1
|
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: 124] [Impact Index Per Article: 124.0] [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.
Collapse
|
2
|
de Boer M, Shiraev T, Waller J, Qasabian R. Has EVAR changed the outcomes of ruptured abdominal aortic aneurysms? A decades worth of experience in an Australian Teaching Hospital. ANZ J Surg 2022; 92:730-735. [PMID: 35170179 DOI: 10.1111/ans.17554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ruptured abdominal aortic aneurysms (rAAA) are associated with significant mortality, and equipoise remains as to whether patients managed with endovascular stent grafts (rEVAR) demonstrate better outcomes when compared to traditional open repair (OR). This study sought to examine the outcomes of patients presenting with rAAA to our institution and assess the perioperative outcomes and outpatient mortality of patients over the past decade. METHODS A retrospective analysis was conducted. Patients treated for rAAA between 2010 and 2019 were identified from a search of the hospital database for ACHI and ICD-10 codes for repair of AAA. Demographic, operative and post-operative variables were collected from electronic medical records of identified patients. RESULTS Eighty patients were identified, 51 of whom presented with a rAAA. The majority of repairs were rEVARs (59%). Median age was 76 years. Median length of admission to ICU was 3 days, and median length of hospital admission was 10 days. Overall in-patient mortality was 26%, with rates of 39% at 3 years and 47% at 5 years. No significant difference in outpatient mortality was found in patients undergoing rEVAR compared to OR, with rates of 61% at 5 years compared to 65% at 5 years, respectively (p = 0.8). CONCLUSION Perioperative outcomes of our cohort of patients undergoing endovascular repair compared to open repair for ruptured and symptomatic AAAs are comparable over the past decade. Given equipoise remains between repair methods, further observational studies are required to quantify benefits of OR and endovascular repairs for ruptured and symptomatic AAAs.
Collapse
Affiliation(s)
- Madeleine de Boer
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Timothy Shiraev
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Jacob Waller
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Raffi Qasabian
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| |
Collapse
|
3
|
Kumar M, Long GW, Major M, Gates E, Studzinski DM, Callahan RE, Brown OW, Welsh RJ. Predictors of mortality in nonagenarians undergoing abdominal aortic aneurysm repair: analysis of the National Surgical Quality Improvement Program dataset. J Vasc Surg 2021; 75:1223-1233. [PMID: 34634420 DOI: 10.1016/j.jvs.2021.09.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The present study used the American College of Surgeons National Surgical Quality Improvement Program dataset to identify the predictors of 30-day mortality for nonagenarians undergoing endovascular aortic aneurysm repair (EVAR) or open surgical repair (OSR). METHODS Patients aged >90 years who had undergone abdominal aortic aneurysm repair from 2005 to 2017 were identified using procedure codes. Those with operative times <15 minutes were excluded. The demographics, preoperative comorbidities, and postoperative complications of those who had died by 30 days were compared with those of the patients alive at 30 days. RESULTS A total of 1356 nonagenarians met the criteria: 1229 (90.6%) had undergone EVAR and 127 (9.4%) had undergone OSR. The overall 30-day mortality was 10.4%. The patients who had died within 30 days were significantly more likely to have undergone OSR than EVAR (40.9% vs 7.2%; P < .001). They also had a greater incidence of dependent functional status (22.0% for those who had died vs 8.1% for those alive at 30 days; P < .001), American Society of Anesthesiology (ASA) classification of ≥4 (81.2% vs 18.8%; P < .001), perioperative blood transfusion (59.6% vs 20.3%; P < .001), postoperative pneumonia (12.1% vs 2.9%; P = .001), mechanical ventilation >48 hours (22.7% vs 2.6%; P < .001), and acute renal failure (12.1% vs 0.5%; P < .001). The EVAR group had a 30-day mortality rate of 2.6% in 1008 elective cases and 28.6% in 221 emergent cases. The OSR group had a 30-day mortality rate of 19.1% in 47 elective cases and 53.7% in 80 emergent cases. In the EVAR cohort, the 30-day mortality group had had a significantly greater incidence of dependent functional status (17% for those who had died vs 8% for those alive at 30 days; P = .004), ASA classification of ≥4 (76.4% vs 40.3%; P < .001), perioperative blood transfusion (57% vs 19%; P < .001), emergency surgery (71% vs 14%; P < .001), and longer operative times (150 vs 128 minutes; P = .001). CONCLUSIONS Nonagenarians had an incrementally increased, but acceptable, risk of 30-day mortality with EVAR in elective and emergent cases compared with that reported for octogenarians and cohorts of patients not selected for age. We found greater mortality for patients with dependent status, a higher ASA classification, emergent repair, and OSR. These preoperative risk factors could help identify the best surgical candidates. Given these results, consideration for EVAR or OSR might be reasonable for highly selected patients, especially for elective patients with a larger abdominal aortic aneurysm diameter for whom the risk of rupture is higher.
Collapse
Affiliation(s)
- Mohineesh Kumar
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Graham W Long
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich.
| | - Matthew Major
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Elizabeth Gates
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Diane M Studzinski
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Rose E Callahan
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - O William Brown
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| | - Robert J Welsh
- Section of Vascular Surgery, Department of Surgery, Oakland University William Beaumont School of Medicine, Royal Oak, Mich
| |
Collapse
|
4
|
Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 873] [Impact Index Per Article: 174.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
5
|
Davidovic LB, Markovic M, Kostic D, Zlatanovic P, Mutavdzic P, Cvetic V. Open repair of ruptured abdominal aortic aneurysm with associated horseshoe kidney. INT ANGIOL 2018; 37:471-478. [DOI: 10.23736/s0392-9590.18.04039-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
6
|
Amato B, Fugetto F, Compagna R, Zurlo V, Barbetta A, Petrella G, Aprea G, Danzi M, Rocca A, de Franciscis S, Serra R. Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review. MINERVA CHIR 2018; 74:472-480. [PMID: 29806754 DOI: 10.23736/s0026-4733.18.07768-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions. EVIDENCE ACQUISITION A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data. EVIDENCE SYNTHESIS Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts. CONCLUSIONS The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.
Collapse
Affiliation(s)
- Bruno Amato
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Francesco Fugetto
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy
| | - Rita Compagna
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Valeria Zurlo
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy
| | - Andrea Barbetta
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | | | - Giovanni Aprea
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Michele Danzi
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Aldo Rocca
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Magna Graecia University, Catanzaro, Italy - .,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| |
Collapse
|
7
|
A retrospective observational cohort study investigating the association between acute kidney injury and all-cause mortality among patients undergoing endovascular repair of abdominal aortic aneurysms. J Anesth 2017. [PMID: 28638973 DOI: 10.1007/s00540-017-2380-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) has been found to be associated with short- and long-term mortality and morbidity in various clinical settings. However, it is unknown whether AKI after endovascular repair of abdominal aortic aneurysms (EVAR) is associated with postoperative mortality. METHODS This observational study analyzed patients who underwent EVAR. The primary outcome was all-cause mortality. The outcomes of patients with and without postoperative AKI were compared using the Kaplan-Meier method and log-rank test. Factors with P < 0.05 on the univariate analysis were entered into the multivariate Cox regression model. Predictors of AKI were also determined using Cox univariate and multivariate analysis. The identified predictors of AKI were excluded from multivariate analysis for all-cause mortality because these factors could intermediate outcome. RESULTS There were 490 eligible patients. After a follow-up of 28.3 (16.8) months [mean (standard deviation)], 62 patients (12.7%) died. AKI occurred in 59 patients (12.0%). AKI was found by the log-rank test to be associated with a significant increase of all-cause mortality (P < 0.001). Preoperative estimated glomerular filtration rate, preoperative peripheral vascular disease, and emergency surgery were found to be independent predictors of AKI and these variables were excluded from the main analysis. Multivariate analysis showed AKI [hazard ratio (HR) = 1.19, 95% confidence interval (CI) 1.01-3.60, P = 0.045] and transfusion (HR = 1.05, 95% CI 1.01-1.09, P = 0.011) were independent predictors of mortality. CONCLUSIONS In the present study, AKI and transfusion were associated with significant increases in all-cause mortality after EVAR.
