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Hawkins A, Jin R, Clouse WD, Tracci M, Weaver ML, Farivar BS. Center-level outcomes following elective fenestrated endovascular aortic aneurysm repair in the Vascular Quality Initiative database. J Vasc Surg 2024; 80:311-322. [PMID: 38604317 DOI: 10.1016/j.jvs.2024.03.453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/25/2024] [Accepted: 03/31/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Hospital volume is associated with mortality after open aortic aneurysm repair. Fenestrated and branched endovascular aortic repair (B-FEVAR) has been increasingly used for repair of complex thoracoabdominal and juxtarenal aneurysms, but evidence of a center-volume relationship is limited. We aimed to measure the association of center volume with in-hospital mortality, postoperative outcomes, and 1-year survival following B-FEVAR. METHODS Patients undergoing elective endovascular thoracoabdominal and complex abdominal aneurysm repair with branch intervention (2014-2021) listed within the national Vascular Quality Initiative Thoracic Endovascular Aortic Repair/Complex EVAR database were analyzed. Centers were grouped into quartiles by mean annual procedure volume. Multivariable regression was used to evaluate the effect of center volume on in-hospital mortality adjusting for baseline and procedural characteristics. Kaplan-Meier estimation, log rank test, and mixed effects Cox regression were used to evaluate 1-year survival. RESULTS A total of 4302 adult elective F-BEVAR procedures were identified at a total of 163 centers. In-hospital mortality did not differ by hospital volume (quartile [Q]1 = 35/1059 [3.3%]; Q2 = 30/1063 [2.8%]; Q3 = 33/1120 [2.9%]; and Q4 = 44/1060 [4.2%]; P = .308). The high volume group had a higher rate of major complication (Q1 = 14.9%; Q2 = 12.8%; Q3 = 13.3%; and Q4 = 20.1%; adjusted P < .001). Physician-modified grafts were more frequently employed in high-volume centers (Q1 = 4.5%; Q2 = 18.7%; Q3 = 11.3%; and Q4 = 19.2%; P < .001), with a decreased incidence of any endoleak noted at the end of the procedure (Q1 = 34.9%; Q2 = 32.8%; Q3 = 30.0%; and Q4 = 29.0%; P = .003). In the multivariable analysis, in-hospital mortality was not associated with center volume, comparing very low volume to medium- and high-volume centers (odds ratio [95% confidence interval] vs Q4: Q1 = 1.1 [0.6-1.9], Q2 = 0.6 [0.4-1.1], and Q3 = 0.9 [0.5-1.5]; all P > .05). No significant difference was found in 1-year survival between center volume groups. CONCLUSIONS In-hospital mortality is not associated with procedure volume within centers performing complex endovascular aortic repair. However, complication rates and endoleak may be associated with procedure volume. Long-term outcomes by annualized procedure volume, specifically graft durability and sac expansion, should be investigated.
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MESH Headings
- Humans
- Endovascular Procedures/adverse effects
- Endovascular Procedures/mortality
- Female
- Male
- Hospital Mortality
- Aged
- Databases, Factual
- Elective Surgical Procedures
- Blood Vessel Prosthesis Implantation/adverse effects
- Blood Vessel Prosthesis Implantation/mortality
- Hospitals, High-Volume
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Abdominal/mortality
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Risk Factors
- United States
- Hospitals, Low-Volume
- Retrospective Studies
- Time Factors
- Aortic Aneurysm, Thoracic/surgery
- Aortic Aneurysm, Thoracic/mortality
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Treatment Outcome
- Aged, 80 and over
- Postoperative Complications/mortality
- Postoperative Complications/etiology
- Risk Assessment
- Middle Aged
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Affiliation(s)
- Andrew Hawkins
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Ruyun Jin
- Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Margaret Tracci
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA
| | - Behzad S Farivar
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
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Gennai S, Leone N, Bartolotti LAM, Andreoli F, Pizzarelli G, Silingardi R. Learning Curve and Long-Term Outcomes of Thoracic Endovascular Repair With the Relay Stent-Graft. J Endovasc Ther 2024; 31:658-667. [PMID: 36382880 DOI: 10.1177/15266028221136450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE To define the learning curve of a widely employed stent-graft for thoracic endovascular repair (TEVAR) by analyzing procedural variables and their impact on long-term outcomes. MATERIALS AND METHODS Standard TEVARs for each major aortic thoracic disease were included excluding procedures using thoracoabdominal, arch fenestrated/branched devices and/or chimneys. The primary outcome was the learning curve analysis using the cumulative sum chart method. The secondary outcomes, presented as early (Q1-Q2) versus latest (Q3-Q4) quartiles of experience, were 30-day major adverse events (MAEs); procedural details (additional maneuvers, operative and fluoroscopy time, and contrast volume); 30-day clinical success; endoleak; aorta-related reintervention; and overall and aorta-related survival. RESULTS Between November 2005 and September 2021, 220 consecutive TEVAR procedures involving the Relay endograft (Terumo Aortic, Sunrise, FL, USA) were performed and included in the present analysis. The mean follow-up was 4.5 ± 3.9 years. The learning curve was reached after 10 patients. Secondary outcomes improved significantly over experience. Thirty-day MAE occurrence was 14.5% versus 11.8% (p=0.550). Additional maneuvers (p=0.009), access-vessel additional maneuvers (p=0.010), operative time (p=0.004), Relay Plus (p=0.001), and implantation of multiple stent-grafts (p=0.034) were independent risk markers for MAEs. Operative time (125.9 ± 66.7 vs 86.7 ± 48.5 minutes, p<0.001), contrast volume (185.4 ± 112.8 vs 140.5 ± 88.2 mL, p=0.003), and fluoroscopy time (12.4 ± 12.7 vs 8.8 ± 7.5 minutes, p=0.017) decreased significantly. Late endoleak occurrence was 19.5% with a nonsignificant reduction (21.8% vs 17.3%, p=0.395). Fluoroscopy time (hazard ratio [HR]=1.0; 95% confidence interval [CI]=1.0-1.1; p=0.008), contrast volume (HR=1.0; 95% CI=1.0-1.1; p=0.018), and type III aortic arch (HR=3.3; 95% CI=1.7-6.4; p<0.001) were independent risk markers for endoleak. Fluoroscopy time (HR=1.0; 95% CI=1.0-1.1; p=0.032) and type III aortic arch (HR=3.6; 95% CI=1.7-7.4; p=0.001) confirmed their significant association in a multivariable analysis. CONCLUSION In a high-volume center with a consistent previous endovascular experience, the Relay graft presented satisfactory long-term results with a short learning curve supporting its reliability. CLINICAL IMPACT The manuscript addresses the understanding of how many TEVAR procedures with a currently implanted device have been required to reach the learning curve for an endovascular skilled center. Our TEVAR experience with the Relay stent-graft (Terumo Aortic) demonstrated that ten implantations were required to achieve the device-related learning curve. The fifteen-year analyzed period showed that intraoperative learning-related variables were associated with long-term clinical outcomes and both improved over time. The Relay stent-graft presented satisfactory long-term results along with a short learning curve in a high-volume endovascular center supporting its ongoing implantation.
