Acute Abdominal Aortic Aneurysm Research Articles

Integration of a Custom-Made Fenestration to Simplify Acute Reno-Visceral In Situ Aortic Repair.

To illustrate the technique of antegrade in situ laser fenestration (ISLF) on a predesign custom-manufactured stent-graft with single reinforced fenestration for use in emergency endovascular repair of complex abdominal aortic aneurysms (AAAs). A short custom-made device (CMD) fenestrated graft was predesigned with a single preloaded 8 mm strut-free fenestration at 12 o'clock position. A modified preloaded system was used to allow unilateral access from the distal port if necessary. After bilateral percutaneous femoral access, the graft was deployed under fusion guidance with the CMD fenestration matching the superior mesenteric artery (SMA) origin and immediately bridged as per standard technique. The aneurysm was then excluded with a bifurcated device. A large steerable sheath was used to allow for sequential antegrade laser in situ fenestration and stenting of the renal arteries. Single-vessel customized short fenestrated grafts for the SMA and antegrade in situ laser renal fenestrations are technically feasible for repair of acute complex AAAs even after previous infrarenal reconstruction. It could become an off-the-shelf solution to limit aortic coverage and reno-visceral ischemia, even in patients with a narrow aortic diameter at the renal level. Single-vessel precustomized short fenestrated grafts for the SMA combined with renal artery antegrade ISLF can be a feasible option for the acute repair of patients with complex aneurysms and a narrow aortic diameter at the reno-visceral segment. It may limit aortic coverage and reno-visceral ischemic time and also be applicable after previous infrarenal endovascular aneurysm repair (EVAR).

Abstract 10828: Stem-Cell Therapy for Abdominal Aortic Aneurysms in Swine

Introduction: The current treatment paradigm of abdominal aortic aneurysms (AAA) focuses on observing patients until their disease reaches certain thresholds for intervention, with no preceding treatment available. There is an opportunity to develop drug or cell-based therapies to prevent further aneurysmal growth and decrease the risk of a highly morbid rupture. A previously validated acute AAA swine model was treated directly with gelfoam containing human adipose-derived stem cells (h-ADSCs). Methods: Male Yorkshire swine (n=16) received periadventitial injections (type 1 collagenase and porcine pancreatic elastase) into a 4 cm segment of infrarenal aorta. Experimental group (n=7) received gel foam soaked with 10 million h-ADSCs and control group (n=9) media-soaked gel foam. Aortic diameters (AD) were monitored at post-operative day (POD) 7 and 14 using ultrasound with euthanasia on POD 21. Suprarenal (control) and infrarenal aortas (experimental) were harvested for PCR, mechanical tensiometry testing, histopathological analyses as well as immunohistochemistry (IHC). Each animal served as their own control. Groups were compared with paired t-tests and Mann Whitney U tests. Results: Twelve animals survived until POD 21. Stem cell treated AAAs, unlike controls, demonstrated no growth (-1.6 ± 8.8% vs. 34.8 ± 13.7%, p<0.001), and had greater medial thickness (682.7 ± 149.1 um vs. 321.7 ± 194.0 um, p<0.001), and greater areas of elastin (5.33 ± 1.49% vs. 2.57 ± 2.25%, p<0.0001), smooth muscle (55.8 ±6.59% vs. 24.0 ± 6.84%, p<0.001), collagen 1 (p=.014), and VEGF (p=.009) than untreated controls. MMP9 mRNA expression in stem cell AAA specimens was downregulated 0.501 (±0.464) fold compared to control segments from those same animals (p= 0.025). Though tensiometry data displayed greater strength within the stem cell AAA rings, this did not reach statistical significance (p=.15). Conclusion: Stem cell therapy prevents the development of aortic aneurysms in a swine model. Stem cell treated swine with induced AAAs show more normal gross features, histologic, and biochemical properties compared to untreated controls with induced AAAs. Further investigation is merited as a possible translatable therapy for aneurysmal disease.

