Randomized study comparing cardiac response in endovascular and open abdominal aortic aneurysm repair

Long-Term Outcomes of Open Versus Endovascular Treatment for Abdominal Aortic Aneurysm: Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data

BACKGROUND

The advent of endovascular techniques has revolutionized the care of patients with uncomplicated abdominal aortic aneurysms. This analysis compares the overall survival and the freedom from reintervention rate between open surgical repair (OSR) and endovascular repair (EVAR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair.

METHODS

PubMed, Scopus, and Cochrane databases were searched for studies including patients who underwent either OSR or EVAR for uncomplicated AAA. All randomized controlled trials and propensity-score-matched cohort studies reporting on the outcomes of interest were considered eligible for inclusion. The systematic search of the literature was performed by 2 independent investigators in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We conducted 1-stage and 2-stage meta-analyses with Kaplan-Meier-derived time-to-event data and meta-analysis with a random-effects model.

RESULTS

Thirteen studies met our eligibility criteria, incorporating 13 409 and 13 450 patients in the OSR and EVAR arms, respectively. Patients who underwent open repair had improved overall survival rates compared with those who underwent EVAR (hazard ratio [HR]=0.93, 95% confidence interval [CI]=0.88-0.98, p=0.004) during a mean follow-up of 53.8 (SD=29.8) months and this was validated by the 2-stage meta-analysis (HR=0.89, 95% CI=0.8-0.99, p=0.03, I2=62.25%). Splitting timepoint analysis suggested that EVAR offers better survival outcome compared with OSR in the first 11 months following elective intervention (HR=1.37, 95% CI=1.22-1.54, p<0.0001), while OSR offers a significant survival advantage after the 11-month timepoint and up to 180 months (HR=0.84, 95% CI=0.8-0.89, p<0.0001). Similarly, freedom from reintervention was found to be significantly better in EVAR patients (HR=1.28, 95% CI=1.14-1.44, p<0.0001) within the first 30 days. After the first month postrepair, however, OSR demonstrated higher freedom-from-reintervention rates compared with EVAR that remained significant for up to 168 months during follow-up (HR=0.73, 95% CI=0.66-0.79, p<0.0001).

CONCLUSIONS

Despite the first-year survival advantage of EVAR in patients undergoing elective AAA repair, OSR was associated with a late survival benefit and decreased risk for reintervention in long-term follow-up.

CLINICAL IMPACT

Open surgical repair for uncomplicated abdominal aortic aneurysm offers better long-term outcomes in terms of survival and freedom from reintervention rate compared to the endovascular approach but in the first year it carries a higher risk of mortality. The novelty of our study lies that instead of comparing study-level effect estimates, we analyzed reconstructed individual patient-level data. This offered us the opportunity to perform our analyses with mathematically robust and flexible survival models, which was proved to be crucial since there was evidence of different hazard over time. Our findings underline the need for additional investigation to clarify the significance of open surgical repair when compared to the latest endovascular devices and techniques within the evolving era of minimally invasive procedures.

Abdominal Ischemia-Reperfusion Induced Cardiac Dysfunction Can Be Prevented by MitoTEMPO

BACKGROUND

Cardiac dysfunction is secondary to acute mesenteric ischemia (AMI) and abdominal aortic aneurysms (AAA). The underlying cause of distant organ damage in the heart is the formation of oxidative stress caused by ischemia-reperfusion. In this study, we investigated the possible protective effects of a novel mitochondria-targeted antioxidant MitoTEMPO on contractile dysfunction and structural defects of the rat papillary muscle caused by abdominal ischemia-reperfusion (AIR).

METHODS AND RESULTS

In the experiments, adult Wistar-Albino rats were used and animals were divided randomly into 3 groups; sham-operated group (SHAM), an IR group that had aortic cross-clamping for 1 h followed by 2 h reperfusion, and a third group that received protective 0.7 mg/kg/day MitoTEMPO injection for 28-day before IR. As a result, it was observed that MitoTEMPO injection had a protective effect on the mechanical activities and structural properties of the papillary muscle impaired by AIR. Our study also showed that AIR disrupted the contractile function of the papillary muscle for each stimulation frequency and post-potentiation responses tested. This is common for each measured and calculated mechanical parameter and MitoTEMPO injection showed its protective effects.

CONCLUSION

Consequently, calcium homeostasis seems to be impaired by AIR, and MitoTEMPO may exert its protective effect through energy metabolism by directly targeting the mitochondria.

ANALYSIS OF SPIN IN VASCULAR SURGERY RANDOMIZED CONTROLLED TRIALS WITH NONSIGNIFICANT OUTCOMES

OBJECTIVES

Spin is the manipulation of language that distorts the interpretation of objective findings. The purpose of this study is to describe the characteristics of spin found in statistically nonsignificant randomized controlled trials (RCT) comparing carotid endarterectomy (CEA) to carotid artery stenting (CAS) for carotid stenosis (CS), and endovascular repair (EVAR) to open repair (OR) for abdominal aortic aneurysms (AAA).

METHODS

A search of MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials was performed in June 2020 for studies published describing AAA or CS. All phase three RCTs with nonsignificant primary outcomes comparing OR to EVAR or CEA to CAS were included. Studies were appraised for the characteristics and severity of spin using a validated tool. Binary logistic regression was performed to assess the association of spin grade to (1) funding source (commercial vs non-commercial) and (2) the publishing journal's impact factor.

RESULTS

Thirty-one of 355 articles captured were included for analysis. Spin was identified in nine abstracts (9/18) and 13 main texts (13/18) of AAA articles and seven abstracts (7/13) and ten main texts (10/13) of CS articles. For both AAA and CS articles, spin was most commonly found in the manuscript discussion section, with the most commonly employed strategy being the interpretation of statistically nonsignificant primary results to show treatment equivalence or rule out adverse treatment effects. Increasing journal impact factor was associated with a statistically significant lower likelihood of spin in the study title or abstract conclusion (βOR = 0.96, 95% CI: 0.94 - 0.98, p < 0.01) while no significant association could be found with funding source (βOR = 1.33, 95% CI: 0.30-5.92, p = 0.71).

CONCLUSIONS

A large proportion of statistically nonsignificant RCTs contain interpretations that are inconsistent with their results. These findings should prompt authors and readers to appraise study findings independently and to limit the use of spin in study interpretations.

[Outcomes of endoprosthetic repair of abdominal aortic aneurysm]

AIM

The study was aimed at assessing efficacy and safety of endovascular treatment of abdominal aortic aneurysms based on 11-year experience with implantation of stent grafts.

PATIENTS AND METHODS

We retrospectively analysed outcomes of treatment of 242 patients with abdominal aortic aneurysm during the period from 2008 to 2019. Of these, 210 (86.78%) were males, mean age 69.32±7.36 years. Diagnosis was made using colour duplex scanning and contrast-enhanced multislice spiral computed tomography, with implanting the following stent grafts: Ella - 44, Ovation Prime - 33, Anaconda - 13, Endurand - 77, Aortix - 2, Zenith - 33, Seal - 39, with one endoprosthesis placement failed. Assessing safety of the operation, we took into consideration lethality due to aortic rupture/thrombosis. Efficacy was taken to mean technical success of the operation (implantation of all components of the endograft without switch to open surgery), the number of reoperations.

