Three-Dimensional Geometric Analysis of Viabahn VBX Bridging Stent Grafts in Fenestrated Endovascular Aortic Repair: A Multicenter, Retrospective Cohort Study

PURPOSE

The primary aim of this study was to assess the 3-dimensional flare geometry of the Gore Viabahn VBX balloon-expandable covered stent (BECS) after fenestrated endovascular aortic repair (FEVAR) and to determine and visualize BECS-associated complications.

METHODS

This multicenter retrospective study included patients who underwent FEVAR between 2018 and 2022 in 3 vascular centers participating in the VBX Expand Registry. Patients with at least one visceral artery treated with the VBX and with availability of 2 post-FEVAR computed tomography angiography (CTA) scans (follow-up [FU] 1: 0-6 months; FU2: 9-24 months) were included. The flare geometry of the VBX, including flare-to-fenestration distance, flare-to-fenestration diameter ratio, flare angle, and apposition with the target artery were assessed using a vascular workstation and dedicated CTA applied software.

RESULTS

In total, 90 VBX BECS were analyzed in 43 FEVAR patients. The median CTA FU for FU1 and FU2 was 35 days (interquartile range [IQR], 29-51 days) and 14 months (IQR, 13-15 months), respectively. The mean flare-to-fenestration distance was 5.6±2.0 mm on FU1 and remained unchanged at 5.7±2.0 mm on FU2 (p=.417). The flare-to-fenestration diameter ratio was 1.19±0.17 on FU1 and remained unchanged at 1.21±0.19 (p=.206). The mean apposition length was 18.6±5.3 mm on FU1 and remained 18.6±5.3 mm (p=.550). The flare angle was 31°±15° on FU1 and changed to 33°±16° (p=.009). On FU1, the BECS-associated complication rate was 1%, and the BECS-associated reintervention rate was 0%. On FU2, the BECS-associated complication rate was 3%, and the BECS-associated reintervention rate was 1%.

CONCLUSIONS

The flare geometry of the VBX bridging stent did not change significantly during 14 months follow-up in this study. Three-dimensional geometric analysis of the flare may contribute to identify the origin of endoleaks and occlusions, but this should be confirmed in a larger study including enough patients and BECS to compare complicated and uncomplicated cases.

CLINICAL IMPACT

The three-dimensional flare geometry of the Gore Viabahn VBX BECS was assessed on the first and second postoperative CTA scans, and geometrical changes during this period were identified. For BECS that were diagnosed with a type 3c endoleak or occlusion, the BECS geometry was analyzed to detect geometrical components that were related to the complication. Geometric analysis of the flare may help to better detect and identify the cause of such complications.

Fostering Collaborative Teamwork-A Comprehensive Approach to Vascular Graft Infection Following Arterial Reconstructive Surgery

Vascular graft infection (VGI) is one of the most serious complications following arterial reconstructive surgery. VGI has received increasing attention over the past decade, but many questions remain regarding its diagnosis and management. In this review, we describe our approach to VGI through multidisciplinary collaboration and discuss decision making for challenging presentations. This review will concentrate on VGI that impacts both aneurysms and pseudoaneurysms excluding the ascending thoracic aorta.

Executive Summary: Fostering Collaborative Teamwork-A Comprehensive Approach to Vascular Graft Infection Following Arterial Reconstructive Surgery

Vascular graft infection (VGI) is one of the most serious complications following arterial reconstructive surgery. VGI has received increasing attention over the past decade, but many questions remain regarding its diagnosis and management. In this review, we describe our approach to VGI through multidisciplinary collaboration and discuss decision-making for challenging presentations. This document will concentrate on VGI that impacts both aneurysms and pseudoaneurysms excluding the ascending thoracic aorta.

Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms-A Global Multicenter Investigation of Perioperative Outcomes

BACKGROUND AND OBJECTIVES

Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms.

METHODS

Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics.

RESULTS

Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers.

