Aneurysm Repair In Patients Research Articles

EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm.

The aim of this study was to compare midterm results of EndoAnchors in EndoSuture aneurysm repair (ESAR) versus fenestrated endovascular aneurysm repair (FEVAR) in short neck abdominal aortic aneurysm (AAA). All patients who underwent an ESAR procedure for a short neck AAA at our center between September 2017 and May 2020 were considered for analysis. To form the control group, preoperative computed tomography angiography of patients who underwent FEVAR for juxtarenal AAA between April 2012 and May 2020 were reviewed and patients who met short neck criteria selected. A propensity-matched score on neck length and neck diameter was calculated, resulting in 18 matched pairs. AAA shrinkage, type Ia endoleaks (EL), AAA-related reinterventions, and AAA-related deaths were compared. The median AAA diameter was 54mm (interquartile range [IQR], 52-61mm) versus 58mm (IQR, 53-63mm) with a median neck length of 8mm (IQR, 6-12mm) vs 10mm (IQR, 6-13mm) in ESAR and FEVAR patients, respectively. Technical success was 100% in both groups. Procedural success was 94% in the ESAR group versus 100% in the FEVAR group. The median procedure duration was 138mm (IQR, 113-182mm) vs 240mm (IQR, 199-293mm) ( P< .001) and the median length of stay was 2days (IQR, 2-3days) vs 7days (IQR, 6-7days) (P< .001) in ESAR and FEVAR patients, respectively. No major hospital complications were observed in ESAR patients compared with two in FEVAR patients (11%) with one transient acute kidney injury and one transient paraplegia. The median follow-up was 23months (IQR, 19-33months) vs 36months (IQR, 22-57months) with 67% versus 61% AAA shrinkage in the ESAR and FEVAR groups, respectively (P= .73). No type Ia EL, proximal neck-related reinterventions, or AAA-related deaths were observed in either group. No AAA-related reintervention was observed in the ESAR group versus three reinterventions in the FEVAR group (P= .23). ESAR seems to be a safe technique with no major postoperative complications or reinterventions observed during follow-up. It seems to offer similar midterm results as FEVAR in terms of type Ia EL, aneurysm shrinkage, and aneurysm-related mortality. ESAR seems to be a good off-the-shelf alternative to FEVAR in case of technical constraints.

EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm

EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm

Five-Year Outcomes of Endosuture Aneurysm Repair in Patients With Short-Neck Abdominal Aortic Aneurysm From the ANCHOR Registry

Hostile aortic neck anatomies such as proximal short necks are known to put patients at an increased risk for type IA endoleaks, migration, and need for reinterventions. The Heli-FX EndoAnchor System (Medtronic) was designed to improve the fixation and seal of aortic stent grafts. Endosuture aneurysm repair (ESAR) using EndoAnchors with the Endurant stent graft has been shown to be safe and effective for the treatment of patients with short necks in the short term. This study reports the 5-year patient outcomes of the ANCHOR (Aneurysm Treatment Using the Heli-FX EndoAnchor System Global Registry) short-neck cohort to assess the durability of their ESAR repair.

Impact of the Isolated Cerebral Perfusion Technique for Aortic Arch Aneurysm Repair in Patients with a Shaggy Aorta.

Objective: Total aortic arch replacement (TAR), particularly in individuals with extensive atherosclerotic alterations, especially shaggy aortas, is more crucial and difficult. The objective of this retrospective investigation was to ascertain if patients with shaggy aortas would respond to modified isolated cerebral perfusion (ICP). Materials and Methods: Between 2015 and 2020, nine individuals with shaggy aortas who received treatment for arch aneurysms were examined. Four and five patients, respectively, who had arch replacement with traditional selective cerebral perfusion (SCP) and modified ICP, were evaluated, and their short- and long-term results were compared. Results: There were no appreciable variations in the postoperative results between patients with traditional SCP and those with modified ICP. Following surgery, one patient developed paraparesis, while two individuals with traditional SCP experienced persistent neurological damage. In patients with modified ICP, there were no postoperative neurological or other problems associated to atherosclerosis; nevertheless, one patient experienced stroke 5 months after surgery. Conclusion: Patients with shaggy aorta may not receive enough brain protection from TAR with standard SCP because single axillary artery perfusion can result in nonphysiological flow and atheroma separation. Even in patients with shaggy aortas, TAR with modified ICP is safe, but late-phase severe adverse cerebrovascular events should be taken into account.

