Comparison of open and endovascular repair of ruptured abdominal aortic aneurysms from the ACS-NSQIP 2005-07

Renal transplant recipients undergoing endovascular abdominal aortic aneurysm repair have increased risk of perioperative acute kidney injury but no difference in late mortality

OBJECTIVE

Renal transplant is associated with substantial survival advantage in patients with end-stage renal disease. However, little is known about the outcomes of renal transplant recipients (RTRs) after endovascular abdominal aortic aneurysm repair (EVAR). This study aimed to study the effect of renal transplant on perioperative outcomes and long-term survival after elective infrarenal EVAR.

METHODS

The Vascular Quality Initiative database was queried for all patients undergoing elective EVAR from 2003 to 2021. Functioning RTRs were compared with non-renal transplant recipients without a diagnosis of end-stage renal disease (non-RTRs). The outcomes included 30-day mortality, acute kidney injury (AKI), new renal failure requiring renal replacement therapy (RRT), endoleak, aortic-related reintervention, major adverse cardiac events, and 5-year survival. A logistic regression analysis was used to assess the association between RTRs and perioperative outcomes.

RESULTS

Of 60,522 patients undergoing elective EVAR, 180 (0.3%) were RTRs. RTRs were younger (median, 71 years vs 74.5 years; P < .001), with higher incidence of hypertension (92% vs 84%; P = .004) and diabetes (29% vs 21%; P = .005). RTRs had higher median preoperative serum creatinine (1.3 mg/dL vs 1.0 mg/dL; P < .001) and lower estimated glomerular filtration rate (51.6 mL/min vs 69.4 mL/min; P < .001). There was no difference in the abdominal aortic aneurysm diameter and incidence of concurrent iliac aneurysms. Procedurally, RTRs were more likely to undergo general anesthesia with lower amount of contrast used (median, 68.6 mL vs 94.8 ml; P < .001) and higher crystalloid infusion (median, 1700 mL vs 1500 mL; P = .039), but no difference was observed in the incidence of open conversion, endoleak, operative time, and blood loss. Postoperatively, RTRs experienced a higher rate of AKI (9.4% vs 2.7%; P < .001), but the need for new RRT was similar (1.1% vs 0.4%; P = .15). There was no difference in the rates of postoperative mortality, aortic-related reintervention, and major adverse cardiac events. After adjustment for potential confounders, RTRs remained associated with increased odds of postoperative AKI (odds ratio, 3.33; 95% confidence interval, 1.93-5.76; P < .001) but had no association with other postoperative complications. A subgroup analysis identified that diabetes (odds ratio, 4.21; 95% confidence interval, 1.17-15.14; P = .02) is associated with increased odds of postoperative AKI among RTRs. At 5 years, the overall survival rates were similar (83.4% vs 80%; log-rank P = .235).

CONCLUSIONS

Among patients undergoing elective infrarenal EVAR, RTRs were independently associated with increased odds of postoperative AKI, without increased postoperative renal failure requiring RRT, mortality, endoleak, aortic-related reintervention, or major adverse cardiac events. Furthermore, 5-year survival was similar. As such, while EVAR may confer comparable benefits and technical success perioperatively, RTRs should have aggressive and maximally optimized renal protection to mitigate the risk of postoperative AKI.

Aortic Neck IFU Violations During EVAR for Ruptured Infrarenal Aortic Aneurysms are Associated with Increased In-Hospital Mortality

OBJECTIVE

Vascular surgeons treating patients with ruptured abdominal aortic aneurysm must make rapid treatment decisions and sometimes lack immediate access to endovascular devices meeting the anatomic specifications of the patient at hand. We hypothesized that endovascular treatment of ruptured abdominal aortic aneurysm (rEVAR) outside manufacturer instructions-for-use (IFU) guidelines would have similar in-hospital mortality compared to patients treated on-IFU or with an infrarenal clamp during open repair (ruptured open aortic aneurysm repair [rOAR]).