CONCLUSION

Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

Hybrid Revision of Dysfunctional Aneurysmal Arteriovenous Fistulas

Endovascular therapy has become the first-line treatment for failing hemodialysis arteriovenous fistulas (AVFs). However, open revision remains an important modality for vascular access maintenance and the recommended approach for AVF aneurysms. This case series describes a hybrid approach for aneurysmal access revision. Three patients were referred for second opinion after failure of endovascular therapy to establish a functioning access. The medical history is briefly described to highlight the limitations of endovascular therapy and the technical advantages of the hybrid approach in these clinical scenarios.

Expanded Utility of Human Acellular Vessel in Hemodialysis Access Surgery and Arterial Aneurysm Repair

Vascular access is essential for hemodialysis (HD) in patients with end-stage renal disease (ESRD). When the standard of care arteriovenous fistula (AVF) is limited, secondary to aneurysmal degeneration, trauma, and thrombus, interposition grafting is a reasonable reconstruction approach. As these grafts and comorbidities place ESRD patients at sustained risk of complications, reconstructions with regenerative medicine biologic conduits hold promise in improving safety and efficacy. Here, a biocompatible human acellular vessel (HAV) is our conduit of interest. With United States Food and Drug Administration use authorization under the Expanded Access Program, we report three cases of complex vascular access surgery with four aneurysm repairs using HAV. Patient selection focused on meeting unmet needs for those without adequate care alternatives, including active access and endoprosthetic stent graft infections, right heart failure due to high-output AVF, and arterial and access outflow aneurysms. In this high-risk expanded access population, operative technical success and interval success for patients given their inherent comorbidities, offer potential expanded utility of HAV in HD access surgery and arterial aneurysm repair.

A Young Adult Presenting With an Abdominal Aneurysm Due to Cystic Medial Necrosis of the Aorta

Cystic medial necrosis is a disorder of large arteries, particularly the thoracic aorta, characterized by an accumulation of a basophilic ground substance in the media with cyst-like lesions. A male in his late 20s was brought to our trauma bay after he met with a road traffic accident with a complaint of abdominal pain. Clinical examination revealed tenderness in the left lumbar region. The contrast-enhanced computerized tomography revealed an aneurysm of size 11×9.6×9.2 cm in the left lateral aspect of the abdominal aorta at the origin of the left renal artery. Intraoperatively, an aneurysm of size 10×10 cm from the juxta renal abdominal aorta was identified, and aortic rent was repaired with a polyester graft. The tissue was sent for histopathology, which showed complicated atherosclerosis with cystic medial degeneration and aneurysmal rupture of the abdominal aorta containing thrombus. The patient had an uneventful postoperative course and is doing well without any complaints at a two-year follow-up.

Systematic Review on Early and Follow-up Mortality Rate in Octogenarians Treated With a Fenestrated and/or Branched Endovascular Aortic Repair

PURPOSE

Advanced age has been related to conflicting outcomes after fenestrated/branched endovascular aortic aneurysm repair (F/BEVAR). The aim of this meta-analysis is to compare 30-day mortality, technical success, and 1-year and 5-year survival in octogenarians and non-octogenarians who underwent F/BEVAR for complex aortic aneurysms.

MATERIALS AND METHODS

This meta-analysis was pre-registered to PROSPERO (CRD42022348659). The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement was followed. A search of the English literature, via Ovid, using MEDLINE, Embase, and CENTRAL databases, until August 30, 2022, was executed. Randomized Control Trials and observational studies (2000-2022), with ≥5 patients, reporting on 30-day mortality and 1-year and 5-year survival rates among octogenarians and non-octogenarians after F/BEVAR were eligible. The Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool was applied to assess the risk of bias. The primary outcome was 30-day mortality and secondary was 1-year and 5-year survival in octogenarians and non-octogenarians. The outcomes were summarized as odds ratio (OR) with 95% confidence intervals (CIs). A narrative presentation was selected in case of missing outcomes.

