vascular Surgery, Royal Gwent Hospital, Newport, United Kingdom.
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8
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Rückert RI, Hanack U, Aronés-Gomez S, Yousefi S. [Aneurysms of the abdominal aorta and iliac arteries: paradigm shift - operative therapy, if possible endovascular?]. Chirurg 2014; 85:782-90. [PMID: 25200628 DOI: 10.1007/s00104-014-2718-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapy of abdominal aortic aneurysms (AAA) is currently based on a high level of evidence. This is not true in the same manner for iliac artery aneurysms (IAA) which are frequently associated with AAAs and occur only rarely as isolated lesions. The therapeutic principles apply in the same way to both aneurysm locations. OBJECTIVES New findings, improved perioperative care and the rapid development of minimally invasive techniques require a constant update which is the aim of this article concerning the therapy of AAAs and IAAs. MATERIAL AND METHODS A systematic literature review was performed in PubMed and Medline and priority was given to recent publications with a high level of evidence. RESULTS Endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR) result in a similar long-term survival. The perioperative survival advantage with EVAR persists only during medium-term postoperative courses. The reintervention rate after EVAR is substantially higher compared to OAR. For older patients and those who are considered unfit for OAR the expected benefits from EVAR has not been proven to date. Aneurysmal ruptures after EVAR demonstrate that a life-long surveillance of these patients is necessary. CONCLUSION Therapy of AAAs and IAAs is increasingly being performed by EVAR. Even the majority of complex aneurysms are amenable to minimally invasive treatment. Nevertheless, indications for OAR continue to exist. Screening for AAAs results in a decrease of aneurysmal ruptures for which EVAR is also gaining importance.
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Affiliation(s)
- R I Rückert
- Klinik für Gefäß- und endovaskuläre Chirurgie, Allgemein- und Viszeralchirurgie Franziskus-Krankenhaus, Akademisches Lehrkrankenhaus der Charité, Universitätsmedizin Berlin, Budapester Str. 15-19, 10787, Berlin, Deutschland,
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9
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Murashita T, Matsuda H, Domae K, Iba Y, Tanaka H, Sasaki H, Ogino H. Less invasive surgical treatment for aortic arch aneurysms in high-risk patients: A comparative study of hybrid thoracic endovascular aortic repair and conventional total arch replacement. J Thorac Cardiovasc Surg 2012; 143:1007-13. [PMID: 21783209 DOI: 10.1016/j.jtcvs.2011.06.024] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 05/16/2011] [Accepted: 06/27/2011] [Indexed: 11/26/2022]
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10
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Inherent problems with randomized clinical trials with observational/no treatment arms. J Vasc Surg 2010; 52:237-41. [PMID: 20620768 DOI: 10.1016/j.jvs.2010.02.255] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 02/18/2010] [Accepted: 02/18/2010] [Indexed: 11/21/2022]
Abstract
Randomized clinical trials (RCTs) offering an observation/no treatment (OBS/NoRx) arm as control and which are focused on the management of a condition with potentially life-threatening consequences, however small the risk, often experience a significant rate of crossover to treatment by those randomized to the OBS/NoRx arm. Results of these trials when analyzed on intent-to-treat basis often fail to resolve the issue at which they were directed. The authors have observed this in trials of abdominal aortic aneurysms with this design and use these to exemplify the dilemmas RCTs of such design create, with crossovers ranging from 27% to over 60% (EVAR II, UKSAT, ADAM, PIVOTAL). Results of these trials are frequently used as level I medical evidence and their potential impact on clinical decision making and reimbursement can be quite significant and long-lasting. Recommendations regarding trial end points and suggestions to mitigate the high crossover effect are offered. It may be that some clinical conditions dealing with potentially life-threatening problems should not be studied in randomized prospective clinical trials containing an OBS/NoRx arm.