Abdominal Ischemia-Reperfusion Induced Cardiac Dysfunction Can Be Prevented by MitoTEMPO

Background Cardiac dysfunction is secondary to acute mesenteric ischemia (AMI) and abdominal aortic aneurysms (AAA). The underlying cause of distant organ damage in the heart is the formation of oxidative stress caused by ischemia-reperfusion. In this study, we investigated the possible protective effects of a novel mitochondria-targeted antioxidant MitoTEMPO on contractile dysfunction and structural defects of the rat papillary muscle caused by abdominal ischemia-reperfusion (AIR). Methods and Results In the experiments, adult Wistar-Albino rats were used and animals were divided randomly into 3 groups; sham-operated group (SHAM), an IR group that had aortic cross-clamping for 1 h followed by 2 h reperfusion, and a third group that received protective 0.7 mg/kg/day MitoTEMPO injection for 28-day before IR. As a result, it was observed that MitoTEMPO injection had a protective effect on the mechanical activities and structural properties of the papillary muscle impaired by AIR. Our study also showed that AIR disrupted the contractile function of the papillary muscle for each stimulation frequency and post-potentiation responses tested. This is common for each measured and calculated mechanical parameter and MitoTEMPO injection showed its protective effects. Conclusion Consequently, calcium homeostasis seems to be impaired by AIR, and MitoTEMPO may exert its protective effect through energy metabolism by directly targeting the mitochondria.

The Weekend Effect in Non-Elective Abdominal Aortic Aneurysm Repair

Introduction - The ‘weekend effect’, first described in 2001, is a hotly debated topic1. It describes the phenomenon where patient outcomes appear worse for those admitted at the weekend when compared to those treated during the week. It has been used recently to justify significant changes in health policy2. Recent evidence has suggested that the effect may be due to a combination of inadequate correction for confounding factors and inaccurate coding3. We investigated the effects of these factors in patients with acute abdominal aortic aneurysm (AAA). Methods - All patients undergoing non-elective AAA repair entered into the prospectively collected National Vascular Registry from January 2013 until December 2015 were included in the study, with patients divided in a case-control study according to whether they were treated during the week (between 8am Monday and 5pm Friday) or at the weekend (between 5pm Friday and 8am Monday). Coding issues were investigated by looking separately at patients treated for ruptured, symptomatic or asymptomatic AAA within the non-elective cohort. The primary outcome was in-hospital mortality. Secondary outcomes included length of inpatient stay and cardiac, respiratory and renal complications. Results - Mortality appeared to be higher at the weekend (odds ratio (OR) 1.65, 95% confidence interval (CI) (1.44–1.89), P<0.001), but this effect disappeared when confounding factors and coding issues were corrected for (corrected OR for ruptured AAA 1.09, 95% CI (0.92–1.29), P=0.33). Differences in outcomes were similar for prolonged length of stay (uncorrected OR 1.42, 95% CI (1.26–1.60), P<0.001; corrected OR for ruptured AAA 1.06, 95% CI (0.91–1.10), P=0.48) and morbidity outcomes. Conclusion - After appropriate correction for confounding factors and coding effects, there is no evidence of a significant ‘weekend effect’ in the treatment of non-elective AAA within this large cohort. Further work is warranted to determine whether previously reported ‘weekend effect’s in other areas are robust to more rigorous statistical analysis.

Retrospective review of abdominal aortic aneurysm deaths in New Zealand: what proportion of deaths is potentially preventable by a screening programme in the contemporary setting?

ObjectivesTo describe the proportions of people dying from abdominal aortic aneurysm (AAA) who might have benefited from a formal screening programme for AAA.DesignRetrospective cross-sectional review of deaths.Setting and study populationsAll...

