Long-term outcomes of endovascular repair versus open repair of abdominal aortic aneurysm

Editor's Choice - Radiation Dose Reduction During Contralateral Limb Cannulation Using Fiber Optic RealShape Technology in Endovascular Aneurysm Repair

OBJECTIVE

The increasing number of endovascular procedures has resulted in an increasing radiation burden, particularly for the treatment team. Fiber Optic RealShape (FORS) technology uses laser light instead of fluoroscopy to visualise the endovascular guidewire and catheters. These devices can be used during the navigational part of procedures, such as cannulation of the contralateral limb (CL) in endovascular aneurysm repair (EVAR). The aim of this study was to describe the effect of using FORS on radiation dose during CL cannulation in standard EVAR.

METHODS

This was a non-randomised, retrospective comparison study of prospectively collected, single centre data from FORS guided EVAR compared with a conventional fluoroscopy only guided EVAR cohort. A total of 27 FORS guided cases were matched 1:1 based on sex, age, and body mass index (BMI) with 27 regular (fluoroscopy only) EVARs. This study primarily focused on (1) technical success of FORS and (2) navigation time and radiation dose (cumulative air kerma [CAK], air kerma area product [KAP], and fluoroscopy time [FT]) during cannulation of the CL. In addition, overall procedure time and radiation dose of the complete EVAR procedure were studied.

RESULTS

In 22 (81%) of the 27 FORS guided cases the CL was successfully cannulated using FORS. All radiation dose parameters were significantly lower in the FORS group (CAK, p < .001; KAP, p = .009; and FT, p < .001) for an equal navigation time (p = .95). No significant differences were found when comparing outcomes of the complete procedure.

CONCLUSION

Use of FORS technology significantly reduces radiation doses during cannulation of the CL in standard EVAR.

Outcomes and Cost-Analysis of Open Versus Endovascular Abdominal Aortic Aneurysm Repair in a Developing Country: A 15-year Experience at a Tertiary Medical Center

BACKGROUND

Endovascular aortic aneurysm repair (EVAR) has become the most common procedure for treating abdominal aortic aneurysms based on multiple studies conducted in the western world. The implication of such findings in developing countries is not well demonstrated. The objective of this study was to compare medical outcomes and costs of EVAR and open surgical repair (OSR) in a developing country.

METHODS

This is a retrospective study of all patients undergoing elective abdominal aortic aneurysm repair between 2005 and 2020 at a tertiary medical center in a developing country. Medical records were used to retrieve demographics, comorbidities, and perioperative complications. Medical records were also used to provide data on the need of reintervention, date of last follow-up, and mortality.

RESULTS

The study included a total of 164 patients. Median follow-up time was 41 months. The mean age was 69.9 +/- 7.84 years and 90.24% (n = 148) of patients were males. Regarding long-term mortality outcomes, no significant difference was detected between both groups; OSR patients had a survival rate of 91.38% and 74.86% at 5 and 10 years, compared to 77.29% and 56.52% in the EVAR group (P value = 0.10). Both groups had comparable long-term reintervention rates (P value = 0.334). The OSR group was charged significantly less than the EVAR group ($27,666.35 vs. $44,528.04, P value = 0.008).

CONCLUSIONS

OSR and EVAR have comparable survival and reintervention outcomes. Unlike what was reported in developed countries, patients undergoing OSR in countries with low hospital stay costs incur lower treatment costs.

Ruptured Abdominal Aortic Aneurysm Treated by Double-Balloon Technique and Endovascular Strategy: Case Series

Purpose: Mortality in patients with ruptured abdominal aortic aneurysms (rAAAs) has remained high despite advances in interventions. Endovascular aneurysm repair (EVAR) was recently developed for treatment of rAAAs. In this study, we assessed our endovascular strategy including a double-balloon technique for rAAA.

Methods: We analyzed 12 consecutive patients with rAAAs who were treated by our double-balloon technique and endovascular strategy from March 2013 to July 2016.

Results: The 30-day and 1-year mortality rates were both 17%. The mean times from admission to arrival at the hybrid operating room, from admission to aortic occlusion, and from admission to completion of EVAR were 46.8, 63.5, and 110.0 minutes, respectively.