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11
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De Bruin JL, Baas AF, Buth J, Prinssen M, Verhoeven ELG, Cuypers PWM, van Sambeek MRHM, Balm R, Grobbee DE, Blankensteijn JD. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med 2010; 362:1881-9. [PMID: 20484396 DOI: 10.1056/nejmoa0909499] [Citation(s) in RCA: 737] [Impact Index Per Article: 52.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND For patients with large abdominal aortic aneurysms, randomized trials have shown an initial overall survival benefit for elective endovascular repair over conventional open repair. This survival difference, however, was no longer significant in the second year after the procedure. Information regarding the comparative outcome more than 2 years after surgery is important for clinical decision making. METHODS We conducted a long-term, multicenter, randomized, controlled trial comparing open repair with endovascular repair in 351 patients with an abdominal aortic aneurysm of at least 5 cm in diameter who were considered suitable candidates for both techniques. The primary outcomes were rates of death from any cause and reintervention. Survival was calculated with the use of Kaplan-Meier methods on an intention-to-treat basis. RESULTS We randomly assigned 178 patients to undergo open repair and 173 to undergo endovascular repair. Six years after randomization, the cumulative survival rates were 69.9% for open repair and 68.9% for endovascular repair (difference, 1.0 percentage point; 95% confidence interval [CI], -8.8 to 10.8; P=0.97). The cumulative rates of freedom from secondary interventions were 81.9% for open repair and 70.4% for endovascular repair (difference, 11.5 percentage points; 95% CI, 2.0 to 21.0; P=0.03). CONCLUSIONS Six years after randomization, endovascular and open repair of abdominal aortic aneurysm resulted in similar rates of survival. The rate of secondary interventions was significantly higher for endovascular repair. (ClinicalTrials.gov number, NCT00421330.)
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Affiliation(s)
- Jorg L De Bruin
- From the Department of Surgery, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
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12
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Endovascular management of delayed complete graft thrombosis after endovascular aneurysm repair. Cardiovasc Intervent Radiol 2009; 33:840-3. [PMID: 20033161 DOI: 10.1007/s00270-009-9780-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 12/03/2009] [Indexed: 10/20/2022]
Abstract
Graft thrombosis rates after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms vary widely in published series. When thrombosis does occur, it usually involves a single limb and occurs within 3 months of stent-graft insertion. If the entire endoprosthesis is thrombosed, treatment may be challenging because femoro-femoral crossover graft insertion is not an option and a greater volume of thrombus is present, thus making thrombolysis more difficult. We present two cases of delayed thrombosis after EVAR involving the entire stent-graft. These were successfully treated by a combined surgical and endovascular technique, and patency has been maintained in both cases to date.
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13
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Diehm N, Dick F, Katzen BT, Do DD, Baumgartner I. Endovascular repair of abdominal aortic aneurysms: only a mechanical solution for a biological problem? J Endovasc Ther 2009; 16 Suppl 1:I119-26. [PMID: 19317573 DOI: 10.1583/08-2586.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Endovascular aneurysm repair has matured significantly over the last 20 years and is becoming increasingly popular as a minimally invasive treatment option for patients with abdominal aortic aneurysms (AAA). Long-term durability of this fascinating treatment, however, is in doubt as continuing aneurysmal degeneration of the aortoiliac graft attachment zones is clearly associated with late adverse sequelae. In recent years, our growing understanding of the physiopathology of AAA formation has facilitated scrutiny of various potential drug treatment concepts. In this article we review the mechanical and biological challenges associated with endovascular treatment of infrarenal AAAs and discuss potential approaches to ongoing aneurysmal degeneration, which hampers long-term outcomes of this minimally invasive therapy.
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Affiliation(s)
- Nicolas Diehm
- Clinical and Interventional Angiology, Swiss Cardiovascular Center, Inselspital, University Hospital Bern, Switzerland.
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14
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Collin N, Haslam E, Fay D, Hardman J, Horrocks M. A review of endovascular management of abdominal aortic aneurysm. Br J Hosp Med (Lond) 2009; 70:146-50. [PMID: 19274003 DOI: 10.12968/hmed.2009.70.3.40555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Abdominal aortic aneurysm is a common finding in older men and is often asymptomatic, either being found incidentally or presenting with acute rupture. This article will discuss the current indications for treatment and the clinical evidence behind the options currently available.