RESULTS

The initial research isolated 3263 articles; 6 retrospective studies were finally included. A total of 7410 patients were managed with F/BEVAR; 1499 patients (20.2%) were ≥80 years old (75.5% males, 259/343). The estimated 30-day mortality was 6% among octogenarians vs 2% in younger patients, with a significantly higher 30-day mortality for patients ≥80 years old (OR 1.21, 95% CI 0.61-1.81; p=0.0.11; Ι²=36.01%). Technical success was similar between the groups (OR -0.83; 95% CI -1.74-0.07, p<0.0.001; Ι²=95.8%). Regarding survival, a narrative approach was decided due to missing data. Two studies reported a statistically significant difference in 1-year survival between groups, with higher mortality in octogenarians (82.5%-90% vs 89.5%-93%), while 3 reported a similar 1-year survival rate in both groups (87.1%-95% vs 88%-89.5%). At 5 years, 3 studies reported a statistically significant lower survival for octogenarians (26.9%-42% vs 61%-71%).

CONCLUSIONS

Octogenarians treated with F/BEVAR presented higher 30-day mortality while a lower survival rate at 1 and 5 years was reported in the literature. Patient selection is thus mandatory among older patients. Further studies, especially on patient risk stratification, are needed to estimate the F/BEVAR outcomes on elder patients.

CLINICAL IMPACT

Age may be a factor of increased early and long-term mortality within patients managed for aortic aneurysms. In this analysis, patients over 80 years old were compared to their younger counterparts when managed with fenestrated or branched endovascular aortic repair (F/BEVAR) . The analysis showed that early mortality was acceptable for octogenrains but significantly higher when compared to patients younger than 80 years. One-year survival rates are controversial. At 5-year follow-up, octogenarians present lower survival but data to provide metanalysis are lacking. Patient selection and risk stratification are mandatory in older candidates for F/BEVAR.

Morphological and Clinical Predictors of Early/Follow-up Failure of the Endovascular Infrarenal Abdominal Aneurysm Repair With Currently Available Endografts

PURPOSE

To report outcomes of endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) with currently-available endografts and identify predictors of technical/clinical failure.

MATERIALS AND METHODS

Patients undergoing EVAR between 2012 and 2020 were prospectively collected and retrospectively analyzed. Technical success (TS: no type I-III endoleaks, renal/hypogastric arteries loss, iliac leg occlusion, conversion to open repair and mortality within 24 postoperative hour), proximal neck-related TS (nr-TS: no proximal type I endoleaks, unplanned renal arteries coverage), and 30-day mortality were assessed as early outcomes. Proximal type I endoleak (ELIa), survival and freedom from reinterventions (FFRs) were assessed during follow-up. Uni/multivariate analysis and Cox-regression were used to identified factors associated with early and follow-up outcomes; FFR and survival were assessed by Kaplan-Meier analysis.

RESULTS

A total of 710 were included. Technical success and nr-TS were 692 (98%) and 700 (99%), respectively. The presence of ≥2 hostile anatomical infrarenal neck characteristics was associated with technical failure (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 1.3-4.1; p: 0.007). Infrarenal neck angle >90° (OR: 2.88; 95% CI: 9.6-50.3; p: 0.004), barrel shape (OR: 2.33; 95% CI: 11.1-100.3; p: 0.02) or presence of ≥2 hostile anatomical infrarenal neck characteristics (OR: 2.16; 95% CI: 2.5-5.3; p: 0.03) were independent risk factors for neck-related technical failures. Six (0.8%) patients died within 30 postoperative days. Chronic obstructive pulmonary disease (OR: 16; 95% CI: 1.1-218.3; p: 0.04) and urgent repair (OR: 15; 95% CI: 1.8-119.6; p: 0.01) were independent risk factors for 30-day mortality. The mean follow-up was 53±13 months. There were 12 (1.7%) ELIa during follow-up. Infrarenal neck length <15 mm (hazard ratio [HR]: 2.8; 95% CI: 1.9-9.6; p: 0.005), diameter >28 mm (HR: 2.7; 95% CI: 1.6-9.5; p: 0.006), angle ≥90° (HR: 2.7; 95% CI: 8.3-50.1; p: 0.007), and persistent type II endoleak (HR: 2.9; 95% CI: 1.6-10.1; p: 0.004) were independent risk factors for ELIa. Freedom from reintervention was 91% at 5 years. The ELIa was an independent risk factor for reinterventions during follow-up (HR: 29.5; 95% CI: 1.4-1.6; p<0.001). Survival was 74% at 5 years with 2 cases (0.3%) of late aortic-related mortality. Peripheral arterial occlusive disease (HR: 1.9; 95% CI: 1.4-3.65; p: 0.03), aneurysm diameter ≥65 mm (HR: 2.2; 95% CI: 1.4-3.26; p<0.001), and infrarenal neck length <15 mm (HR: 1.7; 95% CI: 1.2-2.35; p: 0.04) were independent risk factors for mortality during follow-up.

