Characteristics and One-year Outcomes of Patients with Rupture of Small Abdominal Aortic Aneurysms

OBJECTIVES

Rupture of abdominal aortic aneurysms (rAAA) is typically associated with large sac diameter, however some patients experience rupture before reaching operative thresholds for elective repair. We aim to investigate the characteristics and outcomes of patients who experience small rAAA.

METHODS

The Vascular Quality Initiative database for open AAA repair and endovascular aneurysm repair (EVAR) from 2003-2020 were reviewed for all rAAA cases. Based on the 2018 Society for Vascular Surgery guidelines on operative size thresholds for elective repair, patients with infrarenal aneurysms <5.0cm in women or <5.5cm in men were categorized as "small rAAA." Patients who met operative thresholds or had a concomitant iliac diameter ≥3.5cm were categorized as "large rAAA.". Patient characteristics and perioperative as well as long-term outcomes were compared via univariate regression. Inverse probability of treatment weighting (IPTW) using propensity scores was employed to examine the relationship between rAAA size and adverse outcomes.

RESULTS

There were 3,962 cases that met inclusion criteria, with 12.2% small rAAA. The mean aneurysm diameter was 42.3mm and 78.5mm in the small and large rAAA groups, respectively. Patients in the small rAAA group were significantly more likely to be younger, African American, have lower BMI, and had significantly higher rates of hypertension. Small rAAA were more likely to be repaired via EVAR (p=0.001). Hypotension was significantly less likely in patients with small rAAA (p<0.001). Rates of perioperative myocardial infarction (p<0.001), total morbidity (p<0.004) and mortality (p<0.001) were significantly higher for large rAAA cases. After propensity matching, there was no significant difference in mortality between the 2 groups, but smaller rAAA was associated with lower rates of MI (OR=0.50[0.31-0.82]). On long-term follow up, no difference in mortality was noted between the two groups.

CONCLUSIONS

Patients presenting with small rAAA represent 12.2% of all rAAA and are more likely to be African American. Small rAAA is associated with similar risk of perioperative and long-term mortality compared to rupture at larger size after risk adjustment.

Endovascular Repair Versus Open Surgical Repair for Complex Abdominal Aortic Aneurysms: A Systematic Review and Meta-analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis was to compare the short and long-term outcomes of endovascular repair (ER) versus open surgical repair (OSR) for complex abdominal aortic aneurysms (CAAAs), using propensity-matched and non-propensity-matched methods.

METHODS

PubMed, OVID, Embase, ELSEVIER and Cochrane library were searched for the studies that compared ER versus OSR for CAAAs from January 1999 to December 2020. CAAAs were defined as short neck, juxtarenal, pararenal and suprarenal abdominal aortic aneurysms. The primary outcomes were 30-day mortality, 30-day reintervention, medium and long-term survival. We pooled outcomes of original studies and also performed subgroup analyses using RevMan. The analysis of statistical heterogeneity was performed with STATA 16.0.

RESULTS

21 studies with 12049 patients (3847 ERs, 8202 OSRs) were included in this meta-analysis. In general, the patients undergoing ER were significantly older and likely to be man; more common with diabetes mellitus, congestive heart failure, renal failure, but smaller aortic aneurysms. In the non-propensity-matched subgroup analysis of ER versus OSR, ER was associated with significantly decreased 30-day mortality (odds ratio [OR]: 0.60; 95% confidence interval [CI]: 0.49-0.74; P＜.001; I²=4%) and 30-day reintervention (OR: 0.59; 95% CI: 0.40-0.87; P = .007; I²=56%); lower rate of long-term survival (hazard ratio [HR]: 1.73; 95% CI: 1.21-2.47; P = .002; I²=0%); less perioperative comorbidities including myocardial infarction, arrhythmia, acute kidney injury, permanent dialysis, wound complications, bowel ischemia; and shorter hospital length of stay. In the propensity-matched subgroup, ER was associated with poorer long-term survival (HR: 1.80; 95% CI: 1.06-3.06; P = .03; I²=0%), higher incidences of lower extremity ischemia (OR: 12.25; 95% CI: 1.54-97.48; P = .02; I²=16%) and renal artery restenosis (OR: 7.63; 95% CI: 1.35-43.24; P = .02). However, there was no significant difference in 30-day mortality (OR: 1.31; 95% CI: 0.65-2.66; P = .45; I²=0%), 30-day reintervention (OR: 1.58; 95% CI: 0.62-4.03; P = .34; I²=26%), mid-term survival (HR: 1.03; 95% CI: 0.30-3.56; P = .96; I²=0%) between ER and OSR groups.