Locoregional anesthesia is associated with reduced hospital stay and need for intensive care unit care of elective endovascular aneurysm repair patients in the Vascular Quality Initiative

ObjectiveIt has been shown local or regional anesthetic techniques are a feasible alternative to general anesthesia for endovascular aortic aneurysm repair (EVAR). However, studies to date have shown controversial findings with respect to the benefit of locoregional anesthesia (LR) in the elective setting. The objective of this study is to compare postoperative outcomes between LR and general anesthesia (GA) in the setting of elective EVAR, using a large, multicenter database. MethodsUsing the Society for Vascular Surgery Vascular Quality Initiative database, we retrospectively analyzed all patients who underwent elective EVAR from August 2003 to June 2021. Patients were grouped by anesthetic type based on the level of consciousness afforded by the anesthetic: local or regional anesthesia (LR) vs GA. Primary outcomes were total postoperative hospital length-of-stay (LOS) and intensive care unit (ICU) LOS. Propensity score matching was used for risk adjustment and to analyze the primary outcomes with confirmatory analysis using logistic or linear regression, as appropriate, in single and multilevel models. Secondary outcomes were 30-day mortality, 1-year mortality, postoperative outcomes, operative time, fluoroscopy time, and reoperation rate. These were analyzed following propensity score matching as well as using logistic regression and Cox proportional hazard regression in single and multilevel models, as appropriate. ResultsA total of 50,809 patients underwent elective EVAR from 2003 to 2021. Of these, 4302 repairs used LR (8.5%) and 46,507 (91.5%) were performed under GA. After employing propensity score matching, two groups of 3027 patients were produced. These showed no significant difference in 30-day mortality (odds ratio, 1.22; P = .53), 1-year mortality (hazard ratio, 1.06; P = .62), or any postoperative outcomes. LR was found to be significantly associated with shorter hospital stays (≤2 days) (12.5% vs 14.8%; P = .01), decreased ICU utilization (19.3% vs 30.6%; P < .001), decreased operative time (110.8 vs 117.3 minutes; P < .001), decreased fluoroscopy time (21.0 vs 22.7 minutes; P < .001), and a slight reduction in reoperation rate (1.2% vs 1.9%; P = .02), which all remained significant following single-level and multilevel multivariate analyses accounting for hospital and physician random effects. ConclusionsThese data suggest that LR anesthesia is safe and may offer advantages in reducing resource utilization for patients undergoing elective EVAR, primarily based on associations with reduced ICU care and reduced hospital stay. Given these findings, LR may prove an advantageous technique in appropriately selected patient populations.

Thoracic endovascular aneurysm repair in patients with connective tissue disorders

The contemporary data regarding the role of the thoracic endovascular aneurysm repair (TEVAR) in patients with connective tissue disorders (CTD) are reviewed. We performed search of the data in electronic databases PubMed, SCOPUS, Embase, Google Scholar OVID, related to the use of TEVAR. Currently, there is a limited amount of large cohort size studies outlining the use of TEVAR in patients with CTD. Endovascular prosthetics of the thoracic aorta in patients with accidents is dangerous because of the progressive dilatation of the aorta and the high probability of further re-interventions in later life. The analysis showed that open reconstruction still remains a gold standard of intervention in young patients with progressive CTDs, especially in acute type of aortic dissection. However, long-term data need to be published to support this practice.