Nationwide comparison of long-term survival and cardiovascular morbidity after acute aortic aneurysm repair in patients with and without type 2 diabetes

ObjectiveEpidemiologic data indicate decreased risk for development, growth, and rupture of abdominal aortic aneurysm (AAA) among patients with type 2 diabetes mellitus (DM). We therefore evaluated mortality and cardiovascular morbidity after acute repair of AAA in diabetic and nondiabetic patients. MethodsIn this nationwide observational cohort study of patients registered in the Swedish Vascular Registry and the Swedish National Diabetes Register, we compared mortality and morbidity after acute open (n = 1357 [61%]) or endovascular (n = 860 [39%]) repair of ruptured (n = 1469 [66%]) or otherwise symptomatic (n = 748 [34%]) AAAs in 363 patients with and 1854 patients without DM with propensity score-adjusted analysis. ResultsFollow-up was 3.91 years for patients with DM and 3.18 years for those without. In propensity-adjusted analysis, diabetic patients showed lower total mortality (relative risk [RR], 0.75; 95% confidence interval [CI], 0.59-0.95; P = .016) and cardiovascular mortality (RR, 0.17; 95% CI, 0.06-0.50; P = .01) than those without DM, whereas there were no differences in rates of major adverse cardiovascular events (RR, 1.10; 95% CI, 0.87-1.42; P = .42), acute myocardial infarction (RR, 1.36; 95% CI, 0.70-2.63; P = .37), or stroke (RR, 1.31; 95% CI, 0.84-2.03; P = .23). ConclusionsPatients with type 2 DM had lower rates of both total and cardiovascular mortality after acute AAA repair than those without DM, whereas rates of cardiovascular events, acute myocardial infarction, and stroke did not differ between groups. This might be explained by putative protective effects of DM on the aortic wall.

Surgical Treatment of Synchronous Type B Acute Aortic Dissection and Abdominal Aortic Aneurysm

We report the results of the operative treatment of synchronous type B acute aortic dissection (TBAAD) and infrarenal abdominal aortic aneurysm (AAA). It is an observational, descriptive multicenter case series. Inclusion criterion was patients with diagnosis of TBAAD and AAA detected synchronously for the first time at clinical onset of dissection. Follow-up imaging protocol included triple-phase spiral/computed tomography angiography performed at 1, 6, and 12months after thoracic endovascular aortic repair (TEVAR), and annually thereafter. Major end points were perioperative mortality and long-term survival, freedom from aortic events, and freedom from reintervention. We identified and treated 15 cases. All TBAADs were treated by TEVAR in the acute phase: infrarenal aortic repair was performed with stent graft (SG) in 10 (66.7%) patients, with open repair in 5 (33.3%). Overall, staged repair was used in 11 (73.3%) patients. Mean descending aortic endovascular length coverage was 21cm±7 (range, 10-35; interquartile range [IQR], 150-265). Overall, early perioperative mortality occurred in 1 (6.7%) patient. Median radiologic follow-up was 48months (range, 6-120; IQR, 36-67). During the follow-up, TEVAR-related mortality was not observed. Aortic remodeling after TEVAR was obtained in 12 (85.7%) patients; abdominal sac shrinkage after SG was obtained in 8 (80.0%) patients. Freedom from aortic event rate was 79%±10 (95% confidence interval [CI]: 53.1-92.6) at 1year and 64%±13 (95% CI: 38.1-83.5) at 5year. Freedom from reintervention rate at 1 and 5year was 85%±10 (95% CI: 57.8-95.7). In our experience, the association of TBAAD and AAA was a rare finding. Because of the lack of available evidence to opt for a single intervention or a staged approach, selective approach with TEVAR and endovascular/open conventional treatment of the abdominal aorta yielded satisfactory results at midterm follow-up.

Weekend effect in non-elective abdominal aortic aneurysm repair.

