The impact of large aneurysm diameter on the outcomes of thoracoabdominal aneurysm repair by fenestrated and branched endografts

OBJECTIVES

Aim of the study was to analyse the impact of preoperative thoracoabdominal aneurysm diameter on the outcomes of fenestrated/branched endografting.

METHODS

Patients who underwent endovascular thoracoabdominal repair at 2 European centres (2011-2021) were analysed. Median diameter was calculated; the third quartile was considered a cut-off. Outcomes were compared in 2 groups based on the diameter value. Primary endpoints were technical success, spinal cord ischaemia and 30-day/in-hospital mortality. Survival, freedom from reintervention and target visceral vessels instability were follow-up outcomes.

RESULTS

Out of 247 thoracoabdominal aortic aneurysms, the median diameter was 65 mm, first quartile was 57 mm; third quartile was 80 mm, set as cut-off value. Fifty-nine (24%) patients had diameter ≥80 mm. Custom-made and off-the-shelf branched endograft were used in 160 (65%) and 87 (35%), respectively. Technical success was 93% (<80 mm: 91% vs ≥80 mm: 94%; P = 0.47). Twenty-three (9%) patients had spinal injury (<80 mm: 7% vs ≥80mm: 17%; P = 0.03). Twenty-two (9%) patients died within 30-day/in-hospital (<80 mm: 7% vs ≥80 mm: 15%; P = 0.06). Multivariate analysis did not report preoperative diameter ≥80 mm as significant risk factor for primary endpoints. The median follow-up was 13 (interquartile range: 2-37) months and at 3-year survival and freedom from reintervention rates were 65% and 62%, respectively. After univariate and multivariate analyses, preoperative diameter ≥80 mm was considered an independent risk factor for reinterventions [hazard ratio (HR): 1.9; 95% confidence interval (CI) 1.1-3.6; P = 0.04], and for target visceral vessels instability (HR: 3.1; 95% CI: 1.3-5.1; P = 0.04), occurred in 45 (18%) cases. However, after competing risk methods, preoperative diameter did not show significance for follow-up results.

CONCLUSIONS

A preoperative thoracoabdominal aortic aneurysm diameter >80 mm has not had a direct impact on early technical and clinical outcomes. A diameter≥80 mm is considered risk factor for reinterventions and target vessels instability is considered separately during follow-up.

The association of ruptured abdominal aortic aneurysm diameter with mortality in the International Consortium of Vascular Registries

BACKGROUND

The mortality after ruptured abdominal aortic aneurysm (rAAA) repair is high, despite improvements in perioperative care, centralization of emergency vascular surgical services, and the introduction of endovascular aneurysm repair (EVAR). The diameter of intact AAA has been shown to be a predictor of short- and long-term survival. The aim of this study was to analyze the impact of AAA diameter on mortality for rAAA repair using contemporary data collected from the International Consortium of Vascular Registries and compare outcomes by sex and the type of repair patients received.

METHODS

Prospective registry data on repair of rAAA from seven countries were collected from 2010 to 2016. The primary outcome was perioperative mortality after EVAR and open surgical repair (OSR). Data were stratified by type of repair and sex. Logistic regression models were used to estimate odds ratio (OR) for the association between AAA diameter and perioperative mortality and the association between type of repair and mortality. Multivariable logistic regression models were used to adjust for differences in patient characteristics.

RESULTS

The study population consisted of 6428 patients with a mean age ranging from 70.2 to 75.4 years; the mean AAA diameter was 7.7 ± 1.8 cm. Females had a significantly smaller AAA diameter at presentation compared with males (6.9 ± 1.6 cm vs 7.9 ± 1.8 cm; P < .001). who underwent OSR had larger AAA diameters compared with those who underwent EVAR (P < .001). Females who underwent repair were significantly older (P < .001). Males were more likely to have cardiac disease, diabetes mellitus, and renal impairment. Overall, AAA diameter was a predictor of mortality in univariate and multivariate analysis. When analyzing EVAR and OSR separately, the impact of AAA diameter per cm increase on mortality was apparent in both males and females undergoing EVAR, but not OSR (EVAR: male OR, 1.09 [95% confidence interval, 1.03-1.16] and EVAR: female OR, 1.17 [95% confidence interval, 1.02-1.35]). The early mortality rate for males and females who underwent EVAR was 18.9% and 25.9% (P < .001), respectively. The corresponding mortality for males and females who underwent OSR was 30.2% and 38.6% (P < .001), respectively.