Collapse
|
8
|
Biebl M, Hakaim AG, Oldenburg WA, Klocker J, McKinney JM, Paz-Fumagalli R. Management of a Large Intraoperative Type IIIb Endoleak in a Bifurcated Endograft. Vasc Endovascular Surg 2016; 39:267-71. [PMID: 15920656 DOI: 10.1177/153857440503900308] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this paper is to describe the intraoperative management of a type IIIb endoleak after deployment of a bifurcated endograft in a patient with narrow iliac access vessels. A 62-year-old man underwent elective endovascular repair (EVAR) of a 53 mm abdominal aortic aneurysm. After device deployment, a large IIIb endoleak, arising from the main body of the device, was visualized. Narrow iliac vessels precluded deployment of a second bifurcated graft, and the endoleak was successfully excluded with an aortomonoiliac device, followed by contralateral iliac occlusion and subsequent creation of a femorofemoral bypass. At 1-year follow-up, the aneurysm remains excluded and is decreasing in size. Type III endoleaks are a known complication of EVAR, requiring immediate treatment through their association with aneurysm enlargement and rupture. If an additional bifurcated graft cannot be used, aortomonoiliac conversion represents a feasible endovascular alternative treatment for type III endoleaks, other than conversion to open surgical repair. Therefore, aortomonoiliac converters with appropriate occluder devices should be readily available during deployment of bifurcated devices.
Collapse
Affiliation(s)
- Matthias Biebl
- Section of Vascular Surgery, Mayo Clinic Jacksonville, FL 32224, USA
| | | | | | | | | | | |
Collapse
|
9
|
Verhagen HJM, Prinssen M, Milner R, Blankensteijn JD. Endoleak after Endovascular Repair of Ruptured Abdominal Aortic Aneurysm: Is it a Problem? J Endovasc Ther 2016; 10:766-71. [PMID: 14533965 DOI: 10.1177/152660280301000413] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To illustrate the clinical significance of type I and type II endoleaks following endovascular treatment of a ruptured abdominal aortic aneurysm (AAA). Case Report: An 81-year-old patient presented with a ruptured AAA that was urgently treated with an Ancure aortomonoiliac endograft. After the postoperative computed tomographic (CT) scan, a distal type I endoleak was suspected, but the follow-up angiogram demonstrated only lumbar backbleeding. As the patient was stable, conservative treatment was recommended. After 3 months, a distal as well as a proximal type I endoleak were demonstrated, strangely enough, in the presence of a shrinking aneurysm and clearance of the retroperitoneal hematoma. Both endoleaks were treated endoluminally, after which the CT scan still showed contrast in the aneurysm sac, presumably from lumbar backbleeding. Twelve months after the initial procedure, the patient continues to do well. Conclusions: Although not well understood, the presence of an endoleak after endovascular repair of a ruptured AAA may not always be a life-threatening situation.
Collapse
Affiliation(s)
- Hence J M Verhagen
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | | | | | | |
Collapse
|
10
|
Patelis N, Moris D, Karaolanis G, Georgopoulos S. Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm. Med Sci Monit Basic Res 2016; 22:34-44. [PMID: 27090791 PMCID: PMC4847558 DOI: 10.12659/msmbr.897601] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background Patients presenting with ruptured abdominal aortic aneurysms are most often treated with open repair despite the fact that endovascular aneurysm repair is a less invasive and widely accepted method with clear benefits for elective aortic aneurysm patients. A debate exists regarding the definitive benefit in endovascular repair for patients with a ruptured abdominal aortic aneurysm. The aim of this literature review was to determine if any trends exist in favor of either open or endovascular repair. Material/Methods A literature search was performed using PUBMED, OVID, and Google Scholar databases. The search yielded 64 publications. Results Out of 64 publications, 25 were retrospective studies, 12 were population-based, 21 were prospective, 5 were the results of RCTs, and 1 was a case-series. Sixty-one studies reported on early mortality and provided data comparing endovascular repair (rEVAR) and open repair (rOR) for ruptured abdominal aneurysm groups. Twenty-nine of these studies reported that rEVAR has a lower early mortality rate. Late mortality after rEVAR compared to that of rOR was reported in 21 studies for a period of 3 to 60 months. Results of 61.9% of the studies found no difference in late mortality rates between these 2 groups. Thirty-nine publications reported on the incidence of complications. Approximately half of these publications support that the rEVAR group has a lower complication rate and the other half found no difference between the groups. Length of hospital stay has been reported to be shorter for rEVAR in most studies. Blood loss and need for transfusion of either red cells or fresh frozen plasma was consistently lower in the rEVAR group. Conclusions Differences between the included publications affect the outcomes. Randomized control trials have not been able to provide clear conclusions. rEVAR can now be considered a safe method of treating rAAA, and is at least equal to the well-established rOR method.
Collapse
Affiliation(s)
- Nikolaos Patelis
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Demetrios Moris
- Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Georgios Karaolanis
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - Sotiris Georgopoulos
- Vascular Unit, First Department of Surgery, Laiko General Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
11
|
The Impact of Aortic Occlusion Balloon on Mortality After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Meta-analysis and Meta-regression Analysis. Cardiovasc Intervent Radiol 2015; 38:1425-37. [DOI: 10.1007/s00270-015-1132-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/15/2015] [Indexed: 12/11/2022]
|
12
|
Luebke T, Brunkwall J. Risk-Adjusted Meta-analysis of 30-Day Mortality of Endovascular Versus Open Repair for Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2015; 29:845-63. [DOI: 10.1016/j.avsg.2014.12.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/19/2014] [Accepted: 12/22/2014] [Indexed: 12/20/2022]
|
13
|
Raats JW, Flu HC, Ho GH, Veen EJ, Vos LD, Steyerberg EW, van der Laan L. Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age. Clin Interv Aging 2014; 9:1721-32. [PMID: 25342890 PMCID: PMC4206251 DOI: 10.2147/cia.s64718] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA. Methods We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital. Results Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01–1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70–79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008). Conclusion The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.
Collapse
Affiliation(s)
- Jelle W Raats
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Hans C Flu
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Gwan H Ho
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Eelco J Veen
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Louwerens D Vos
- Department of Radiology, Amphia Hospital, Breda, the Netherlands
| | | | | |
Collapse
|
14
|
Piffaretti G, Caronno R, Tozzi M, Lomazzi C, Rivolta N, Castelli P. Endovascular versus open repair of ruptured abdominal aortic aneurysms. Expert Rev Cardiovasc Ther 2014; 4:839-52. [PMID: 17173500 DOI: 10.1586/14779072.4.6.839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although major improvement has occurred to make elective repair of abdominal aortic aneurysms a safe procedure, the incidence of ruptured abdominal aortic aneurysms and mortality rates are still disappointing. Endovascular abdominal aortic aneurysm repair has produced quantum changes in aneurysm treatment. The successful application of the endovascular approach for the treatment of abdominal aortic aneurysms in the elective setting has prompted a strong interest regarding its possible use in dealing with the long-standing challenge of a ruptured abdominal aortic aneurysm. Since the first report, several centers have reported results and a wide spectrum of opinion regarding its application, with special consideration to logistical and practical barriers for appropriate utilization. The purpose of this article is to review all the available literature on the endovascular repair of ruptured abdominal aortic aneurysms and to analyze the most recent trends in their management, with special consideration given to comparing results of conventional and endovascular approaches.