BackgroundThe ‘weekend effect’ describes the phenomenon where patient outcomes appear worse for those admitted at the weekend. It has been used recently to justify significant changes in UK health policy. Recent evidence has suggested that the effect may be due to a combination of inadequate correction for confounding factors and inaccurate coding. The effects of these factors were investigated in patients with acute abdominal aortic aneurysm (AAA).MethodsPatients undergoing non‐elective AAA repair entered into the UK National Vascular Registry from January 2013 until December 2015 were included in a case–control study. The patients were divided according to whether they were treated during the week (Monday 08.00 hours to Friday 17.00 hours) or at the weekend. Data extracted included demographics, co‐morbidities, preoperative medications and baseline blood test results, as well as outcomes. Coding issues were investigated by looking at patients treated for ruptured, symptomatic or asymptomatic AAA within the non‐elective cohort. The primary outcome was in‐hospital mortality. Secondary outcomes included length of inpatient stay, and cardiac, respiratory and renal complications.ResultsThe mortality rate appeared to be higher at the weekend (odds ratio (OR) 1·69, 95 per cent c.i. 1·47 to 1·94; P < 0·001), but this effect disappeared when confounding factors and coding issues were corrected for (corrected OR for ruptured AAA 1·09, 0·92 to 1·29; P = 0·330). Differences in outcomes were similar for prolonged length of hospital stay (uncorrected OR 1·21, 95 per cent c.i. 1·06 to 1·37, P = 0·005; corrected OR for ruptured AAA 1·06, 0·91 to 1·10, P = 0·478), and morbidity outcomes.ConclusionAfter appropriate correction for confounding factors and coding effects, there was no evidence of a significant weekend effect in the treatment of non‐elective AAA in the UK.

No Evidence of a ‘Weekend Effect’ in the Management of Acute Abdominal Aortic Aneurysm in the UK

No Evidence of a ‘Weekend Effect’ in the Management of Acute Abdominal Aortic Aneurysm in the UK

Long-term outcome and quality of life after ruptured abdominal aortic aneurysm repair.

Objectives To evaluate long-term outcome and quality of life after open and endovascular repair of ruptured abdominal aortic aneurysms. Methods All consecutive ruptured abdominal aortic aneurysm patients at the St. Antonius Hospital treated for ruptured abdominal aortic aneurysm between January 2005 and January 2015 were included. Mortality, morbidity, and re-interventions within 30 days and during follow-up were registered. Quality of life was measured with Short Form-36 questionnaire among survivors. Additional subgroup analysis between open repair and endovascular repair was performed. Results A total of 192 patients with ruptured abdominal aortic aneurysm were included: 76.6% (147/192) underwent open repair and 23.4% (45/192) endovascular repair. All-cause 30-day mortality rate was 31.3% (60/192), and 30-day morbidity rate was 70.3% (135/192). Median stay at the intensive care unit was two days for endovascular repair and four days for open repair ( p = 0.002). No other statistically significant differences between endovascular repair and open repair were observed. After a mean follow-up period of 62 months (range 9-126), 72.4% (76/105) of the responders had equivalent Short Form-36 scores as compared to the age-matched general Dutch population, and 84.2% (64/76) of the responders would choose surgery again if they would have a ruptured abdominal aortic aneurysm. Conclusions Survivors of ruptured abdominal aortic aneurysm have similar long-term quality of life scores compared to the age-matched general population. The majority of all survivors would choose to undergo acute abdominal aortic aneurysm repair again.

Adjusted Hospital Outcomes of Abdominal Aortic Aneurysm Surgery Reported in the Dutch Surgical Aneurysm Audit