CONCLUSIONS

In these real-world international data, there is a significant association between rAAA diameters and early mortality in males and females. This association was more evident in patients undergoing EVAR, but not shown in OSR. Despite improvements in overall AAA repair outcomes, the risk of mortality after rAAA repair is consistently higher for females.

Myocardial Injury after Non-Cardiac Surgery in Patients Who Underwent Open Repair for Abdominal Aortic Aneurysm: A Retrospective Study

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) has been known to be associated with mortality in various surgical patients; however, its prognostic role in abdominal aortic aneurysm (AAA) open repair remains underexplored. This study aimed to investigate the role of MINS as a predictor of mortality in patients who underwent AAA open repair.

METHODS

This retrospective study investigated 352 patients who underwent open repair for non-ruptured AAA. The predictors of 30-day and 1-year mortalities were investigated using logistic regression analysis.

RESULTS

MINS was diagnosed in 41% of the patients after AAA open repair in this study. MINS was an independent risk factor of 30-day mortality (odds ratio [OR]: 10.440, 95% confidence interval [CI]: 1.278-85.274, p = 0.029) and 1-year mortality (OR: 5.189, 95% CI: 1.357-19.844, p = 0.016). Kaplan-Meier survival curves demonstrated significantly lower overall survival rates in patients with MINS compared to those without MINS (p = 0.003).

CONCLUSION

This study revealed that MINS is a common complication after AAA open repair and is an independent risk factor of 30-day and 1-year mortalities. Patients with MINS have lower overall survival rates than those without MINS.

Association of women-specific size threshold and mortality in elective abdominal aortic aneurysm repair

BACKGROUND

It is unclear whether women derive mortality benefit from early repair of abdominal aortic aneurysms (AAA). The aim of this study was to compare short- and mid-term mortality for women treated at small versus large diameters.

METHOD

Women receiving elective repair of AAA at small (49-54 mm) and large (≥55 mm) diameters from 2008 to 2022 were extracted from the Swedish National Registry for Vascular Surgery (n = 1642 women). The effect of diameter on 90-day, 1- and 3-year mortality was studied in logistic regression and propensity score models. Age, co-morbidities, smoking and repair modality were considered as confounders. Men (n = 9047) were analysed in parallel.

RESULTS

Some 1642 women were analysed, of whom 34% underwent repair at small diameters (versus 52% of men). Women with small (versus large) AAAs were younger (73 versus 75 years, P < 0.001), and 63% of women in both size groups had endovascular repairs (P = 0.120). Mortality was 3.5% (90 days), 7.1% (1 year) and 15.8% (3 years), with no differences between the size strata. There was no consistent association between AAA size and mortality in multivariable models. Sex differences in mortality were almost entirely due to mortality in younger-than-average women versus men (3-year mortality: small AAAs 11.1% versus 7.3%, P < 0.030, or large 14.4% versus 10.7%, P < 0.038).

CONCLUSION

Mortality in women is high and unaffected by AAA size at repair. The optimal threshold for women remains undefined. The higher rupture risk in women should not automatically translate into a lower, women-specific threshold.

Extent of mural thrombus is not associated with increased 5-year mortality following elective AAA repair

BACKGROUND

Mural thrombus in abdominal aortic aneurysm (AAA) has been associated with increased rates of aneurysm growth as well as adverse cardiovascular events. The extent of mural thrombus in thoracoabdominal aortic aneurysms has recently been linked to 1-year mortality following endovascular repair and has been hypothesized as a marker for reduced cardiac reserve. This study investigates whether the extent of mural thrombus in infra-renal AAA is associated with 5-year mortality following elective repair.