Conclusion: This study indicates that the herein-described double-balloon endovascular technique is feasible for use in the management of rAAA.

The long-term outcomes of open and endovascular repair for abdominal aortic aneurysm: A meta-analysis

To provide a meta-analysis of studies evaluating long-term all-cause mortality, aneurysm-related mortality and re-intervention after open or endovascular repair for abdominal aortic aneurysm. Electronic bibliographic sources were interrogated using a combination of free text and controlled vocabulary searches to identify studies comparing the long-term outcomes of open and endovascular repair for abdominal aortic aneurysm. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Fixed effect or random effects models were used. We retrieved 4 randomized controlled trials (RCTs; 2,783 patients), 7 nonrandomized trials (86,035 patients). The primary outcome was all-cause mortality. Heterogeneity was high and publication bias could not be excluded. Despite these limitations, the analysis showed that open and endovascular abdominal aortic aneurysm repair had similar all-cause mortality (OR 1.16, 95% CI, 0.89-1.51) over 5 years follow up, which was maintained after at least 10 years of follow-up (OR 0.87, 95% CI, 0.73-1.03). There was no significant difference in aneurysm-related mortality by 5 years or longer follow-up. A significantly lower proportion of patients undergoing open repair required reintervention (OR 0.38, 95% CI 0.24-0.64), which was maintained over 5 years of follow-up. There is no long-term survival difference between the patients who underwent open or endovascular aneurysm repair. There is significantly higher risk of reinterventions after endovascular aneurysm repair.

Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm

BACKGROUND

Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective repair of abdominal aortic aneurysm (AAA) for many patients. However, the superiority of the endovascular procedure has recently been challenged by reports of impaired long-term survival in patients who underwent EVAR. A systematic review of long-term survival following AAA repair was therefore undertaken.

METHODS

A systematic review was performed according to PRISMA guidelines. Articles reporting short- and/or long-term mortality of EVAR and open surgical repair (OSR) of AAA were identified. Pooled overall survival estimates (hazard ratios (HRs) with corresponding 95 per cent c.i. for EVAR versus OSR) were calculated using a random-effects model. Possible confounding owing to age differences between patients receiving EVAR or OSR was addressed by estimating relative survival.

RESULTS

Some 53 studies were identified. The 30-day mortality rate was lower for EVAR compared with OSR: 1·16 (95 per cent c.i. 0·92 to 1·39) versus 3·27 (2·71 to 3·83) per cent. Long-term survival rates were similar for EVAR versus OSR (HRs 1·01, 1·00 and 0·98 for 3, 5 and 10 years respectively; P = 0·721, P = 0·912 and P = 0·777). Correction of age inequality by means of relative survival analysis showed equal long-term survival: 0·94, 0·91 and 0·76 at 3, 5 and 10 years for EVAR, and 0·96, 0·91 and 0·76 respectively for OSR.

CONCLUSION

Long-term overall survival rates were similar for EVAR and OSR. Available data do not allow extension beyond the 10-year survival window or analysis of specific subgroups.

Sarcopenia predicts mortality and adverse outcomes after endovascular aneurysm repair and can be used to risk stratify patients

BACKGROUND

Endovascular aneurysm repair (EVAR) is currently the most common treatment of abdominal aortic aneurysms. Potential predictors of long-term survival after EVAR include physiologic, functional, and cognitive status, but assessments of these conditions have been difficult to standardize. Objective radiographic findings, such as skeletal muscle atrophy, or sarcopenia, may provide an additional means for selection of patients. This study investigates sarcopenia as a method to predict 1-year survival in patients undergoing EVAR.

METHODS

A single-institution retrospective review was conducted of all patients who underwent elective EVAR from September 2002 to June 2014. Patients with an available periprocedural computed tomography (CT) scan and clinical data were included in the analysis. Normalized total psoas cross-sectional area (nTPA) was measured on axial CT images using the area of the bilateral psoas muscle at the third lumbar vertebral level normalized to the square of patient height. A threshold for optimal estimate of sarcopenia based on nTPA was determined using a receiver operating characteristic curve. Sarcopenia was evaluated as an independent risk predictor using univariate, multivariate, and survival analysis.