CONCLUSION

Endovascular repair with currently-available endografts has high TS and low 30-day mortality. Survival and FFRs were satisfactory at mid-term. Pre/postoperative risk factors for technical and clinical failure were identified and they should be considered in EVAR indication and postoperative management to reduce complications and improve mid-term outcome.

CLINICAL IMPACT

Pre and postoperative risk factors for technical and clinical EVAR failure can be identified and they should be considered in EVAR indication and postoperative management to reduce complications and improve mid-term outcome.

Thoracic Endovascular Aortic Repair with Supra-Aortic Trunk Revascularization is Associated with Increased Risk of Periprocedural Ischemic Stroke

BACKGROUND

Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study is to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR.

METHODS

The Vascular Quality Initiative registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysms. Our primary outcomes were any stroke or death at 30 days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable Poisson regression.

RESULTS

Among 3,072 patients with degenerative aneurysms (197 [6.4%] arch versus 2,875 [93.6%] descending) treated with elective TEVAR, the median age was 73 years (interquartile range 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (52.9%), left carotid (20.7%), left vertebrobasilar (11.5%), right carotid (9.2%), and right vertebrobasilar (5.7%). Although mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysm versus descending aneurysms (7.1% arch versus 2.9% descending, P = 0.001). Factors that were associated with ischemic stroke after TEVAR included age (>79 years, relative risk [RR] 1.79, 95% confidence interval [CI] 1.08-2.98 vs. <79 years), dependent functional status (RR 1.73, 95% CI 1.07-2.78), procedural time (RR 1.25, 95% CI 1.15-1.36), and endovascular intervention for supra-aortic trunk revascularization (RR 2.66, 95% CI 1.06-6.70 versus no intervention).

CONCLUSIONS

Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increasing risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization.

A Sinister Gut Feeling

Women are generally spared from abdominal aortic aneurysm (AAA) formation by the immunomodulating effects of estrogen. However, once they develop it, especially in the postmenopausal group, its behavior is more sinister with rapid expansion, a higher tendency to rupture, and higher mortality as compared to the male counterparts. Reported here is a case of AAA in a postmenopausal woman who came to the outpatient department with low backache, vague abdominal pain, and dysuria which initially gave a picture of pelvic inflammation with urinary tract infection but was later found out to be aortic aneurysm.

A systematic review and meta-analysis on the management of concomitant abdominal aortic aneurysms and renal tumours

OBJECTIVES

The treatment of concomitant abdominal aortic aneurysms and renal tumours is controversial. The aim of this study was to ascertain which of the following three strategies, one-stage open aneurysm repair and nephrectomy, two-stage open aneurysm repair and nephrectomy or two-stage endovascular aneurysm repair and nephrectomy, is the best approach.

METHODS

systematic review and meta-analysis of articles published between January 1992 and April 2021 describing the treatment of concomitant abdominal aortic aneurysms and renal tumours.