CONCLUSION

Our analyses suggest that OSR of CAAAs, compared with ER, is associated with improved long-term survival without increasing of perioperative deaths. ER may be considered in the patients who are high-risk for open repair.

Retrograde Recanalization for Proximal Occlusion of the Right Renal Artery through a Compensated Collateral Artery in a 10-year-old Patient

BACKGROUND

To describe a retrograde recanalization for the proximal occluded lesion in right renal artery (RRA) in young patient with fibromuscular dysplasia (FMD).

METHODS

A 10-year-old girl presented to our hospital with proximal RRA occlusion and refractory hypertension though she took anti-hypertension medicines. Her renin and aldosterone were beyond the normal level in both base state and excited state. Her glomerular filtration rate at right kidney was only 18.4 ml/min. Angiography revealed proximal RRA occlusion and a compensated collateral artery (CCA) from the infrarenal aorta to the RRA. She was thus diagnosed with focal FMD. A retrograde recanalization was performed through this CCA.

RESULTS

Angioplasty and stenting were successfully performed to treat the proximal RRA occlusion. Postoperatively, the glomerular filtration rate in the right kidney improved. One-year follow-up revealed that, the blood pressure maintained at normal range without any antihypertensive agents. No other discomfort was complained.

CONCLUSIONS

It is feasible to establish a working pathway with patient's compensated collateral artery to treat the renal artery occlusion.

Endovascular repair of a common iliac pseudoaneurysm and aortic ectasia in a patient with horseshoe kidney and pancreatitis: a case report

We present the first case of 45 year-old male with an incidental non-symptomatic right common iliac artery pseudoaneurysm with concomitant aortic ectasia in the setting of severe alcoholic pancreatitis and a horseshoe kidney diagnosed by CT and MRA. Such findings would have posed significant difficulty during an open approach precluding safe surgical repair. Therefore, an exclusion endovascular repair of the pseudoaneurysm was employed using a unibody bifurcated endovascular aortic stent-graft to good results. Although not without their complications, endovascular stent-grafts may be life saving to patients who are not candidates for conventional surgical repair. We describe the diagnosis alongside our technique of endovascular repair.

Comparison of costs of endovascular repair versus open surgical repair for abdominal aortic aneurysm in Korea

This study was designed to compare the hospital-related costs of elective abdominal aortic aneurysm (AAA) treatment and cost structure between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) in Korean health care system. One hundred five primary elective AAA repairs (79 OSRs and 26 EVARs) performed in the Seoul National University Hospital from 2005 to 2009 were included. Patient characteristics were similar between two groups except for older age (P = 0.004) and more frequent history of malignancy (P = 0.031) in EVAR group. Thirty-day mortality rate was similar between two groups and there was no AAA-related mortality in both groups for 5 yr after repair. The total in-hospital costs for the index admission were significantly higher in EVAR patients (mean, KRW19,857,119) than OSR patients (mean KRW12,395,507) (P < 0.001). The reimbursement was also significantly higher in EVAR patients than OSR patients (mean, KRW14,071,081 vs KRW6,238,895, P < 0.001) while patients payments was comparable between two groups. EVAR patients showed higher follow-up cost up to 2 yr due to more frequent imaging studies and reinterventions for type II endoleaks (15.4%). In the perspective of cost-effectiveness, this study suggests that the determination of which method to be used in AAA treatment be more finely trimmed and be individualized.

Hybrid endovascular repair of thoracic aortic aneurysm in a patient with Behçet's disease following right to left carotid-carotid bypass grafting

Endovascular repair of inflammatory aortic aneurysms has been reported as an alternative to open surgical treatment. In selective cases, adjunctive bypass surgery may be required to provide an adequate landing zone. We report a case of endovascular repair of an inflammatory aortic aneurysm in a patient with Behçet's disease using a carotid-carotid bypass graft to provide an adequate landing zone. A 45-yr-old man with a voice change was referred to our hospital with the diagnosis of saccular aneurysm of the distal aortic arch resulting from vasculitis. Computed tomography showed a thoracic aortic aneurysm with thrombosis. Right to left carotid-carotid bypass grafting was performed. After 8 days, the patient underwent an endovascular stent graft placement distal to the origin of the innominate artery. The patient was discharged with medication and without postoperative complications after 5 days. Hybrid endovascular treatment may be suitable a complementary modality for repairing inflammatory aortic aneurysms.