RESULTS

Technical success of the operation was achieved in 98.35% of cases. In 1 case due to pronounced arterial calcification for technical reasons we failed to position the stent graft and in another case - the contralateral leg of the Ella prosthesis. The early postoperative period revealed: type A1 endoleak - 3.7%, type IB - 4.13%, type IIA - 6.6%, type IIB - 4.54%, type III - 0.83%, type IV - 0.83%. Repeat operations were performed in 20 (8.2%) patients within 30 days after the intervention and in 32 (13.22%) in the remote period. In the early postoperative period two conversions were performed: 1) iliorenal bypass grafting for restoration of blood flow through the renal artery occluded by endoprosthesis wall; 2) evacuation of retroperitoneal haematoma due to rupture of the common femoral artery. Lethality during the whole period of follow up amounted to 32 (13.22%) cases. Of these, due to aortic complications 4.54% (n=11) and due to accompanying pathology 8.67% (n=21). A direct correlation was revealed between the aortic diameter and duration of the operation which in turn increases the risk of complications requiring re-operation or resulting in a lethal outcome (RR - 1; 95% CD 1- 1; p=0.026).

CONCLUSION

Our experience showed high safety and efficacy of stent graft implantation in treatment of patients with abdominal aortic aneurysms and high surgical risk.

Editor's Choice - Endovascular vs. Open Repair for Abdominal Aortic Aneurysm: Systematic Review and Meta-analysis of Updated Peri-operative and Long Term Data of Randomised Controlled Trials

OBJECTIVE

The objective was to investigate whether endovascular aneurysm repair (EVAR) has better peri-operative and late clinical outcomes than open repair for non-ruptured abdominal aortic aneurysm.

METHODS

Electronic bibliographic sources (MEDLINE, EMBASE, and CENTRAL) were searched up to July 2019 using a combination of thesaurus and free text terms to identify randomised controlled trials (RCTs) comparing the outcomes of EVAR and open repair. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI). A time to event data meta-analysis was performed using the inverse variance method and the results were reported as summary hazard ratio (HR) and 95% CI.

RESULTS

Seven RCTs reporting a total of 2 983 patients were included in quantitative synthesis. Three of the trials reported long term follow up that extended to 15.8 years, 14.2 years, and 12.5 years. Meta-analysis found significantly lower odds of 30 day (OR, 0.36; 95% CI 0.20-0.66) and in hospital mortality with EVAR (RD -0.03; 95% CI -0.04 to -0.02). Meta-analysis of the three trials reporting long term follow up found no significant difference in all cause mortality at any time between EVAR and open repair (HR 1.02; 95% CI 0.93-1.13; p = .62). The hazard of all cause (HR 0.62; 95% CI 0.42-0.91) and aneurysm related death within six months (HR 0.42; 95% CI 0.24-0.75) was significantly lower in patients who underwent EVAR, but with further follow up, the pooled hazard estimate moved in favour of open surgery; in the long term (>8 years) the hazard of aneurysm related mortality was significantly higher after EVAR (HR 5.12; 95% CI 1.59-16.44). The risk of secondary intervention (HR 2.13; 95% CI 1.69-2.68), aneurysm rupture (OR, 5.08; 95% CI 1.11-23.31), and death due to rupture (OR, 3.57; 95% CI 1.87-6.80) was significantly higher after EVAR, but the risk of death due to cancer was not significantly different between EVAR and open repair (OR, 1.03; 95% CI 0.84-1.25).

CONCLUSION

Compared with open surgery, EVAR results in a better outcome during the first six months but carries an increased risk of aneurysm related mortality after eight years.

Simultaneous endovascular repair for abdominal aortic aneurysm and coronary artery bypass grafting in an octogenarian: A case report

INTRODUCTION

Coronary artery disease (CAD) is commonly associated with abdominal aortic aneurysms (AAAs) in elderly patients. When severe CAD requiring coronary artery bypass grafting (CABG) is associated with an impending AAA in a high-risk patient, the options for the suitable timing of CABG and AAA repair strategy (one-stage or two-stage) are still being debated.

PRESENTATION OF CASE

An 87-year-old man with non-ST-segment elevation myocardial infarction and a giant abdominal aortic aneurysm was transferred to our centre. Coronary angiography revealed triple-vessel coronary disease, and computed tomography confirmed a giant infrarenal fusiform abdominal aortic aneurysm 9 cm in maximal diameter. We simultaneously performed endovascular aneurysm repair prior to on-pump beating-heart coronary artery bypass grafting. The postoperative course was uneventful, and the patient was discharged on the 15th postoperative day.

CONCLUSION

Combined endovascular aneurysm repair and on-pump beating heart coronary artery bypass grafting in a one-stage operation is a promising strategy to improve therapeutic efficiency in octogenarians. More studies are needed to compare the efficacy and safety of one-stage and two-stage operations to treat concomitant coronary artery disease and aortovascular pathology in the high-risk octogenarian patients.

Endovascular treatment for ruptured abdominal aortic aneurysm

BACKGROUND

An abdominal aortic aneurysm (AAA) (pathological enlargement of the aorta) is a condition that can occur as a person ages. It is most commonly seen in men older than 65 years of age. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, which is fatal unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. Endovascular aneurysm repair (EVAR), a minimally invasive technique, has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. More recently emergency endovascular aneurysm repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in select patients; however, it is unclear if eEVAR will lead to significant improvements in outcomes for these patients or if indeed it can replace conventional open repair as the preferred treatment for this lethal condition. This is an update of the review first published in 2006.

OBJECTIVES

To assess the advantages and disadvantages of emergency endovascular aneurysm repair (eEVAR) in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm (RAAA). This will be determined by comparing the effects of eEVAR and conventional open surgical repair on short-term mortality, major complication rates, aneurysm exclusion (specifically endoleaks in the eEVAR treatment group), and late complications.

SEARCH METHODS

For this update the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (last searched June 2016), CENTRAL (2016, Issue 5), and trials registries. We also checked reference lists of relevant publications.

SELECTION CRITERIA

Randomised controlled trials in which participants with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies identified for potential inclusion for eligibility. Two review authors also independently completed data extraction and quality assessment. Disagreements were resolved through discussion. We performed meta-analysis using fixed-effect models with odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data and mean differences with 95% CIs for continuous data.

MAIN RESULTS

We included four randomised controlled trials in this review. A total of 868 participants with a clinical or radiological diagnosis of RAAA were randomised to receive either eEVAR or open surgical repair. Overall risk of bias was low, but we considered one study that performed randomisation in blocks by week and performed no allocation concealment and no blinding to be at high risk of selection bias. Another study did not adequately report random sequence generation, putting it at risk of selection bias, and two studies were underpowered. There was no clear evidence to support a difference between the two interventions for 30-day (or in-hospital) mortality (OR 0.88, 95% CI 0.66 to 1.16; moderate-quality evidence). There were a total of 44 endoleak events in 128 participants from three studies (low-quality evidence). Thirty-day complication outcomes (myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation, and respiratory failure) were reported in between one and three studies, therefore we were unable to draw a robust conclusion. We downgraded the quality of the evidence for myocardial infarction, renal complications, and respiratory failure due to imprecision, inconsistency, and risk of bias. Odds ratios for complications outcomes were OR 2.38 (95% CI 0.34 to 16.53; 139 participants; 2 studies; low-quality evidence) for myocardial infarction; OR 1.07 (95% CI 0.21 to 5.42; 255 participants; 3 studies; low-quality evidence) for renal complications; and OR 3.62 (95% CI 0.14 to 95.78; 32 participants; 1 study; low-quality evidence) for respiratory failure. There was low-quality evidence of a reduction in bowel ischaemia in the eEVAR treatment group, but very few events were reported (OR 0.37, 95% CI 0.14 to 0.94), and we downgraded the evidence due to imprecision and risk of bias. Six-month and one-year outcomes were evaluated in three studies, but only results from a single study could be used for each outcome, which showed no clear evidence of a difference between the interventions. We rated six-month mortality evidence as of moderate quality due to imprecision (OR 0.89, 95% CI 0.40 to 1.98; 116 participants).