RESULTS

A total of 1168 records were identified. After the selection process, 12 studies with data on 89 patients were included. Sixty-two patients underwent one-stage open procedures, 18 patients underwent two-stage open procedures and nine underwent two-stage endovascular procedures. The overall postoperative mortality was 0.82% (95% CI, 0.00-4.61). The postoperative mortality for one-stage open procedures was 3.09% (95% CI, 0.00-10.11). No deaths occurred in the postoperative period open two-stage procedures or two-stage endovascular procedures. The weighted postoperative morbidity for all procedures was 23.86% (95% CI, 12.64-35.08) and for open one-stage procedures was 37.40% (95% CI, 14.33-60.47). Data concerning postoperative complications of two-stage open procedures were extractable from only one patient in whom no complications were reported. Two postoperative complications were reported after two-stage endovascular procedures from a total of six patients with extractable postoperative data. We were unable to perform meta-analysis on long-term outcomes as the data were reported non-uniformly.

CONCLUSION

There is currently no evidence to suggest that any procedure is associated with better outcomes. However, a one-stage open approach was the most commonly used option, favoured as it avoids delaying treatment of either of the conditions. Two-stage open procedures were preferred in cases where the surgical risk of a one-stage procedure was higher than the potential benefit. For such cases, two-stage endovascular repair is becoming more popular as a less invasive approach.

Duodenal Obstruction in a Patient Previously Treated With EndoVascular Aneurysm Sealing System Repair

The Nellix® endovascular aneurysm sealing system (EVAS) is a relatively novel approach for the treatment of abdominal aortic aneurysms (AAAs). We present herein a case of duodenal obstruction (DO) which occurred following an EVAS treatment for the repair of an AAA. A 77-year old man was admitted to our hospital with acute abdominal pain and recurrent vomiting. Computed tomography (CT) revealed a retroperitoneal 66 × 59 × 90 mm (antero-posterior, AP; latero-lateral, LL; cranio-caudal: CC) solid mass located in the epigastrium, corresponding to the infrarenal abdominal aortic aneurysm sac, previously treated by EVAS. An exploratory laparotomy was performed, which revealed a retroperitoneal mass compressing the third and fourth parts of the duodenum. A gastroenteroanastomosis was performed in order to bypass the duodenal obstruction. An extensive search of biomedical literature databases was conducted to identify similar cases. To our knowledge, this is the first reported case of DO following an AAA repair with EVAS.

Surgical approaches in juxtarenal and pararenal aortic aneurysms repair

BACKGROUND

In this study, surgical tactic features and juxtarenal and pararenal treatment immediate results were analyzed depending on the use of various surgical approaches.

METHODS

Between 2015 and 2019, a total of 89 patients received surgical treatment, of which 52(58%) had juxtarenal aneurysms and 37 (42%) - pararenal aneurysms. During repairs, three types of surgical approaches were used: midline laparotomy, extended retroperitoneal approach and thoraco-phreno-retroperitoneal approach. The patients were divided into three groups accordingly.

RESULTS

At the immediate postoperative period, mortality rate equaled 2 (2.2%). The reasons were pulmonary embolism and sepsis. Statistically reliable data were obtained, confirming the advantages of midline laparotomic approach over the lateral retroperitoneal ones, which consisted in a shorter operative time, less pronounced pain syndrome, lesser blood loss, fewer postoperative days. The disadvantages were that enteroparesis occurred more often when the midline laparotomy was used in comparison to extended retroperitoneal or thoraco-phrenoretroperitoneal approaches.

CONCLUSION

Thus, open repairs of juxtarenal and pararenal aortic aneurysms have some specific technical and strategical features which are associated with intraoperative renal ischemia. During open surgical intervention, it is important to first consider the possibility of repair with midline laparotomy. However, lateral retroperitoneal approaches can also be used on a case-by-case basis noting their advantages and disadvantages.

