Friendly neck anatomy does not prevent neck-related adverse events after EVAR

OBJECTIVE

Life-long follow-up after EVAR is costly and burdensome to the patient. Follow-up should be stratified based on the risk of EVAR failure. Aneurysm neck is thought to be the single most important risk factor. This study investigated neck anatomy as a predictor of neck-related adverse events after EVAR.

METHODS

This retrospective single-center study included consecutive patients undergoing elective EVAR for infrarenal abdominal aortic aneurysms between 2011- 2016 (n=222) who were followed with yearly imaging until December 2020. Hostile neck was defined as neck length ≤15mm, width ≥28mm, angulation ≥60^°, calcification or thrombus ≥50% of circumference or conical neck based on preoperative computed tomography angiography. Neck-related adverse event was defined as aneurysm rupture, any neck-related re-intervention or type 1a endoleak during follow-up.

RESULTS

Ninety (41%) patients had hostile neck, and 132 (59%) had friendly neck. There were no differences in 30-day mortality (1% vs. 1%, p=0.78), major adverse events (20% vs. 16%, p=0.43) or re-interventions during the hospital stay (8% vs 4%, p=0.20) between patients with hostile and friendly neck. Estimated survival at 1 year was 89±3% for hostile neck and 95±2% for friendly neck patients (p<0.01). Five-year survival estimates were 51±6% and 66±4%, respectively. Aneurysm-related mortality was higher after six years in patients with hostile neck (p<0.01). Twenty-four patients (11%) suffered neck-related adverse events with mean time-to-event of 3.3±2.8 years, there were no differences between the groups stratified by neck anatomy. Incidentally, preoperative aneurysm diameter was found to be an independent risk factor for neck-related adverse events and aneurysm-related mortality; 53 patients (24%) had aneurysm diameter ≥70mm, which was associated with nearly four-fold risk of neck-related complications during the follow-up.

CONCLUSIONS

Friendly neck anatomy may not protect from neck-related adverse events after EVAR in the long-term. Especially patients with large aneurysms should be followed closely.

Effect of patient frailty status on outcomes of fenestrated-branched endovascular aortic repair for complex abdominal and thoracoabdominal aortic aneurysms

OBJECTIVE

In the present study, we assessed the effects of patient frailty status on the early outcomes and late survival after fenestrated-branched endovascular aortic repair (FB-EVAR) for complex abdominal and thoracoabdominal aortic aneurysms.

METHODS

We retrospectively reviewed the clinical data and outcomes of consecutive patients who had undergone elective FB-EVAR from 2007 to 2019 in a single institution. A previously validated 11-item modified frailty index (mFI-11) was derived from the comorbidity and preoperative functional status data. An mFI-11 <0.3 was defined as low risk, 0.3 to 0.5 as medium risk, and >0.5 as high risk. The studied outcomes were 90-day mortality, major adverse events (MAE), and long-term survival. Multivariate analyses were performed to identify the independent predictors of these outcomes.

RESULTS

A total of 592 patients (155 women, mean age, 75 ± 8 years) had undergone FB-EVAR. Using the mFI-11, 310 patients (52%) were included in the low-risk, 199 (34%) in the medium-risk, and 83 (14%) in the high-risk group. The 90-day mortality was significantly higher in the high-risk group than in the medium- and low-risk groups (13%, 4%, and 3%, respectively; P < .01). The corresponding MAE rates were 27%, 18%, and 19% (P = .23). As a subgroup, 44 patients in the high-risk group had had chronic kidney disease (CKD). The 90-day mortality for these patients was as high as 23%, and 32% had experienced MAE. On multivariable analysis, the independent risk factors for 90-day mortality were CKD, respiratory disease, and a high mFI-11. The independent risk factors for MAE were female sex, CKD, larger aneurysm diameter, and the high-risk subgroup with CKD. The independent risk factors for long-term mortality were age, a low body mass index, CKD, larger aneurysm diameter, extent I-III thoracoabdominal aortic aneurysm, respiratory disease, congestive heart failure, a history of cerebrovascular problems, and higher mFI-11. The estimated survival at 1 year was 91% ± 2% in the low-risk, 88% ± 2% in the medium-risk, and 78% ± 5% in the high-risk group (P < .001). The corresponding 5-year survival estimates were 60% ± 4%, 52% ± 5%, and 32% ± 6%. The mean follow-up time was 2.9 ± 2.3 years. The patients treated during the first quartile of the study period were significantly more frail than were those in the later quartiles. Also, the outcomes of FB-EVAR had improved over time.