AUTHORS' CONCLUSIONS

The conclusions of this review are currently limited by the paucity of data. We found from the data available moderate-quality evidence suggesting there is no difference in 30-day mortality between eEVAR and open repair. Not enough information was provided for complications for us to make a well-informed conclusion, although it is possible that eEVAR is associated with a reduction in bowel ischaemia. Long-term data were lacking for both survival and late complications. More high-quality randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.

Endovascular versus “Fast-Track” Abdominal Aortic Aneurysm Repair

Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 ±0.13 vs 6.1 ±0.17 cm, p=0.008), and had more patients designated American Society of Anesthesia class 4 (p<0.0001). Both groups were predominantly male. Otherwise there were no statistically significant differences in risk factors. Patients who underwent fast-track repair tended to have a longer operation (216 ±7.4 vs 158 ±6.8 minutes, p<0.0001), with a greater volume of blood (1.8 ±0.29 vs 0.32 ±0.24 units, p=0.0005), colloid (565 ±89 vs 32 ±22 cc, p<0.0001), and crystalloid transfusions (4,625 ±252 vs 2,627 ±170 cc, p<0.0001). There were no statistically significant differences in the number of intraoperative or postoperative complications between the 2 groups. EVAR patients resumed a regular diet earlier (0.21 ±0.08 vs 1.8 ±0.11 days, p<0.0001). Intensive care unit stay was shorter for EVAR (0.50 ±0.10 vs 0.87 ±0.10 days, p=0.01), but floor (2.1 ±0.23 vs 2.6 ±0.21 days, p=0.17), and total hospital lengths of stay (2.8 ±0.32 vs 3.4 ±0.18 days, p=0.07) were similar between the 2 groups. Total hospital cost was lower in the fast-track ($10,205 ±$736 vs $20,640 ±$1,206, p<0.0001) leading to greater overall hospital earnings ($6,141 ±$1,280 vs $107 ±$1,940, p=0.01). Fast-track AAA repair is a viable alternative for the treatment of abdominal aortic aneurysms. Compared to endovascular repair, the fast-track method had increased transfusions of blood and intravenous fluids and increased operating room times, but equivalent lengths of floor and total hospital stay and increased total hospital earnings.

Open Surgical Treatment of Aneurysmal Sac Expansion following Endovascular Abdominal Aneurysm Repair: Solution for an Unresolved Clinical Dilemma

The advantages of endovascular aneurysm repair (EVAR) are probably related to the avoidance of the three major physiological insults associated with open abdominal aortic aneurysm (AAA) repair: laparotomy, aortic cross-clamping and ischemia reperfusion injury. Continuing aneurysm expansion indicates a failure to exclude the AAA from the circulation. We describe our experience with open surgery of post-EVAR sac expansion. A consecutive series of 68 EVAR patients was followed up. Endovascular and minimally invasive procedures were the initial treatment option. Failure of these attempts to curtail AAA sac expansion or type 2 large endoleaks (EL) resulted in opening of the aneurysm sac. The procedure includes positioning of a deflated occlusion balloon proximal to the stent graft (SG). Laparotomy with opening of the eneurysm sac was then performed. The thrombus was removed and backbleeding vessels oversewn. The aneurysm sac was then plicated over the SG. Four patients (5.9%) were diagnosed as having either persistent large type 2 EL or sac enlargement. In all patients the procedure was accomplished successfully. One patient died from acute myocardial infarction perioperatively. Three patients recovered uneventfully and follow-up computed tomography confirmed the absence of endoleak and a disappearance of the AAA. We believe that whenever EVAR fails to exclude the aneurysm from the circulation, open exploration without graft replacement should be considered.

Endovascular repair or open repair for ruptured abdominal aortic aneurysm: a Cochrane systematic review

OBJECTIVES

Emergency endovascular aneurysm repair (eEVAR) may improve outcomes for patients with ruptured abdominal aortic aneurysm (RAAA). The study aim was to compare the outcomes for eEVAR with conventional open surgical repair for the treatment of RAAA.

SETTING

A systematic review of relevant publications was performed. Randomised controlled trials (RCTs) comparing eEVAR with open surgical repair for RAAA were included.

PARTICIPANTS

3 RCTs were included, with a total of 761 patients with RAAA.

INTERVENTIONS

Meta-analysis was performed with fixed-effects models with ORs and 95% CIs for dichotomous data and mean differences with 95% CIs for continuous data.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was short-term mortality. Secondary outcome measures included aneurysm-specific and general complication rates, quality of life and economic analysis.

RESULTS

Overall risk of bias was low. There was no difference between the 2 interventions on 30-day (or in-hospital) mortality, OR 0.91 (95% CI 0.67 to 1.22; p=0.52). 30-day complications included myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation and respiratory failure. Reporting was incomplete, and no robust conclusion was drawn. For complication outcomes that did include at least 2 studies in the meta-analysis, there was no clear evidence to support a difference between eEVAR and open repair. Longer term outcomes and cost per patient were evaluated in only a single study, thus precluding definite conclusions.

CONCLUSIONS

Outcomes between eEVAR and open repair, specifically 30-day mortality, are similar. However, further high-quality trials are required, as the paucity of data currently limits the conclusions.

Endovascular treatment for ruptured abdominal aortic aneurysm

BACKGROUND

An abdominal aortic aneurysm (AAA) (pathological enlargement of the aorta) can develop in both men and women as they grow older. It is most commonly seen in men over the age of 65 years. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, a fatal event unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. A newer minimally invasive technique, endovascular aneurysm repair (EVAR), has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. Emergency endovascular aneurysm repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in selected patients. However, it is not yet known if eEVAR will lead to significant improvements in outcomes for these patients or indeed if it can replace conventional open repair as the preferred treatment for this lethal condition.

OBJECTIVES

To assess the advantages and disadvantages of emergency endovascular aneurysm repair (eEVAR) in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm (RAAA). This will be determined by the effect on short-term mortality, major complication rates, aneurysm exclusion, and late complications when compared with the effects in patients who have had conventional open repair of RAAA.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2014) and CENTRAL (2014, Issue 2). Reference lists of relevant publications were also checked.

SELECTION CRITERIA

Randomised controlled trials in which patients with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair.

DATA COLLECTION AND ANALYSIS

Studies identified for potential inclusion were independently assessed for eligibility by at least two review authors. Data extraction and quality assessment were also completed independently by two review authors. Disagreements were resolved through discussion. Meta-analysis was performed using fixed-effect models with odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data and mean differences with 95% CIs for continuous data.

MAIN RESULTS

Three randomised controlled trials were included in this review. A total of 761 patients with a clinical or radiological diagnosis of RAAA were randomised to receive either eEVAR or open surgical repair. Overall risk of bias was low but one study did not adequately report random sequence generation, putting it at risk of selection bias, two studies did not report on outcomes identified in their protocol, indicating reporting bias, and one study was underpowered. There was no clear evidence to support a difference between the two interventions on 30-day (or in-hospital) mortality, OR of 0.91 (95% CI 0.67 to 1.22; P = 0.52). The 30-day complications included myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, re-operation, amputation, and respiratory failure. Individual complication outcomes were reported in only one or two studies and therefore no robust conclusion can currently be drawn. For complication outcomes that did include at least two studies in the meta-analysis there was no clear evidence to support a difference between eEVAR and open repair. Six-month outcomes were evaluated in only a single study, which included mortality and re-operation, with no clear evidence of a difference between the interventions and no overall association. Cost per patient was only evaluated in a single study and therefore no overall associations can currently be derived.