Collapse
Affiliation(s)
- Gabriele Piffaretti
- University of Insubria, Vascular Surgery-Department of Surgery, Viale Borri 57 21100, Varese, Italy.
| | | | | | | | | | | |
Collapse
|
15
|
Antoniou GA, Georgiadis GS, Antoniou SA, Pavlidis P, Maras D, Sfyroeras GS, Georgakarakos EI, Lazarides MK. Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair. J Vasc Surg 2013; 58:1091-105. [DOI: 10.1016/j.jvs.2013.07.109] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/16/2013] [Accepted: 07/26/2013] [Indexed: 01/08/2023]
|
16
|
Stokmans R, Teijink J, Cuypers P, Riambau V, van Sambeek M. No Differences in Perioperative Outcome between Symptomatic and Asymptomatic AAAs after EVAR: An Analysis from the ENGAGE Registry. Eur J Vasc Endovasc Surg 2012; 43:667-73. [DOI: 10.1016/j.ejvs.2012.02.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 02/21/2012] [Indexed: 11/29/2022]
|
17
|
Endovascular vs open repair for ruptured abdominal aortic aneurysm. J Vasc Surg 2012; 56:15-20. [PMID: 22626871 DOI: 10.1016/j.jvs.2011.12.067] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 12/02/2011] [Accepted: 12/24/2011] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Endovascular repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) has become first-line therapy at our institution and is performed under a standardized protocol. We compare perioperative mortality, midterm survival, and morbidity after EVAR and open surgical repair (OSR). METHODS Records were retrospectively reviewed from May 2000 to September 2010 for repair of infrarenal rAAAs. Primary end points included perioperative mortality and midterm survival. Secondary end points included acute limb ischemia, length of stay, ventilator-dependent respiratory failure, myocardial infarction, renal failure, abdominal compartment syndrome, and secondary intervention. Statistical analysis was performed using the t-test, χ(2) test, the Fisher exact test, and logistic regression calculations. Midterm survival was assessed with Kaplan-Meier analysis and Cox proportional hazard models. RESULTS Seventy-four infrarenal rAAAs were repaired, 19 by EVAR and 55 by OSR. Despite increased age and comorbidity in the EVAR patients, perioperative mortality was 15.7% for EVAR, which was significantly lower than the 49% for OSR (odds ratio, 0.19; 95% CI, 0.05-0.74; P = .008). Midterm survival also favored EVAR (hazard ratio, 0.40; 95% CI, 0.21-0.77; P = .028, adjusted for age and sex). Mean follow-up was 20 months, and 1-year survival was 60% for EVAR vs 45% for OSR. Mean length of stay for patients surviving >1 day was 10 days for EVAR and 21 days for OSR (P = .004). Ventilator-dependent respiratory failure was 5% in the EVAR group vs 42% for OSR (odds ratio, 0.08; 95% CI, 0.01-0.62; P = .001). CONCLUSIONS EVAR of rAAA has a superior perioperative survival advantage and decreased morbidity vs OSR. Although not statistically significant, overall survival favors EVAR. We recommend that EVAR be considered as the first-line treatment of rAAAs and practiced as the standard of care.
Collapse
|
18
|
Mid-term Outcomes following Emergency Endovascular Aortic Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2012; 43:382-5. [DOI: 10.1016/j.ejvs.2011.12.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 12/20/2011] [Indexed: 11/17/2022]
|
19
|
Karkos CD, Sutton AJ, Bown MJ, Sayers RD. A meta-analysis and metaregression analysis of factors influencing mortality after endovascular repair of ruptured abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2011; 42:775-86. [PMID: 21908210 DOI: 10.1016/j.ejvs.2011.07.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 07/19/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine factors that may influence the perioperative mortality after endovascular repair of ruptured abdominal aortic aneurysms (RAAAs) using metaregression analysis. METHODS A meta-analysis of all English-language literature with information on mortality rates after endovascular repair of RAAAs was conducted. A metaregression was subsequently performed to determine the impact on mortality of the following 8 factors: patient age; mid-time study point; anaesthesia; endograft configuration; haemodynamic instability; use of aortic balloon; conversion to open repair; and abdominal compartment syndrome. RESULTS The pooled perioperative mortality across the 46 studies (1397 patients) was 24.3% (95% CI: 20.7-28.3%). Of the 8 variables, only bifurcated approach was significantly associated with reduced mortality (p = 0.005). A moderate negative correlation was observed between bifurcated approach and haemodynamic instability (-0.35). There was still a strong association between bifurcated approach and mortality after simultaneously adjusting for haemodynamic instability, indicating that the latter was not a major factor in explaining the observed association. CONCLUSIONS Endovascular repair of RAAAs is associated with acceptable mortality rates. Patients having a bifurcated endograft were less likely to die. This may be due to some surgeons opting for a bifurcated approach in patients with better haemodynamic condition. Further studies will be needed to clarify this.
Collapse
Affiliation(s)
- C D Karkos
- The 5th Department of Surgery, Medical School, Aristotle University of Thessaloniki, Hippocratio Hospital, Greece.
| | | | | | | |
Collapse
|
20
|
Carrafiello G, Piffaretti G, Laganà D, Fontana F, Mangini M, Ierardi AM, Piacentino F, Canì A, Mariscalco G, Di Massa A, Cuffari S, Castelli P, Fugazzola C. Endovascular treatment of ruptured abdominal aortic aneurysms: aorto-uni-iliac or bifurcated endograft? LA RADIOLOGIA MEDICA 2011; 117:410-25. [PMID: 21892717 DOI: 10.1007/s11547-011-0717-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 02/21/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE This study evaluated the safety and technical and clinical success rates of positioning endovascular endografts (EG) in ruptured abdominal aneurysms. MATERIALS AND METHODS Patients with a ruptured abdominal aortic aneurysm confirmed by contrast-enhanced computed tomography angiography (CTA) were eligible for the analysis. Of 67 patients, 42 (62.7%) were treated with EG. Thirteen patients (30.9%) received an aorto-uni-iliac EG (group A) and 29 a bifurcated EG (group B). Patients were divided for comparative analysis according to the configuration of the EG implanted. RESULTS The primary technical success rate was 100%; the primary clinical success rate was 95% (40/42). There were two intraoperative deaths (4.7%) related to intractable shock. No patient required conversion to open repair. Overall, 12 patients (28.5%) died within 30 days. The in-hospital death rate was 30.9% (13/42). Hospital mortality rate was statistically higher in group A; the type of EG and intensive care unit admission were the only independent predictors of hospital mortality. CONCLUSIONS In our experience, a higher mortality rate was observed for the aorto-uni-iliac configuration; shock at admission was confirmed as the most important factor for postoperative survival.