METHODS

Vascular Quality Initiative datasets for endovascular and open aortic repair were queried for patients presenting with ruptured infrarenal AAA between 2013-2018. Graft-specific IFU criteria were correlated with case-specific proximal neck dimension data to classify rEVAR cases as on- or off-IFU. Univariate comparisons between the on- and off-IFU groups were performed for demographic, operative and in-hospital outcome variables. To investigate mortality differences between rEVAR and rOAR approaches, coarsened exact matching was used to match patients receiving off-IFU rEVAR with those receiving complex rEVAR (requiring at least one visceral stent or scallop) or rOAR with infrarenal, suprarenal or supraceliac clamps. A multivariable logistic regression was used to identify factors independently associated with in-hospital mortality.

RESULTS

621 patients were treated with rEVAR, with 65% classified as on-IFU and 35% off-IFU. The off-IFU group was more frequently female (25% vs. 18%, P = 0.05) and had larger aneurysms (76 vs. 72 mm, P= 0.01) but otherwise was not statistically different from the on-IFU cohort. In-hospital mortality was significantly higher in patients treated off-IFU vs. on-IFU (22% vs. 14%, P= 0.02). Off-IFU rEVAR was associated with longer operative times (135 min vs. 120 min, P= 0.004) and increased intraoperative blood product utilization (2 units vs. 1 unit, P= 0.002). When off-IFU patients were matched to complex rEVAR and rOAR patients, no baseline differences were found between the groups. Overall in-hospital complications associated with off-IFU were reduced compared to more complex strategies (43% vs. 60-81%, P< 0.001) and in-hospital mortality was significantly lower for off-IFU rEVAR patients compared to the supraceliac clamp group (18% vs. 38%, P= 0.006). However, there was no significantly increased mortality associated with complex rEVAR, infrarenal rOAR or suprarenal rOAR compared to off-IFU rEVAR (all P> 0.05). This finding persisted in a multivariate logistic regression.

CONCLUSIONS

Off-IFU rEVAR yields inferior in-hospital survival compared to on-IFU rEVAR but remains associated with reduced in-hospital complications when compared with more complex repair strategies. When compared with matched patients undergoing rOAR with an infrarenal or suprarenal clamp, survival was no different from off-IFU rEVAR. Taken together with the growing available evidence suggesting reduced long-term durability of off-IFU EVAR, these data suggest that a patient's comorbidity burden should be key in making the decision to pursue off-IFU rEVAR over a more complex repair when proximal neck violations are anticipated preoperatively.

Patients with a Ruptured Abdominal Aortic Aneurysm Are Better Informed in Hospitals with an "EVAR-preferred" Strategy: An Instrumental Variable Analysis of the Dutch Surgical Aneurysm Audit

BACKGROUND

While several observational studies suggested a lower postoperative mortality after minimal invasive endovascular aneurysm repair (EVAR) in patients with a ruptured abdominal aortic aneurysm (RAAA) compared to conventional open surgical repair (OSR), landmark randomized controlled trials have not been able to prove the superiority of EVAR over OSR. Randomized controlled trials contain a selected, homogeneous population, influencing external validity. Observational studies are biased and adjustment of confounders can be incomplete. Instrumental variable (IV) analysis (pseudorandomization) may help to answer the question if patients with an RAAA have lower postoperative mortality when undergoing EVAR compared to OSR.

METHODS

This is an observational study including all patients with an RAAA, registered in the Dutch Surgical Aneurysm Audit between 2013 and 2017. The risk difference (RD) in postoperative mortality (30 days/in-hospital) between patients undergoing EVAR and OSR was estimated, in which adjustment for confounding was performed in 3 ways: linear model adjusted for observed confounders, propensity score model (multivariable logistic regression analysis), and IV analysis (two-stage least square regression), adjusting for observed and unobserved confounders, with the variation in percentage of EVAR per hospital as the IV instrument.

RESULTS

2419 patients with an RAAA (1489 OSR and 930 EVAR) were included. Unadjusted postoperative mortality was 34.9% after OSR and 22.6% after EVAR (RD 12.3%, 95% CI 8.5-16%). The RD adjusted for observed confounders using linear regression analysis and propensity score analysis was, respectively, 12.3% (95% CI 9.6-16.7%) and 13.2% (95%CI 9.3-17.1%) in favor of EVAR. Using IV analysis, adjusting for observed and unobserved confounders, RD was 8.9% (95% CI -1.1-18.9%) in favor of EVAR.