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Affiliation(s)
- Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Luigi A M Bartolotti
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Andreoli
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Ginevra Pizzarelli
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Pouncey AL, Meuli L, Lopez-Espada C, Budtz-Lilly J, Boyle JR, Behrendt CA, Mani K, Pherwani AD. Editor's Choice - Vascular Registries Contributing to VASCUNET Collaborative Abdominal Aortic Aneurysm Outcome Projects: A Scoping Review. Eur J Vasc Endovasc Surg 2024; 68:152-160. [PMID: 38697257 DOI: 10.1016/j.ejvs.2024.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/06/2024] [Accepted: 04/25/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVE Vascular surgery registries report on procedures and outcomes to promote patient safety and drive quality improvement. International registries have contributed significantly to the VASCUNET collaborative abdominal aortic aneurysm (AAA) outcome projects. This scoping review aimed to outline the national registries in vascular surgery that currently participate in the VASCUNET collaborative AAA projects. METHODS A scoping review of all published VASCUNET AAA studies and validation reports between 1997 and 2024 was undertaken. A survey was conducted among representatives of the international vascular registries contributing to VASCUNET collaborative AAA projects. RESULTS Currently, vascular registries from 10 countries (Australia, Denmark, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, Switzerland, and the UK) contribute to the current VASCUNET collaborative AAA project, of which eight have national coverage. In the past, three countries (Germany, Malta, and Italy) have participated in previous VASCUNET AAA projects, and a further three countries (Serbia, Greece, and Portugal) have planned participation in future projects. External validity is high for all current registries, with most reporting rates of > 90%. The majority have internal validation processes to assess data accuracy. VASCUNET mediated validation has also been performed by the consortium for five countries to date (Hungary, Sweden, Denmark, Malta, and Switzerland), for which a high degree of external and internal validity was identified. Most registries have established mechanisms for data linkage with national administrative datasets or insurance claims datasets and contribute to quality improvement through regular reporting to participating centres. CONCLUSION National vascular registries from nations participating in the VASCUNET collaborative AAA projects are largely comprehensive, with high case ascertainment rates and good quality data with internal quality assurance. This provides a template for new registries wishing to join the VASCUNET collaboration and a benchmark for future research.
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Affiliation(s)
- Anna L Pouncey
- Vascular Department, Division of Surgery and Cancer, Imperial College London, London, UK
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich (USZ), University of Zurich (UZH), Zurich, Switzerland; Copenhagen Aortic Centre, Department of Vascular Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Cristina Lopez-Espada
- Department of Surgery, University Hospital Virgen de las Nieves, University of Granada, Granada, Spain
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular surgery, Uppsala University, Uppsala, Sweden
| | - Arun D Pherwani
- Keele University School of Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK; The National Vascular Registry (NVR), UK.
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Smeltz AM, Newton EJ, Kumar PA, Isaak RS, Doyal A, Fernando RJ, Vanneman MW, Augoustides JGT. 2023 Update on Vascular Anesthesia. J Cardiothorac Vasc Anesth 2024; 38:1769-1776. [PMID: 38862283 DOI: 10.1053/j.jvca.2024.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 06/13/2024]
Abstract
The authors thank the editors for this opportunity to review the recent literature on vascular surgery and anesthesia and provide this clinical update. The last in a series of updates on this topic was published in 2019.1 This review explores evolving discussions and current trends related to vascular surgery and anesthesia that have been published since then. The focus is on the major points discussed in the recent literature in the following areas: carotid artery surgery, infrarenal aortic surgery, peripheral vascular surgery, and the preoperative evaluation of vascular surgical patients.
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Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily J Newton
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Priya A Kumar
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS; Outcomes Research Consortium, Cleveland, OH
| | - Robert S Isaak
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Alexander Doyal
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Wake Forest University, Winston-Salem, NC
| | - Matthew W Vanneman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
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Behrendt CA, Heckenkamp J, Bergsträßer A, Billing A, Böckler D, Bücker A, Cotta L, Donas KP, Grözinger G, Heidecke CD, Hinterseher I, Horn S, Kaltwasser A, Kiefer A, Kirnich-Müller C, Kock L, Kölbel T, Czerny M, Kralewski C, Kurz S, Larena-Avellaneda A, Mutlak H, Oberhuber A, Oikonomou K, Pfeiffer M, Pfister K, Reeps C, Schäfer A, Schmitz-Rixen T, Steinbauer M, Steinbauer C, Strupp D, Stolecki D, Trenner M, Veit C, Verhoeven E, Waydhas C, Weber CF, Adili F. [Recommendations for the specialist further training of nursing personnel on intensive care units in the treatment of abdominal aortic aneurysms: results of a modified Delphi procedure with experts]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:395-405. [PMID: 38498123 PMCID: PMC11031449 DOI: 10.1007/s00104-024-02066-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION The medical development in the previous 15 years and the changes in treatment reality of the comprehensive elective treatment of abdominal aortic aneurysms necessitate a re-evaluation of the quality assurance guidelines of the Federal Joint Committee in Germany (QBAA-RL). In the current version this requires a specialist further training quota for nursing personnel in intensive care wards of 50%. The quota was determined in 2008 based on expert opinions, although a direct empirical evidence base for this does not exist. METHODS Representatives from the fields of patient representation, physicians, nursing personnel and other relevant interface areas were invited to participate in a modified Delphi procedure. Following a comprehensive narrative literature search, a survey and focus group discussions with national and international experts, a total of three anonymized online-based voting rounds were carried out for which previously determined key statements were assessed with a 4‑point Likert scale (totally disagree up to totally agree). In addition, the expert panel had also defined a recommendation for a minimum quota for the specialist training of nursing personnel on intensive care wards in the treatment of abdominal aortic aneurysms, whereby an a priori agreement of 80% of the participants was defined as the consensus limit. RESULTS Overall, 37 experts participated in the discussions and three successive voting rounds (participation rate 89%). The panel confirmed the necessity of a re-evaluation of the guideline recommendations and recommended the introduction of a shift-related minimum quota of 30% of the full-time equivalent of nursing personnel on intensive care wards and the introduction of structured promotional programs for long-term elevation of the quota. CONCLUSION In this national Delphi procedure with medical and nursing experts as well as representatives of patients, the fundamental benefits and needs of professional specialist qualifications in the field of intensive care medicine were confirmed. The corresponding minimum quota for specialist further training of intensive care nursing personnel should generally apply without limitations to specific groups. The expert panel stipulates a shift-related minimum quota for intensive care nursing personnel with specialist training of 30% of the nursing personnel on intensive care wards and the obligatory introduction of structured and transparent promotion programs for the long-term enhancement.