AUTHORS' CONCLUSIONS

The conclusions of this review are currently limited by the paucity of data. From the data available there is no difference in the outcomes evaluated in this review between eEVAR and open repair, specifically 30-day mortality. Not enough information was provided for complications in order to make a well informed conclusion at this time. Long-term data are lacking for both survival and late complications. More high quality, randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed in order to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.

Endovascular repair of abdominal aortic aneurysm

BACKGROUND

An abnormal dilatation of the abdominal aorta is referred to as an abdominal aortic aneurysm (AAA). Due to the risk of rupture, surgical repair is offered electively to individuals with aneurysms greater than 5.5 cm in size. Traditionally, conventional open surgical repair (OSR) was considered the first choice approach. However, over the past two decades endovascular aneurysm repair (EVAR) has gained popularity as a treatment option. This article intends to review the role of EVAR in the management of elective AAA.

OBJECTIVES

To assess the effectiveness of EVAR versus conventional OSR in individuals with AAA considered fit for surgery, and EVAR versus best medical care in those considered unfit for surgery. This was determined by the effect on short, intermediate and long-term mortality, endograft related complications, re-intervention rates and major complications.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (January 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12). The TSC also searched trial databases for details of ongoing or unpublished studies.

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) comparing EVAR with OSR in individuals with AAA considered fit for surgery. and comparing EVAR with best medical care in individuals considered unfit for surgery. We excluded studies with inadequate data or using an inadequate randomisation technique.

DATA COLLECTION AND ANALYSIS

Three reviewers independently evaluated trials for appropriateness for inclusion and extracted data using pro forma designed by the Cochrane PVD Group. We assessed the quality of trials using The Cochrane Collaboration's 'Risk of bias' tool. We entered collected data in to Review Manager (version 5.2.3) for analysis. Where direct comparisons could be made, we determined odds ratios (OR). We tested studies for heterogeneity and, when present, we used a random-effects model; otherwise we used a fixed-effect model. We tabulated data that could not be collated.

MAIN RESULTS

Four high-quality trials comparing EVAR with OSR (n = 2790) and one high-quality trial comparing EVAR with no intervention (n = 404) fulfilled the inclusion criteria. In individuals considered fit for surgery, a pooled analysis, including 1362 individuals randomised to EVAR and 1361 randomised to OSR, found short-term mortality (including 30-day or inhospital mortality, excluding deaths prior to intervention) with EVAR to be significantly lower than with OSR (1.4% versus 4.2%, OR 0.33, 95% confidence interval (CI) 0.20 to 0.55; P < 0.0001). Using intention-to-treat analysis (ITT) there was no significant difference in mortality at intermediate follow-up (up to four years from randomisation), with 221 (15.8%) and 237 (17%) deaths in the EVAR (n = 1393) and OSR (n = 1390) groups, respectively (OR 0.92, 95% CI 0.75 to 1.12; P = 0.40). There was also no significant difference in long-term mortality (beyond four years), with 464 (37.3%) deaths in the EVAR and 470 (37.8%) deaths in the OSR group (OR 0.98, 95% CI 0.83 to 1.15; P = 0.78). Similarly, there was no significant difference in aneurysm-related mortality between groups, either at the intermediate- or long-term follow up.Studies showed that both EVAR and OSR were associated with similar incidences of cardiac deaths (OR 1.14, 95% CI 0.86 to 1.52; P = 0.36) and fatal stroke rate (OR 0.81, 95% CI 0.42 to 1.55; P = 0.52). The long-term reintervention rate was significantly higher in the EVAR group than in the OSR group (OR 1.98, 95% CI 1.12 to 3.51; P = 0.02; I(2) = 85%). Results of the reintervention analysis should be interpreted with caution due to significant heterogeneity. Operative complications, health-related quality of life and sexual dysfunction were generally comparable between the EVAR and OSR groups. However, there was a slightly higher incidence of pulmonary complications in the OSR group compared with the EVAR group (OR 0.36, 95% CI 0.17 to 0.75; P = 0.006).In individuals considered unfit for conventional OSR, the one included trial found no difference between the EVAR and no-intervention groups with regard to all-cause mortality at final follow up, with 21.0 deaths per 100 person-years in the EVAR group and 22.1 deaths per 100 person years in the no-intervention group (adjusted hazard ratio (HR) with EVAR 0.99, 95% CI 0.78 to 1.27; P = 0.97). Aneurysm-related deaths were, however, significantly higher in the no-intervention group than in the EVAR group (adjusted HR 0.53, 95% CI 0.32 to 0.89; P = 0.02). There was no difference in myocardial events (HR 1.07, 95% CI 0.60 to 1.91) between the groups in this study.

AUTHORS' CONCLUSIONS

In individuals considered fit for conventional surgery, EVAR was associated with lower short-term mortality than OSR. However, this benefit from EVAR did not persist at the intermediate- and long-term follow ups. Individuals undergoing EVAR had a higher reintervention rate than those undergoing OSR. Most of the reinterventions undertaken following EVAR, however, were catheter-based interventions associated with low mortality. Operative complications, health-related quality of life and sexual dysfunction were generally comparable between EVAR and OSR. However, there was a slightly higher incidence of pulmonary complications in the OSR group than in the EVAR group.In individuals considered unfit for open surgery, the results of a single trial found no overall short- or long-term benefits of EVAR over no intervention with regard to all-cause mortality, but individuals may differ and individual preferences should always be taken into account.

Successful Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm in a Patient with Severe Coronary Artery Disease Undergoing Off-Pump Coronary Artery Bypass Grafting

It is well known that patients with abdominal aortic aneurysm (AAA) often have concomitant coronary artery disease (CAD). In cases of AAA with severe CAD requiring coronary artery bypass grafting (CABG), two therapeutic strategies regarding the timing of CABG can be considered: staged or simultaneous operations. However, the ideal treatment of patients with large AAA and critical CAD remains controversial. We experienced a case of successful endovascular aneurysm repair after off-pump CABG in a 70-year-old patient who had a huge AAA and critical CAD.

Ruptured AAA: suitability for endovascular repair is associated with lower mortality following open repair

OBJECTIVES

Perioperative mortality of open repair of ruptured abdominal aortic aneurysms (rAAA) remains unacceptably high: 30-day mortality ≈ 40 %. This study aimed to assess, quantify, and determine the consequences of anatomic suitability for endovascular repair of rAAA.

DESIGN

A retrospective analysis of the prospectively maintained database identified patients with rAAA.

METHODS

Preoperative CT scans were assessed for anatomic suitability for emergency EVAR and precluding factors recorded. Demographic information was collected and analysed for all patients.

RESULTS

A total of 141 patients underwent open surgical repair of rAAA. Forty-six patients had preoperative CT scans suitable for reconstruction. Morphological measurements indicated that 41 % would have been anatomically suitable for EVAR. Suitability was associated with lower mortality rates than unsuitability: 0, 11, and 20 % (24 h, 30 days, and 1 year respectively) versus 11, 33, and 59 % (statistically significant at 1 year; p = 0.02). The groups were comparable excepting diabetes incidence, which was higher in those suitable for EVAR (p = 0.003).