The Dutch Surgical Aneurysm Audit (DSAA) is mandatory for all patients with primary abdominal aortic aneurysms (AAAs) in the Netherlands. The aims are to present the observed outcomes of AAA surgery against the predicted outcomes by means of V-POSSUM (Vascular–Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity). Adjusted mortality was calculated by the original and re-estimated V(physiology)-POSSUM for hospital comparisons. All patients operated on from January 2013 to December 2014 were included for analysis. Calibration and discrimination of V-POSSUM and V(p)-POSSUM was analysed. Mortality was benchmarked by means of the original V(p)-POSSUM formula and risk-adjusted by the re-estimated V(p)-POSSUM on the DSAA. In total, 5898 patients were included for analysis: 4579 with elective AAA (EAAA) and 1319 with acute abdominal aortic aneurysm (AAAA), acute symptomatic (SAAA; n = 371) or ruptured (RAAA; n = 948). The percentage of endovascular aneurysm repair (EVAR) varied between hospitals but showed no relation to hospital volume (EAAA: p = .12; AAAA: p = .07). EAAA, SAAA, and RAAA mortality was, respectively, 1.9%, 7.5%, and 28.7%. Elective mortality was 0.9% after EVAR and 5.0% after open surgical repair versus 15.6% and 27.4%, respectively, after AAAA. V-POSSUM overestimated mortality in most EAAA risk groups (p < .01). The discriminative ability of V-POSSUM in EAAA was moderate (C-statistic: .719) and poor for V(p)-POSSUM (C-statistic: .665). V-POSSUM in AAAA repair overestimated in high risk groups, and underestimated in low risk groups (p < .01). The discriminative ability in AAAA of V-POSSUM was moderate (.713) and of V(p)-POSSUM poor (.688). Risk adjustment by the re-estimated V(p)-POSSUM did not have any effect on hospital variation in EAAA but did in AAAA. Mortality in the DSAA was in line with the literature but is not discriminative for hospital comparisons in EAAA. Adjusting for V(p)-POSSUM, revealed no association between hospital volume and treatment or outcome. Risk adjustment for case mix by V(p)-POSSUM in patients with AAAA has been shown to be important.

Adjusted Hospital Outcomes of Abdominal Aortic Aneurysm Surgery Reported in the Dutch Surgical Aneurysm Audit

The Dutch Surgical Aneurysm Audit (DSAA) is mandatory for all patients with primary abdominal aortic aneurysms (AAAs) in the Netherlands. The aims are to present the observed outcomes of AAA surgery against the predicted outcomes by means of V-POSSUM (Vascular-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity). Adjusted mortality was calculated by the original and re-estimated V(physiology)-POSSUM for hospital comparisons. All patients operated on from January 2013 to December 2014 were included for analysis. Calibration and discrimination of V-POSSUM and V(p)-POSSUM was analysed. Mortality was benchmarked by means of the original V(p)-POSSUM formula and risk-adjusted by the re-estimated V(p)-POSSUM on the DSAA. In total, 5898 patients were included for analysis: 4579 with elective AAA (EAAA) and 1319 with acute abdominal aortic aneurysm (AAAA), acute symptomatic (SAAA; n=371) or ruptured (RAAA; n=948). The percentage of endovascular aneurysm repair (EVAR) varied between hospitals but showed no relation to hospital volume (EAAA: p=.12; AAAA: p=.07). EAAA, SAAA, and RAAA mortality was, respectively, 1.9%, 7.5%, and 28.7%. Elective mortality was 0.9% after EVAR and 5.0% after open surgical repair versus 15.6% and 27.4%, respectively, after AAAA. V-POSSUM overestimated mortality in most EAAA risk groups (p<.01). The discriminative ability of V-POSSUM in EAAA was moderate (C-statistic: .719) and poor for V(p)-POSSUM (C-statistic: .665). V-POSSUM in AAAA repair overestimated in high risk groups, and underestimated in low risk groups (p<.01). The discriminative ability in AAAA of V-POSSUM was moderate (.713) and of V(p)-POSSUM poor (.688). Risk adjustment by the re-estimated V(p)-POSSUM did not have any effect on hospital variation in EAAA but did in AAAA. Mortality in the DSAA was in line with the literature but is not discriminative for hospital comparisons in EAAA. Adjusting for V(p)-POSSUM, revealed no association between hospital volume and treatment or outcome. Risk adjustment for case mix by V(p)-POSSUM in patients with AAAA has been shown to be important.

When to activate a multidisciplinary team for an acute abdominal aortic aneurysm?

