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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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Epple J, Svidlova Y, Schmitz-Rixen T, Böckler D, Lingwal N, Grundmann RT. Long-Term Outcome of Intact Abdominal Aortic Aneurysm After Endovascular or Open Repair. Vasc Endovascular Surg 2023; 57:829-837. [PMID: 37224305 DOI: 10.1177/15385744231178130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Endovascular aortic aneurysm repair (EVAR) has been established as a standard treatment option for intact abdominal aortic aneurysm (iAAA) and gained importance due to a lower perioperative mortality than open repair (OAR). However, whether this survival advantage can be maintained or if OAR is beneficial in terms of long-term complications and reinterventions remains questionable. DESIGN In this retrospective cohort study data from patients undergoing elective EVAR or OAR for iAAAs in the years 2010-2016 was analyzed. The patients were followed through 2018. METHODS In the propensity score matched cohorts the perioperative and long-term outcomes of the patients were assessed. We identified 20 683 patients undergoing elective iAAA repair (76.4% EVAR). The propensity matched cohorts included 4886 pairs of patients. RESULTS The perioperative mortality was 1.9% for EVAR and 5.9% for OAR (P = <.001). The perioperative mortality was mainly influenced by patients age (Odds-Ratio (OR):1.073, confidence interval (CI):1.058-1.088, P ≤ .001) and OAR (OR:3.242, CI:2.552-4.119, P ≤ .001). The early survival benefit after endovascular repair persisted for approximately 3 years (estimated survival EVAR 82.3%, OAR 80.9%, P = .021). After that time the estimated survival curves were similar. After 9 years the estimated survival was 51.2% after EVAR as compared to 52.8% after OAR (P = .102). The operation method didn't influence long-term survival significantly (Hazard-Ratio (HR): 1.046, CI: .975-1.122, P = .211). The vascular reintervention rate was 17.4% in the EVAR cohort and 7.1% in the OAR cohort (P ≤ .001). CONCLUSION EVAR has a significantly lower perioperative mortality than OAR, a survival benefit that lasts up to 3 years after intervention. Thereafter, no significant difference in survival was observed between EVAR and OAR. The decision between EVAR or OAR may depend on patient preference, surgeons' experience, and the institutions' ability to handle complications.
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Affiliation(s)
- Jasmin Epple
- Department of Vascular and Endovascular Surgery University Hospital, Frankfurt Am Main, Germany
| | - Yuliya Svidlova
- Department of Vascular and Endovascular Surgery University Hospital, Frankfurt Am Main, Germany
| | - Thomas Schmitz-Rixen
- German Institute for Vascular Healthcare Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital, Heidelberg, Germany
| | - Neelam Lingwal
- Institute for Biostatistics and Mathematical Modeling, Goethe University Frankfurt Am Main, Germany
| | - Reinhart T Grundmann
- German Institute for Vascular Healthcare Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany
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Talvitie M, Åldstedt-Nyrønning L, Stenman M, Roy J, Cohnert T, Hultgren R. Women with large intact abdominal aortic aneurysms remain untreated. J Vasc Surg 2023; 78:657-667.e5. [PMID: 37211143 DOI: 10.1016/j.jvs.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/20/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE A lower elective repair rate among women with abdominal aortic aneurysms (AAAs) has been a consistent finding. Reasons behind this gender gap have not been thoroughly outlined. METHODS This was a retrospective multicenter cohort study (ClinicalTrials.gov: NCT05346289) at three European vascular centers in Sweden, Austria and Norway. Patients in surveillance with AAAs were consecutively identified starting from January 1, 2014, until reaching a total sample size of 200 women and 200 men. All individuals were followed for 7 years through medical records. Final treatment distributions and the proportion of "truly untreated" (surgically untreated despite reaching guideline-directed thresholds: 50 mm for women and 55 mm for men) were determined. In a complementary analysis, a universal 55-mm threshold was used. Gender-specific primary reasons behind untreated statuses were clarified. Eligibility for endovascular repair among the truly untreated was assessed in a structured computed tomography analysis. RESULTS Women and men had similar median diameters at inclusion (46 mm; P = .54) and at treatment decisions (55 mm; P = .36). After 7 years, the repair rate was lower among women (47% vs 57%). More women were truly untreated (26% vs 8%; P < .001) despite similar mean ages as for male counterparts (79.3 years; P = .16). With the 55-mm threshold, 16% women still classified as truly untreated. Similar reasons for nonintervention were captured for women and men (50% due to comorbidities alone, 36% morphology and comorbidity). The endovascular repair imaging analysis revealed no gender differences. Among truly untreated women, ruptures were common (18%), and mortality was high (86%). CONCLUSIONS Surgical AAA management differed between women and men. Women could be underserved in terms of elective repairs: one in every four women was untreated with over-the-threshold AAAs. The lack of obvious gender differences in eligibility analyses could imply unmeasured discrepancies (eg, in disease extent or patient frailty).