METHODS

Retrospective review of all patients undergoing elective infra-renal AAA repair at a single academic medical center between 2007 and 2016 was performed. The following variables at the time of surgery were investigated for association with 5-year mortality: age, sex, ethnicity, insurance status and co-morbidities, repair type, renal insufficiency, end-stage renal disease on dialysis, history of smoking, coronary artery disease, congestive heart failure, diabetes mellitus, hypertension, stroke, chronic obstructive pulmonary disease, body mass index category, AAA diameter, and ratio of aortic thrombus to total aneurysm diameter.

RESULTS

Amongst 427 patients undergoing infra-renal AAA repair during the study period, 232 met extensive inclusion criteria. Univariate analysis found mean age (76 vs 72, p < 0.01), age cohort over 72 years (OR = 1.9, p = 0.04), renal insufficiency (OR = 3.1, p < 0.01), ESRD (OR = 6.5, p < 0.01), AAA diameter 6 cm or greater (OR = 2.3, p < 0.01), and mean AAA diameter (61.36 vs 56.99 mm, p < 0.01) all predictive of 5-year mortality. Multivariate analysis revealed renal insufficiency (p < 0.01) and AAA diameter 6 cm or greater (p = 0.03) to be significantly associated with 5-year mortality. The extent of mural thrombus was identical between 5-year survivors and non-survivors. The mean inner to outer AAA diameter was 0.65 in the survivor cohort and 0.64 in the mortality cohort. Inner to outer ratio of < 0.5 was identified in 23% of 5-year survivors and 27% of the mortality group.

CONCLUSIONS

In our experience, the extent of mural thrombus in AAA does not influence long-term survival after elective repair. AAA repair may provide protection against circulating components of mural thrombus which have the potential to promote atherosclerotic-related adverse events. Patients with renal insufficiency and larger AAA have increased risk of mortality 5 years after elective repair.

The Effect of Abdominal Aortic Aneurysm Size on Endoleak, Secondary Intervention and Overall Survival Following Endovascular Aortic Aneurysm Repair

OBJECTIVE

The purpose of this study was to identify the effect of abdominal aortic aneurysm (AAA) size on endoleak development and secondary intervention after endovascular repair (EVAR), as well as to examine the effect on overall survival and cause of mortality.

METHODS

Retrospective analysis was performed on all non-ruptured AAA treated by elective EVAR using FDA-approved endografts in our facility from July 2004 to December 2017. Patients were grouped into 3 cohorts based on preoperative aneurysm size: Group I (<5.5 cm), Group II (5.5-6.4 cm), and Group III (≥ 6.5 cm). Occurrences of endoleak, secondary intervention and overall survival underwent univariate and multivariate analysis. Cause of death data on deceased patients was similarly examined.

RESULTS

A total of 517 patients were analyzed. There was no difference between size groups in the rate of endoleak (Group I 48/277, 17.3%; Group II 33/160, 20.6%; Group III 18/80, 22.5%; p = 0.46) or time until endoleak development. Univariate analysis showed no difference in the rate of secondary intervention (Group I 36/277, 13.0%; Group II 24/160, 15.0%; Group III 18/80, 22.5%; p = 0.11), time until intervention or number of interventions performed. Multivariate analysis showed an association with shorter time to secondary intervention for both Group III aneurysms (HR 2.03, 95% CI 1.11-3.73; p = 0.02) and female patients (HR 1.79, 95% CI 1.02-3.13; p = 0.04). There was no difference in overall survival, aneurysm-related mortality or overall cause of mortality.

CONCLUSION

AAA diameter prior to EVAR was not associated with any differences in rates of endoleak or secondary intervention, and was not associated with poorer overall survival or greater aneurysm-related mortality. Patients with suitable anatomy for EVAR can be considered for this intervention without concern for increased complications or poorer outcomes related to large aneurysm diameter alone.

The variable impact of aneurysm size on outcomes after open abdominal aortic aneurysm repairs

OBJECTIVE

Previous studies evaluating the association between abdominal aortic aneurysm (AAA) size with postoperative outcomes after open repairs seldom accounted for renal or visceral artery involvement, proximal clamp site, intraoperative renal ischemia time, and hospital volume. This study examined the association between aneurysm size with outcomes after open repairs.

METHODS

We identified patients who underwent open repairs of infrarenal versus juxtarenal nonruptured AAAs, defined by proximal clamp site, in the 2004-2019 Vascular Quality Initiative. Outcomes included 30-day mortality, postoperative complications, failure to rescue, and 1-year mortality. Multivariable logistic regressions adjusted for patient characteristics, operative factors, hospital volume, and hospital clustering.