Collapse
Affiliation(s)
- G Carrafiello
- Interventional Radiology, Department of Radiology, University of Insubria, Viale Borri 57, 21100, Varese, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Gómez Palonés F, Vaquero Puerta C, Gesto Castromil R, Serrano Hernando F, Maeso Lebrun J, Vila Coll R, Clará Velasco A, Escudero Román J, Riambau Alonso V. Tratamiento endovascular del aneurisma de aorta abdominal. ANGIOLOGIA 2011. [DOI: 10.1016/j.angio.2011.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
22
|
Perrott S, Puckridge P, Foreman R, Russell D, Spark J. Anatomical Suitability For Endovascular AAA Repair May Affect Outcomes following Rupture. Eur J Vasc Endovasc Surg 2010; 40:186-90. [DOI: 10.1016/j.ejvs.2010.04.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 04/04/2010] [Indexed: 10/19/2022]
|
23
|
Davenport DL, O'Keeffe SD, Minion DJ, Sorial EE, Endean ED, Xenos ES. Thirty-day NSQIP database outcomes of open versus endoluminal repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2010; 51:305-9.e1. [DOI: 10.1016/j.jvs.2009.08.086] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 08/26/2009] [Accepted: 08/26/2009] [Indexed: 11/25/2022]
|
24
|
Giles KA, Hamdan AD, Pomposelli FB, Wyers MC, Dahlberg SE, Schermerhorn ML. Population-based outcomes following endovascular and open repair of ruptured abdominal aortic aneurysms. J Endovasc Ther 2010; 16:554-64. [PMID: 19842719 DOI: 10.1583/09-2743.1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate national outcomes after endovascular and open surgical repair of ruptured abdominal aortic aneurysms (rAAA). METHODS The Nationwide Inpatient Sample was interrogated to identify all repairs between 2000 and 2005 for rAAA based on ICD-9 codes. In the study period, 2323 patients (1794 men; median age 75 years, range 45-98) with rAAAs had endovascular repair, while 26,106 patients (20,311 men; median age 73 years, range 22-99) had an open procedure. Outcomes included in-hospital mortality, length of stay (LOS), complications, and hospitalization charge. A secondary analysis was performed to compare outcomes from low-, medium-, and high-volume institutions based on annual rAAA repair volume. RESULTS Patients in the endovascular group were significantly older (p<0.05). Mortality was 41% overall: 33% and 41% for endovascular versus open repair, respectively (p<0.001). Mortality after endovascular repair was lower than open surgery for patients >or=70 years (36% versus 47%, p<0.001), but not for those <70 years (24% versus 30%, p = 0.15). LOS was shorter after endovascular repair (7 versus 9 days, p<0.001). Respiratory complications (8% versus 4%, p<0.05) and acute renal failure were more common following open repair (30% versus 23%, p<0.01). Costs were similar (endo $73,590 versus open $67,287, p = 0.15). Mortality decreased as hospital surgical volume increased (low 44%, medium 39%, high 38%; p<0.001). Over time, endovascular repair utilization increased more rapidly at high-volume centers, and a lower mortality was seen with endovascular repair at high-volume compared to low-volume hospitals (22% versus 44%, p<0.001). Multivariate predictors of mortality were age, female gender, lower hospital surgical volume, open repair, and year of surgery. CONCLUSION This population-based study found that mortality associated with rAAAs may be improved by the performance of endovascular repair, especially in older patients. Mortality after rAAA for both endovascular and open repairs was also lower at high-volume institutions.
Collapse
Affiliation(s)
- Kristina A Giles
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | | | | | | |
Collapse
|
25
|
Holst J, Resch T, Ivancev K, Björses K, Dias N, Lindblad B, Mathiessen S, Sonesson B, Malina M. Early and Intermediate Outcome of Emergency Endovascular Aneurysm Repair of Ruptured Infrarenal Aortic Aneurysm: A Single-Centre Experience of 90 Consecutive Patients. Eur J Vasc Endovasc Surg 2009; 37:413-9. [PMID: 19211279 DOI: 10.1016/j.ejvs.2008.12.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 12/21/2008] [Indexed: 10/21/2022]
|
26
|
10 Years of Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortoiliac Aneurysms: Lessons Learned. Ann Surg 2009; 249:510-5. [DOI: 10.1097/sla.0b013e31819a8b65] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
27
|
A Systematic Review and Meta-analysis of Endovascular Repair (EVAR) for Ruptured Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2008; 36:536-44. [DOI: 10.1016/j.ejvs.2008.08.008] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 08/06/2008] [Indexed: 11/17/2022]
|
28
|
Gerassimidis TS, Karkos CD, Karamanos DG, Papazoglou KO, Papadimitriou DN, Demiropoulos FP, Malkotsis DP, Kamparoudis AG. Endovascular management of ruptured abdominal aortic aneurysms: an 8-year single-centre experience. Cardiovasc Intervent Radiol 2008; 32:241-9. [PMID: 18931874 DOI: 10.1007/s00270-008-9441-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Revised: 07/27/2008] [Accepted: 08/27/2008] [Indexed: 11/26/2022]
Abstract
We aimed to review our experience with the endovascular treatment of ruptured abdominal aortic aneurysm (RAAA). During an 8-year period, 69 patients with a RAAA presented to our department; 67 underwent assessment by computed axial tomography, and 2 died on arrival before any evaluation was possible. A total of 42 patients (63%) were suitable for stent-grafting, and all but 1 (c-arm failure) proceeded to endovascular repair. Of these, 27 underwent surgery with local anaesthesia; 3 did so under general anaesthesia; and a further 11 procedures were commenced with the patient under local anaesthesia and then converted to general anaesthesia. A total of 28 bifurcated and 14 aorto-uni-iliac stent-grafts were implanted. Aortic occlusion balloons were used in 2 (5%) patients. The in-hospital and the 30-day mortality rates were 36% and 41%, respectively. After surgery, 21 complications were encountered in 17 patients. Two patients required reintervention during their hospital stay (1 type I endoleak and 1 limb occlusion). During the follow-up (median 730 days [range 90 to 580 days]), the 1-year and 5-year cumulative survival probabilities were 53% (SE 7.9%) and 50% (SE 8.0%), respectively. Three reinterventions were necessary during follow-up (2 type I endoleaks and 1 graft occlusion). We conclude that endovascular treatment is feasible in the emergency setting, and the early experience is promising. Whether such an approach is superior to open surgery remains to be determined.
Collapse
Affiliation(s)
- Thomas S Gerassimidis
- Fifth Department of Surgery, Hippocrateio Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Sadat U, Boyle JR, Walsh SR, Tang T, Varty K, Hayes PD. Endovascular vs open repair of acute abdominal aortic aneurysms—A systematic review and meta-analysis. J Vasc Surg 2008; 48:227-36. [DOI: 10.1016/j.jvs.2007.11.028] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Revised: 11/07/2007] [Accepted: 11/11/2007] [Indexed: 01/25/2023]
|
30
|
Endovascular aneurysm repair: current and future status. Cardiovasc Intervent Radiol 2008; 31:451-9. [PMID: 18231829 DOI: 10.1007/s00270-008-9295-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Revised: 12/01/2007] [Accepted: 12/06/2007] [Indexed: 10/22/2022]
Abstract
Endovascular aneurysm repair has rapidly expanded since its introduction in the early 1990s. Early experiences were associated with high rates of complications including conversion to open repair. Perioperative morbidity and mortality results have improved but these concerns have been replaced by questions about long-term durability. Gradually, too, these problems have been addressed. Challenges of today include the ability to roll out the endovascular technique to patients with adverse aneurysm morphology. Fenestrated and branch stent-graft technology is in its infancy. Only now are we beginning to fully understand the advantages, limitations, and complications of such technology. This paper outlines some of the concepts and discusses the controversies and challenges facing clinicians involved in endovascular aneurysm surgery today and in the future.