RESULTS

A total of 272 EVAR-treated patients were evaluated, including 237 men and 35 women with a median age of 72 years and mean body mass index of 28.6 kg/m². There was a significant increase in overall mortality in patients in the lowest quartile of nTPA (Q1, 23.53%; Q2, 13.24%; Q3, 7.35%; Q4, 5.88%; P = .01). The estimated nTPA threshold for increased mortality after EVAR was 500 mm²/m². Using this threshold, sarcopenia accounted for 57% of the risk effect in our 1-year survival model.

CONCLUSIONS

Sarcopenia can assist in identifying EVAR candidates who are less likely to benefit from surgery. It can be readily evaluated from preoperative CT scans and may be a useful tool in evaluation of abdominal aortic aneurysm patients with applications in risk evaluation and telemedicine.

Kilt Technique as an Angle Modification Method for Endovascular Repair of Abdominal Aortic Aneurysm with Severe Neck Angle

PURPOSE

Kilt technique can be useful for overcoming the severe angle in endovascular abdominal aortic repair. Thus, we investigate the utility of the Kilt technique as an angle modification method.

METHODS

This study included 16 patients with abdominal aortic aneurysm having severe neck angle (over 60°). Of these, eight were treated using Kilt technique, whereas the remaining eight were by the conventional endovascular method. We investigated the pre- and post-procedural differences in neck angle between the two groups using aortic computed tomography (CT) angiography.

RESULTS

Mean pre-procedural neck angles in the conventional group and the Kilt group were 70° ± 13° and 93° ± 14° (p = 0.007) and supra-renal neck angles were 54° ± 16° and 89° ± 26°, respectively (p = 0.016). However, the angle differences disappeared between the two groups after the procedure. Consequently, the Kilt group showed greater angle change than the conventional group (p value for ∆ supra-renal angle and ∆ neck angle were 0.015 and 0.021, respectively). There was no type 1 endoleak during 16 ± 16 months of CT follow-up.

CONCLUSION

Kilt technique may be an effective tool for modifying the neck angle without leaving increased risk of type 1 endoleak in this subset of patients.

Comparison of perioperative outcomes in endovascular versus open repair for juxtarenal and pararenal aortic aneurysms: A propensity-matched analysis

Objective

Endoluminal aortic aneurysm repair is suitable within certain anatomic specifications. This study aims to compare 30-day outcomes of endovascular versus open repairs for juxtarenal and pararenal aortic aneurysms (JAA/PAAs).

Methods

The ACS-NSQIP database was queried from 2012 to 2015 for JAA/PAA repairs. Procedures characterized as emergent were included in the study; however, failed prior repairs and ruptured aneurysms were excluded. The preoperative and perioperative patient characteristics, operative techniques, and outcome variables were compared between the open aortic repair and the endovascular aortic repair groups. Propensity scoring was performed to clinically match open aortic repair and endovascular aortic repair groups on preoperative risk and select perioperative factors that differed significantly in the unmatched groups. Outcome comparisons were then performed between matched groups.

Results

A total of 1005 (789 JAAs and 216 PAAs) aneurysm repairs were included in the study. Of these, there were 395 endovascular aortic repairs and 610 open aortic repairs. Propensity scoring created a matched group of 263 endovascular aortic repair and 263 open aortic repair patients. There was no statistically significant difference in 30-day mortality rates between matched endovascular aortic repair and open aortic repair patients (2.7% vs. 5.7%). The endovascular aortic repair group had a shorter ICU length of stay and overall hospital stay. The 30-day morbidity significantly favored endovascular aortic repair over open aortic repair (16% vs. 35%, p < 0.001). The main drivers of morbidity for endovascular aortic repair versus open aortic repair included return to the OR (6.8% vs. 15%, p < 0.001), rate of cardiac or respiratory failure (7.6% vs. 21%, p = 0.001), rate of renal insufficiency or failure (3.8% vs. 9.9%, p = 0.009), and rate of pneumonia (1.5% vs. 6.8%, p = 0.004).