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Affiliation(s)
- Mareia Talvitie
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Linn Åldstedt-Nyrønning
- Department of Surgery, Vascular Surgery, St Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, NTNU, Trondheim, Norway
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Tina Cohnert
- Department of Vascular Surgery, Medical University of Graz, Graz, Austria
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Mao J, Behrendt CA, Falster MO, Varcoe RL, Zheng X, Peters F, Beiles B, Schermerhorn ML, Jorm L, Beck AW, Sedrakyan A. Long-term Mortality and Reintervention After Endovascular and Open Abdominal Aortic Aneurysm Repairs in Australia, Germany, and the United States. Ann Surg 2023; 278:e626-e633. [PMID: 36538620 PMCID: PMC10225011 DOI: 10.1097/sla.0000000000005768] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To examine long-term outcomes after endovascular (EVAR) and open repairs (OAR) for intact abdominal aortic aneurysms in Australia, Germany, and the United States, using a unified study design. BACKGROUND Similarities and differences in long-term outcomes after EVAR versus OAR across countries remained unclear, given differences in designs across existing studies. METHODS We identified patients aged >65 years undergoing intact abdominal aortic aneurysm repairs during 2010-2017/2018. We compared long-term patient mortality and reintervention after EVAR and OAR using Kaplan-Meier analyses and Cox regressions. Propensity score matching was performed within each country to adjust for differences in baseline patient characteristics between procedure groups. RESULTS We included 3311, 4909, and 145363 patients from Australia, Germany, and the United States, respectively. The median patient age was 76 to 77 years, and most patients were males (77%-84%). Patient mortality was lower after EVAR than OAR within the first 60 days and became similar at 3-year follow-up (Australia 14.7% vs 16.5%, Germany 18.2% vs 19.7%, United States: 24.4% vs 24.4%). At the end of follow-up, patient mortality after EVAR was higher than OAR in Australia [ hazard ratio (HR) 95% CI: 1.21 (0.96-1.54)] but similar to OAR in Germany [HR 95% CI: 0.92 (0.80-1.07)] and the United States [HR 95% CI: 1.02 (0.99-1.05)]. The risk of reintervention after EVAR was more than twice that after OAR in Australia [HR 95% CI: 2.60 (1.09-6.15)], Germany [HR 95% CI: 4.79 (2.56-8.98)], and the United States [HR 95% CI: 2.67 (2.38-3.00)]. The difference in reintervention risk appeared early in German and United States patients. CONCLUSIONS This multinational study demonstrated important similarities in long-term outcomes after EVAR versus OAR across 3 countries. Variation in long-term mortality and reintervention comparisons indicates possible differences in patient profiles, surveillance, and best medical therapy across countries.