BackgroundIt is often difficult to determine when a multidisciplinary aneurysm team should be summoned based on the (often limited) pre-hospital information provided MethodWe performed a retrospective cohort study of patients brought to our hospital between January 1st 2013 and October 1st 2014 by the emergency medical services (EMS) with a clinical suspicion of an acute AAA. Within this group we compared patients with a documented acute AAA and without an acute AAA in order to identify patient characteristics that could be used for the development of evidence based activation criteria for multidisciplinary acute aneurysm teams. ResultsOf the 63 patients presented by the EMS with a clinical suspicion of an acute AAA, 16 had an acute AAA. The optimal age cut-off value to discriminate patients with- from patients without an acute AAA was 70 years, whereas the optimal cut-off systolic blood pressure was 137 mmHg. "Age> 70" (LR+ 2.6 [1.8-3.8], "SBP <137mm Hg" (LR+ 2.6 [1.5-4.9], the "presence of diaphoresis " (LR+ 2.5 [1.7-3.8] and a "prior history of AAA" (LR+ 2.9 [1.5-5.7] were independent predictors of the presence of an acute AAA. The presence of any of these factors increased the pre-test probability of an acute AAA to > 50%. ConclusionPre-hospital information regarding the patient's age, history (known AAA), blood pressure and general appearance (presence of diaphoresis) can be useful when EMS services announce the arrival of a patient with suspected acute AAA in order to improve appropriate triage and minimize time to definitive care.

Global Experience With the Nellix Endosystem for Ruptured and Symptomatic Abdominal Aortic Aneurysms

Purpose: To assess the feasibility and safety of the endovascular aneurysm sealing (EVAS) technique in the treatment of acute abdominal aortic aneurysm (AAA). Methods: A retrospective, multicenter, observational study was conducted at 8 centers (7 European and 1 in New Zealand) experienced with EVAS in the elective setting. From February 2013 to April 2015, 58 patients (mean age 74±9 years; 46 men) with an acute AAA were treated (28 ruptured and 30 symptomatic). The primary endpoint of the study was 30-day mortality; secondary endpoints included endoleak, reinterventions, and 30-day morbidity. Results: The overall intensive care unit and hospital stays were 2.2±6.6 days and 9.7±11.4 days, respectively. Thirty-day mortality rates were 32% (9/28) for the ruptured group and 7% (2/30) for the symptomatic group, with morbidity rates of 57% and 17%, respectively. Early endoleak was present in only 2 (3%) patients, one in each group; both leaks were type Ia. Reinterventions within 30 days were performed in 8 patients in the ruptured group; in the symptomatic patients, the only perioperative reintervention was embolization a type Ia endoleak. The mean follow-up was 9.3±3.1 months in the ruptured group and 12.4±5.4 months in the symptomatic group. The mean aneurysm diameter at 30-day follow-up was 71.8±16.0 mm compared with 74.7±15.7 mm preoperatively in the ruptured group and 66.1±13.5 mm compared with 65.8±13.0 mm in the symptomatic group. Conclusion: EVAS in the acute setting appears safe and feasible and concordant with the literature for endovascular aneurysm repair. More robust prospective and comparative data are required to establish the position of the technique in the treatment algorithm of acute AAA.

Population‐Based Study of Incidence of Acute Abdominal Aortic Aneurysms With Projected Impact of Screening Strategy

In the article by Howard et al, “Population‐Based Study of Incidence of Acute Abdominal Aortic Aneurysms With Projected Impact of Screening Strategy,” which published online August 19, 2015, and appeared in the August 2015 issue of the journal ( J Am Heart Assoc . 2015;4:e001926 doi: 10.1161/

Population-Based Study of Incidence of Acute Abdominal Aortic Aneurysms With Projected Impact of Screening Strategy.