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Affiliation(s)
- Christian-Alexander Behrendt
- Deutsches Institut für Gefäßmedizinische Gesundheitsforschung gGmbH, Berlin, Deutschland.
- Abt. für Allgemeine und Endovaskuläre Gefäßchirurgie, Asklepios Klinik Wandsbek, Asklepios Medical School, Alphonsstr. 14, 22043, Hamburg, Deutschland.
| | | | | | - Arend Billing
- Kommission Krankenhausökonomie, Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin e. V., Berlin, Deutschland
| | - Dittmar Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Arno Bücker
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Livia Cotta
- Deutsches Institut für Gefäßmedizinische Gesundheitsforschung gGmbH, Berlin, Deutschland
| | - Konstantinos P Donas
- Rhein Main Vascular Center, Klinik für vaskuläre und endovaskuläre Chirurgie, Asklepios Kliniken Langen, Paulinen Wiesbaden und Seligenstadt, Langen, Deutschland
| | - Gerd Grözinger
- Abt. für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Claus-Dieter Heidecke
- Institut für Qualität und Transparenz im Gesundheitswesen (IQTIG), Berlin, Deutschland
| | - Irene Hinterseher
- Klinik für Gefäßchirurgie, Universitätsklinikum Ruppin-Brandenburg, Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - Silvio Horn
- Gefäßchirurgie, Alexianer St. Josefs Krankenhaus Potsdam, Potsdam, Deutschland
| | - Arnold Kaltwasser
- Sektion Pflegeforschung und Pflegequalität, Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin e. V., Berlin, Deutschland
| | - Andrea Kiefer
- Deutscher Berufsverband für Pflegeberufe (DBfK) Bundesverband e. V., Berlin, Deutschland
| | | | - Lars Kock
- Klinik für Gefäßchirurgie, Immanuel Albertinen Diakonie, Hamburg, Deutschland
| | - Tilo Kölbel
- Klinik für Gefäßmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Martin Czerny
- Abteilung für Herz- und Gefäßchirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
- Medizinische Fakultät, Albert Ludwigs Universität Freiburg, Freiburg, Deutschland
| | - Christian Kralewski
- Kompetenz-Centrum Qualitätssicherung (KCQ), Medizinischer Dienst Baden-Württemberg, Tübingen, Deutschland
| | - Stephan Kurz
- Klinik für Herz‑, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum der Charité (DHZC), Berlin, Deutschland
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Deutschland
| | - Axel Larena-Avellaneda
- Abteilung für Gefäß- und endovaskuläre Chirurgie, Asklepios Klinik Altona, Asklepios Medical School, Hamburg, Deutschland
| | - Haitham Mutlak
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, SANA Klinikum Offenbach, Offenbach, Deutschland
| | - Alexander Oberhuber
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Uniklinik Münster, Münster, Deutschland
| | - Kyriakos Oikonomou
- Abteilung für Gefäß- und Endovaskularchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Manfred Pfeiffer
- Interessenvertretung Patienten-&-Versicherte, Sörgenloch, Deutschland
| | - Karin Pfister
- Universitäres Gefäßzentrum Ostbayern, Abteilung für Gefäßchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Christian Reeps
- Bereich Gefäß- und Endovaskuläre Chirurgie, Uniklinikum Dresden, Dresden, Deutschland
| | - Andreas Schäfer
- Deutsche Gesellschaft für Pflegewissenschaft e. V., Duisburg, Deutschland
| | | | - Markus Steinbauer
- Klinik für Gefäßchirurgie, Gefäßzentrum, Barmherzige Brüder Regensburg, Regensburg, Deutschland
| | - Claudia Steinbauer
- Katholische Akademie für Berufe im Gesundheits- und Sozialwesen, Regensburg, Deutschland
| | - Daniel Strupp
- Intensivpflege, Asklepios Klinik Wandsbek, Hamburg, Deutschland
| | - Dietmar Stolecki
- Deutsche Gesellschaft für Fachkrankenpflege und Funktionsdienste e. V., Berlin, Deutschland
| | | | | | - Eric Verhoeven
- Klinikum Nürnberg und Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - Christian Waydhas
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin e. V., Berlin, Deutschland
- Klinik Für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Christian F Weber
- Abteilung für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Klinik Wandsbek, Hamburg, Deutschland
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Frankfurt, Frankfurt am Main, Deutschland
| | - Farzin Adili
- Klinik für Gefäßmedizin, Gefäßchirurgie und Endovaskuläre Chirurgie, Klinikum Darmstadt, Darmstadt, Deutschland
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Ramirez JL, Matthay ZA, Lancaster E, Smith EJT, Gasper WJ, Zarkowsky DS, Doyle AJ, Patel VI, Schanzer A, Conte MS, Iannuzzi JC. Decreasing prevalence of centers meeting the Society for Vascular Surgery abdominal aortic aneurysm guidelines in the United States. J Vasc Surg 2024; 79:240-249. [PMID: 37774990 DOI: 10.1016/j.jvs.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/14/2023] [Accepted: 09/03/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE Based on data supporting a volume-outcome relationship in elective aortic aneurysm repair, the Society of Vascular Surgery (SVS) guidelines recommend that endovascular aortic repair (EVAR) be localized to centers that perform ≥10 operations annually and have a perioperative mortality and conversion-to-open rate of ≤2% and that open aortic repair (OAR) be localized to centers that perform ≥10 open aortic operations annually and have a perioperative mortality ≤5%. However, the number and distribution of centers meeting the SVS criteria remains unclear. This study aimed to estimate the temporal trends and geographic distribution of Centers Meeting the SVS Aortic Guidelines (CMAG) in the United States. METHODS The SVS Vascular Quality Initiative was queried for all OAR, aortic bypasses, and EVAR from 2011 to 2019. Annual OAR and EVAR volume, 30-day elective operative mortality for OAR or EVAR, and EVAR conversion-to-open rate for all centers were calculated. The SVS guidelines for OAR and EVAR, individually and combined, were applied to each institution leading to a CMAG designation. The proportion of CMAGs by region (West, Midwest, South, and Northeast) were compared by year using a χ2 test. Temporal trends were estimated using a multivariable logistic regression for CMAG, adjusting by region. RESULTS Overall, 67,865 patients (49,264 EVAR; 11,010 OAR; 7591 aortic bypasses) at 336 institutions were examined. The proportion of EVAR CMAGs increased nationally by 1.7% annually from 51.6% (n = 33/64) in 2011 to 67.1% (n = 190/283) in 2019 (β = .05; 95% confidence interval [CI], 0.01-0.09; P = .02). The proportion of EVAR CMAGs across regions ranged from 27.3% to 66.7% in 2011 to 63.9% to 72.9% in 2019. In contrast, the proportion of OAR CMAGs has decreased nationally by 1.8% annually from 32.8% (n = 21/64) in 2011 to 16.3% (n = 46/283) in 2019 (β = -.14; 95% CI, -0.19 to -0.10; P < .01). Combined EVAR and OAR CMAGs were even less frequent and decreased by 1.5% annually from 26.6% (n = 17/64) in 2011 to 13.1% (n = 37/283) in 2019 (β = -.12; 95% CI, -0.17 to -0.07; P < .01). In 2019, there was no significant difference in regional variation of the proportion of combined EVAR and OAR CMAGs (P = .82). CONCLUSIONS Although an increasing proportion of institutions nationally meet the SVS guidelines for EVAR, a smaller proportion meet them for OAR, with a concerning downward trend. These data question whether we can safely offer OAR at most institutions, have important implications about sufficient OAR exposure for trainees, and support regionalization of OAR.