Conclusions

There is no difference in mortality rates between endovascular aortic repair versus open aortic repair when repairing JAAs/PAAs. There is a significant difference in overall morbidity, and ICU and hospital length of stay favoring endovascular aortic repair over open aortic repair. This supports the expanded applicability and efficacy of endovascular repair for complex aneurysms.

Comparison of outcomes after endovascular and open repair of abdominal aortic aneurysms in low-risk patients

Background

In randomized trials endovascular aortic aneurysm repair (EVAR) has been shown to have superior perioperative outcomes compared with open aneurysm repair (OAR). However, outcomes in patients at low risk of complications are unclear and many surgeons still prefer OAR in this cohort. The objective was to analyse perioperative and longer-term outcomes of OAR and EVAR in this low-risk group of patients.

Methods

All elective infrarenal EVARs and OARs in the Vascular Study Group of New England database were reviewed from 2003 to 2014. The Medicare scoring system was used to identity patients at low risk of perioperative complications and death. Perioperative and longer-term outcomes were analysed in this cohort. A Kaplan–Meier plot was constructed for evaluation of longer-term survival. Further propensity matching and multivariable analysis were performed to analyse additional differences between the two groups.

Results

Some 1070 patients who underwent EVAR and 476 who had OAR were identified. Mean(s.d.) age was 67·3(5·7) and 65·1(6·3) years respectively (P &lt; 0·001). EVAR was associated with a lower overall perioperative complication rate (4·2 versus 26·5 per cent; P &lt; 0·001). There was no difference in 30-day mortality (0·4 versus 0·6 per cent; P = 0·446). Overall survival at 3 years was similar after EVAR and OAR (92·5 versus 92·1 per cent respectively; P = 0·592). In multivariable analyses there was no difference in freedom from reintervention (odds ratio 1·69, 95 per cent c.i. 0·73 to 3·90; P = 0·220) or survival (hazard ratio 0·85, 0·61 to 1·20; P = 0·353).

Conclusion

In patients predicted to be at low risk of perioperative death following aneurysm repair, EVAR resulted in fewer perioperative complications than OAR. However, perioperative mortality, reinterventions and survival rates in the longer term appeared similar between endovascular and open repair.

Characterizing the evolution of perioperative outcomes and costs of endovascular abdominal aortic aneurysm repair

OBJECTIVE

The purpose of this study is to characterize the evolution in perioperative outcomes and costs of endovascular abdominal aortic aneurysm (AAA) repair (EVAR) by detailing changes in adjusted outcomes and costs over time.

METHODS

National Inpatient Sample (2000-2011) data were used to evaluate patient characteristics, outcomes, and perioperative costs for elective EVAR performed for intact AAA. Outcomes were adjusted for patient demographics and comorbidities, and hospital factors by multivariate analysis. Costs were calculated from hospital cost to charge ratio files and adjusted to 2011 dollars.

RESULTS

From 2000 to 2011, 185,249 patients underwent elective EVAR for intact AAA. The absolute rates of in-hospital major morbidity, mortality, and procedural costs all decreased significantly over time (P < .0001). The prevalence of major comorbidities in patients undergoing EVAR, including obesity, diabetes, and dyslipidemia, all increased significantly over time. After adjusting for multiple demographics, comorbidities, and hospital-level factors, recent outcomes of EVAR (2009-2011) remain superior to the early experience (2000-2002) with respect to mortality and major complications.

CONCLUSIONS

From 2000-2011, the perioperative outcomes of EVAR improved significantly despite a higher prevalence of comorbidities among patients undergoing repair. Concurrently, procedure-associated costs declined. Advanced technology is often implicated in escalating healthcare spending, and the value of novel techniques is often questioned. These findings highlight that, in the case of EVAR, procedural outcomes have improved while the initial costs of repair have declined over time. EVAR offers an interesting example for stakeholders to consider in the era of cost-containment pressures and criticism of nascent, expensive technology in healthcare.