Collapse
|
31
|
Kubin K, Sodeck GH, Teufelsbauer H, Nowatschka B, Kretschmer G, Lammer J, Schoder M. Endovascular Therapy of Ruptured Abdominal Aortic Aneurysm: Mid- and Long-Term Results. Cardiovasc Intervent Radiol 2008; 31:496-503. [DOI: 10.1007/s00270-007-9253-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2007] [Revised: 10/31/2007] [Accepted: 11/09/2007] [Indexed: 11/28/2022]
|
32
|
Mastracci TM, Garrido-Olivares L, Cinà CS, Clase CM. Endovascular repair of ruptured abdominal aortic aneurysms: A systematic review and meta-analysis. J Vasc Surg 2008; 47:214-221. [DOI: 10.1016/j.jvs.2007.07.052] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Revised: 07/26/2007] [Accepted: 07/28/2007] [Indexed: 02/07/2023]
|
33
|
Harkin DW, Dillon M, Blair PH, Ellis PK, Kee F. Endovascular Ruptured Abdominal Aortic Aneurysm Repair (EVRAR): A Systematic Review. Eur J Vasc Endovasc Surg 2007; 34:673-81. [PMID: 17719809 DOI: 10.1016/j.ejvs.2007.06.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Accepted: 06/03/2007] [Indexed: 10/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- D W Harkin
- Regional Vascular Surgery Unit, Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland, UK.
| | | | | | | | | |
Collapse
|
34
|
Baril DT, Kahn RA, Ellozy SH, Carroccio A, Marin ML. Endovascular Abdominal Aortic Aneurysm Repair: Emerging Developments and Anesthetic Considerations. J Cardiothorac Vasc Anesth 2007; 21:730-42. [PMID: 17905287 DOI: 10.1053/j.jvca.2007.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Donald T Baril
- Department of Surgery, Division of Vascular Surgery, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
| | | | | | | | | |
Collapse
|
35
|
Klonaris C, Georgopoulos S, Markatis F, Katsargyris A, Tsigris C, Bastounis E. Endovascular repair of late abdominal aortic aneurysm rupture owing to mixed-type endoleak following endovascular abdominal aortic aneurysm repair. Vascular 2007; 15:167-71. [PMID: 17573024 DOI: 10.2310/6670.2007.00021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report the successful endovascular repair of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 8 months after endovascular abdominal aortic aneurysm repair (EVAR). A 74-year-old man with a history of EVAR 8 months earlier presented with hypotension, severe back pain, and tenderness on abdominal palpation. A contrast-enhanced computed tomographic scan showed a large retroperitoneal hematoma and confirmed the diagnosis of secondary abdominal aortic rupture. Because the patient had severe comorbidities, the endovascular method was chosen for further management. Two stent grafts were placed appropriately to eliminate a type 1a and a type 3 endoleak owing to modular separation of the left iliac graft limb from the main body stent graft. An additional self-expanding stent was deployed in the solitary right renal artery to open its origin, which was partially overlapped by the proximal cuff. The patient was discharged on the tenth postoperative day and is alive and well 1 year postoperatively. This case indicates that endovascular repair is feasible not only in cases of primarily ruptured AAAs but also in secondarily ruptured AAAs after failure of EVAR.
Collapse
Affiliation(s)
- Chris Klonaris
- 1st Department of Surgery, LAIKON Hospital, Athens University Medical School, Greece.
| | | | | | | | | | | |
Collapse
|
36
|
Hoornweg LL, Wisselink W, Vahl A, Balm R. The Amsterdam Acute Aneurysm Trial: Suitability and Application Rate for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2007; 33:679-83. [PMID: 17276096 DOI: 10.1016/j.ejvs.2006.12.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Accepted: 12/06/2006] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate anatomical suitability and application rate for endovascular repair of patients with a ruptured abdominal aortic aneurysm (RAAA). METHODS The Amsterdam Acute Aneurysm trial is a multicenter randomised trial comparing open with endovascular treatment in patients with a RAAA (International Standard Randomized Controlled Trial Number (ISRCTN) 66212637). Between April 2004 and January 2006, all consecutive patients with clinical suspicion of a RAAA at presentation were assessed prospectively. Anatomical suitability for endovascular repair was based on use of an aorto-uni-iliac endovascular graft and assessed in patients with a proven aortic rupture on CT angiography (CTA). RESULTS In 128/256 patients, presenting with clinical suspicion of a ruptured aneurysm, RAAA was diagnosed. 105 patients were brought to a trial center and CTA confirmed RAAA in 83 patients. In 38 of 83 patients (45.8%) with positive CTA, the anatomy of the aorta and iliac arteries was considered suitable for endovascular repair. Exclusion from endovascular repair was due to unsuitable infrarenal neck or iliac anatomy (37 and 8 patients respectively). Overall, endovascular treatment was applicable in 38/128 patients (29.7%) with a RAAA in the Amsterdam region and in 38 out of 105 patients (35.5%) admitted to the trial centers. CONCLUSION In this prospective cohort of all patients with a RAAA in the Amsterdam Acute Aneurysm Trial region, the suitability for endovascular repair in patients with a RAAA confirmed on CTA is 45.8%, but the application rate was lower.
Collapse
Affiliation(s)
- L L Hoornweg
- Department of Vascular Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | | |
Collapse
|
37
|
Coppi G, Silingardi R, Gennai S, Saitta G, Ciardullo AV. A single-center experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms. J Vasc Surg 2006; 44:1140-7. [PMID: 17145413 DOI: 10.1016/j.jvs.2006.08.070] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Accepted: 08/26/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To retrospectively compare a single center's immediate and mid-term outcomes of ruptured abdominal aortic aneurysm open and endovascular repair (EVAR) for two patient groups-hemodynamically stable and unstable patients-in the same time period. METHODS Patients presenting at our center with confirmed rupture of an abdominal aortic aneurysm between December 1999 and April 2006 were considered according to an intention-to-treat model with EVAR. Patients with symptomatic or acute (but not ruptured) AAAs were not included in this study. Thirty-three patients underwent EVAR, and 91 underwent open repair. Seventy-two patients (EVAR, 45%; open, 63%) were classified as hemodynamically unstable at arrival, and 52 were classified as stable (EVAR, 55%; open, 37%). Ninety-seven percent of EVAR procedures commenced under local anesthesia, and 100% of open repairs occurred with general anesthesia. Overall successful graft deployment, 30-day mortality, overall reintervention rate, and complications were the study primary end points. RESULTS Overall successful graft deployment for EVAR was 91%; for open repair, it was 96%. Overall 30-day mortality for EVAR was 30% (unstable, 53%; stable, 11%), and the rate was 46% for open repair (unstable, 61%; stable, 21%). The EVAR postoperative reintervention rate (within 30 days) was 15% (unstable, 20%; stable, 11%), and for open repair it was 10% (unstable, 9%; stable, 15%). We recorded a 27% severe complication rate for EVAR patients (unstable, 40%; stable, 17%), and for patients treated with open repair, it was 33% (unstable, 35%; stable, 29%). Our overall EVAR eligibility rate was 52%, and our overall EVAR treatment rate was 27%. CONCLUSIONS Our study's overall results for EVAR remain encouraging when compared with those of conventional repair, but large randomized trials are required to confirm the efficacy of the procedure.