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Affiliation(s)
- Joel L Ramirez
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA; Chan Zuckerberg Biohub, San Francisco, CA
| | - Zachary A Matthay
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Elizabeth Lancaster
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Eric J T Smith
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Devin S Zarkowsky
- Division of Vascular Surgery, Department of Surgery, Scripps Clinic, La Jolla, CA
| | - Adam J Doyle
- Division of Vascular Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Virendra I Patel
- Division of Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Andres Schanzer
- UMassMemorial Center for Complex Aortic Disease, University of Massachusetts Medical School, Worcester, MA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Lopez Espada C, Behrendt CA, Mani K, D'Oria M, Lattman T, Khashram M, Altreuther M, Cohnert TU, Pherwani A, Budtz-Lilly J. Editor's Choice - The VASCUNExplanT Project: An International Study Assessing Open Surgical Conversion of Failed Non-Infected Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2023; 66:653-660. [PMID: 37490979 DOI: 10.1016/j.ejvs.2023.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/09/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE The need for open surgical conversion (OSC) after failed endovascular aortic aneurysm repair (EVAR) persists, despite expanding endovascular options for secondary intervention. The VASCUNExplanT project collected international data to identify risk factors for failed EVAR, as well as OSC outcomes. This retrospective cross sectional study analysed data after OSC for failed EVAR from the VASCUNET international collaboration. METHODS VASCUNET queried registries from its 28 member countries, and 17 collaborated with data from patients who underwent OSC (2005 - 2020). Any OSC for infection was excluded. Data included demographics, EVAR, and OSC procedural details, as well as post-operative mortality and complication rates. RESULTS There were 348 OSC patients from 17 centres, of whom 33 (9.4%) were women. There were 130 (37.4%) devices originally deployed outside of instructions for use. The most common indication for OSC was endoleak (n = 143, 41.1%); ruptures accounted for 17.2% of cases. The median time from EVAR to OSC was 48.6 months [IQR 29.7, 71.6]; median abdominal aortic aneurysm diameter at OSC was 70.5 mm [IQR 61, 82]. A total of 160 (45.6%) patients underwent one or more re-interventions prior to OSC, while 63 patients (18.1%) underwent more than one re-intervention (range 1 - 5). Overall, the 30 day mortality rate post-OSC was 11.8% (n = 41), 11.1% for men and 18.2% for women (p = .23). The 30 day mortality rate was 6.1% for elective cases, and 28.3% for ruptures (p < .0001). The predicted 90 day survival for the entire cohort was 88.3% (95% CI 84.3 - 91.3). Multivariable analysis revealed rupture (OR 4.23; 95% CI 2.05 - 8.75; p < .0001) and total graft explantation (OR 2.10; 95% CI 1.02 - 4.34; p = .04) as the only statistically significant predictive factors for 30 day death. CONCLUSION This multicentre analysis of patients who underwent OSC shows that, despite varying case mix and operative techniques, OSC is feasible but associated with significant morbidity and mortality rates, particularly when performed for rupture.
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Affiliation(s)
- Cristina Lopez Espada
- Vascular Surgery Unit, University Hospital Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain.
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Thomas Lattman
- Kantonsspital Winterthur, Swissvasc Registry, Zurich, Switzerland
| | - Manar Khashram
- Waikato Hospital, University of Auckland, Auckland, New Zealand
| | - Martin Altreuther
- Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway
| | - Tina U Cohnert
- Department of Vascular Surgery, Graz Medical University, Graz, Austria
| | - Arun Pherwani
- University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, Aarhus, Denmark
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9
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Cheng TW, Farber A, Levin SR, Arinze N, Garg K, Eslami MH, King EG, Patel VI, Rybin D, Siracuse JJ. Analysis of Early Death after Elective Open Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2023; 96:71-80. [PMID: 37244479 DOI: 10.1016/j.avsg.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Mortality after open abdominal aortic aneurysm repair is a quality measure and early death may represent a technical complication or poor patient selection. Our objective was to analyze patients who died in the hospital within postoperative day (POD) 0-2 after elective abdominal aortic aneurysm repair. METHODS The Vascular Quality Initiative was queried from 2003-2019 for elective open abdominal aortic aneurysm repairs. Operations were categorized as in-hospital death on POD 0-2 (POD 0-2 Death), in-hospital death beyond POD 2 (POD ≥3 Death), and those alive at discharge. Univariable and multivariable analyses were performed. RESULTS There were 7,592 elective open abdominal aortic aneurysm repairs with 61 (0.8%) POD 0-2 Death, 156 (2.1%) POD ≥3 Death, and 7,375 (97.1%) alive at discharge. Overall, median age was 70 years and 73.6% were male. Iliac aneurysm repair and surgical approach (anterior/retroperitoneal) were similar among groups. POD 0-2 Death, compared to POD ≥3 Death and those alive at discharge, had the longest renal/visceral ischemia time, more commonly had proximal clamp placement above both renal arteries, an aortic distal anastomosis, longest operative time, and largest estimated blood loss (all P < 0.05). Postoperative vasopressor usage, myocardial infarction, stroke, and return to the operating room were most frequent in POD 0-2 Death and extubation in the operating room was least frequent (all P < 0.001). Postoperative bowel ischemia and renal failure occurred most commonly among POD ≥3 Death (all P < 0.001).On multivariable analysis, POD 0-2 Death was associated with congestive heart failure, prior peripheral vascular intervention, female sex, preoperative aspirin use, lower center volume quartile, renal/visceral ischemia time, estimated blood loss, and older age (all P < 0.05). CONCLUSIONS POD 0-2 Death was associated with comorbidities, center volume, renal/visceral ischemia time, and estimated blood loss. Referral to high-volume aortic centers could improve outcomes.