Feasibility and Cost Analysis of Ambulatory Endovascular Aneurysm Repair

Purpose: We sought to compare the costs of ambulatory endovascular aneurysm repair (a-EVAR) and inpatient EVAR (i-EVAR) at up to 1-year of follow-up. Materials and Methods: A retrospective cohort study of consecutive patients undergoing elective EVAR between April 2016 and December 2018 at two academic centers. Patients planned for a-EVAR were compared with i-EVAR. Costs at 30 days and 1 year were extracted. These included operating room (OR) use, bed occupancy, laboratory and imaging, emergency department (ED) visits, readmissions, and reinterventions. Baseline characteristics were compared. Multiple regression model was used to identify predictors of increased EVAR costs. Repeated measures analysis of variance (ANOVA) was used to compare cost differences at 30 days and 1 year via an intention-to-treat analysis. Bonferroni post hoc test compared between-group differences. A p value<0.05 was considered statistically significant. Results: One hundred seventy patients were included. Most underwent percutaneous EVAR (>94%) under spinal anesthesia (>84%). Ambulatory endovascular aneurysm repair was successful in 84% (84/100). Ambulatory endovascular aneurysm repair patients (76±8 years) were younger than i-EVAR (78±9 years). They also had a smaller mean aneurysm diameter (56±6 mm) compared with i-EVAR (59±6 mm). Emergency department visits, readmissions, and reinterventions were similar up to 1 year (all p=NS). Ambulatory endovascular aneurysm repair costs showed a non-statistically significant reduction in total costs at 30 days and 1 year by 27% and 21%, respectively. Patients younger than 85 years and males had a 30-day cost reduction by 34% (p=0.027) and 33% (p=0.035), respectively with a-EVAR. Conclusions: Same-day discharge is feasible and successful in selected patients. Patients younger than 85 years and males have a short-term cost benefit with EVAR done in the ambulatory setting without increased complications or reinterventions. Clinical Impact This study shows the overall safety of ambulatory EVAR with proper patient selection. These patient had similar post-intervention complications to inpatients. Same day discharge also resulted in short-term reduction in costs in male patients and patients younger than 85 years.

Outcomes of Abdominal Aortic Aneurysm Repair in Patients with Recent Intraabdominal Malignancy Diagnosis

Outcomes of Abdominal Aortic Aneurysm Repair in Patients with Recent Intraabdominal Malignancy Diagnosis

Cost of Follow Up After Endovascular Abdominal Aortic Aneurysm Repair in Patients With an Initial Post-Operative Computed Tomography Angiogram Without Abnormalities

The Observing a Decade of Yearly Standardised Surveillance in EVAR patients with Ultrasound or CT Scan (ODYSSEUS) study was conducted to assess differences in outcomes of patients with continued or discontinued yearly follow up after endovascular abdominal aortic aneurysm repair (EVAR). Earlier results of this study showed that discontinued follow up was not associated with poor outcomes. Therefore, an incremental cost analysis and budget impact analysis of de-implementation of yearly imaging following EVAR was performed. In total, 1 596 patients from the ODYSSEUS study were included. The expected cost savings were assessed if yearly imaging was reduced in patients with a post-operative computed tomography angiogram without abnormalities made around 30 days after EVAR. Costs were derived from the Dutch costs manual, benchmark cost prices, and literature review. Costs were expressed in euros (€) and displayed at 2019 prices. Sensitivity analysis was performed by varying costs. A difference of 24% in cost was found between patients with continued and discontinued imaging follow up. The cost per patient was €1 935 in the continued group vs. €1 603 per patient in the discontinued group at five years post-EVAR, with a mean difference of €332 (95% bias corrected and accelerated bootstrap confidence interval -741 to 114). De-implementation of yearly imaging would result in an annual nationwide cost saving of €678 471. Sensitivity analysis with variation in adherence rates, imaging, or secondary intervention costs resulted in a saving of at least €271 388 per year. This study provided an in depth analysis of hospital costs for post-EVAR patients in the Netherlands with a modest impact on the Dutch healthcare budget.

Management of retroperitoneal fibrosis with endovascular aneurysm repair in patients refractory to medical management.

BackgroundEarly diagnosis and treatment of under-recognized retroperitoneal fibrosis (RPF) are essential before reaching the poorly responsive fibrotic stage. Although most patients respond to medical therapy, relapses and unresponsiveness are common. However, open surgery in medically resistant patients is associated with major adverse clinical events.MethodsThis is a single-centre longitudinal study of optimal medical therapy (OMT) vs. endovascular aneurysm repair (EVAR) in patients presenting with RPF to our tertiary referral vascular centre. Out of 22,349 aortic referrals, we performed 1,555 aortic interventions over twenty years. Amongst them, 1,006 were EVAR, TEVAR and BEVAR. Seventeen patients (1.09%) had documented peri-aortic RPF.ResultsOut of the 17 RPF patients, 11 received OMT only, while 6 underwent EVAR after the failure of OMT. 82% (n = 14) were male, and the median follow-up was 62.7 months (IQR: 28.2–106). Nine (52%) had immunoglobulin G4-related disease (4 OMT vs. 5 EVAR). EVAR patients had 100% technical success without perioperative mortality. Furthermore, all the EVAR patients were symptom-free following the intervention. Pre-operative aortic RPF index (maximum peri-aortic soft tissue diameter/maximum aortic diameter) was higher in the EVAR than in OMT. However, there was a significant decrement in the aortic RPF index following EVAR (P = 0.04).ConclusionWe believe that when optimal medical therapy fails in RPF, EVAR provides a promising outcome. Further studies are recommended to establish the role of endovascular repair.