CONCLUSIONS

A minority of patients with ruptured AAA are anatomically suitable for EVAR. Anatomical suitability appears to identify patients at low risk from open surgery. Whether this is due to technically less demanding open surgery is unknown. This may be resolved by the IMPROVE trial results, which are eagerly awaited.

Mortality and reintervention following elective abdominal aortic aneurysm repair

BACKGROUND

The objective of this study is to provide an up-to-date meta-analysis on the short- and long-term mortality rates of elective repair of abdominal aortic aneurysms (AAAs) via the open and endovascular approaches.

METHODS

MEDLINE, EMBASE, and Cochrane Central Register of Controlled trials, conference proceeding from major vascular meetings were searched for randomized trials comparing open vs elective endovascular aneurysm repair (EVAR) of AAAs. A random-effects model was used for analysis. Risk ratio (RR) and 95% confidence intervals (CIs) of open vs EVAR were calculated for short- and long-term mortality and reintervention rates.

RESULTS

The analysis encompassed four randomized controlled trials with a total of 2783 patients. The open repair group resulted in significantly increased 30-day postoperative all-cause mortality compared with EVAR repair group (3.2% vs 1.2%; RR, 2.81; 95% CI, 1.60-4.94); however, there is no statistical difference in the long-term all-cause mortality between both groups (RR, 0.97; 95% CI, 0.86-1.10). Interestingly, fewer patients underwent reintervention procedures in the open repair group compared with those who had EVAR repair (9.3% vs 18.9%; RR, 0.49; 95% CI, 0.40-0.60), but this finding is doubtful due to the large heterogeneity. Lastly, no statistical difference in long-term mortality rates attributable to cardiovascular disease (CVD), aneurysm related, or stroke were found between the two types of repair.

CONCLUSIONS

Results of this meta-analysis demonstrate that the 30-day all-cause mortality rate is higher with open than with EVAR repair; however, there is no statistical difference in the long-term all-cause and cause-specific mortality between both groups. The reintervention rate attributable to procedural complication was higher in the EVAR group. Because of the equivalency of long-term outcomes and the short-term benefits of EVAR, an endovascular-first approach to AAAs can be supported by the meta-analysis.

Comparison of endovascular and open repair of ruptured abdominal aortic aneurysm in the United States in the past decade

PURPOSE

The purpose of this study is national-level comparison of the endovascular (EVAR) and open repair (OAR) of ruptured abdominal aortic aneurysm (AAA) in the United States from 2001 to 2010.

METHODS

The data were obtained from nationwide inpatient sample from the Department of Health and Human Services. Ruptured AAA treated by OAR or EVAR were selected using combination ICD-9 codes.

RESULTS

There were 42,126 cases of ruptured AAA of which 8,140 (19.3%) were repaired by EVAR. EVAR patients were older (74.1 vs. 72.8 years, p < 0.001) and had higher incidence of comorbidities compared with OAR group. EVAR patients had lower in-hospital mortality (25.9 vs. 39.1%, p < 0.001) and shorter hospital stay (10.4 vs. 13.7 days, p < 0.001). More patients were discharged home following EVAR (36.8 vs. 21.5%, p < 0.001). There was reduced need for institutional rehabilitation following EVAR (26.3 vs. 29.1%, p < 0.001). Females had significantly higher mortality compared with males after both EVAR (32.2 vs. 24.1%, p < 0.001) and OAR (46.2 vs. 36.9%, p < 0.001). The hospital mortality (41.3-25.8%, p < 0.001) and mean length of stay (11.8-9.7 days, p < 0.01) of EVAR steadily improved over the study period.

CONCLUSIONS

National level comparison of data from the past decade shows that in suitable cases, EVAR for ruptured AAA is associated with reduced hospital mortality, shorter hospital stay, and reduced need for rehabilitation. EVAR outcomes showed consistent improvement with time. Regardless of the type of repair, women had higher mortality compared with men.

Endovascular abdominal aortic aneurysm repair in the geriatric population

Abdominal aortic aneurysm (AAA) is a relatively common pathology among the elderly. More people above the age of 80 will have to undergo treatment of an AAA in the future. This review aims to summarize the literature focusing on endovascular repair of AAA in the geriatric population. A systematic review of the literature was performed, including results from endovascular abdominal aortic aneurysm repair (EVAR) registries and studies comparing open repair and EVAR in those above the age of 80. A total of 15 studies were identified. EVAR in this population is efficient with a success rate exceeding 90% in all cases, and safe, with early mortality and morbidity being superior among patients undergoing EVAR against open repair. Late survival can be as high as 95% after 5 years. Aneurysm-related death over long-term follow-up was low after EVAR, ranging from 0 to 3.4%. Endovascular repair can be offered safely in the geriatric population and seems to compare favourably with open repair in all studies in the literature to date.

Nationwide trends in abdominal aortic aneurysm repair and use of endovascular repair in the emergency setting

PURPOSE

To analyze nationwide trends in abdominal aortic aneurysm (AAA) repair and the use of endovascular abdominal aortic aneurysm repair (EVAR) in the emergency setting.

MATERIALS AND METHODS

Data were obtained from the Nationwide Inpatient Sample (NIS) using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes for open and endovascular repairs from 2001-2009. Trends in outcome parameters and hospital charges were compared.

RESULTS

The number of emergency EVAR procedures increased from 382 in 2001 to 1,247 in 2009 (P < .001). During the study period, length of hospital stay associated with total number of EVAR procedures decreased from 3.8 days to 3.4 days (P < .05), and the in-hospital mortality decreased from 2.4% to 2% (P = .32). From 2001-2009, mean hospital charges associated with EVAR increased from $50,630 to $91,401 (74% increase), whereas charges associated with open repairs increased from $54,578 to $128,925 (136% increase). The proportion of patients needing rehabilitation or nursing home placement after EVAR increased from 5.8% to 7.7% (P < .01), and need for home health increased from 6.9% to 10.5% (P < .01).

CONCLUSIONS

There was a significant increase in the number of emergency EVAR procedures during the study period; however, the overall in-hospital mortality associated with EVAR remained unchanged, and the length of hospital stay showed a decreasing trend. The total hospital charges for EVAR were lower than the charges for open abdominal aneurysm repair throughout the study period; the difference in charges between the procedures showed a significant increasing trend with time.

Tratamento endovascular do aneurisma da aorta abdominal infrarrenal em pacientes com anatomia favorável para o procedimento: experiência inicial em um serviço universitário

CONTEXTO: Desde sua introdução, em 1991, o reparo endovascular do aneurisma da aorta abdominal infrarrenal tem se tornado uma alternativa atraente para o tratamento dessa doença. Avaliar nossos resultados iniciais quanto à segurança e eficácia dessa técnica nos levou à realização deste estudo. OBJETIVOS: Analisar a mortalidade perioperatória, a sobrevida tardia, as reoperações, as taxas de perviedade e o comportamento do saco aneurismático em pacientes com anatomia favorável para a realização do procedimento. MÉTODOS: Trata-se de um estudo longitudinal, observacional e retrospectivo realizado entre outubro de 2004 e janeiro de 2009 com 41 pacientes que foram submetidos à correção endovascular do aneurisma de aorta abdominal infrarrenal por apresentarem anatomia favorável para o procedimento. Foram analisados os achados dos exames diagnósticos, o tratamento e o seguimento em todos os pacientes. RESULTADOS: Foram implantadas, com sucesso, 31 (75,6%) próteses bifurcadas e 10 (24,5%) monoilíacas, de 5 diferentes marcas. O diâmetro médio dos aneurismas fusiformes era de 62 mm. A mortalidade perioperatória foi de 4,8% e a sobrevida tardia, 90,2%. Durante o acompanhamento médio de 30 meses, 2 (4,8%) pacientes necessitaram de reintervenção, um por migração da endoprótese e outro por vazamento tipo II. Dois (4,8%) pacientes apresentaram oclusão de ramo da prótese. Oito (19,5%) vazamentos foram diagnosticados e não houve nenhuma rotura dos aneurismas. CONCLUSÃO: Apesar do pequeno número de pacientes, os resultados observados parecem justificar a realização do procedimento endovascular nos pacientes com anatomia favorável.