CONCLUSIONS

Greater frailty was significantly associated with early mortality. Together with CKD, frailty was also associated with MAE and lower patient survival after FB-EVAR. The mFI-11 represents the accumulation of comorbidities and can be used to assist in better patient selection for FB-EVAR.

Radiographically Quantified Sarcopenia and Traditional Cardiovascular Risk Assessment in Predicting Long-term Mortality after EVAR

OBJECTIVE

This study evaluated radiographically quantified sarcopenia and patient's comorbidity burden based on traditional cardiovascular risk assessment as potential predictors of long-term mortality after endovascular aortic repair (EVAR).

METHODS

The study included 480 patients treated with standard EVAR for intact infrarenal abdominal aortic aneurysms. Patient characteristics, comorbidities, aneurysm dimensions and other preoperative risk factors were collected retrospectively. Preoperative computed tomography was used to measure psoas muscle area (PMA) at L3 level. Patients were divided into three groups based on ASA-score and PMA. In high-risk group, patients had sarcopenia (PMA <8.0 cm² for males and <5.5 cm² for females) and ASA score 4. In medium-risk group, patients had either sarcopenia or ASA 4. Patients in the low-risk group had no sarcopenia and ASA score was less than 4. Risk factors for long-term mortality were determined using multivariable analysis. Kaplan-Meier survival estimates were calculated for all-cause mortality.

RESULTS

Patients in the high- and medium risk-groups were older than in the low-risk group (77±7, 76±6 and 74±8 years, respectively, p<0.01). Patients in the high-risk group had higher prevalence of coronary artery disease, pulmonary disease and chronic kidney disease. There were no differences in 30-day or 90-day mortality between the groups. The independent predictors of long-term mortality were age, ASA-score, PMA, chronic kidney disease and maximum aneurysm sac diameter. The estimated one-year mortality rates were 5±2% for the low-risk, 5±2% for the medium-risk and 18±5% for the high-risk group (p<0.01). Five-year mortality estimates were 23±4%, 36±3% and 60±6%, respectively (p<0.01). The mean follow-up time was 5.0±2.8 years.

CONCLUSIONS

Both ASA and PMA were strong predictors of increased mortality after elective EVAR. The combination of these two can be used as a simple risk stratification tool to identify patients in whom aneurysm repair or the intensive long-term surveillance after EVAR may be unwarranted.

Effect of Endovascular Treatment Rate on Population Level Outcomes and Survival After Intact Abdominal Aortic Aneurysm Repair

OBJECTIVES

The aim was to study outcomes of endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) in four geographically adjacent populations with identical demographics and variable EVAR rates.

METHODS

This was a multicentre cohort study based on local and national registry data from an area of 815 000 inhabitants. The study involved 527 consecutive patients with an intact AAA treated with EVAR (n = 327) or OSR (n = 200) between 2010 and 2016. The catchment area was divided into four health care districts (populations A, B, C, and D) with one central hospital in each district. Each hospital decided independently between OSR and EVAR for patients within their population; OSR was performed in all hospitals while EVAR was centralised in one of them. Patient demographics and treatment outcomes were extracted from local registries. Population demographics, overall AAA incidence, and mortality data were retrieved from a national database.

RESULTS

The rate of new intact AAA diagnosis varied between 20 and 29 per 100 000 inhabitants/year with the highest incidence in population D (p < .001). The intact AAA repair rates were 9.8, 8.9, 9.9, and 8.7 per 100 000 inhabitants/year for populations A, B, C, and D, respectively (p = .64). There were no significant differences in mean age (73.6 ± 8.0 years) or mean aortic diameter (62 ± 13 mm) between the treated patient populations. Groups A and B had high EVAR rates (74% and 72%, respectively) whereas the EVAR rates were lower in groups C and D (50% and 38%, respectively) (p < .001). The 30 day mortality rates were 2%, 2%, 4%, and 1% (p = .55), and complication rates were 17%, 12%, 15%, and 11% (p = .39) for A, B, C and D, respectively. There were no significant differences in mortality, complication or re-intervention rates between the groups during the mean follow up of 3.3 ± 2.0 years.

CONCLUSIONS

At population level, high EVAR rates had no measurable effect compared with lower EVAR rates on the outcomes in patients with intact AAA.

Diagnostic Potential of Magnetic Resonance Imaging in Chronic Abdominal Pain

INTRODUCTION

About half of the adult patients suffering from chronic abdominal pain may have no organ-related cause. Our purpose was to evaluate the additional information of magnetic resonance imaging (MRI) in diagnosing the underlying organic causes of such pain.