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Affiliation(s)
- Neil Collin
- Radiology Department, Royal United Hospital, Bath BA1 3NG, UK
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15
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Martínez-Mira C, Fernández-Samos R, Ortega-Martín J, del Barrio-Fernández M, Peña-Cortés R, Vaquero-Morillo F. Tratamiento endovascular de aneurismas de aorta abdominal infrarrenal de gran tamaño. ANGIOLOGIA 2009. [DOI: 10.1016/s0003-3170(09)16005-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Brown LC, Thompson SG, Greenhalgh RM, Powell JT. Fit patients with small abdominal aortic aneurysms (AAAs) do not benefit from early intervention. J Vasc Surg 2008; 48:1375-81. [DOI: 10.1016/j.jvs.2008.07.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Revised: 07/07/2008] [Accepted: 07/07/2008] [Indexed: 11/29/2022]
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Böckler D. Reply. J Endovasc Ther 2008. [DOI: 10.1177/152660280801500501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Dittmar Böckler
- Department of Vascular and Endovascular Surgery Chirurgische Universitätsklinik Heidelberg, Germany
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18
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Böckler D. Reply:. J Endovasc Ther 2008. [DOI: 10.1583/1545-1550(2008)15[627:r]2.0.co;2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Greenhalgh RM, Brown LC. The Most Important Misinterpretations of the UK Randomised Trials on Abdominal Aortic Aneurysm Repair. Scand J Surg 2008; 97:116-20. [DOI: 10.1177/145749690809700207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- R. M. Greenhalgh
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, U.K
| | - L. C. Brown
- Vascular Surgery Research Group, Imperial College London, Charing Cross Hospital, London, U.K
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Sadat U, Hayes PD, Gaunt ME, Varty K, Boyle JR. Assessment of pre-operative delays in the management of elective abdominal aortic aneurysms. Ann R Coll Surg Engl 2008; 90:65-8. [PMID: 18201505 DOI: 10.1308/003588408x242088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Successful endovascular aneurysm repair (EVAR) requires detailed pre-operative imaging to allow device planning. This process may delay surgery and some aneurysms may rupture prior to intervention. The aim of this study was to quantify these delays. PATIENTS AND METHODS Data were collected prospectively on all patients presenting with non-ruptured abdominal aortic aneurysms (AAAs) between January 2003 and October 2005. The delay between referral, the first out-patient visit, CT-scan, follow-up appointment and surgery were quantified in all patients and compared between two groups undergoing open repair and EVAR. RESULTS A total of 146 patients underwent AAA repair during the study (48 EVAR versus 98 open repair). There was no significant differences in the wait for CT scans between the groups (median 42 days for EVAR versus 47 days for open repairs [P = 0.48]) or the median interval between decision to operate and surgery (56 days versus 42 days [P = 0.075]). However, the median delay between referral and surgery was significantly longer in those patients undergoing EVAR at 129 days versus 77 days for open repair (P = 0.02). CONCLUSIONS Patients presenting electively with AAAs experienced significant delay from referral to surgery. This delay was significantly greater in those patients undergoing endovascular repair. Inevitably, some patients will rupture whilst waiting and strategies aimed at reducing delay should be pursued.
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Affiliation(s)
- U Sadat
- Cambridge Vascular Unit, Addenbrooke's Hospital NHS Foundation Trust, Cambridge, UK
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Barba-Vélez A, Céniga MVD, Estallo-Laliena L, la Fuente-Sánchez ND, Viviens-Redondo B. Veinte años en la reparación abierta electsiva de los aneurismas de aorta abdominal infrarrenal. ANGIOLOGIA 2008. [DOI: 10.1016/s0003-3170(08)03002-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Brown LC, Greenhalgh RM, Howell S, Powell JT, Thompson SG. Patient fitness and survival after abdominal aortic aneurysm repair in patients from the UK EVAR trials. Br J Surg 2007; 94:709-16. [PMID: 17514695 DOI: 10.1002/bjs.5776] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The aim was to use a validated fitness score to determine whether fitter patients with a large abdominal aortic aneurysm (AAA) benefited from having open rather than endovascular repair.
Methods
The Customized Probability Index (CPI) was applied to patients in the Endovascular Aneurysm Repair (EVAR) I and II trials. Interaction tests between CPI and randomized group assessed the effect of fitness and type of AAA repair on elective 30-day mortality and 4-year survival.
Results
The mean(s.d.) CPI scores were 3·6(9·3) for 1252 EVAR I patients and 10·0(11·3) for 404 EVAR II patients (range − 25 to + 43) (P < 0·001). The fitness of EVAR I patients was classified as good (579 patients, mean CPI − 4·2), moderate (331 patients, mean CPI 5·7) or poor (338 patients, mean CPI 15·1). Only in the good fitness group did 30-day mortality convincingly favour endovascular repair (odds ratio 0·24, P = 0·030), but overall the test of interaction was not significant (P = 0·363). For 4-year all-cause and aneurysm-related mortality, there was no benefit for either treatment across all fitness scores (P = 0·281 and P = 0·371 respectively).
Conclusion
The benefit of endovascular repair was most convincing in the fittest patients. There was no evidence that the fittest patients benefited more from open surgery.
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Affiliation(s)
- L C Brown
- Vascular Surgery Research Group, Imperial College, London, UK.