CONCLUSIONS

Adjusting for observed confounders, patients with an RAAA undergoing EVAR had a significant better survival than OSR in a consecutive large cohort. Adjustment for unobserved confounders resulted in a clinical relevant RD. An "EVAR preference strategy" in patients with an RAAA could result in lower postoperative mortality.

Operative Strategy of Ruptured Abdominal Aortic Aneurysms and Management of Postoperative Complications

In addition to traditional open surgical repair (OSR), endovascular aneurysm repair (EVAR) is currently another strong option to treat RAAA. All vascular surgeons who try to save RAAA patients must be deeply versed in both OSR and EVAR. In this article, current trend of RAAA treatment and abdominal compartment syndrome, which has been most important postoperative complication, are reviewed. (This is a translation of Jpn J Vasc Surg 2019; 28: 127–132.)

Does the choice of intraoperative fluid modify abdominal aneurysm repair outcomes?: A cohort analysis

Intraoperatively administered hydroxyethyl starch could be a risk indicator for postoperative acute kidney injury (AKI) in vascular surgical patients.In a single-center retrospective cohort analysis, we assessed the impact of hydroxyethyl starch and other risk indicators on AKI and mortality in 1095 patients undergoing elective open abdominal aneurysm repair (AAA-OR) or endovascular aortic repair (EVAR). We established logistic regression models to determine the effect of various risk indicators, including hydroxyethyl starch, on AKI, as well as Cox proportional hazard models to assess the effect on mortality.The use of intravenous hydroxyethyl starch was not associated with an increased risk of AKI or mortality. Patients undergoing EVAR were less likely to develop AKI (4% vs 18%). Multivariate risk indicators associated for AKI included suprarenal or pararenal aortic cross-clamp [odds ratio (OR), 4.44; 95% confidence interval (95% CI), 2.538-7.784; P < .001] and procedure length (OR, 1.005; 95% CI, 1.003-1.007; P < .001), and favored EVAR (OR, 0.351; 95% CI, 0.118-0.654; P < .01). Main multivariate risk indicators associated with mortality included patients needing an urgent procedure [hazard ratio (HR), 2.294; 95% CI, 1.541-3.413; P < .001], those with suprarenal or pararenal aortic cross-clamp (HR, 1.756; 95% CI, 1.247-2.472; P < .01), and patients undergoing EVAR (HR, 1.654; 95% CI, 1.292-2.118; P < .001).We found neither a benefit nor a negative effect of hydroxyethyl starch on the risk of AKI or mortality. Instead, other variables and comorbidities were found to be relevant for the development of postoperative AKI and survival. Nevertheless, clinicians should be aware of the high risk of postoperative AKI, particularly among those undergoing AAA-OR procedures.

Finite element analysis in symptomatic and asymptomatic abdominal aortic aneurysms for aortic disease risk stratification

BACKGROUND

Advanced biomechanical models can provide additional information concerning rupture risk in abdominal aortic aneurysms (AAA). Here we evaluated the predictive value of finite element analysis (FEA) to assess AAA rupture risk.

METHODS

In a case-control study, we compared FEA parameters in a group of symptomatic AAA (sAAA) patients, considered as a high risk of rupture group, with FEA parameters in asymptomatic AAA patients (aAAA).

RESULTS

We included 15 sAAA and 28 aAAA patients matched for age- and maximum diameter diagnosed with infrarenal non-ruptured AAA at our center between 2009 and 2013. Mean age was 75±69 years and mean maximum diameter was 77±17 mm. Peak wall stress (PWS) was significantly higher in sAAA patients than in aAAA patients (354.3±139.6 kPa vs. 248.6±81.9 kPa; P=0.001). The C statistic for the ROC curve based on PWS was 0.748 (95% CI: 0.592-0.903; P=0.008). CART analysis classified patients into high and low PWS groups. The high-PWS group (>305.15 kPa; N.=15) had a higher incidence of sAAA (33.3% aAAA, 66.7% sAAA) than the low-PWS-group (≤305.15 kPa; N.=28. 82.1% aAAA, 17.9% sAAA).

CONCLUSIONS

In conclusion, PWS was significantly higher in sAAA patients. Measuring PWS may help estimate the individual rupture risk in patients with AAA, but larger studies are needed to confirm our results.