Collapse
Affiliation(s)
- Gioacchino Coppi
- Department of Vascular Surgery, Policlinico Hospital of Modena and University of Studies of Modena and Reggio Emilia, Modena, Italy.
| | | | | | | | | |
Collapse
|
38
|
Hinchliffe RJ, Bruijstens L, MacSweeney STR, Braithwaite BD. A Randomised Trial of Endovascular and Open Surgery for Ruptured Abdominal Aortic Aneurysm – Results of a Pilot Study and Lessons Learned for Future Studies. Eur J Vasc Endovasc Surg 2006; 32:506-13; discussion 514-5. [PMID: 16887369 DOI: 10.1016/j.ejvs.2006.05.016] [Citation(s) in RCA: 218] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Accepted: 05/25/2006] [Indexed: 12/21/2022]
Abstract
INTRODUCTION EVAR has the potential to improve outcome after ruptured abdominal aortic aneurysm (AAA). Published series have been based upon selected populations. METHODS An interim analysis of a single centre prospective randomised controlled trial comparing endovascular aneurysm repair (EVAR) with open aneurysm repair (OAR) in patients with ruptured AAA was performed. Patients who had a ruptured AAA and who were considered fit for open repair were randomised to EVAR or OAR after consent had been obtained. Those in the EVAR group had pre-operative spiral computed tomographic angiography (CTA). The primary endpoint was operative (30-day) mortality and secondary endpoints were moderate or severe operative complications, hospital stay and time between diagnosis and operation. A power study calculation required 100 patients to be recruited. RESULTS Between September 2002 and December 2004, 103 patients were admitted with suspected ruptured AAA. Only 32 patients were recruited to the study. Of these, four patients died before receiving surgical treatment. On an intention to treat basis the 30-day mortality rate was 53% in the EVAR group and 53% in the OAR group. Moderate or severe operative complications occurred in 77% in the EVAR group and in 80% in the OAR group. Median total hospital stay in the EVAR group was 10 days (inter-quartile range 6-28) and 12 days (4-52) in the OAR group. Median time between diagnosis and operation was 75 minutes (64-126) in the EVAR group and 100 minutes (48-138) in the OAR group. CONCLUSIONS Despite the relative high operative mortality in the EVAR group, these preliminary results show that it is possible to recruit patients to a randomised trial of OAR and EVAR in patients with ruptured AAA. CT scanning does not delay treatment.
Collapse
MESH Headings
- Aged
- Aged, 80 and over
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/mortality
- Aneurysm, Ruptured/surgery
- Aneurysm, Ruptured/therapy
- Angiography, Digital Subtraction
- Angioplasty
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/mortality
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Abdominal/therapy
- Blood Vessel Prosthesis Implantation
- Female
- Humans
- Male
- Pilot Projects
- Prospective Studies
- Radiography, Interventional
- Stents
- Survival Analysis
- Tomography, Spiral Computed
- Treatment Outcome
Collapse
Affiliation(s)
- R J Hinchliffe
- Department of Vascular and Endovascular Surgery, University Hospital, Nottingham, UK
| | | | | | | |
Collapse
|
39
|
Oranen BI, Bos WTGJ, Verhoeven ELG, Tielliu IFJ, Zeebregts CJ, Prins TR, van den Dungen JJAM. Is emergency endovascular aneurysm repair associated with higher secondary intervention risk at mid-term follow-up? J Vasc Surg 2006; 44:1156-1161. [PMID: 17055694 DOI: 10.1016/j.jvs.2006.07.048] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 07/26/2006] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The study assessed mid-term outcome of emergency endovascular repair for acute infrarenal abdominal aortic aneurysms, with special attention to secondary interventions. METHODS Between May 1998 and August 2005, 56 patients underwent emergent endovascular repair for a ruptured abdominal aortic aneurysm (n = 34) or an acute nonruptured abdominal aortic aneurysm (n = 22). During the same period, 322 consecutive patients underwent elective endovascular aneurysm repair and were used as control group. Five types of stent grafts were used: Vanguard, Talent, Excluder, Zenith, and Quantum. Follow-up included abdominal radiograph, duplex ultrasound scanning, and computed tomographic angiography. Outcome measures included all-cause and aneurysm-related mortality, complications, and secondary interventions. RESULTS Mortality at 30 days was 18%, 5%, and 1% in the ruptured, acute nonruptured, and elective aneurysm groups, respectively. Overall mean follow-up was 38 +/- 26 months. In the ruptured aneurysm group, survival was 67.8% +/- 8.6% at 1 year and 62.1% +/- 9.5% at 2 and 3 years. Seven secondary interventions (4 early and 3 late) were required in five patients (15%), with a cumulative risk of 9.2% +/- 5.1% at 1 year and 16.2% +/- 8.2% at 2 and 3 years. In the acute nonruptured aneurysm group, survival was 90.9% +/- 6.1% at 1 year, 84.8% +/- 8.2% at 2 years, and 76.4% +/- 10.9% at 3 years. Four secondary interventions (1 early and 3 late) were required in four patients (18%), with a cumulative risk of 9.6% +/- 6.5% at 1 and 2 years and 20.9% +/- 12.0% at 3 years. In the elective aneurysm (control) group, survival was 95.2% +/- 1.2% at 1 year, 89.9% +/- 1.8% at 2 years, and 86.2% +/- 2.1% at 3 years. A total of 51 secondary interventions (4 early, 47 late) were required in 38 patients (12%), with a cumulative risk of 4.2% +/- 1.1% at 1 year, 7.6% +/- 1.6% at 2 years, and 12.9% +/- 2.2% at 3 years. CONCLUSIONS To our surprise, emergency endovascular aneurysm repair did not present with higher secondary intervention rate at mid-term follow-up.
Collapse
Affiliation(s)
- Björn I Oranen
- Department of Surgery, University Medical Centre Groningen, Groningen, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
40
|
Arya N, Makar RR, Lau LL, Loan W, Lee B, Hannon RJ, Soong CV. An intention-to-treat by endovascular repair policy may reduce overall mortality in ruptured abdominal aortic aneurysm. J Vasc Surg 2006; 44:467-71. [PMID: 16950418 DOI: 10.1016/j.jvs.2006.05.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2006] [Accepted: 05/07/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) has been restricted to a small number of specialized units on a selected group of patients. The aim of this study is to assess if the overall mortality in these patients with ruptured AAA may be reduced in a unit where all patients with ruptured AAA are considered first for EVAR. METHODS During a 24-month period beginning in July 2002, 51 patients admitted with ruptured AAA were considered for EVAR as the treatment of choice and comprised the study group. EVAR was performed in 17 patients. Open repair was performed in 34 patients: 13 patients had hemodynamic instability and 16 patients had an unsuitable aortic neck anatomy. The study group was compared with a historical control group of 41 patients with ruptured AAA who were treated by open repair from July 2000 to June 2002. RESULTS Mortality rate was 39% in the study group compared with 59% in the control group (P = .065). The duration of stay in the intensive care unit was significantly lower in the study group than in the control group (P = .01), although the total in-hospital stay was similar (17 days vs 14 days, P = .83). Within the study group, EVAR patients had a mortality rate of 24% compared with 47% in the open group (P = .14). CONCLUSION Although the number of patients was small, offering EVAR to as many patients as possible with ruptured AAA has resulted in a 20% reduction in mortality, albeit statistically insignificant. However, it is in the unstable patients that EVAR will need to improve survival before it may be hailed to supersede the conventional approach.