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Affiliation(s)
- Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Christian-Alexander Behrendt
- Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Asklepios Medical School Hamburg, Asklepios Clinic Wandsbek, Department of Vascular and Endovascular Surgery, Hamburg, Germany
| | - Michael O. Falster
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Ramon L. Varcoe
- Department of Surgery, Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Frederik Peters
- Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Barry Beiles
- Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Louisa Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Adam W. Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
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Nana P, Spanos K, Kölbel T, Panuccio G, Jama K, Jakimowicz T, Rohlffs F. Early and Mid-Term Outcomes of Females Treated with t-Branch off the Shelf Device. Ann Vasc Surg 2023; 95:32-41. [PMID: 37268105 DOI: 10.1016/j.avsg.2023.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/16/2023] [Accepted: 05/26/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Female sex has been characterized as a risk factor of increased mortality in patients managed for complex aortic aneurysm using endovascular means. This study aimed to present the perioperative and follow-up outcomes of females managed electively or urgently with the t-Branch device and investigate factors affecting the early outcomes. METHODS A 2-center retrospective observational study was conducted including elective and urgent female patients managed with the t-Branch device (Cook Medical, Bjaeverskov, Denmark) for thoracoabdominal and pararenal aneurysms between January 1, 2018 and September 30, 2020. Primary early outcomes included technical success and 30-day mortality and morbidity [spinal cord ischemia (SCI) and acute kidney injury]. Follow-up survival and freedom from reintervention rates were assessed using Kaplan-Meier estimates. RESULTS In total, 153 females were included; 81 (52.9%) treated urgently. Urgent patients were older (73.2 ± 8.6 vs. 68.5 ± 6.8 years; P < 0.001) and presented higher previous coronary angioplasty/stenting (16.0% vs. 5.6%, P = 0.005) and lower double antiplatelet therapy (DAPT, 46.3% vs. 53.7%, P = 0.04) rates. Technical success was 97.4%. Early mortality was 16.3% (22% in urgent; 12% in elective; P = 0.2) and SCI and acute kidney injury were diagnosed in 13.7% (11% in urgent; 16% in elective; P = 0.2) and 18.3% (22.2% in urgent; 13.9% in elective; P = 0.18), respectively. Multivariate regression analyses showed that DAPT and b-blockers were related to lower 30-day mortality. DAPT was also preventive for SCI. Survival rates were 68.4% [standard error (SE) 0.07] at 12 months for the urgent and 75.6% (SE 0.09) at 24 months for the elective group (P = 0.14). Freedom from reintervention rates were 81.4% (SE 0.06) at 6 months and 64.7% (SE 0.09) at 18 months for the urgent and 81.7% (SE 0.06) at 6 months and 75.4% (SE 0.081) at 18 months for the elective group (P = 0.94). CONCLUSIONS Female patients managed with the t-Branch device for thoracoabdominal and pararenal aneurysms in elective and urgent setting presented similar 30-day mortality and SCI rates.
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Affiliation(s)
- Petroula Nana
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany.
| | - Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany; Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Giuseppe Panuccio
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
| | - Katarzyna Jama
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Jakimowicz
- Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Fiona Rohlffs
- Department of Vascular Medicine, German Aortic Center, University Heart and Vascular Center UKE Hamburg, Hamburg, Germany
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DeJong M, Peterson L, Zielke T, Simone A, Penton A, Blecha M. Investigation of Renal Decline and New Onset Dialysis Following Endovascular Aneurysm Repair in the Vascular Quality Initiative. Vasc Endovascular Surg 2023; 57:203-214. [PMID: 36906859 DOI: 10.1177/15385744221141229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The purpose of this study is to identify variables significantly associated with renal function decline after elective endovascular infra-renal abdominal aortic aneurysm repair and to identify the rate and risks of subsequent progression to dialysis. Specifically, we investigate the long-term impact of supra-renal fixation, female gender, and physiologically stressful perioperative events on renal function following endovascular aneurysm repair (EVAR). METHODS Review of all EVAR cases in the Vascular Quality Initiative between 2003 and 2021 was conducted to investigate variable associations with three primary outcomes: postoperative acute renal insufficiency (ARI); greater than 30% decline in glomerular filtration