Ureteric complications and left retroperitoneal abdominal aortic surgery

BACKGROUND

Open surgery for abdominal aortic aneurysms in the UK is usually performed via a midline transperitoneal incision. However, the left retroperitoneal (RP) approach may be beneficial for juxtarenal abdominal aortic aneurysms and certain physiological reasons. One potential disadvantage is that the left kidney usually requires mobilization anteromedially risking injury to the renal tract and possibly the ureter.

METHODS

In this retrospective study, the time of onset, clinical presentation and treatment of left renal tract complications are scrutinized and discussed. Reasons for open aortic surgery as opposed to endovascular repair being undertaken were documented. Also, the aortic cross-clamp positions and type of reconstruction were examined.

RESULTS

A total of 208 patients underwent RP aortic surgery for aneurysmal disease. The aortic cross-clamp positions were infrarenal in 115 (55%), suprarenal in 78 (38%) and supra-superior mesenteric artery or supracoeliac in 15 (7%). Two percent (4/208) sustained ureteric complications and all occurred in the upper third of the left ureter. The time of onset of symptoms ranged from 2 to 14 days post-operatively with a median of 3.5. Clinical signs were non-specific including pyrexia, tachycardia and flank pain.

CONCLUSION

Ureteric complications following left RP aortic surgery is uncommon and usually occurs in the upper third of the renal tract. Trauma appears to be the most common cause, although ureteric ischaemia can occur but presents later particularly in those with comorbidities.

[Reconstruction of aneurismal arteriovenous fistula after arrosive bleeding]

Aneurysmal transformation of arteriovenous fistula (AVF) is a common complication and associated with increased risk of arrosive bleeding. Ligation of fistulous vein is conventional surgery for bleeding. This is followed by AVF malfunction and need for implantation of central venous catheter. We report reconstructive surgery and maintaining the function of AVF in a patient with aneurysmal transformation of AVF after arrosive bleeding. Reconstructive vascular surgery can significantly extend the period of patent AVF for hemodialysis. This is extremely important in patients with reduced resources of native vessels suitable for AVF formation. The same is true if conversion of the type of renal replacement therapy is associated with significant difficulties.

Sinus of Valsalva aneurysm repairs: Operative technique and lessons learned

OBJECTIVE

Sinus of Valsalva (SOV) aneurysms are rare and data on operative management are limited. They can cause right ventricular outflow tract or pulmonary artery compression, and rupture may be fatal. In this study, we describe our experience with the repair of 13 SOV aneurysms.

METHODS

All patients who underwent SOV aneurysm repair from May 2001 to December 2017 at our single tertiary referral center were reviewed retrospectively.

RESULTS

Thirteen patients (92% male) with a mean age of 60 years underwent repair of an SOV aneurysm; mean aneurysm diameter was 5.9 ± 0.8 cm and four patients (30.7%) presented with rupture into another cardiac chamber. Operative interventions included six Bentall procedures, five patch repairs (one with aortic valve replacement [AVR]), and two primary aneurysm closures both with concomitant AVR. There were no strokes, myocardial infarctions, re-explorations, or deaths in the postoperative period. After an average of 2.25 years, computed tomographic imaging in five patients demonstrated no aneurysm recurrence.

CONCLUSIONS

Surgery is a safe option for both ruptured and nonruptured SOV aneurysms. A variety of repair strategies may be used. Larger studies are needed.

Cohort study of risk factors for 30-day readmission after abdominal aortic aneurysm repair