RESULTS

We identified 8011 patients (54% infrarenal, 46% juxtarenal). The median aneurysm size did not differ between infrarenal versus juxtarenal aneurysms (5.7 cm vs 5.9 cm; P = .12). For infrarenal aneurysms, every 1-cm increase in size increase the adjusted odds ratio (OR) or hazard ratio (HR) of 30-day mortality by 18% (OR, 1.18; 95% CI, 1.06-1.31), failure to rescue by 20% (OR, 1.20; 95% CI, 1.06-1.34), 1-year mortality by 18% (HR, 1.18; 95% CI, 1.10-1.26), but not complications (OR, 1.03; 95% CI, 0.98-1.07). For juxtarenal aneurysm, larger aneurysm sizes were not associated with any outcome. Proximal clamp site, ischemia time, and volume were associated with outcomes.

CONCLUSIONS

The association between AAA size and outcomes matters less with renal and visceral artery aneurysmal involvement, having important implications for surgical decision-making, operative planning, and patient counseling.

Embelin inhibits abdominal aortic aneurysm through decreasing IL‑6‑induced STAT3 and NF‑κB inactivation

The aim of the present study was to investigate the effect of embelin on abdominal aortic aneurysm (AAA). AAA model mice were induced by chronic infusion of 1,000 ng/kg/min Angiotensin II. AAA model mice were treated with 25, 50 or 100 mg/kg embelin for 28 days. Embelin inhibited tumor necrosis factor‑α, interleukin (IL)‑1β, IL‑6, IL‑18 and malondialdehyde (MDA) level activities, increased superoxide dismutase, glutathione (GSH) and GSH peroxidase level activities and inhibited MDA level activities in AAA mice Embelin suppressed the secretion of matrix metalloproteinase‑9 protein expression, monocyte chemoattractant protein‑2 activity and epithelial neutrophil‑activating peptide expression levels in AAA mice. Embelin suppressed phosphorylated‑signal transducer and activator of transcription (STAT) 3, phosphorylated‑p38 mitogen‑activated protein kinase and nuclear factor (NF)‑κB protein expression in AAA mice. These findings indicate that embelin inhibits AAA through decreasing IL‑6‑induced STAT3, and NF‑κB inactivation.

Survival Disparity Following Abdominal Aortic Aneurysm Repair Highlights Inequality in Ethnic and Socio-economic Status

OBJECTIVES

Socio-economic status (SES) and ethnicity have been reported as markers influencing the likelihood of increased mortality. The aim of this study was to investigate how SES and ethnicity impacted patient survival after abdominal aortic aneurysm (AAA) repair.

METHODS

Consecutive patients undergoing open and endovascular AAA repair during a 14.5 year period were identified. Ethnicity was defined as recorded on health records and SES (a score of 10, where 1 is least deprived and 10 being most deprived) and was linked to census data. Operative outcomes were reported at 30 days and a medium-term survival analysis used the Cox model to report adjusted hazard ratios (HR).

RESULTS

A total of 6239 patients with a median age of 75 years and 78.7% males were included. The majority (5,654) were identified as New Zealand (NZ) Europeans, with 421 identified as NZ Maori, 97 identified as belonging to a Pacific ethnic group, and 67 identified as an Asian ethnic group. The median survival follow-up period was 5 years and after adjusting for confounders, those who identified as NZ Maori had the lowest survival compared with all other ethnic groups with a HR of 1.46 (95% CI 1.23-1.72). Living in areas of high social deprivation ≥ 7 was an independent predictor of short and medium-term overall mortality when compared with living in deprivation deciles 1 or 2.

CONCLUSIONS

Low SES was identified as a marker of risk for all ethnic groups in relation to both reduced short and medium-term survival. However, regardless of SES, NZ Maori had worse overall medium-term survival following AAA repair than the other ethnic groups. Therefore it appears that both SES and being Maori were markers of increased exposure to risk that negatively impact upon survival after AAA repair. There is a need to ensure systemic processes support initiatives that reduce this inequality.