Collapse
Affiliation(s)
- Nityanand Arya
- Vascular & Endovascular Unit, Belfast City Hospital, Belfast, United Kingdom.
| | | | | | | | | | | | | |
Collapse
|
41
|
Dalainas I, Nano G, Bianchi P, Stegher S, Casana R, Malacrida G, Tealdi DG. Endovascular Techniques for the Treatment of Ruptured Abdominal Aortic Aneurysms: 7-year Intention-to-treat Results. World J Surg 2006; 30:1809-14; discussion 1815-6. [PMID: 16847714 DOI: 10.1007/s00268-005-0667-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The purpose of this single-institution study was to describe our 7-year intention-to-treat results, obtained with the use of endovascular techniques for the treatment of ruptured abdominal aortic aneurysms (rAAA). PATIENTS AND METHODS From October 1998 until March 2005, a total of 28 patients were admitted or transferred to our department with an rAAA. They were all treated according to a management protocol of intention-to-treat with endovascular techniques. Twenty of the patients received endovascular treatment and the remaining 8 underwent an open surgery procedure. RESULTS The mortality rate of the endovascularly treated patients was 40% (8 in 20), whereas of the 8 surgical patients 3 survived (mortality = 62.5%). The overall mortality rate of the 28 patients admitted with an rAAA was 46.4% (13 of 28 patients). CONCLUSIONS In our experience the intension-to-treat protocol for rAAA offered acceptable results in terms of mortality rates. Multi-center studies are necessary to establish the role of endovascular treatment in patients with rAAA.
Collapse
Affiliation(s)
- Ilias Dalainas
- 1st Unit of Vascular Surgery, Istituto Policlinico San Donato-School of Vascular Surgery, University of Milan, Milan, Italy.
| | | | | | | | | | | | | |
Collapse
|
42
|
Laganà D, Carrafiello G, Mangini M, Fontana F, Caronno R, Castelli P, Cuffari S, Fugazzola C. Emergency Endovascular Treatment of Abdominal Aortic Aneurysms: Feasibility and Results. Cardiovasc Intervent Radiol 2006; 29:241-8. [PMID: 16447000 DOI: 10.1007/s00270-005-0080-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the feasibility and effectiveness of emergency endovascular treatment of abdominal aortic aneurysms (AAAs). METHODS During 36 months we treated, on an emergency basis, 30 AAAs with endovascular exclusion. In 21 hemodynamically stable patients preoperative CT angiography (CTA) was performed to confirm the diagnosis and to plan the treatment; 9 patients with hemorrhagic shock were evaluated with angiography performed in the operating room. Twenty-two Excluder (Gore) and 8 Zenith (Cook) stent-grafts (25 bifurcated and 5 aorto-uni-iliac) were used. The follow-up was performed by CTA at 1, 3, 6, and 12 months. RESULTS Technical success was achieved in 100% of cases with a 10% mortality rate. The total complication rate was 23% (5 increases in serum creatinine level and 2 wound infections). During the follow-up, performed in 27 patients (1-36 months, mean 15.2 months), 4 secondary endoleaks (15%) (3 type II, 2 spontaneously thrombosed and 1 under observation, and 1 type III treated by iliac extender insertion) and 1 iliac leg occlusion (treated with femoro-femoral bypass) occurred. We observed a shrinkage of the aneurysmal sac in 8 of 27 cases and stability in 19 of 27 cases; we did not observe any endotension. CONCLUSIONS Endovascular repair is a good option for emergency treatment of AAAs. The team's experience allows correct planning of the procedure in emergency situations also, with technical results comparable with elective repair. In our experience the bifurcated stent-graft is the device of choice in patients with suitable anatomy because the procedure is less time-consuming than aorto-uni-iliac stent-grafting with surgical crossover, allowing faster aneurysm exclusion. However, further studies are required to demonstrate the long-term efficacy of endovascular repair compared with surgical treatment.
Collapse
Affiliation(s)
- Domenico Laganà
- Vascular and Interventional Radiology, Department of Radiology, University of Insubria, Viale Borri, 57, Varese, 21100, Italy
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Eagleton MJ, Srivastava SD, Upchurch GR. Endovascular Grafts. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50046-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
44
|
Alsac JM, Desgranges P, Kobeiter H, Becquemin JP. Emergency Endovascular Repair for Ruptured Abdominal Aortic Aneurysms: Feasibility and Comparison of Early Results with Conventional Open Repair. Eur J Vasc Endovasc Surg 2005; 30:632-9. [PMID: 16061405 DOI: 10.1016/j.ejvs.2005.06.010] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Accepted: 06/10/2005] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess the feasibility of endovascular aortic repair (EVAR) on patients presenting with a ruptured abdominal aortic aneurysm (AAA) in a teaching hospital, and to compare there post-operative outcomes with contemporaneous patients treated with open repair (OR). METHODS A series of consecutive of patients presenting ruptured AAA with retro/intraperitoneal haematoma were included in the study. EVAR was attempted whenever possible. In all other cases (severe haemodynamic instability, adverse anatomy, device unavailability), ruptured AAA were treated by OR. RESULTS Thirty-seven patients were enrolled between January 2001 and July 2004. Seventeen (46%) patients were treated using adapted designed aortoiliac endografts (eight bifurcated, eight aorto-uniiliac, one iliac extension). Twenty (54%) patients unfit for EVAR because of severe haemodynamic instability (n=8), adverse anatomical configuration (n=7), or unavailability of an appropriate endograft (n=5) were treated by OR. Twenty-seven (73%) had a retrospective suitable anatomy for EVAR. Three early conversions from EVAR to OR were performed. Blood loss, operating time, and intensive care stay were significantly decreased in EVAR patients (respectively: 156 min+/-60, 1520 ml+/-1175, 3 days for EVAR; vs. 222 min+/-82, 3075 ml+/-1750, 13 days for OS; P<.01). The 30-day mortality rate was 23.5% for EVAR vs. 50% for OR (P=0.09). CONCLUSION EVAR of ruptured AAA is feasible for selected patients based on haemodynamic and morphologic criteria, and should be associated with improved immediate outcomes as compared with OR. These results should be tempered by the fact that these patients have heavy comorbidities which explains the absence of difference in mid-term mortality rates between the two groups, but should also encourage surgical institutions that are managing such life-threatening emergencies to introduce EVAR as part of their therapeutic arsenal for ruptured AAA.