Endovascular repair versus open repair in the treatment of ruptured aortic aneurysms: a systematic review

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.

Patient selection and perioperative outcomes are similar between targeted and nontargeted hospitals (in the National Surgical Quality Improvement Program) for abdominal aortic aneurysm repair

OBJECTIVE

The targeted vascular module in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) consists of self-selected hospitals that choose to collect extra clinical details for better risk adjustment and improved procedure-specific outcomes. The purpose of this study was to compare patient selection and outcomes between targeted and nontargeted hospitals in the NSQIP regarding the operative management of abdominal aortic aneurysm (AAA).

METHODS

We identified all patients who underwent endovascular aneurysm repair (EVAR) or open AAA repair from 2011 to 2013 and compared cases by whether the operation took place in a targeted or nontargeted hospital. EVAR and open repair as well as intact and ruptured aneurysms were evaluated separately. Only variables contained in both modules were used to evaluate rupture status and operation type. All thoracoabdominal aneurysms were excluded. Univariate analysis was performed for intact and ruptured EVAR and open repair grouped by complexity, defined as visceral involvement in open repair and a compilation of concomitant procedures for EVAR. Multivariable models were developed to identify effect of hospital type on mortality.

RESULTS

There were 17,651 AAA repairs identified. After exclusion of aneurysms involving the thoracic aorta (n = 352), there were 1600 open AAA repairs at targeted hospitals (21% ruptured) and 2725 at nontargeted hospitals (19% ruptured) and 4986 EVARs performed at targeted hospitals (6.7% ruptured) and 7988 at nontargeted hospitals (5.2% ruptured). There was no significant difference in 30-day mortality rates between targeted and nontargeted hospitals for intact aneurysms (EVAR noncomplex, 1.8% vs 1.4% [P = .07]; open repair noncomplex, 4.2% vs 4.5% [P = .7]; EVAR complex, 5.0% vs 3.2% [P = .3]; open repair complex, 8.0% vs 6.0% [P = .2]). For ruptured aneurysms, again there was no difference in mortality between the targeted and nontargeted hospitals (EVAR noncomplex, 23% vs 25% [P = .4]; open repair noncomplex, 38% vs 34% [P = .2]; EVAR complex, 29% vs 33% [P = 1.0]; open repair complex, 27% vs 41% [P = .09]). Multivariable analysis further demonstrated that having an operation at a targeted vs nontargeted hospital had no impact on mortality for both intact and ruptured aneurysms (odds ratio, 1.1 [0.9-1.4] and 1.0 [0.8-1.3], respectively).

CONCLUSIONS

This analysis highlights the similarities between targeted and nontargeted hospitals within the NSQIP for AAA operative management and suggests that data from the targeted NSQIP, in terms of AAA management, are generalizable to all NSQIP hospitals.

Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm

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.

Renal Function is the Main Predictor of Acute Kidney Injury after Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

Postoperative acute kidney injury (AKI) may occur in up to 18% of elective endovascular abdominal aortic aneurysm repair (EVAR) and has been associated with poor outcome; however, it is not clear which patients are at highest risk, to target renoprotection effectively. We sought to determine the predictive factors of AKI after elective EVAR.

METHODS

Overall, 947 patients undergoing elective EVAR between January 2004 and December 2014 were analyzed, using prospectively collected data. Postoperative AKI was defined by serum creatinine change within 48 hr, as per the Kidney Disease Improving Global Outcomes guidelines. Cardiovascular and kidney-disease risk factors were entered in univariate and multivariate analyses to assess influence on AKI development.

RESULTS

Overall, 167 (17.6%) patients developed AKI but only 2 patients required dialysis perioperatively. At multivariate analysis, adjusted for established AKI-risk factors and parameters that differed between groups at baseline, preoperative estimated glomerular filtration rate (eGFR; as per the chronic kidney disease epidemiology [CKD] formula); odds ratio (OR): 1.02 (per unit decrease); 95% confidence interval (CI): 1.003-1.041; P = 0.025; and chronic kidney disease (CKD) stage > 2 (OR: 1.28; 95% CI: 1.249-2.531, P = 0.001) were associated with development of AKI.