Diagnosis and treatment of a patient with type IV endoleak as a late complication after endovascular aneurysm repair

Type IV endoleak is a very rare complication observed after implantation of aortobiiliac stent grafts. The difficult diagnosis of type IV endoleak leads to the application of many imaging methods in the diagnostic process. We present a case report of a patient who underwent implantation of an aortobiiliac stent graft in 2004. After surgery, the size of the aneurysm sac was monitored continually in the subsequent imaging studies. Progression of the aneurysm sac volume was detected in 2009. In a short period of time, the diameter of the aneurysm increased from 100 to 140 mm. Angio-computed tomography and angiography did not reveal the location of the endoleak. The attempt at localization and endovascular closure of the source of the endoleak failed. It was decided to treat the patient surgically. Intraoperatively, the source of the endoleak was visualized, and the endoleak was closed with surgical sutures.

Early and delayed rupture after endovascular abdominal aortic aneurysm repair in a 10-year multicenter registry

OBJECTIVE

Rupture after abdominal endovascular aortic aneurysm repair (EVAR) is a function of graft maintenance of the seal and fixation. We describe our 10-year experience with rupture after EVAR.

METHODS

From 2000 to 2010, 1736 patients with abdominal aortic aneurysm (AAA) from 17 medical centers underwent EVAR in a large, regional integrated health care system. Preoperative demographic and clinical data of interest were collected and stored in our registry. We retrospectively identified patients with postoperative rupture, characterized as "early" and "delayed" rupture (≤30 days and >30 days after the initial EVAR, respectively), and identified predictors associated with delayed rupture.

RESULTS

The overall follow-up rate was 92%, and the median follow-up was 2.7 years (interquartile range, 1.2-4.4 years) in these 1736 EVAR patients. We identified 20 patients with ruptures; 70% were male, the mean age was 79 years, and mean AAA size at the initial EVAR was 6.3 cm. Six patients underwent initial EVAR for rupture (n = 2) or symptomatic presentation (n = 4). Of the 20 post-EVAR ruptures, 25% (five of 20) were early, all occurring within 2 days after the initial EVAR. Of these five patients, four had intraoperative adverse events leading directly to rupture, with one type I and one type III endoleak. Of the five early ruptures, four patients underwent endovascular repair and one received repair with open surgery, resulting in two perioperative deaths. Among the remaining 15 patients, the median time from initial EVAR to rupture was 31.1 months (interquartile range, 13.8-57.3 months). Most of these delayed ruptures (10 of 15) were preceded by AAA sac increases, including three patients with known endoleaks who underwent reintervention. At the time of delayed rupture, nine of 15 patients had new endoleaks. Among all 20 patients, six patients did not undergo repair (all delayed patients) and died, nine underwent repeated EVAR, and five had open repair. For patients who underwent repair for delayed rupture, mortality at 30 days and 1 year were 44.4% and 66.7%, respectively. Multivariable Cox regression analysis identified age 80 to 89 (hazard ratio, 3.3; 95% confidence interval, 1.1-9.4; P = .03), and symptomatic or ruptured initial indication for EVAR (hazard ratio, 7.4; 95% confidence interval, 2.2-24.8; P < .01) as significant predictors of delayed rupture.

CONCLUSIONS

Rupture after EVAR is a rare but devastating event, and mortality after repair exceeds 60% at 1 year. Most delayed cases showed late AAA expansion, thereby implicating late loss of seal and increased endoleaks as the cause of rupture in these patients and mandating vigilant surveillance.

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.

Fenestrated endovascular aortic repair grafts

Endovascular repair of AAAs has been embraced by the vascular surgery community. Fenestrated endovascular repair of AAAs is the logical next step to repairing those aneurysms whose anatomy does not provide a secure landing area for the graft below the renal and other visceral vessels. While the early morbidity and mortality reported with endovascular repair is less than with open procedures, additional monitoring and endovascular interventions are necessary with EVAR. Those same issues are presumed to persist with interventions utilizing f-EVAR, along with the additional concern for end-organ ischemia. In addition to fenestrated grafts, grafts with scallop, "chimney," and side branch configurations are being developed. PAs need to keep abreast of developments and understand the benefits and concerns associated with these applications in order to guide and monitor patients whose conditions are suitable for these emerging interventions.

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.