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Affiliation(s)
- Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Nkiruka Arinze
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Karan Garg
- Division of Vascular Surgery, NYU Langone Medical Center, New York, NY
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Elizabeth G King
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, New York-Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Denis Rybin
- Department of Biostatistics, Boston University, School of Public Health, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
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10
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Mehta A, Patel P, Elmously A, Iannuzzi J, Garg K, Siracuse J, Takayama H, Schermerhorn ML, O'Donnell TFX, Patel VI. Low-volume surgeons can have better outcomes at certain hospital settings for open abdominal aortic repairs. J Vasc Surg 2023; 78:638-646. [PMID: 37172621 DOI: 10.1016/j.jvs.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 03/28/2023] [Accepted: 04/09/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE The volume-outcomes relationship is cross-cutting among open abdominal aortic operations, where higher-volume surgeons have better perioperative outcomes. However, there has been minimal focus on low-volume surgeons and how to improve their outcomes. This study sought to identify if there are any differences in outcomes among low-volume surgeons for open abdominal aortic surgeries by different hospital settings. METHODS We used the 2012-2019 Vascular Quality Initiative registry to identify all patients who underwent open abdominal aortic surgery for aneurysmal or aorto-iliac occlusive disease by a low-volume surgeon (<7 operations annually). We categorized high-volume hospitals using three distinct definitions: those that performed ≥10 operations annually, those with at least one high-volume surgeon, and by the number of surgeons (1-2 surgeons, 3-4 surgeons, 5-7 surgeons, and 8+ surgeons). Outcomes included 30-day perioperative mortality, overall complications, and failure-to-rescue. We compared outcomes among low-volume surgeons using univariable and multivariable logistic regressions across each of these three hospital categorizations. RESULTS Among 14,110 patients who underwent open abdominal aortic surgery, 10,252 (7 3%) were performed by 1155 low-volume surgeons. Two-thirds of these patients (66%) underwent their surgery at a high-volume hospital, fewer than one-third (30%) at a hospital that had at least one high-volume surgeon, and one-half (49%) at hospitals with at least five surgeons. Among all patients operated on by low-volume surgeons, rates of 30-day mortality were 3.8%, perioperative complications were 35.3%, and failure-to-rescue were 9.9%. Low-volume surgeons operating at high-volume hospitals for aneurysmal disease had lower rates of perioperative death (adjusted odds ratio [aOR], 0.66; 95% confidence interval [CI], 0.48-0.90) and failure-to-rescue (aOR, 0.70; 95% CI, 0.50-0.98), but similar rates of complications (aOR, 1.06; 95% CI, 0.89-1.27). Similarly, patients undergoing their operation at hospitals that had at least one high-volume surgeon had lower rates of death (aOR, 0.71; 95% CI, 0.50-0.99) for aneurysmal disease. Patient outcomes among low-volume surgeons for aorto-iliac occlusive disease did not vary by hospital setting. CONCLUSIONS The majority of patients undergoing open abdominal aortic surgery have a low-volume surgeon, where outcomes are slightly better for those taking place at a high-volume hospital. Focused and incentivized interventions may be needed to improve outcomes among low-volume surgeons across all practice settings.
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Affiliation(s)
- Ambar Mehta
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - Priya Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY; Division of General Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Adham Elmously
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - James Iannuzzi
- Division of Vascular and Endovascular Surgery, UCSF, San Francisco, CA
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Jeffrey Siracuse
- Division of Vascular and Endovascular Surgery, Boston University, Boston, MA
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Thomas F X O'Donnell
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian Columbia University Medical Center, New York, NY.
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11
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Grandi A, Bertoglio L, Lepidi S, Kölbel T, Mani K, Budtz-Lilly J, DeMartino R, Scali S, Hanna L, Troisi N, Calvagna C, D’Oria M. Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms: A Scoping Review. J Clin Med 2023; 12:5505. [PMID: 37685573 PMCID: PMC10488165 DOI: 10.3390/jcm12175505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA). MATERIALS AND METHODS A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)? RESULTS The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies. CONCLUSIONS The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events.
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Affiliation(s)
- Alessandro Grandi
- Department of Vascular Medicine, University Heart and Vascular Center, 20251 Hamburg, Germany
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Clinical and Experimental Sciences, ASST Spedali Civili of Brescia, 25123 Brescia, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Tilo Kölbel
- Department of Vascular Medicine, University Heart and Vascular Center, 20251 Hamburg, Germany
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 751 05 Uppsala, Sweden
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL 32610, USA
| | - Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London SW7 5NH, UK
| | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, 34129 Trieste, Italy
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12
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Sulzer T, Tenorio ER, Mesnard T, Vacirca A, Baghbani-Oskouei A, de Bruin JL, Verhagen HJM, Oderich GS. Intraoperative complications during standard and complex endovascular aortic repair. Semin Vasc Surg 2023; 36:189-201. [PMID: 37330233 DOI: 10.1053/j.semvascsurg.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 06/19/2023]
Abstract
This study aimed to provide a comprehensive overview of the most common intraoperative adverse events that occur during standard endovascular repair and fenestrated-branched endovascular repair to treat abdominal aortic aneurysms, thoracoabdominal aortic aneurysms, and aortic arch aneurysms. Despite advancements in endovascular techniques, sophisticated imaging and improved graft designs, intraoperative difficulties still occur, even in highly standardized procedures and high-volume centers. This study emphasized that with the increased adoption and complexity of endovascular aortic procedures, strategies to minimize intraoperative adverse events should be protocolized and standardized. There is a need for robust evidence on this topic, which could potentially optimize treatment outcomes and durability of the available techniques.