BackgroundCurrent abdominal aortic aneurysm (AAA) screening in men age 65 might have limited impact on overall AAA death rates if incidence is moving to older ages. Up-to-date population-based studies of age-specific incidence, risk factors, and outcome of acute AAA are needed to inform screening policy.Methods and ResultsIn a prospective, population-based study (Oxfordshire, UK, 2002–2014), the incidence and outcome of acute AAA events were determined. Based on population projections and current incidence trends, the impact of screening strategies in the UK was estimated. Over the 12-year period, 103 incident acute AAA events occurred in the study population of 92 728. Incidence/100 000/year was 55 in men ages 65 to 74 years, but increased to 112 at 75 to 85 and 298 at ≥85, with 66.0% of all events occurring at age ≥75 years. Incidence at ages 65 to 74 was highest in male smokers (274), with 96.4% of events in men <75 years occurring in ever-smokers. Extrapolating rates to the UK population, using trial evidence of screening efficacy, the current UK screening program would prevent 5.6% of aneurysm-related deaths (315 200 scans/year: 1426/death prevented, 121/year-of-life saved). Screening only male smokers age 65 and then all men at age 75 would prevent 21.1% of deaths (247 900 scans/year; 297/death prevented, 34/year-of-life saved). By 2030, 91.0% of deaths will occur at age ≥75, 61.6% at ≥85, and 28.6% in women.ConclusionsGiven that two thirds of acute AAA occurred at ≥75 years of age, screening older age groups should be considered. Screening nonsmokers at age 65 is likely to have very little impact on AAA event rates.

Age-specific incidence, risk factors and outcome of acute abdominal aortic aneurysms in a defined population.

BackgroundContemporary population‐based data on age‐specific incidence and outcome from acute abdominal aortic aneurysm (AAA) events are needed to understand the impact of risk factor modification and demographic change, and to inform AAA screening policy.MethodsIn a prospective population‐based study (Oxfordshire, UK, 2002–2014), event rates, incidence, early case fatality and long‐term outcome from all acute AAA events were determined, both overall and in relation to the four main risk factors: smoking, hypertension, male sex and age.ResultsOver the 12‐year interval, 103 incident acute AAA events occurred in the study population of 92 728 (men 72·8 per cent; 59·2 per cent 30‐day case fatality rate). The incidence per 100 000 population per year was 55 in men aged 65–74 years, but increased to 112 at age 75–84 years and to 298 at age 85 years or above. Some 66·0 per cent of all events occurred in those aged 75 years or more. The incidence at 65–74 years was highest in male smokers (274 per 100 000 population per year); 27 (96 per cent) of 28 events in men aged less than 75 years occurred in ever‐smokers. Mean(s.d.) age at event was lowest in current smokers (72·2(7·2) years), compared with that in ex‐smokers (81·2(7·0) years) and never‐smokers (83·3(7·9) years) (P < 0·001). Hypertension was the predominant risk factor in women (diagnosed in 93 per cent), with 20 (71 per cent) of all 28 events in women occurring in those aged 75 years or above with hypertension. The 30‐day case fatality rate increased from 40 per cent at age below 75 years to 69 per cent at age 75 years or more (P = 0·008).ConclusionTwo‐thirds of acute AAA events occurred at age 75 years or above, and more than 25 per cent of events were in women. Taken with the strong associations with smoking and hypertension, these findings could have implications for AAA screening.

Atmospheric pressure changes are associated with type a acute aortic dissections and spontaneous abdominal aortic aneurysm rupture in tuzla canton.

Aim:The aim of this study was to investigate a relationship between seasonal variation and incidence of type A acute aortic dissection (AAD) and spontaneous abdominal aneurysm rupture (rAAA) in Canton Tuzla, Bosnia and Herzegovina.Patients and methods:A total of 81 cases, 41 AAD and 40 of ruptured AAA were identified from one center over a 6-year, from 2008 till 2013. In 2012 were admitted (45.6% or 36 patients).Results:Seasonal analysis showed that 19(23.4%) patients were admitted in spring, 15(18.5) in summer, 26(32%) in autumn and 21(25.9) in winter. The most frequent period was autumn/winter with 47 or 58% patients. A causal link between atmospheric pressure (AP) and incidence of rAAA and AAD on seasonal and monthly basis was found.