CONCLUSIONS

AKI was common after elective infrarenal EVAR and preoperative renal function appears to be the main factor associated with AKI. Patients with a low eGFR need to be targeted with more aggressive renal protection.

Perioperative Outcomes in Patients Requiring Iliac Conduits or Direct Access for Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

Iliac conduit or direct iliac access (ICDA) can be used when anatomy is unfavorable for femoral access during abdominal endovascular aortic aneurysm repair (EVAR). The impact of this approach has not been adequately addressed. The objective of this study was to analyze perioperative outcomes of patients requiring use of ICDAs for EVAR.

METHODS

Patients undergoing EVAR with and without ICDA were identified in the 2005-2012 National Surgical Quality Improvement Program data sets. Perioperative morbidity and mortality were assessed by crude comparison of matched groups and multivariate analyses.

RESULTS

Of 15,082 patients undergoing infrarenal EVAR 147 (1%) required ICDA. The ICDA group had a higher proportion of females (25.9% vs. 17.8%, P = 0.017), peripheral vascular disease (12.9% vs. 5.5%, P = 0.001), and patients with a history of dyspnea (31.3% vs. 23.1%, P = 0.024). There was no difference in age (74.5 ± 8.4 conduit vs. 73.5 ± 8.5). On multivariate analysis, the ICDA cohort had a higher rate of mortality (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.4-5.4; P = 0.004) and an increase in other major complications including cardiac arrest and/or myocardial infarction (OR, 2.9; 95% CI, 1.3-6.3; P = 0.007), pulmonary complications (OR, 2.1; 95% CI, 1.2-3.9; P = 0.013), and postoperative length of stay (means ratio, 1.3; 95% CI, 1.1-1.4; P = 0.001). There was a trend toward increased bleeding complications with ICDA. Matched analyses of comorbidities revealed that patients requiring ICDA had higher perioperative mortality (6.8% vs. 2.3%, P = 0.008), cardiac (4.8% vs. 1%, P = 0.004), pulmonary (8.8% vs. 3.4%, P = 0.006), and bleeding complications (10.2% vs. 4.6%, P = 0.016).

CONCLUSIONS

Our results demonstrate that the use of ICDA during EVAR is associated with increased morbidity and mortality. In situations where anatomy mandates the use of iliac conduits or access for EVAR, surgeons should consider this increased risk. Open repair or the use of lower profile devices, if possible, should be considered as options for these patients.

Incidence of Acute Kidney Injury (AKI) after Endovascular Abdominal Aortic Aneurysm Repair (EVAR) and Impact on Outcome

BACKGROUND

Acute kidney injury (AKI) is an important post-operative complication that may impact on mortality, morbidity, and cost. The incidence after endovascular aneurysm repair (EVAR) remains unknown, as the current literature has not employed consistent definitions. The aim of this study is to assess the incidence of AKI after elective EVAR and examine the impact of AKI on mortality and cardiovascular morbidity using the current universally accepted definitions.

METHODS

This was a cohort study using prospectively collected data, including consecutive patients undergoing elective EVAR for an infrarenal abdominal aortic aneurysm (AAA). Those with end stage renal failure were excluded. The primary endpoint was incidence of AKI as per the "Acute Kidney Injury Network" (AKIN), and "Kidney Disease Improving Global Outcomes" (KDIGO) criteria. Secondary endpoints included AKI stage, drop in estimated glomerular filtration rate (eGFR), and mortality and cardiovascular morbidity.

RESULTS

149 patients were included (16 females, 11%; mean age: 69 ± 8 years; mean AAA diameter: 6.0 ± 1.1 cm), 28 (18.8%) of whom developed AKI (26 patients classified as stage 1 and 2 as stage 2). Within 48 hours, those with AKI dropped their eGFR from 61 ± 20 mL/kg/1.73 m(2) to 51 ± 20 units (p < .001), and those without from 75 ± 9 to 74 ± 10 units (p < .001). None required dialysis during a 33 ± 11 month follow up. Development of AKI was associated with mortality (HR 0.035, 95% CI: 0.005 to 0.240, p < .001) and cardiovascular morbidity (HR: 0.021, 95% CI: 0.004 to 0.11, p < .001) on adjusted regression analysis.