Collapse
Affiliation(s)
- J-M Alsac
- Department of Vascular Surgery, Henri-Mondor University Hospital, Créteil, France.
| | | | | | | |
Collapse
|
45
|
Gerassimidis TS, Papazoglou KO, Kamparoudis AG, Konstantinidis K, Karkos CD, Karamanos D, Sfyroeras G. Endovascular management of ruptured abdominal aortic aneurysms: 6-year experience from a Greek center. J Vasc Surg 2005; 42:615-23; discussion 623. [PMID: 16242541 DOI: 10.1016/j.jvs.2005.05.061] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2005] [Accepted: 05/15/2005] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To report our early experience with endovascular treatment of patients with ruptured abdominal aortic aneurysms (RAAAs). METHODS Between March 1998 and October 2004, 40 consecutive patients with an RAAA presented to our unit; 38 underwent assessment by computed tomography, whereas 2 died on arrival before any assessment and treatment was possible. Twenty-three patients (61%) were suitable for stent grafting, and all proceeded to endovascular repair. Of these, 17 underwent operation with local anesthesia, 1 did so under general anesthesia, and a further 5 procedures were commenced under local anesthesia and converted to general anesthesia. A total of 14 bifurcated and 10 aortouni-iliac stent grafts were implanted; in 1 patient, the bifurcated graft was converted to an aortouni-iliac repair during surgery because of technical difficulties. RESULTS Stent-graft deployment in the intended location without a type I or III endoleak was technically successful in 22 of the 23 patients. There were no conversions to open surgery. The 30-day mortality was 39%. Six patients died immediately or soon after the procedure because of severe hypovolemic shock, and three died within 30 days from cardiac causes. After surgery, 13 complications were encountered in 10 patients (3 cardiac, 4 respiratory, 5 renal, and 1 implant related). Two patients required reintervention--one for a type I endoleak and one for limb occlusion. There were 14 survivors. During a median follow-up of 410 days (range, 90-1650 days), 2 more patients died from myocardial infarction, and 9 remain well; 3 patients were lost to follow-up. There were three secondary interventions (two for type I endoleak and one for stent-graft thrombosis). CONCLUSIONS Endovascular treatment of RAAAs is feasible, and the early experience is promising. More experience and evidence from randomized trials are needed to determine whether such an approach is superior to open surgery.
Collapse
Affiliation(s)
- Thomas S Gerassimidis
- Fifth Surgical Clinic, Medical School, Aristotle University of Thessaloniki, Ippokratio Hospital, Greece
| | | | | | | | | | | | | |
Collapse
|
46
|
Boyle JR, Gibbs PJ, Kruger A, Shearman CP, Raptis S, Phillips MJ. Existing Delays Following the Presentation of Ruptured Abdominal Aortic Aneurysm Allow Sufficient Time to Assess Patients for Endovascular Repair. Eur J Vasc Endovasc Surg 2005; 29:505-9. [PMID: 15966089 DOI: 10.1016/j.ejvs.2005.01.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The greatest benefit of endovascular AAA repair (EVAR) may be in the management of rupture (RAAA). However, the detailed anatomical assessment required for EVAR has lead to concerns of surgical delay and death during cross-sectional imaging. In this study, we prospectively assessed patients with RAAA and correlated time of hospital arrival with time of surgery or death to ascertain whether these concerns are justified. METHODS All patients presenting with RAAA between October 2000 and December 2002 were included. The hospital arrival time, onset of surgery or time of death, were recorded, as were demographic and physiological parameters. RESULTS One hundred consecutive patients were studied, median age 75 years (range 54-94). Seventy-nine patients underwent attempted conventional surgical repair and 21 were palliated. The median delay from arrival to operation was 159 min (range 16-1450 min). Mortality in the surgical group was not affected by the length of delay (p = 1.0) or by CT scanning (p = 0.34). The median time from arrival to death in the non-surgical group was 435 min (15 min-6 days). CONCLUSIONS Most patients who present with ruptured AAA experience a significant delay prior to surgery. This study suggests it is safe to assess the majority of RAAA patients for EVAR.
Collapse
Affiliation(s)
- J R Boyle
- Department of Vascular Surgery, Southampton General Hospital, Southampton, UK.
| | | | | | | | | | | |
Collapse
|
47
|
Towne JB. Endovascular treatment of abdominal aortic aneurysms. Am J Surg 2005; 189:140-9. [PMID: 15720980 DOI: 10.1016/j.amjsurg.2004.09.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2004] [Revised: 09/18/2004] [Accepted: 09/18/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endovascular treatment of abdominal aortic aneurysms is a rapidly evolving technique that has gained broad acceptance in the treatment of patients with abdominal aortic aneurysms. METHODS A review of the English literature was done to determine the short- and long-term outcomes of endovascular repair of abdominal aortic aneurysms. Reports of complications such as endoleak, graft migration, graft limb occlusion, aneurysm rupture, and aneurysm enlargement were evaluated. RESULTS Short-term results of endovascular repair of abdominal aortic aneurysms are excellent. The necessity for open conversions is less than 5%. The cumulative risk of aneurysm rupture is approximately 1% per year. The coverall incidence of graft limb occlusion was 2.8% in the follow-up period. The cumulative risk for a secondary procedure was 12% at 1 year, 24% at 2 years, and 35% at 3 years. Moderate and severe neck angulation was associated with an increased incidence of adverse events in the follow-up period. Endografts have the potential to become infected and develop aortoduodenal fistula. The treatment of ruptured aneurysms with endovascular grafts has been successful and a technique that is increasingly used. CONCLUSION Endovascular treatment of abdominal aortic aneurysm is an effective technique with excellent short-term results. The long-term results remain to be determined. Ongoing surveillance is necessary to avoid late complications of aneurysm rupture.
Collapse
Affiliation(s)
- Jonathan B Towne
- Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA.
| |
Collapse
|
48
|
Erfolgreiche endovaskul�re Notfallversorgung eines rupturierten infrarenalen Aortenaneurysmas unter Reanimationsbedingungen. GEFASSCHIRURGIE 2004. [DOI: 10.1007/s00772-004-0363-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
49
|
Peppelenbosch N, Zannetti S, Barbieri B, Buth J. Endograft Treatment in Ruptured Abdominal Aortic Aneurysms Using the Talent® AUI Stentgraft System. Design of a Feasibility Study∗∗. Eur J Vasc Endovasc Surg 2004; 27:366-71. [PMID: 15015185 DOI: 10.1016/j.ejvs.2004.01.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- N Peppelenbosch
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | | | | | | |
Collapse
|
50
|
Castelli P, Caronno R, Piffaretti G, Tozzi M, Laganà D, Carrafiello G, Cuffari S, Bacuzzi A. Ruptured abdominal aortic aneurysm: endovascular treatment. ACTA ACUST UNITED AC 2004; 30:263-9. [PMID: 15759206 DOI: 10.1007/s00261-004-0272-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND This report describes our preliminary experience in endovascular management of 25 ruptured abdominal aortic aneurysms (rAAAs). METHODS In the past 3 years we treated 46 patients who had rAAA, and 25 (54.3%) were treated with an endovascular approach. Patients' mean age was 76 +/- 9 years. The diagnosis was confirmed by computed tomographic angiography in 23 patients (92%). Mean aneurysm diameter was 73 +/- 17 mm. We used an infrarenal bifurcated device in 17 patients (68%), a suprarenal bifurcated in four patients (16%), and an aortomonoiliac graft in four patients (16%). Overall, nine patients (36%) required intensive care. Every patient underwent radiologic follow-up according to the Eurostar register, with concomitant evaluation of the D-dimer level (cut-off <200 microg/L) as a biological marker for endoleaks. RESULTS The primary technical success rate was 100%. Overall in-hospital mortality rate was 20%. Mean hospitalization was 7 days (range, 3-30), and mean follow-up was 7 months. One occlusion (4%) of the iliac limb and two type II endoleaks (8%) occurred. The mean D-dimer level in type I endoleak was 1045 microg/L (range, 459-2021). CONCLUSIONS In our experience, endovascular management of rAAA is feasible and safe and produces better results than conventional surgery, provided the morphology is suitable and the procedure is carried out by an experienced endovascular team.
Collapse
Affiliation(s)
- P Castelli
- Department of Surgery, University of Insubria, Ospedale di Circolo, 21100, Varese, Viale Borri 57, Italy.
| | | | | | | | | | | | | | | |
Collapse
|