Long‐Term Survival and Quality of Life After Open Abdominal Aortic Aneurysm Repair

Open repair of abdominal aortic aneurysm (AAA) generally involves postsurgery admission to the intensive care unit (ICU). Few studies have evaluated the impact of surgery for either ruptured or nonruptured AAA (with postoperative ICU treatment) on long-term survival and quality of life. The primary aim of this study was to quantify long-term survival and health-related quality of life (HrQpL) of a cohort of patients undergoing open AAA repair after hospital discharge. Consecutive patients undergoing open elective or acute AAA reconstruction with postoperative admission to the ICU and discharged alive from the hospital during 2009 were identified. Primary outcome measures were 1-year and long-term mortality. The secondary outcome was the HrQoL using the EuroQol-6D (EQ-6D) questionnaire at the end of the follow-up period. A total of 263 patients were treated and postoperatively discharged alive: 56 had a ruptured AAA (rAAA), 35 a symptomatic AAA, and 172 an asymptomatic AAA. The 1-year mortality after open AAA repair was 8 %. Overall, 39 % of patients died within 10 postoperative years (mean 6.0 ± 2.8 years). Long-term survival of patients with a ruptured or symptomatic aneurysm was similar to that of patients undergoing elective aneurysm repair. Long-term HrQoL of the total study population was worse than that of an age-matched general Dutch population on the EQ-us (range 0-1, difference 0.12). This decrease in HrQoL was mainly seen in mobility, self-care, usual activities, and cognition. Ten years after open AAA repair, the overall survival rate was 59 %. Long-term survival and HrQoL were similar for patients with a repaired ruptured or symptomatic aneurysm and those who underwent elective aneurysm repair. There were also no differences in patients with infrarenal versus juxtarenal/suprarenal aneurysms. Surviving patients had a lower HrQoL than the age-matched general Dutch population, especially regarding mobility, self-care, usual activities, and cognition.

Perioperative Haemorrhage in Endovascular Abdominal Aneurysm Repair Affects Outcome

This study aimed to evaluate the outcome and predisposing factors related to perioperative bleeding in patients treated with endovascular aneurysm repair (EVAR) for ruptured and non-ruptured abdominal aortic aneurysm (AAA). This was a retrospective cohort study. A total of 525 consecutive patients (73% elective) with AAA underwent EVAR at two vascular centres from 2008 to 2011. From registry data perioperative bleeding was analysed in relation to outcome and preoperative data. A total of 453 (86%) patients presented with a perioperative bleeding <1000 ml, 42 (8%) patients 1000-1999 ml, 19 (4%) patients 2000-5000 ml and 11 (2%) >5000 ml. Other than ruptured AAA (n = 90), no preoperative risk factors for increased perioperative bleeding were found. Open femoral artery access (n = 101), branched (n = 18) and uni-iliacal endografts (n = 18) and introducer size were associated with increased perioperative bleeding (P < 0.001). In multivariable logistic regression only rupture and perioperative bleeding >2000 ml were significantly related to 30-day mortality (odds ratio 10.6 (range 3.8-29.6) and 13.4 (range 4.8-37.4), respectively). Postoperative renal failure, multi-organ failure, >5 days at intensive care unit, bowel ischaemia and abdominal compartments syndrome were significantly related to perioperative bleeding >2000 ml (P < 0.001). Large perioperative bleeding during EVAR is a clinical problem that affects outcome. About 10% of elective AAA patients and 34% of patients with ruptured AAA, undergoing EVAR, present a perioperative blood loss exceeding 1 l. In our study, a perioperative blood loss exceeding 2 l was independently associated with increased mortality and morbidity in both acute and elective AAA patients. Open femoral access, branched EVAR and larger diameter introducers were associated with increased perioperative blood loss. ETHICAL APPLICATION: 2011/664-31/3 (approved).