CONCLUSIONS

The incidence of AKI after EVAR is significant and is independently associated with medium-term mortality and morbidity.

Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age

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.

Endovascular repair of a large ruptured abdominal aortic aneurysm using monitored anesthesia care and local anesthesia

Over the last decade, there has been a paradigm shift in the treatment of ruptured abdominal aortic aneurysm (AAA) from open repair to endovascular aneurysm repair (EVAR). Regardless of the method used during emergent rupture, open verses endovascular repair, the overall mortality remains high. Recent studies have compared patient outcomes using different types of anesthesia during elective EVAR procedures. The data show that during an elective EVAR, monitored anesthesia care (MAC) with local anesthesia is not only just as safe as general anesthesia, but it offers other potential benefits as well. There is limited data in regards to patient outcomes using MAC and local anesthesia during cases of large ruptured aneurysms that are treated with EVAR. This case report discusses the treatment of a patient who presented with a large 13 cm ruptured AAA which was successfully repaired using EVAR with MAC and local anesthesia.

Emergent endovascular vs. open surgery repair for ruptured abdominal aortic aneurysms: a meta-analysis

Objectives

To systematically review studies comparing peri-operative mortality and length of hospital stay in patients with ruptured abdominal aortic aneurysms (rAAAs) who underwent endovascular aneurysm repair (EVAR) to patients who underwent open surgical repair (OSR).

Methods

The Medline, Cochrane, EMBASE, and Google Scholar databases were searched until Apr 30, 2013 using keywords such as abdominal aortic aneurysm, emergent, emergency, rupture, leaking, acute, endovascular, stent, graft, and endoscopic. The primary outcome was peri-operative mortality and the secondary outcome was length of hospital stay.

Results

A total of 18 studies (2 randomized controlled trials, 5 prospective studies, and 11 retrospective studies) with a total of 135,734 rAAA patients were included. rAAA patients who underwent EVAR had significantly lower peri-operative mortality compared to those who underwent OSR (overall OR = 0.62, 95% CI = 0.58 to 0.67, P<0.001). rAAA patients with EVAR also had a significantly shorter mean length of hospital stay compared to those with OSR (difference in mean length of stay ranged from −2.00 to −19.10 days, with the overall estimate being −5.25 days (95% CI = −9.23 to −1.26, P = 0.010). There was no publication bias and sensitivity analysis showed good reliability.

Conclusions

EVAR confers significant benefits in terms of peri-operative mortality and length of hospital stay. There is a need for more randomized controlled trials to compare outcomes of EVAR and OSR for rAAA.

Abdominal aortic aneurysms: endovascular options and outcomes - proliferating therapy, but effective?

Abdominal aortic aneurysm (AAA) has a reported prevalence rate of 1.4% in the US. AAA rupture accounts for an estimated 15,000 deaths per year, rendering it the 10th leading cause of death in men over the age of 55. Endovascular repair (EVR) has proliferated in the last two decades as an increasingly popular alternative to traditional open surgery, and is now the default treatment in the majority of centres worldwide. This review article outlines the evidence supporting this stance. The development of EVR is reviewed, alongside trends in utilisation of this therapy over time. The evidence for the relative short-term and long-term outcomes of EVR and open AAA repair is discussed, and ongoing controversies surrounding the use of EVR are considered.

Nonelective colon cancer resections in elderly patients: results from the dutch surgical colorectal audit

AIMS

The aim of the study was to assess which factors contribute to postoperative mortality, especially in elderly patients who undergo emergency colon cancer resections, using a nationwide population-based database.

METHODS

6,161 patients (1,172 nonelective) who underwent a colon cancer resection in 2010 in the Netherlands were included. Risk factors for postoperative mortality were investigated using a multivariate logistic regression model for different age groups, elective and nonelective patients separately.

RESULTS

For both elective and nonelective patients, mortality risk increased with increasing age. For nonelective elderly patients (80+ years), each additional risk factor increased the mortality risk. For a nonelective patient of 80+ years with an American Society of Anesthesiologists score of III+ and a left hemicolectomy or extended resection, postoperative mortality rate was 41% compared with 7% in patients without additional risk factors.