METHODS

We performed retrospective audit of 636 consecutive abdominal MRI in patients suffering from nonspecific abdominal pain (NSAP) during years 2014-2017. Medical history, clinical examination, endoscopy reports, and the results of MRI were compared in all patients. The hypothesis was that MRI increases markedly the diagnostic specificity of patients' symptoms.

RESULTS

The mean age of patients was 66 ± 14 years and 60 percent were females. Duration of abdominal pain ranged from 1 month to 30 years (median 1.1 ± 4.0 years). Concurrently with abdominal MRI (n = 636), also ultrasound (n = 106, 17%), colonoscopy (n = 222, 35%), and gastroscopy (n = 217, 34%) were performed. Abdominal MRI revealed additional information in 161/636 (25%) of NSAP patients. Spinal and pelvic bone abnormalities (n = 107) and malignant tumors (n= 31) were the most significant organ-specific findings changing the treatment algorithm.

CONCLUSIONS

When computerized tomography is not available in outpatient clinics, abdominal MRI increases markedly diagnostic specificity and alters the treatment in 1 of 4 patients suffering from NSAP. Abdominal MRI is therefore suggested for patients suffering from severe symptoms of NSAP.

Non-specific abdominal pain remains as the most common reason for acute abdomen: 26-year retrospective audit in one emergency unit

OBJECTIVE

Distribution of diagnoses causing acute abdominal pain (AAP) may change because of population aging, increased obesity, advanced diagnostic imaging and changes in nutritional habits. Our aim was to evaluate the diagnoses causing AAP during a 26-year period.

MATERIALS AND METHODS

This was a retrospective cross-sectional cohort study in one emergency department (ED) covering population about 250,000. All patients admitted to the ED in 1986, 2003 and 2012 were evaluated from hospital electronic database. Demographic data, utilization of diagnostic tests, surgical treatment and discharge diagnosis were analyzed. Statistical data of population aging, obesity and alcohol consumption during 1980-2012 were obtained from national registers.

RESULTS

The AAP patients represented 10-20% of our total ED census. The most common causes of AAP were nonspecific abdominal pain (NSAP, 31-37%), acute appendicitis (11-23%), biliary disease (9-11%), bowel obstruction (5-7%), acute pancreatitis (4-8%) and acute diverticulitis (1-7%). The percentage of NSAP remained highest throughout the study period. Decrease in the number of acute appendicitis (from 23 to 11%; p < .0001), increase in acute diverticulitis (from 1 to 5%; p ≤ .0001) and acute pancreatitis (from 4 to 7%; p = .0273) was observed over time. The utilization of diagnostic imaging increased significantly (CT from 2 to 37% and US from 4 to 38%, p < .0001). Hospital mortality was very low (1-2%).

CONCLUSIONS

NSAP is still the main differential diagnostic problem in the ED. Except acute appendicitis, distribution of specific diagnoses causing AAP remained rather stable through 26-year audit.

Declining cholecystectomy rate during the era of statin use in Finland: a population-based cohort study between 1995 and 2009

BACKGROUND AND AIMS

Aging with comorbidities, obesity, and rapid recovery from operation may increase the need for laparoscopic cholecystectomy, but long-term use of statins may be associated with a decreased risk of gallstones. This population-based cohort study presents the changing rate and causative factors of laparoscopic cholecystectomy in Finland during the era of statin use.

MATERIALS AND METHODS

Age structure of the population, changes in body mass index and diabetes, and the number of all cholecystectomies in 1995-2009 were retrieved from the registers of National Institute for Health and Welfare. Additionally, these results were supplemented by a population-based retrospective cohort (1581 laparoscopic cholecystectomy) in one community-based hospital area. The risk factors for laparoscopic cholecystectomy, use of statins, and surgical outcome were analyzed.

RESULTS

During the 15 years, 123,794 cholecystectomies were performed in Finland, of which 94,740 (76.5%) were performed using laparoscopic technique. The median rate of laparoscopic cholecystectomy varied between 110 and 140 operations per 100,000 inhabitants. In 1995-2009, the annual number of cholecystectomies decreased from 8600 to 7500, the number of laparoscopic cholecystectomies increased by 10%, and the number of open cholecystectomies declined by 60%. In a cohort of 1581 laparoscopic cholecystectomies, the proportion of elderly (>65 years of age), obese (body mass index > 30 kg/m(2)), and diabetic patients increased from 17% to 28%, 9% to 34%, and 4% to 8%, respectively. Use of statins increased more than fourfold during the 15 years.

CONCLUSIONS

The rates of all cholecystectomies decreased despite marked increase in laparoscopic cholecystectomies performed. The increase in risk factors for gallstones in Finland implied more marked increase in laparoscopic cholecystectomies. The possible role of statins on gallstone disease is discussed.