rate (GFR) in patients beyond 1 year of follow up; and new onset dialysis requirement at any point in follow up. Binary logistic regression analysis was performed for the events of acute renal insufficiency and new onset dialysis requirement. Cox proportional hazard regression was performed regarding long term GFR decline. RESULTS Postoperative ARI occurred in 3.4% (1692/49 772) of patients. Significant (P < .05) association with postoperative ARI was noted for: age (OR 1.014/year, 95% CI 1.008-1.021); female gender (OR 1.44, 95% CI 1.27-1.67); hypertension (OR 1.22, 95% CI 1.04-1.44); chronic obstructive pulmonary disease (OR 1.34, 95% CI 1.20-1.50); anemia (OR 4.24, 95% CI 3.71-4.84); reoperation at index admission (OR 7.86, 95% CI 6.47-9.54); baseline renal insufficiency (OR 2.29, 95% CI 2.03-2.56); larger aneurysm diameter; increased blood loss; and higher volumes of intra-operative crystalloid. Risk factors (P < .05) correlating with a decline of 30% in GFR at any time beyond 1 year were: female gender (HR 1.43, 95% CI 1.24-1.65); body mass index (BMI) less than 20 (HR 1.34, 95% CI 1.03-1.74); hypertension (HR 1.38, 95% CI 1.15-1.64); diabetes (HR 1.34, 95% CI 1.17-1.53); COPD (HR 1.21, 95% CI 1.07-1.37); anemia (HR 1.92, 95% CI 1.52-2.42); baseline renal insufficiency (HR 1.31, 95% CI 1.15-1.49); absence of discharge ace-inhibitor (HR 1.27, 95% CI 1.13-1.42); long term re-intervention (HR 2.43, 95% CI 1.84-3.21) and larger AAA diameter. Patients who experienced long term GRF decline had a significantly higher long-term morality. New onset dialysis following EVAR occurred in .47% (234/49 772) of those meeting inclusion criteria. Higher rate (P < .05) of new onset dialysis was associated with age (OR 1.03/year, 95% CI 1.02-1.05); diabetes (OR 1.376, 95% CI 1.005-1.885); baseline renal insufficiency (OR 6.32, 95% CI4.59-8.72); Reoperation at index admission (OR 2.41, 95% CI 1.03-5.67); postoperative ARI (OR 23.29, 95% CI 16.99-31.91); absence of beta blocker (OR 1.67, 95% CI 1.12-2.49); long term graft encroachment on renal arteries (OR 4.91, 95% CI 1.49-16.14). CONCLUSIONS New onset dialysis following EVAR is a rare event. Perioperative variables influencing renal function following EVAR include blood loss, arterial injury, and reoperation. Supra-renal fixation is not associated with postoperative acute renal insufficiency or new onset dialysis in long term follow up. Renal protective measures are recommended for patients with baseline renal insufficiency undergoing EVAR as acute renal insufficiency following EVAR portends a 20-fold increased risk of new onset dialysis in long term follow up.
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Affiliation(s)
- Matthew DeJong
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Laelle Peterson
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Tara Zielke
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Avital Simone
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Ashley Penton
- Department of Surgery, 25815Loyola University Medical Center, Maywood, IL, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
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Tan X, Jung G, Herrmann E, Derwich W, Grundmann R, Schmitz-Rixen T, Gray D. Sex difference in early mortality after abdominal aortic aneurysm repair. J Vasc Surg 2023; 77:1658-1668.e2. [PMID: 36773666 DOI: 10.1016/j.jvs.2023.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVE Although female patients have a lower prevalence of abdominal aortic aneurysm (AAA), they seem to have a worse treatment outcome compared with male patients. Both maximum aneurysm diameter and aortic size index (ASI) are important indicators of the risk of AAA rupture, among which ASI has been shown capable of equalizing sex-related anatomical differences. Our study aimed to investigate whether sex is an independent risk factor for early postoperative mortality and how the diameter or ASI affects the association between sex and mortality. METHODS We performed a retrospective analysis of patients who enrolled in the AAA registry of the German Society of Vascular Surgery from 2013 to 2019. The patients were treated by either open surgical repair (OSR) or endovascular aneurysm repair (EVAR). The association between sex and 30-day mortality was investigated using logistic regression analysis. The interaction and mediating effects of maximum aneurysm diameter and ASI were investigated to verify their roles in the effect of sex on mortality. The relationships between the diameter (or ASI) and the risk of 30-day mortality in different sexes were demonstrated by the restricted cubic spline. RESULTS Overall, 23,275 cases were included in our analysis, with 20,130 male (86.5%) and 3139 female (13.5%) patients. Female patients had a smaller maximum aneurysm diameter (OSR, 55.23 ± 10.29 mm vs 58.05 ± 11.28 mm [P < .001]; EVAR, 54.06 ± 9.08 mm vs 56.11 ± 9.38 mm [P < .001]), but a higher ASI (OSR, 3.16 ± 0.71 vs 2.92 ± 0.69 [P < .001]; EVAR, 3.05 ± 0.66 vs 2.80 ± 0.59 [P < .001]) compared with male patients. The 30-day mortality rate was higher for female patients in both OSR (6.6% vs 4.2%; P = .002) and EVAR groups (1.8% vs 0.8%; P < .001). Logistic regression confirmed a significantly higher risk of 30-day mortality for female patients compared with male patients (odds ratio, 1.55; 95% confidence interval, 1.21-1.99; P = .001). No interaction was found between sex and diameter or ASI, but there were mediating effects for diameter and ASI in the effect of sex on 30-day mortality. For female patients, the risk of 30-day mortality linearly increased with the increase of diameter (PNonlinear = .089) or ASI (PNonlinear = .888), whereas the risk for male patients was U-shaped (for diameter, PNonlinear < .001; for ASI, PNonlinear = .020). CONCLUSIONS Sex is an independent risk factor for 30-day mortality after AAA repair. Both diameter and ASI are mediating factors for the effect of sex on 30-day mortality. The relationship between diameter or ASI and the risk of 30-day mortality is different for male and female patients.
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Affiliation(s)
- Xinji Tan
- Department of Vascular and Endovascular Surgery, University Hospital of Goethe University Frankfurt, Frankfurt, Germany
| | - Georg Jung
- Department of Vascular Surgery, Luzern, Switzerland
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Wojciech Derwich
- Department of Vascular and Endovascular Surgery, University Hospital of Goethe University Frankfurt, Frankfurt, Germany
| | - Reinhart Grundmann
- Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery, University Hospital of Goethe University Frankfurt, Frankfurt, Germany
| | - Daphne Gray
- Department of Vascular and Endovascular Surgery, University Hospital of Goethe University Frankfurt, Frankfurt, Germany.
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Die Regierungskommission für eine moderne und bedarfsgerechte Krankenhausversorgung und das Bauchaortenaneurysma – Haben wir eine inhaltliche Diskussion um Mindestmengen und Qualitätsindikatoren verpasst? GEFÄSSCHIRURGIE 2023. [DOI: 10.1007/s00772-023-00975-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mangel T, Mastracci TM. Outcomes of endovascular repair of abdominal and thoracoabdominal aneurysms in women - A review. Semin Vasc Surg 2022; 35:334-340. [DOI: 10.1053/j.semvascsurg.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/30/2022] [Accepted: 07/20/2022] [Indexed: 11/11/2022]
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Blecha M, Malach L, Dickens B, Decicco E, D'Andrea M, DeJong M, Bechara CF. Predictors of Decline in Renal Function 5 Years after EVAR. Vasc Endovascular Surg 2021; 56:166-172. [PMID: 34694174 DOI: 10.1177/15385744211054283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION While there exists copious short-term data regarding renal function following infra-renal endovascular abdominal aortic aneurysm repair (EVAR), long-term analysis is sparse. This is a single institution retrospective review of predictors of renal function decline 5 years after elective EVAR. METHODS All EVAR between 2007 and 2015 were queried. Patients in whom renal function was documented 5 years postoperatively were included in analysis. Exclusion criteria were ruptured aneurysm, mortality before 56 months, lack of follow-up, ESRD status, and concomitant renal intervention. The primary outcome investigated was a 20% or greater drop in glomerular filtration rate (GFR) 5 years postoperatively. The following variables at the time of surgery were investigated as potential predictors: age, gender, hypertension, hyperlipidemia, diabetes, CAD or prior MI, COPD, prior stroke, baseline eGFR under 60 mL/min/1.73 m2, supra-renal fixation, infra-renal fixation, neck diameter, neck length, and number of contrast CT. RESULTS 354 EVAR were identified of which 143 met inclusion criteria (211 excluded). Univariate analysis revealed female gender (OR 2.7), hypertension (OR 9.4), baseline renal insufficiency (OR 3.8), larger neck diameter, and supra-renal fixation (OR 2.32) all predictive (P < .05) of GFR drop at 5 years. Multivariate binary logistic regression analysis found female gender (multivariate OR 3.9, P = .023) and baseline renal insufficiency (multivariate OR 3.0, P = .029) as significant predictors of greater than 20% GFR drop at 5 years. Only 2 patients of the 143 progressed to dialysis requirement at 5 years. CONCLUSIONS Females and patients with baseline renal insufficiency are more vulnerable to significant decline in renal function 5 years following EVAR. Consistent with analogous literature, supra-renal fixation appears moderately deleterious toward renal function with no clinical significance in those with baseline normal renal function. The potential benefit of avoidance of supra-renal fixation in female patients with baseline renal insufficiency is worth further investigation in a more robust multi-center study.