CONCLUSIONS

For elderly patients with two or more additional risk factors, a nonelective resection should be considered a high-risk procedure with a mortality risk of up to 41%. The results of this study could be used to adequately inform patient and family and should have consequences for composing an operative team.

Endovascular abdominal aortic aneurysm repair in the geriatric population

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

Endovascular vs open repair for ruptured abdominal aortic aneurysm

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.

Evolution of quality and surgical risk assessment in the USA

As health-care reforms progress, quality and risk assessment in the health-care system of the USA surface as critical issues. This review considers past, present and possible future changes in quality assessment along with formal programs of complication reduction and pay for performance (PFP) as related to surgery and vascular interventions. Strategies for quality improvement include aggregate and risk-adjusted outcome measurement, process compliance with the Surgical Complication Improvement Program, oversight and PFP, now policies of the Centers for Medicare and Medicaid Services (CMS). Advantages, disadvantages and unintended consequences of these policies are discussed. While ongoing system changes will influence vascular surgical practice, unique opportunities and obligations exist for vascular surgeons to contribute to quality assessment of their interventions, to evaluate long-term outcomes and to devise strategies for comprehensive cost-effective care for the conditions affecting patients with vascular disease.

Resident and fellow experiences after the introduction of endovascular aneurysm repair for abdominal aortic aneurysm

OBJECTIVES

This study assessed trends in open and endovascular repair (EVAR) of intact and ruptured abdominal aortic aneurysm (AAA) in the Medicare population and evaluated recent trends in AAA repair at vascular fellowship training programs.

METHODS

We identified all Medicare beneficiaries with a diagnosis of AAA who underwent repair or had a primary diagnosis of rupture (1995-2008). Cohorts were compared by type of repair (open vs EVAR) and presentation (intact vs ruptured AAA). Demographics of age, sex, and race were evaluated. We used unique hospital identifier codes to compare trends and 30-day mortality between hospitals that participate in vascular surgery fellowship training and those that do not. American Council on Graduate Medical Education data, only available for the years 1999 to 2008, were further used to better understand the changes in number of EVAR and open repairs of AAA performed each year for vascular fellows and general surgery residents, over time.

RESULTS

We identified 449,122 patients (76% men), with 376,355 intact AAAs (84%) and 72,767 ruptured AAAs (16%). Mean age was 75.1 years. Use of EVAR for intact AAA rose to from 35% in 2001 to 63% in 2005 and comprised 78% of repairs by 2008. During the same period, the number of ruptured AAAs decreased by 40% overall, with nonoperative ruptured AAAs decreasing by 29% and EVAR increasing to 31% of rupture repairs. Hospitals training vascular fellows were quicker to adopt EVAR (2-year lag time) for intact AAA and had higher rates of EVAR for ruptured AAA (41.1% vs 29.2%; P = .001) than did hospitals without fellows. Mortality rates for open repairs of intact (4.0% vs 5.0%; P = .01) and ruptured AAA (34.1% vs 41.0%; P = .031) were lower at fellowship hospitals. The average number of open AAA repairs performed by vascular fellows dropped 50% (44.1 to 21.6/year) from 1999 to 2008.

CONCLUSIONS

Contrary to the expectation of a plateau, use of EVAR for intact AAA continues to rise at fellowship and nonfellowship hospitals. Use of EVAR for rupture is being used more often at fellowship programs. The decline in open repairs performed by vascular fellows, and at fellowship and non-fellowship hospitals, may have important implications for future attending experience.

Volume-outcome relationships in vascular surgery: the current status

Vascular surgery has been widely practiced in hospitals within a general surgical service, although the consequent workload of individual vascular units has been small. There is an increasing body of evidence in favor of a positive relationship between hospital and surgeon volumes and the outcome of arterial surgery. These relationships suggest that vascular surgical procedures might be best placed within a centralized model of care to increase volume and thereby attain best outcomes. This systematic review appraises the current evidence for volume-outcome relationships in vascular surgery from a number of healthcare systems to examine the basis for centralization of vascular surgical services. The index procedures addressed in this review are open or endovascular repair of abdominal aortic aneurysm (AAA), ruptured AAA, descending thoracic aortic aneurysm, and thoracoabdominal aortic aneurysm, along with carotid endarterectomy and lower extremity arterial bypass.