Use of non-randomised evidence alongside randomised trials in a systematic review of endovascular aneurysm repair: strengths and limitations

OBJECTIVE

To assess whether limitations of randomised controlled trials (RCTs) of endovascular aneurysm repair (EVAR) can be addressed by evidence from non-randomised studies.

DESIGN

Analysis of data from a systematic review.

METHODS

We conducted a review of EVAR versus open repair or non-surgical management of abdominal aortic aneurysms. In addition to RCTs, we included pre-specified registries of EVAR and open repair.

RESULTS

The six included RCTs randomised patients in 2003 and earlier. Of the three registries included, one contributed data on a large (>8000) sample of patients treated with newer generation EVAR devices and followed up for up to 8 years. However, treatment dates of these patients overlapped with those of the RCTs. The other registries were of limited usefulness. A large (>45,000) controlled observational study published while the review was in progress broadly supported the findings of RCTs comparing EVAR with open surgery. A comparison of outcomes across all studies did not support the hypothesis that the findings of the RCTs are no longer representative of clinical practice.

CONCLUSIONS

Both randomised and non-randomised sources of evidence have strengths and weaknesses for assessing the effectiveness of EVAR. Further research should explore the optimum use of registry data, including patient-level analyses.

Revised Cardiac Risk Index (Lee) and perioperative cardiac events as predictors of long-term mortality in patients undergoing endovascular abdominal aortic aneurysm repair

OBJECTIVE

To determine if the Revised Cardiac Risk Index (Lee) is useful for stratification of patients by risk of both perioperative cardiac morbidity and long-term all-cause mortality in the setting of endovascular repair of abdominal aortic aneurysms.

DESIGN

This study was designed as a retrospective review.

SETTING

It was conducted at a single academic medical institution.

PARTICIPANTS

The analysis included 225 patients with abdominal aortic aneurysms admitted to the authors' institution from 1999 to 2006.

INTERVENTIONS

All patients underwent endovascular aortic aneurysm repair.

MEASUREMENTS AND MAIN RESULTS

Data were collected from medical records, office charts, and physician quality-assurance databases. There were no in-hospital cardiac deaths. The major adverse cardiac event rate in the perioperative period was 6.2%. Long-term all-cause mortality was 23%. Univariate analysis showed that a history of coronary artery disease (CAD) (likelihood ratio [LR] = 8.7, p = 0.023), history of congestive heart failure (LR = 4, p = 0.042), and a Revised Cardiac Risk Index (RCRI) > or =3 (LR = 8.6, p = 0.004) were significant predictors for perioperative major adverse cardiac events. A history of CAD (LR = 10.7, p = 0.002), echocardiographic evidence of myocardial infarction (LR = 8.5, p = 0.006), exercise tolerance of only 1 block (LR = 8.4, p = 0.005), RCRI > or =3 (LR = 5.6, p = 0.022), and perioperative cardiac events (LR = 15.9, p < 0.0001) were significantly associated with long-term all-cause mortality. Perioperative cardiac events remained highly significant in predicting long-term mortality within the RCRI > or =3 subgroup (LR = 6.1, p = 0.019).

CONCLUSIONS

The results of this study confirm that long-term mortality remains high after endovascular repair of abdominal aortic aneurysms. The Lee index may be a useful tool for stratification of high-risk patients from both a short- and long-term perspective in the setting of endoluminal graft repair.

Effects of study design and trends for EVAR versus OSR

Purpose:

To investigate if study design factors such as randomization, multi-center versus single center evidence, institutional surgical volume, and patient selection affect the outcomes for endovascular repair (EVAR) versus open surgical repair (OSR). Finally, we investigate trends over time in EVAR versus OSR outcomes.

Methods:

Search strategies for comparative studies were performed individually for: OVID’s MEDLINE, EMBASE, CINAHL, HAPI, and Evidence Based Medicine (EBM) Reviews (including Cochrane DSR, ACP Journal Club, DARE and CCTR), limited to 1990 and November 2006.

Results:

Identified literature: 84 comparative studies pertaining to 57,645 patients. These include 4 randomized controlled trials (RCTs), plus 2 RCTs with long-term follow-up. The other 78 comparative studies were nonrandomized with 75 reporting perioperative outcomes, of which 16 were multi-center, and 59 single-center studies. Of the single-center studies 31 were low-volume and 28 were high-volume centers. In addition, 5 studies had all patients anatomically eligible for EVAR, and 8 studies included high-risk patients only. Finally, 25 long term observational studies reported outcomes up to 3 years.

Outcomes:

Lower perioperative mortality and rates of complications for EVAR versus OSR varied across study designs and patient populations. EVAR adverse outcomes have decreased in recent times.

Conclusion:

EVAR highlights the problem of performing meta-analysis when the experience evolves over time.

A comparative study of myocardial injury during conventional and endovascular aortic aneurysm repair: measurement of cardiac troponin T and plasma cytokine release

BACKGROUND

Major aortic surgery results in significant haemodynamic and oxidative stress to the myocardium. Cytokine release is a major factor in causing cardiac injury during aortic surgery. Endovascular aortic aneurysm repair (EVAR) has the potential to reduce the severity of the ischaemia reperfusion syndrome and its systemic consequences.

AIM

The aim of this study was to investigate the occurrence of myocardial injury during conventional and endovascular abdominal aortic aneurysm repair using measurement of the myocardial-specific protein, cardiac troponin T. Interleukin-6 was also measured in both groups and haemodynamic responses to surgery assessed.

METHODS

Nine consecutive patients undergoing conventional infra-renal aortic aneurysm surgery were compared with 13 patients who underwent EVAR. Patients were allocated on the basis of aneurysm morphology and suitability for endovascular repair.

RESULTS

Patients undergoing open repair had significantly more haemodynamic disturbance than those having endovascular repair (mean arterial pressure at 5 min following unclamping or balloon deflation: open (69.6 + 3.3 mmHg); endovascular (86 + 4.4 mmHg), P < 0.05 vs. pre-op). Troponin T levels at 48 h post-operatively were higher in patients who underwent open repair (open 0.164 + 0.1 ng/ml; endovascular 0.008 + 0.0005 ng/ml, P < 0.04). Significantly more patients in the open repair group had troponin T levels > 0.1 ng/l when compared with the endovascular group (P < 0.01, chi (2) test)

CONCLUSION

Endovascular aortic surgery produces significantly less myocardial injury than the open technique of aortic aneurysm repair.

A meta-analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm

Background

Several studies have compared outcomes after elective open and endovascular approaches to abdominal aortic aneurysm (AAA) surgery, with varying results.

Methods

A random-effects meta-analysis was undertaken to compare operative outcomes, postoperative complications, 30-day mortality and long-term patient survival after surgery. Endpoints were compared using odds ratios (ORs), weighted mean differences (WMDs) or log hazard ratios (HRs) as appropriate.