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Rutherford RB. Randomized EVAR Trials and Advent of Level I Evidence: A Paradigm Shift in Management of Large Abdominal Aortic Aneurysms? Semin Vasc Surg 2006; 19:69-74. [PMID: 16782510 DOI: 10.1053/j.semvascsurg.2006.03.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The recent endovascular aneurysm repair (EVAR) 1 and 2 and Dutch Randomized Endovascular Aneurysm Management (DREAM) trials addressed management of abdominal aortic aneurysms (AAAs) larger than 5.5 cm in diameter. The DREAM and EVAR 1 trials randomized patients appropriate for open repair between endovascular repair (EVAR) and open repair (OR), and the EVAR 2 trial randomized patients unfit for OR between EVAR and conservative nonoperative management (No Rx). The EVAR 1 trial showed a 3% lower initial mortality for EVAR, with a persistent reduction in aneurysm-related death at 4 years. Improvement in overall late survival was not demonstrated. Similarly, the DREAM trial observed an initial mortality advantage for EVAR, but overall 1-year survival was equivalent in both groups. Both trials found significantly higher complication and intervention rates and higher hospital costs with EVAR, and by 1 year a quality of life (QOL) benefit was not evident. The EVAR 2 trial did not demonstrate a survival advantage of EVAR with respect to nonoperative management, while noting that EVAR was associated with greater likelihood of treatment complications, subsequent interventions, and threefold higher costs. Both EVAR trials were limited by long delays between randomization and treatment. Moreover, 27% of patients in EVAR 2 crossed over from nonoperative to endovascular repair, and these patients had a lower procedure mortality from EVAR than those originally assigned to it (2% v 9%). These 47 cases, and the exclusion of 14 patients dying while waiting for EVAR, appears to confer a survival advantage to those receiving EVAR over those receiving no treatment in a post-hoc analysis, but per-protocol analysis of the EVAR 2 trial data performed by the EVAR investigators did not show a significant difference in either all-cause or aneurysm-related mortality. Thus, outcomes of the EVAR 2 trial have not settled the choice between EVAR and no treatment in this scenario to everyone's satisfaction. In patients with large AAAs who are fit for OR, EVAR offers an initial mortality advantage over OR, with a persistent reduction in AAA-related death at 4 years. However, EVAR offers no overall survival benefit, is more costly, and requires more interventions and indefinite surveillance with only a brief QOL benefit. It may or may not offer a mortality benefit over nonoperative management in patients with large AAAs who are unfit for open repair, but the statistical significance of this comparison is inconclusive.
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Affiliation(s)
- Robert B Rutherford
- Department of Surgery, University of Colorado Medical School, Denver, CO, USA.
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Franks S, Lloyd G, Fishwick G, Bown M, Sayers R. Endovascular treatment of ruptured and symptomatic abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2006; 31:345-50. [PMID: 16439168 DOI: 10.1016/j.ejvs.2005.08.037] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2005] [Accepted: 08/22/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To report the experience of endovascular repair (ER) in patients with ruptured and symptomatic abdominal aortic aneurysms (rAAA and sAAA), comparing results with a cohort of controls who underwent open repair (OR) of sAAA or rAAA. DESIGN A historically controlled cohort study. MATERIALS Retrospective data from 21 patients who underwent ER and prospective data from 23 patients who underwent OR. METHODS Results were compared using the Mann-Whitney U-test. RESULTS Eleven ER patients had sAAAs and 10 had rAAAs. Nine OR patients had rAAAs and 13 had sAAAs. Thirty-day mortality was 11% in patients with rAAA in the ER group, and 54% in the OR group (p=0.03). There were no post-operative deaths in the patients who had an sAAA in the ER group, and one death in the patients who had sAAA in the OR group. Results as expressed as mean ER value versus mean OR value and p-value. ER was associated with significant reductions in the length of operation (2.6 versus 3.1h, p=0.03), blood transfusion requirements (0.86 versus 10.7 units p<0.01), time in critical care (1.5 versus 6.1 days, p=0.02), and total hospital stay (8.5 versus 17.5 days, p=0.01) compared with OR. There was no difference in time from admission to arrival in theatre between the two groups (3.4 versus 5.0h, p=0.35). CONCLUSIONS In patients with rAAA and sAAA that are suitable for stenting, ER has reduced mortality compared with open repair. Assessment for ER does not cause a pre-operative delay, operating time is reduced, blood transfusion requirements are reduced and there is a faster recovery.
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Affiliation(s)
- S Franks
- Cardiovascular Sciences Department, University of Leicester, Clinical Sciences Building, Leicester, UK.
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Upchurch GR. Open versus endovascular abdominal aortic aneurysm repair: which offers the best long-term outcome? NATURE CLINICAL PRACTICE. CARDIOVASCULAR MEDICINE 2005; 2:562-3. [PMID: 16258565 DOI: 10.1038/ncpcardio0350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Accepted: 08/16/2005] [Indexed: 05/05/2023]
Affiliation(s)
- Gilbert R Upchurch
- Section of Vascular Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI, USA.
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