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Affiliation(s)
- Titia Sulzer
- The University of Texas Health Science Center at Houston, Houston, TX 77030; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Emanuel R Tenorio
- The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Thomas Mesnard
- The University of Texas Health Science Center at Houston, Houston, TX 77030
| | - Andrea Vacirca
- The University of Texas Health Science Center at Houston, Houston, TX 77030
| | | | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gustavo S Oderich
- The University of Texas Health Science Center at Houston, Houston, TX 77030
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13
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Mesnard T, Dubosq M, Pruvot L, Azzaoui R, Patterson BO, Sobocinski J. Benefits of Prehabilitation before Complex Aortic Surgery. J Clin Med 2023; 12:jcm12113691. [PMID: 37297886 DOI: 10.3390/jcm12113691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/14/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
The purpose of this narrative review was to detail and discuss the underlying principles and benefits of preoperative interventions addressing risk factors for perioperative adverse events in open aortic surgery (OAS). The term "complex aortic disease" encompasses juxta/pararenal aortic and thoraco-abdominal aneurysms, chronic aortic dissection and occlusive aorto-iliac pathology. Although endovascular surgery has been increasingly favored, OAS remains a durable option, but by necessity involves extensive surgical approaches and aortic cross-clamping and requires a trained multidisciplinary team. The physiological stress of OAS in a fragile and comorbid patient group mandates thoughtful preoperative risk assessment and the implementation of measures dedicated to improving outcomes. Cardiac and pulmonary complications are one of the most frequent adverse events following major OAS and their incidences are correlated to the patient's functional status and previous comorbidities. Prehabilitation should be considered in patients with risk factors for pulmonary complications including advanced age, previous chronic obstructive pulmonary disease, and congestive heart failure with the aid of pulmonary function tests. It should also be combined with other measures to improve postoperative course and be included in the more general concept of enhanced recovery after surgery (ERAS). Although the current level of evidence regarding the effectiveness of ERAS in the setting of OAS remains low, an increasing body of literature has promoted its implementation in other specialties. Consequently, vascular teams should commit to improving the current evidence through studies to make ERAS the standard of care for OAS.
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Affiliation(s)
- Thomas Mesnard
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
- Univ. Lille, INSERM U1008-Advanced Drug Delivery Systems and Biomaterials, 59000 Lille, France
| | - Maxime Dubosq
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Louis Pruvot
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Richard Azzaoui
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
| | - Benjamin O Patterson
- Department of Vascular Surgery, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Jonathan Sobocinski
- Service de Chirurgie Vasculaire, Centre de l'Aorte, CHU Lille, 59000 Lille, France
- Univ. Lille, INSERM U1008-Advanced Drug Delivery Systems and Biomaterials, 59000 Lille, France
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14
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D'Oria M, Trimarchi S, Lomazzi C, Upchurch GR, Suominen V, Bissacco D, Taglialavoro J, Lepidi S. Incidence, predictors, and prognostic impact of in-hospital serious adverse events in patients ≥75 years of age undergoing elective endovascular aneurysm repair. Surgery 2023; 173:1093-1101. [PMID: 36526489 DOI: 10.1016/j.surg.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/26/2022] [Accepted: 11/13/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study sought to identify the factors associated with the occurrence of in-hospital serious adverse events after elective endovascular aortic repair (EVAR) in older patients within the Global Registry for Endovascular Aortic Treatment. METHODS Consecutive patients ages ≥75 years who received GORE EXCLUDER AAA Endoprosthesis (W.L. Gore & Associates, Inc, Flagstaff, AZ) for elective EVAR. Based on the age at index elective EVAR, patients were categorized into 3 groups for subsequent analyses: those ages 75 to 79, 80 to 84, and ≥85 years. The primary end points for this study were the incidence of serious adverse events and all-cause mortality. In-hospital complications were defined according to the International Organization for Standardization 14155 standard (https://www.iso.org/standard/71690.html) and considered serious adverse events if they led to any of the following: (1) a life-threatening illness or injury, (2) a permanent impairment of a body structure or a body function, (3) in-patient or prolonged hospitalization, or (4) medical or surgical intervention to prevent life-threatening illness or injury or permanent impairment to a body structure or a body function. RESULTS Overall, 1,333 older patients (ages 75-79: n = 601; 80-84: n = 474; and ≥85: n = 258) underwent elective EVAR in the Global Registry for Endovascular Aortic Treatment data set and were included in the present analysis. In total, 12 patients (0.9%) died perioperatively, and 103 patients (7.7%) experienced ≥1 in-hospital serious adverse event, with 18 patients (1.3%) experiencing >1 in-hospital complications. No significant differences were seen between the age groups in the rates of in-hospital serious adverse events (7.3% vs 8.2% vs 7.8%; P = .86). In logistic regression analysis, a history of chronic obstructive pulmonary disease (odds ratio = 2.014; 95% confidence interval, 1.215-3.340; P = .006) and prior requirement for dialysis (odds ratio = 4.655; 95% confidence interval, 1.087-19.928; P = .038) resulted as predictors for occurrence of in-hospital serious adverse events. In the whole cohort, the 5-year survival was 63% for patients who did not experience any in-hospital serious adverse events compared with 51% for those who experienced any complications (P = .003). Using multivariable Cox proportional hazards models, it was found that the occurrence of in-hospital serious adverse events (hazard ratio = 6.2; 95% confidence interval, 1.8-21.317; P = .003) and being underweight (hazard ratio = 7.0; 95% confidence interval, 1.371-35.783; P = .019) were the only independent predictors of death in ≤30 days from the initial intervention. Although age did not independently affect the risk for all-cause mortality in ≤180 days after the initial intervention, increasing age was associated with a higher risk for long-term death (ie, ≥181 days from index elective EVAR) in the multivariable analysis (ages 75-79: hazard ratio = 0.379; 95% confidence interval, 0.281-0.512; P < .001; and 80-84: hazard ratio = 0.562; 95% confidence interval, 0.419-0.754; P < .001). CONCLUSION After elective EVAR in older patients (ie, ≥75 years), the occurrence of in-hospital serious adverse events appears to increase the risk of death, particularly in ≤180 days after the initial elective EVAR intervention, and might be related to patient baseline characteristics, including history of pulmonary and renal disease.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Italy.