Results

Forty-two studies comprising 21 178 patients (10 855 open; 10 323 endovascular) were included. In the elective setting (20 715 patients), the endovascular method was associated with a shorter stay in intensive care (WMD − 36 h; P &lt; 0·001) and a shorter total postoperative stay (WMD − 5·4 days; P &lt; 0·001). Cardiac (OR 1·76; P = 0·002) and respiratory (OR 4·01; P &lt; 0·001) complications were more common after open surgery. In the endovascular group, 30-day mortality was lower (OR 0·46; P &lt; 0·001). Endovascular surgery was also associated with an improved long-term aneurysm-related mortality (HR 0·39; P &lt; 0·001). For ruptured AAA (463 patients), the less invasive operation was associated with a reduced stay in intensive care (WMD − 100·4 h; P = 0·005) and a significantly lower 30-day mortality (OR 0·45; P = 0·005).

Conclusions

The endovascular repair of AAA offers a clear benefit in terms of reduction in postoperative adverse events and 30-day mortality. In the longer term, it is also associated with a reduction in aneurysm-related mortality, but not in all-cause mortality.

Endovascular Ruptured Abdominal Aortic Aneurysm Repair (EVRAR): A Systematic Review

BACKGROUND

To review evidence supporting the use of endovascular ruptured aneurysm repair (EVRAR) for treatment of ruptured abdominal aortic aneurysm (RAAA).

METHODS

A systematic review of the medical literature was performed for relevant studies. We searched a number of electronic databases and hand-searched relevant journals until November 2006 to identify studies for inclusion. We considered studies in which patients with a confirmed ruptured abdominal aortic aneurysm were treated with EVRAR, which reported endpoints of mortality and major complications.

RESULTS

There was 1 randomised controlled trial (RCT), 33 non-randomised case series (24 retrospective and 9 prospective) reports were identified comparing EVRAR (n=891) with conventional open surgical repair for the treatment of RAAA. Whilst no benefit in the primary outcome of mortality was noted in the only RCT, evidence from non-randomised studies suggest that EVRAR is feasible in selected patients, where it may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, early complications, and mortality.

CONCLUSIONS

For the treatment of symptomatic or ruptured abdominal aortic aneurysm, emergency endovascular repair (EVRAR) is feasible in selected patients, with early outcomes comparable to best conventional open surgical repair for the treatment of RAAA.

Long-Term Single-Center Results with Aneurx Endografts for Endovascular Abdominal Aortic Aneurysm Repair

PURPOSE

To evaluate the long-term single-center results with the AneuRx stent-graft in endovascular abdominal aortic aneurysm (AAA) repair (EVAR).

METHODS

Between December 1996 and August 2003, 212 patients (197 men; mean age 71.3+/-7.0 years) were treated with the AneuRx stent-graft for an infrarenal AAA. Postoperatively, patients were enrolled in a fixed surveillance protocol, and data were prospectively captured into a database.

RESULTS

Graft deployment was successful in 98.6% (209/212). Thirty-day mortality was 2.4%. Median hospital stay was 4.3+/-5.5 days. Median follow-up was 52.0 months (range 1-109); only 1 patient was lost to follow-up. At 9 years, patient survival was 56% and freedom from secondary interventions was 48%. In 68% of cases, these reinterventions were needed for a fixation-related complication, and most of these complications (75%) encompassed the area of the proximal aneurysm neck. Primary clinical success was 37% at 9 years. After secondary interventions, the assisted primary clinical success improved to 73% at 9 years. Freedom from aneurysm-related death was 97% at 1 year and 90% at 9 years.

CONCLUSION

As an alternative to open repair, EVAR with the AneuRx device has low perioperative mortality. Reinterventions are mostly due to fixation-related complications. While the overall mortality risk in this population was 5% per year, annual aneurysm-related death was only 1%. The focus should be on surveillance and reducing the rate of long-term complications, which might be possible with improved proximal stent-graft fixation.

Myocardial Damage in High-risk Patients Undergoing Elective Endovascular or Open Infrarenal Abdominal Aortic Aneurysm Repair

OBJECTIVE

Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results.

METHODS

Consecutive patients with >or=3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death.

RESULTS

All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair.

CONCLUSION

In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.

Endovascular treatment for ruptured abdominal aortic aneurysm

BACKGROUND

An abdominal aortic aneurysm (AAA) (the pathological enlargement of the aorta) can develop in both men and women as they grow older. It is most commonly seen in men over the age of 65 years. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, a fatal event unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. A newer minimally invasive technique, endovascular repair, has been shown to reduce early morbidity and mortality, as compared to conventional open surgery, for planned AAA repair. Emergency endovascular repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in selected patients. However, it is not yet known if eEVAR will lead to significant improvements in outcomes for these patients or indeed if it can replace conventional open repair as the preferred treatment for this lethal condition.

OBJECTIVES

To compare the advantages and disadvantages of eEVAR in comparison with conventional open surgical repair for the treatment of RAAA.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched October 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) database (last searched Issue 4, 2006). We searched a number of electronic databases and handsearched relevant journals until March 2006 to identify studies for inclusion.

SELECTION CRITERIA

Randomised controlled trials in which patients with a confirmed ruptured abdominal aortic aneurysm were randomly allocated to eEVAR, or conventional open surgical repair.

DATA COLLECTION AND ANALYSIS

Studies identified for potential inclusion were independently assessed for eligibility by at least two reviewers, with excluded studies further checked by the agreed arbitrators. As no randomised controlled trials were identified at present no tests of heterogeneity or sensitivity analysis were performed.

MAIN RESULTS

There were no randomised controlled trials identified at present comparing eEVAR with conventional open surgical repair for the treatment of RAAA.

AUTHORS' CONCLUSIONS

There is no high quality evidence to support the use of eEVAR in the treatment of RAAA. However, evidence from prospective controlled studies without randomisation, prospective studies, and retrospective case series suggest that eEVAR is feasible in selected patients, with outcomes comparable to best conventional open surgical repair for the treatment of RAAA . Furthermore, endovascular repair in selected patients may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, and mortality.

Defining the role of endovascular therapy in the treatment of abdominal aortic aneurysm: results of a prospective randomized trial

Following publication of early registry data showing poor durability for first-generation endografts, EVAR was labeled by some as a failed experiment. The EVAR trial results prove such a pessimistic appraisal of EVAR wrong. In patients fit for open AAA repair EVAR w ith current devicesachieves a 3% benefit in operative and 4-year aneurysm-related mortality compared with open surgery. In patients unfit for open repair 30-day mortality is significantly greater and can no longer be described as safe. Nor does EVAR affect aneurysm-related or all-cause mortality in the 4-year follow-up. EVAR, at least for the first 4 years, is not safe or effective. Based on these results it seems appropriate in unfit patients to attend to concurrent medical problems before considering intervention for an asymptomatic aneurysm. Before the publication of this trial it was generally believed that EVAR would be of benefit in such patients; indeed, it was for the high-risk patient that EVAR was originally conceived. The focus changes from urgency to deploy EVAR to improvement of fitness, recognizing that such patients are very sick with multiple comorbidities. In both fit and unfit patients with large aneurysms most late deaths were cardiovascular related. The importance of risk factor management in both patient groups cannot be overstated. Despite the cost implications of EVAR and its failure to improve mid-term all-cause mortality over open AAA repair it is likely that the bias of both patients and surgeons toward this minimally invasive procedure means that it will continue to have a significant role. Experience and endograft developments have the potential to reduce postoperative complications; surveillance strategies could then be amended to reduce cost implications. Alternatively, over time the currently static rate of complications may increase as endografts reach the end of their working life. The long-term follow-up of patients in both the both EVAR Trials 1 and 2 has the potential for future surprises.