Background: We conducted a retrospective cohort study of thirty-day readmission after abdominal aortic aneurysm (AAA) repair. Patients and methods: Inpatients (2009-2016) undergoing elective AAA repair were selected from the multicenter Cerner Health Facts® database using ICD-9 procedure codes. We identified characteristics associated with 30-day readmission with chi-square analysis and logistic regression. Results: 4,723 patients undergoing elective AAA procedures were identified; 3,101 endovascular aneurysm repairs (EVAR) and 1,622 open procedures. Readmission differed by procedure type (6.5 % EVAR vs. 9.3 % open, p =.0005). Multivariable logistic regression found that patients undergoing EVAR were less likely to be readmitted (OR 0.71, 95 % CI 0.54-0.92) than patients undergoing open repair. The following risk factors were associated with 30-day readmission following any AAA repair: surgical site infection during the index admission (OR 2.79, 95 % CI 1.25-6.22), age (OR 1.03, 95 % CI 1.01-1.05), receipt of bronchodilators (OR 1.34, 95 % CI 1.06-1.70) or steroids (OR 1.45, 95 % CI 1.04-2.02), serum potassium > 5.2 mEq/L (OR 1.89, 95 % CI 1.16-3.06), and higher Charlson co-morbidity scores (OR 1.12, 95 % CI 1.04-1.21). Subgroup analysis revealed that age (OR 1.02, 95 % CI 1.01-1.04), higher Charlson comorbidity scores (OR 1.20, 95 % CI 1.09-1.33), and receipt of post-operative bronchodilators (OR 1.39, 95 % CI 1.03-1.88) were risk factors for 30-day readmission following EVAR. After open procedures, readmission was associated with surgical site infection during the index admission (OR 2.91, 95 % CI 1.17-7.28), chronic heart failure (OR 2.18, 95 % CI 1.22-3.89), and receipt of post-operative steroids (OR 1.92, 95 % CI 1.24-2.96). The most common infections were pneumonia after open procedures and urinary tract infection after EVAR. Conclusions: The risk factor most associated with 30-day readmission after elective AAA repair was surgical site infection. Awareness of these risk factors and vulnerable groups may help identify high-risk patients who could benefit from increased surveillance programs to reduce readmission.

Repair of intraoperative aneurysm neck tear utilizing the cotton-clipping technique

Intraoperative rupture of an intracranial aneurysm is a potentially devastating but controllable complication. The authors have successfully used the previously described cotton-clip technique to repair tears at the necks of aneurysms. (1-4) A tear on the neck of the aneurysm is covered with a piece of cotton and held in place with a suction device. The cotton is then clipped onto the tear with an aneurysm clip, using the cotton as a bolster. This simple, effective method has been useful in repairing a partial avulsion of the neck of an aneurysm. (1 , 3) The video can be found here: http://youtu.be/nT86RYVQWpc .

Glasgow aneurysm scores in patients undergoing open surgical procedure for aortic aneurysm

BACKGROUND

To assess the applicability of the Glasgow aneurysm score (GAS) in patients with aortic aneurysm undergoing an elective open surgical procedure in our hospital.

MATERIALS AND METHODS

A total of 105 patients undergoing elective open surgical procedure between January 2006 and June 2012 were evaluated retrospectively. Glasgow aneurysm score (GAS) was calculated as age+7 points for myocardial disease, +10 points for cerebrovascular disease, and +14 points for renal disease. The best cut-off value for GAS was determined using the ROC curve analysis.

RESULTS

The hospital mortality rate was 3.8% (4 patients). GAS was significantly lower in patients who survived the operation (76.05 ± 14.71 vs. 92.0 ± 10.8 respectively, p = 0.031). The ICU stay was also significantly lower in patients who survived the operation (2.37 ± 5.23) compared to the nonsurvivors (25.67 ± 13.80, p = 0.001). No significant difference was observed regarding age, duration of hospital stay, and aortic diameter. The area under the ROC curve was 0.818 and for a 100% sensitivity rate, the cut-off value for GAS was 77.5 with a 58.4% specificity rate (p = 0.031). All patients with a GAS < 77.5 were alive after surgery.

CONCLUSION

The GAS appears to be a reliable clinical predictor for in hospital mortality following elective repair of abdominal aortic aneurysm following open surgical procedure.