| | - Santi Trimarchi
- Division of Vascular and Endovascular Surgery, IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Chiara Lomazzi
- Division of Vascular and Endovascular Surgery, IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Velipekka Suominen
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, and Tampere University, Faculty of Medicine and Life Sciences, Tampere, Finland
| | - Daniele Bissacco
- Division of Vascular and Endovascular Surgery, IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Jacopo Taglialavoro
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste, Italy
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15
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Die Regierungskommission für eine moderne und bedarfsgerechte Krankenhausversorgung und das Bauchaortenaneurysma – Haben wir eine inhaltliche Diskussion um Mindestmengen und Qualitätsindikatoren verpasst? GEFÄSSCHIRURGIE 2023. [DOI: 10.1007/s00772-023-00975-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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16
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Dias NV, Hultgren R. Sex Differences in Complex Endovascular Aortic Repair: Confused on a Higher Level? Eur J Vasc Endovasc Surg 2022; 64:209. [PMID: 35598722 DOI: 10.1016/j.ejvs.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 05/14/2022] [Indexed: 01/12/2023]
Affiliation(s)
- Nuno V Dias
- Vascular Centre Malmö, Department of Thoracic Surgery and Vascular Diseases, Skåne University Hospital and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
| | - Rebecka Hultgren
- Department of Molecular medicine and Surgery, Karolinska Institutet and Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Borzsák S, Süvegh A, Szentiványi A, Fontanini DM, Vecsey-Nagy M, Banga P, Sótonyi P, Szeberin Z, Csobay-Novák C. Midterm Results of Iliac Branch Devices in a Newly Established Aortic Center. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081154. [PMID: 36013332 PMCID: PMC9409818 DOI: 10.3390/life12081154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 11/16/2022]
Abstract
The first-line treatment of common iliac artery aneurysms is endovascular repair. International guidelines recommend the preservation of the internal iliac artery, which is best achieved by the implantation of an iliac bifurcation device (IBD). Our aim was to evaluate the initial midterm results of IBDs in the leading vascular center of Hungary. In this single-center retrospective study, relevant clinical data and the results of the imaging examinations were collected and analyzed in all patients who underwent IBD implantation between December 2010 and July 2021. Thirty-five patients (31 males, mean age: 67.9 ± 8.5 years) underwent endovascular treatment with 37 IBD implantations. Technical success was achieved in 88.2% of the patients, with no perioperative mortality or open surgical conversion. One patient was lost during follow-up. Internal iliac artery occlusion was detected in three (8.8%) patients, and reintervention was performed in five (14.7%) patients. Primary patency of the internal iliac branch was 97.1% at 1 month, 93% at 2 months, and 89.0% at 5 years. The average follow-up time was 20.1 ± 26.2 months, during which two (5.9%) deaths occurred. Our initial experience with iliac branch devices was associated with a low complication rate and a favorable outcome, which confirms the midterm success of this intervention.
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Affiliation(s)
- Sarolta Borzsák
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (P.S.); (Z.S.)
| | - András Süvegh
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
| | - András Szentiványi
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
| | - Daniele Mariastefano Fontanini
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (P.S.); (Z.S.)
| | - Milán Vecsey-Nagy
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
| | - Péter Banga
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (P.S.); (Z.S.)
- Department of Vascular and Endovascular Surgery, Semmelweis University, 1122 Budapest, Hungary
| | - Péter Sótonyi
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (P.S.); (Z.S.)
- Department of Vascular and Endovascular Surgery, Semmelweis University, 1122 Budapest, Hungary
| | - Zoltán Szeberin
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (P.S.); (Z.S.)
- Department of Vascular and Endovascular Surgery, Semmelweis University, 1122 Budapest, Hungary
| | - Csaba Csobay-Novák
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (P.S.); (Z.S.)
- Correspondence: ; Tel.: +36-1-458-6870
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18
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Center Volume and Failure to Rescue after Open or Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. J Vasc Surg 2022; 76:1565-1576.e4. [PMID: 35872329 DOI: 10.1016/j.jvs.2022.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 04/26/2022] [Accepted: 05/05/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The correlation between center volume and elective abdominal aortic aneurysm(AAA) repair outcomes is well established; however, these effects for either endovascular(EVAR) or open(OAR) repair of ruptured AAA(rAAA) remains unclear. Notably, the capacity to either avert or manage complications associated with postoperative mortality is an important cause of outcome disparities following elective procedures; however, there is a paucity of data surrounding non-elective presentations. Therefore, the purpose of this analysis was to describe the association between annual center volume, complications, and failure to rescue(FtR) after EVAR and OAR of rAAA. METHODS All consecutive endovascular and open rAAA repairs from 2010-2020 in the Vascular Quality Initiative were examined. Annual center volume(procedures/year per center) was grouped into quartiles: EVAR-Q1[<14](3.4%), Q2[14-23](12.8%), Q3[24-37](24.7%), Q4[>38](59.1%); OAR-Q1[<3](5.4%), Q2[4-6](12.8%), Q3[7-10](22.7%), Q4[>10](59.1%). The primary end-point was FtR, defined as in-hospital death after experiencing one of six major complications(cardiac, renal, respiratory, stroke, bleeding, colonic ischemia). Risk-adjusted analyses for inter-group comparisons was completed using multivariable logistic regression. RESULTS The unadjusted in-hospital death rate was 16.5% and 28.9% for EVAR and OAR, respectively. Complications occurred in 45% of EVAR(n=1,439/3,188) and 70% of OAR(n=1,366/1,961) patients with corresponding FtR rates of 14%(EVAR) and 26%(OAR). For OAR, Q4-centers had a 43% lower FtR risk(OR 0.57, 95%CI 0.4-0.9;p=.017) compared to Q1 centers. Centers performing >5 OARs/year had a 43% lower risk(OR 0.57, 95%CI 0.4-0.7;p<.001) of FtR and this decreased 4% for each additional 5 procedures performed annually(95%CI .93-.991;p=.013). However, there was no significant relationship between center volume and FtR after EVAR. The risk of FtR was strongly associated with a greater number of complications for both procedures(OR multiplied by 6.5 for EVAR and 1.5 for OAR for each additional complication;p<.0001). Among OAR patients with a single recorded complication, return to the operating room for bleeding had highest risk of in-hospital mortality(OR 4.1, 95%CI 1.1-4.8;p=.034), while no specific type of complication increased FtR risk after EVAR. CONCLUSIONS FtR occurs commonly after EVAR and OAR of rAAA within VQI centers. Importantly, increasing center volume was associated with reduced FtR risk after OAR but not EVAR. Complication pattern and frequency predicted FTR after either repair strategy. For stable patients, especially those deemed anatomically ineligible for EVAR, these findings emphasize the need to improve coordination of regional referral networks that centralize rAAAs to high-volume centers. Moreover, hospitals that treat rAAA should invest resources that develop protocols targeting specific complications to mitigate risk of preventable postoperative death.