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Affiliation(s)
- Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
| | - Lillian Malach
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Brooke Dickens
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Emily Decicco
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Melissa D'Andrea
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Matthew DeJong
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Carlos F Bechara
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
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Shih CW, Ho ST, Shui HA, Tang CT, Shih CC, Chen TJ, Lin KC, Liang CY, Wang KY. Endovascular aortic repair is a cost-effective option for in-hospital patients with abdominal aortic aneurysm. J Chin Med Assoc 2021; 84:890-899. [PMID: 34261982 DOI: 10.1097/jcma.0000000000000581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To investigate the cost-effectiveness of endovascular aortic repair (EVAR) versus open aortic repair (OAR) for abdominal aortic aneurysm (AAA) using incremental costs per decreased in-hospital mortality rate gained through our patients' cohort. METHODS Medical records and healthcare costs of patients with AAA hospitalized between 2010 and 2015 were extracted from the National Health Insurance Research Database (NHIRD) of Taiwan. Multiple regression analysis was applied to adjust for confounding factors and to compare the differences in postoperative clinical outcomes between patients who received EVAR and OAR. The incremental cost-effectiveness ratio (ICER) of EVAR was determined based on the healthcare cost obtained from the analyzed data. RESULTS A total of 2803 AAA patients were identified (n = 559 with ruptured AAA and n = 2244 unruptured AAA). Patients with ruptured AAA who underwent EVAR compared with OAR patients had shorter hospital and intensive care unit (ICU) stays (all p < 0.05). For patients with unruptured AAA, those who received EVAR compared with OAR, the adjusted odds ratio (aOR) of postoperative complications and in-hospital mortality were 0.371 and 0.447 (all p < 0.05). The total direct surgical costs and medical expenses during hospitalization in all AAA patients were higher for the EVAR group; however, ICER was <1 per capita gross domestic product. Stratification by age groups further suggested that ICER for patients with unruptured AAA who received EVAR, compared with OAR, decreased with age. CONCLUSION Total direct medical costs were higher for AAA patients receiving EVAR regardless of rupture status; however, the cost is offset by lower odds of postoperative complications and in-hospital mortality. The observed decrease in ICER with age and EVAR use warrants further analysis. Our findings further validate the use of EVAR over OAR. These results provides supporting evidence for physicians and patients with AAA to inform shared decision making regarding endovascular or OAR options.
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Affiliation(s)
- Chia-Wen Shih
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shung-Tai Ho
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Anesthesiology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Hao-Ai Shui
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chi-Tun Tang
- Department of Neurological Surgery, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Chun-Che Shih
- Taipei Heart Institute, Taipei Medical University, Division of Cardiovascular Surgery, Taipei, Taiwan, ROC
- Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tzeng-Ji Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Kuan-Chia Lin
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Community Medicine Research Center, Taipei, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Chun-Yu Liang
- School of Nursing, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Kwua-Yun Wang
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Nursing, National Defense Medical Center, Taipei, Taiwan, ROC
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