An Algorithm to Analyze Cost Heterogeneity using Counterfactual Scenarios in Endovascular versus Open Repair of Abdominal Aortic Aneurysm: Predicting Costs for Subsequent Patients

Objectives: We examined patient-specific predictors of high cost for endovascular (EVAR) and open (OPEN) repair of abdominal aortic aneurysm (AAA). Methods: Vascular Study Group of Northern New England data specific to Fletcher Allen Health Care were merged with cost data from the same source. We retrospectively analyzed 389 elective AAA repairs (230 EVAR, 159 OPEN) between 2003 and 2011 to determine clinical characteristics that contribute to membership in the upper quartile of cost (UQC) versus the remaining three quartiles. For the purpose of this exercise, it was assumed that clinical outcomes were equally good with EVAR versus OPEN repair. Results: Significant predictors of UQC for OPEN repair procedures were: history of treated chronic obstructive pulmonary disease (COPD), previous bypass surgery, transfer from hospital and age >70 (area under receiver operating curve [ROC] = 0.726). Predictors of UQC for EVAR were: presence of iliac aneurysm(s), coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty within the past 5 years, ejection fraction ≤30%, absence of beta blockers, creatinine ≥1.5mg/dL, and current use of tobacco (area under ROC = 0.784). The mean length of stay for EVAR and OPEN repair were 2.22 and 8.55 days, respectively. Costs for EVAR and OPEN repair were $32,656 (standard error of the mean [SEM] $591) and $28,183 (SEM $1,571), respectively. Conclusions: Certain risk factors at the individual patient level are predictive of UQC. Under such circumstances, it is our expectation that such algorithms may be used to select the most cost-efficient treatment.

Aorto-iliac aneurysm infected by Brucella: distinctive presentation patterns of a rare entity

There is currently a lack of information on presentation patterns and the appropriate investigation and treatment of aortic brucellosis. Herein a case affecting the iliac component of an aorto-iliac aneurysm, managed successfully with in situ graft repair, is reported. A review of the literature identified 25 cases, with the infrarenal abdominal aorta (65%) followed by the ascending thoracic aorta (23%) being mostly affected; only our case involved the iliacs. Aortic brucellosis affected mostly older men, caused pain more often than fever (in 73% and 57%, respectively), and involved frequently the spine or the aortic valve (n = 14, 56%). Preoperative diagnosis was made more often in the presence of fever (67% versus 18% in afebrile patients, P = 0.021). In situ aneurysm repair in the form of open (54%) or endovascular (8%) grafting was mostly performed. Mortality was 12% and graft infection was 13% at two years. In conclusion, aortic brucellosis has unique presentation patterns, usually affecting an abnormal or aneurysmal aorta and/or due to a contiguous spinal or aortic valve infection. Acute symptomatology with pain and/or fever occurs very often and should raise suspicion for aortic infection. Despite the seriousness of aortic involvement, mortality and reinfection rates are within acceptable levels.

Evaluation of angiography as the sole imaging study for the proximal aortic neck prior to EVAR

BACKGROUND

Angiographic assessment is an alternative to computerised tomography (CT) prior to endovascular aneurysm repair (EVAR). We evaluated angiography in aortic neck morphology assessment as an alternative investigation.

METHODS

Patients admitted for elective or emergency EVAR were assessed by pre-operative CT and intra-operative angiography. The proximal and distal aortic neck diameters, and neck length were measured. Measurements were expressed as median (95% CI).

RESULTS

35 patients (20 male) were assessed from August 2003 to January 2005 for elective (26) and emergency (9) EVAR. In the overall group, the proximal neck diameter was 22.0mm (21.0-23.0) on CT, and 20.7 mm (19.3-22.3) on angiography. The distal neck diameter was 23.0mm (22.0-24.0) on CT, and 22.3mm (20.3-24.6) on angiography, while the neck length was only slightly greater on angiography [23.0mm (17.5-28.4)] relative to CT [23.0mm (20.0-28.0)]. The stent-grafts deployed were oversized by 26.8% (+/- 14.8%) relative to the CT measurements, and 33.7% (+/- 15.6%) relative to angiographic measurements. Good correlation was found for all three measurements between CT and angiography.

CONCLUSIONS

Angiography alone is inadequate for endovascular aneurysm repair. Although it has timesaving potential, the accuracy achieved is not sufficient to use alone.