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Tenorio ER, Dias-Neto MF, Lima GBB, Baghbani-Oskouei A, Oderich GS. Lessons learned over two decades of fenestrated-branched endovascular aortic repair. Semin Vasc Surg 2022; 35:236-244. [DOI: 10.1053/j.semvascsurg.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
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20
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Bjorck M. Author response to: Comment on: Collaborative research: population-based data and validation are necessary. Br J Surg 2022; 109:e113. [PMID: 35762940 PMCID: PMC10364774 DOI: 10.1093/bjs/znac209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala, Sweden
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21
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Xodo A, D’Oria M, Mendes B, Bertoglio L, Mani K, Gargiulo M, Budtz-Lilly J, Antonello M, Veraldi GF, Pilon F, Milite D, Calvagna C, Griselli F, Taglialavoro J, Bassini S, Wanhainen A, Lindstrom D, Gallitto E, Mezzetto L, Mastrorilli D, Lepidi S, DeMartino R. Peri-Operative Management of Patients Undergoing Fenestrated-Branched Endovascular Repair for Juxtarenal, Pararenal and Thoracoabdominal Aortic Aneurysms: Preventing, Recognizing and Treating Complications to Improve Clinical Outcomes. J Pers Med 2022; 12:jpm12071018. [PMID: 35887518 PMCID: PMC9317732 DOI: 10.3390/jpm12071018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/06/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022] Open
Abstract
The advent and refinement of complex endovascular techniques in the last two decades has revolutionized the field of vascular surgery. This has allowed an effective minimally invasive treatment of extensive disease involving the pararenal and the thoracoabdominal aorta. Fenestrated-branched EVAR (F/BEVAR) now represents a feasible technical solution to address these complex diseases, moving the proximal sealing zone above the renal-visceral vessels take-off and preserving their patency. The aim of this paper was to provide a narrative review on the peri-operative management of patients undergoing F/BEVAR procedures for juxtarenal abdominal aortic aneurysm (JAAA), pararenal abdominal aortic aneurysm (PRAA) or thoracoabdominal aortic aneurism (TAAA). It will focus on how to prevent, diagnose, and manage the complications ensuing from these complex interventions, in order to improve clinical outcomes. Indeed, F/BEVAR remains a technically, physiologically, and mentally demanding procedure. Intraoperative adverse events often require prolonged or additional procedures and complications may significantly impact a patient's quality of life, health status, and overall cost of care. The presence of standardized preoperative, perioperative, and postoperative pathways of care, together with surgeons and teams with significant experience in aortic surgery, should be considered as crucial points to improve clinical outcomes. Aggressive prevention, prompt diagnosis and timely rescue of any major adverse events following the procedure remain paramount clinical needs.
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Affiliation(s)
- Andrea Xodo
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Mario D’Oria
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
- Correspondence: ; Tel.: +39-0403994645
| | - Bernardo Mendes
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, “Vita-Salute” San Raffaele University, 58-20132 Milan, Italy;
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Mauro Gargiulo
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Jacob Budtz-Lilly
- Department of Cardiovascular Surgery, Division of Vascular Surgery, Aarhus University Hospital, 161-8200 Aarhus, Denmark;
| | - Michele Antonello
- Vascular and Endovascular Surgery, University Hospital of Padova, DSCTV-University of Padova, 35128 Padova, Italy;
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Fabio Pilon
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Domenico Milite
- Vascular and Endovascular Surgery Unit, “San Bortolo” Hospital, AULSS8 Berica, 36100 Vicenza, Italy; (A.X.); (F.P.); (D.M.)
| | - Cristiano Calvagna
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Filippo Griselli
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Jacopo Taglialavoro
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Silvia Bassini
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - David Lindstrom
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, 75236 Uppsala, Sweden; (K.M.); (A.W.); (D.L.)
| | - Enrico Gallitto
- Vascular Surgery, IRCCS-University Hospital Policlinico S. Orsola, DIMES-University of Bologna, 40138 Bologna, Italy; (M.G.); (E.G.)
| | - Luca Mezzetto
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Davide Mastrorilli
- Unit of Vascular Surgery, Integrated University Hospital of Verona, 37126 Verona, Italy; (G.F.V.); (L.M.); (D.M.)
| | - Sandro Lepidi
- Cardiovascular Department, Division of Vascular and Endovascular Surgery, Trieste University Hospital ASUGI, 34149 Trieste, Italy; (C.C.); (F.G.); (J.T.); (S.B.); (S.L.)
| | - Randall DeMartino
- Gonda Vascular Center, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, NY 55902, USA; (B.M.); (R.D.)
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22
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Alberga AJ, von Meijenfeldt GCI, Rastogi V, de Bruin JL, Wever JJ, van Herwaarden JA, Hamming JF, Hazenberg CEVB, van Schaik J, Mees BME, van der Laan MJ, Zeebregts CJ, Schurink GWH, Verhagen HJM. Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study. Ann Surg 2021; 277:00000658-900000000-93144. [PMID: 34913891 DOI: 10.1097/sla.0000000000005337] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We evaluate nationwide perioperative outcomes of complex EVAR and assess the volume-outcome association of complex EVAR. SUMMARY OF BACKGROUND DATA Endovascular treatment with fenestrated (FEVAR) or branched (BEVAR) endografts is progressively used for excluding complex aortic aneurysms (complex AAs). It is unclear if a volume-outcome association exists in endovascular treatment of complex AAs (complex EVAR). METHODS All patients prospectively registered in the Dutch Surgical Aneurysm Audit who underwent complex EVAR (FEVAR or BEVAR) between January 2016 and January 2020 were included. The effect of annual hospital volume on perioperative mortality was examined using multivariable logistic regression analyses. Patients were stratified into quartiles based on annual hospital volume to determine hospital volume categories. RESULTS We included 694 patients (539 FEVAR patients, 155 BEVAR patients). Perioperative mortality following FEVAR was 4.5% and 5.2% following BEVAR. Postoperative complication rates were 30.1% and 48.7%, respectively. The first quartile hospitals performed <9 procedures/yr; second, third, and fourth quartile hospitals performed 9-12, 13-22, and ≥23 procedures/yr. The highest volume hospitals treated the significantly more complex patients. Perioperative mortality of complex EVAR was 9.1% in hospitals with a volume of < 9, and 2.5% in hospitals with a volume of ≥13 (P = 0.008). After adjustment for confounders, an annual volume of ≥13 was associated with less perioperative mortality compared to hospitals with a volume of < 9. CONCLUSIONS Data from this nationwide mandatory quality registry shows a significant effect of hospital volume on perioperative mortality following complex EVAR, with high volume complex EVAR centers demonstrating lower mortality rates.
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Affiliation(s)
- Anna J Alberga
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands Department of Vascular Surgery, Haga Teaching Hospital, The Hague, the Netherlands Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
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23
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Bicknell CD, Beck AW. A Technical Tour de Force, but Not for the Faint of Heart! Eur J Vasc Endovasc Surg 2021; 62:746. [PMID: 34507893 DOI: 10.1016/j.ejvs.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Colin D Bicknell
- Department of Surgery and Cancer, Imperial College London and Imperial Vascular Unit, Imperial College Healthcare NHS Trust, UK.
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Alabama, USA
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