Perioperative and long-term cardiovascular outcomes in patients undergoing endovascular treatment compared with open vascular surgery for abdominal aortic aneurysm or iliaco-femoro-popliteal bypass

The aim of the present study was to determine the perioperative and long-term cardiac outcomes of patients who underwent elective open or endovascular major vascular surgery corrected for cardiac risk factors and dobutamine stress echocardiography. Consecutive patients who underwent either endovascular (n = 123) or open (n = 560) vascular surgery from 1996 to 2004 at Erasmus Medical Center were enrolled. Patients were screened for cardiac risk factors (advanced age, gender, angina pectoris, myocardial infarction, heart failure, diabetes, stroke, renal failure), cardioprotective medication, and the presence of stress-induced ischemia by dobutamine stress echocardiography. Postoperative data on troponin release and electrocardiography were routinely collected on days 1, 3, and 7 and before discharge. After discharge, patients were regularly screened at the outpatient clinic. The main outcome measures were perioperative and long-term cardiac death and myocardial infarction. The incidence of perioperative cardiac events was significantly less in endovascular-treated patients compared with conventionally treated patients, also after adjustment for clinical risk factors, dobutamine stress echocardiography, and medication (hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.07 to 0.53). In contrast, during long-term follow-up (median 3.8 years, range 0 to 8.4), the incidence of long-term cardiac mortality and myocardial infarction were similar in the 2 groups (HR 0.89, 95% CI 0.52 to 1.52). In conclusion, endovascular stent grafting is associated with a reduced incidence of perioperative complications compared with open vascular surgery. Despite the initial perioperative survival benefit, patients who undergo endovascular surgery remain at high risk for late cardiac events.

Local anesthesia for endovascular abdominal aortic aneurysm repair

OBJECTIVES

This study reports the results of a prospective continuous cohort of patients treated for endovascular aneurysm repair (EVAR) with a unified anesthetic strategy based on the use of local anesthesia (LA) in all patients, while reserving regional (RA) or general anesthesia (GA) only for those with predefined individually or surgically specific indications.

METHODS

All patients treated by EVAR for an elective aortic abdominal aneurysm (AAA) between April 1998 and December 2003 were included. The strategy of treatment generated three cohorts of patients (LA, RA, or GA). Primary outcome included all-cause mortality, nonfatal cardiac morbidity, respiratory complications, and renal failure. Secondary outcome measures included conversion to general anesthesia, use of analgesics, and time-related outcomes (operating time, length of stay in intensive care unit and hospital, time required to resume oral intake, and time to ambulation).

RESULTS

A total of 239 patients underwent EVAR: 170 LA, 31 RA, and 38 GA. Overall mortality was one patient (0.4%). LA was associated with a lower incidence of complications compared with GA (P < .001). In the LA group, two patients had to be converted to GA, one because of a dissection and one because of anxiety. In 13% of the patients in the LA group, additional intravenous sedation or analgesia was required. Operating time and length of stay in intensive care was shorter in the LA and RA groups than in the GA group (P < .001). Length of stay in hospital and time to ambulation and regular diet was shorter in the LA group compared with the RA and GA groups (P < .001).

CONCLUSIONS

A strategy based on the preferential use of LA for EVAR restricting RA or GA only to those with predefined contraindications is feasible and appears to be well tolerated.

Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm

Background

Conventional management of abdominal aortic aneurysm (AAA) is by open repair and is associated with a mortality rate of 2–6 per cent. Endovascular aneurysm repair (EVAR) is an alternative technique first introduced in 1991. A systematic review was undertaken of the evidence for the safety and efficacy of elective EVAR in the management of asymptomatic infrarenal AAA.

Methods

Thirteen electronic bibliographical databases were searched, covering biomedical, health-related, science and social science literature. Outcomes were assessed with respect to efficacy (successful deployment, technical success, conversion rates and secondary intervention rates) and safety (30-day mortality rate, procedure morbidity rates and technical issues—endoleaks, graft thrombosis, stenosis and migration).

Results

Of 606 reports identified, 61 met the inclusion criteria (three randomized and 15 non-randomized controlled trials, and 43 uncontrolled studies). There were 29 059 participants in total; 19 804 underwent EVAR. Deployment was successful in 97·6 per cent of cases. Technical success (complete aneurysm exclusion) was 81·9 per cent at discharge and 88·8 per cent at 30 days. Secondary intervention to treat endoleak or maintain graft patency was required in 16·2 per cent of patients. Mean stay in the intensive care unit and mean hospital stay were significantly shorter following EVAR. The 30-day mortality rate for EVAR was 1·6 per cent (randomized controlled trials) and 2·0 per cent in nonrandomized trials and case series. Technical complications comprised stent migration (4·0 per cent), graft limb thrombosis (3·9 per cent), endoleak (type I, 6·8 per cent; type II, 10·3 per cent; type III, 4·2 per cent) and access artery injury (4·8 per cent).

Discussion

EVAR is technically effective and safe, with lower short-term morbidity and mortality rates than open surgery. However, there is a need for extended follow-up as the long-term success of EVAR in preventing aneurysm-related deaths is not yet known.

Complications of major aortic and lower extremity vascular surgery

Atheromatous disease and invasive intervention of the aortoiliac and distal arteries are common. Morbidity and mortality have been reduced through understanding and management of patient risk factors. Complications of this form of treatment affect all organ systems; mortality is most frequently caused by a cardiovascular complication (eg, myocardial infarction). Infection, leading to aortoenteric fistula is a dreaded complication, and paraplegia, though rare, is a devastating outcome. Multiorgan failure and death may result from a systemic inflammatory response syndrome. Vascular surgery for infrainguinal disease also has a significant cardiovascular complication rate. Resulting complications may affect all organs; loss of an extremity may occur. The first part of this article reviews perioperative and postoperative complications of open aortic repair and lower-extremity revascularization and addresses the issue of regional anesthesia for major vascular surgery. The second part reviews endovascular aortic repair (EVAR). EVAR is a new intervention that combines surgery and radiology. Complications of EVAR are similar to open repair, but early results suggest they may be less frequent. New technology leads to new complications; endoleaks, migration of the endoprosthesis, and surgical conversion are unique to EVAR. The benefits of EVAR may be less blood loss, shorter hospitalization, and less cardiovascular stress; the risks may be aneurysm recurrence, prolonged surveillance and repeated secondary procedures. The development of EVAR, the complications, and the anesthesia-related concerns of EVAR, including its use in management of acute abdominal aortic aneurysm are reviewed.

Endograft Treatment in Ruptured Abdominal Aortic Aneurysms Using the Talent® AUI Stentgraft System. Design of a Feasibility Study∗∗

OBJECTIVES

To study the outcome of patients with ruptured AAA treated by EVAR using the Talent AUI stentgraft system.

DESIGN

A multicenter prospective consecutive patient cohort of 100 patients.

MATERIALS

Consecutive patients with ruptured AAA will be screened for treatment by EVAR. All patients screened, including those excluded from EVAR, will be clustered and called the study group. The study group will be compared with a historical group of patients with ruptured AAA derived from literature. The New ERA study started February 2003.

OUTCOME

Main outcome events are applicability rate and operative mortality rate of the study group.

CONCLUSION

The study rationale and design are reported here.