Post-operative Surveillance and Long Term Outcome after Endovascular Aortic Aneurysm Repair in Patients with an Initial Post-operative Computed Tomography Angiogram Without Abnormalities: the Multicentre Retrospective ODYSSEUS Study

Lifelong imaging surveillance is recommended following endovascular aneurysm repair (EVAR). This study aimed to examine the association between adherence to post-operative surveillance and survival and secondary interventions in patients with an initial post-operative computed tomography angiogram (CTA) without abnormalities. All consecutive patients undergoing EVAR for intact abdominal aortic aneurysm (AAA) in 16 hospitals between 2007 and 2012 were identified retrospectively, with follow up until December 2018. Patients were included if the initial post-operative CTA showed no types I – III endoleak, kinking, infection, or limb occlusion. Discontinued follow up was defined as at least one 16 month period in which no imaging surveillance was performed. Primary outcomes were aneurysm related mortality and secondary interventions, and secondary outcome all cause mortality. Kaplan–Meier analysis was used to estimate survival, and Cox regression analyses to identify the association between independent variables and outcome. Sensitivity analyses were performed by varying the definition of continued yearly follow up. The study protocol was published (bmjopen-2019-033584). 1 596 patients (552 continued, 1 044 discontinued follow up) were included with a median (interquartile range) follow up of 89.1 months (52.6). Cumulative aneurysm related, overall, and intervention free survival was 99.4/94.8/96.1%, 98.5/72.9/85.9%, and 96.3/45.4/71.1% at 1, 5, and 10 years, respectively. American Society of Anesthesiologists (ASA) classification (ASA IV hazard ratio [HR] 3.810, 95% confidence interval [CI] 1.296 – 11.198), increase in AAA diameter (HR 3.299, 95% CI 1.408 – 7.729), and continued follow up (HR 3.611, 95% CI 1.780 – 7.323) were independently associated with aneurysm related mortality. The same variables and age (HR 1.063 per year, 95% CI 1.052 – 1.074) were significantly associated with all cause mortality. No difference in secondary interventions was observed between patients with continued vs. discontinued follow up (89/552; 16% vs. 136/1044; 13%; p = .091). Sensitivity analyses showed worse aneurysm related and overall survival in patients with continued follow up. Discontinued follow up is not associated with poor outcomes. Future prospective studies are indicated to determine in which patients imaging follow up can be safely reduced.

Nationwide Analysis of Persistent Type II Endoleak and Late Outcomes of Endovascular Abdominal Aortic Aneurysm Repair in Japan: A Propensity-Matched Analysis.

Background:We reviewed the results of endovascular aneurysm repair in patients from the Japanese Committee for Stentgraft Management registry to determine the significance of persistent type II endoleak (p-T2EL) and the risk of late adverse events, including aneurysm sac enlargement.Methods:The prospectively captured medical records of 17 099 patients <75 years of age who underwent endovascular aneurysm repair for abdominal aortic aneurysm from 2006 to 2015 were reviewed. Patients were divided into 2 groups (with or without p-T2EL) and compared to examine the correlation between p-T2EL and the occurrence of aneurysm sac enlargement after endovascular aneurysm repair.Results:Of the patients, 4957 (29.0%) had p-T2EL and 12 142 (71.0%) had no p-T2EL (non-T2EL). Mean age was significantly higher (P<0.001), and there were fewer men (P<0.001) in the p-T2EL group. Among comorbidities, hypertension (P=0.019) and chronic kidney disease (P=0.040) were more prevalent and respiratory disorders were less prevalent (P<0.001) in the p-T2EL group. From each group, 4957 patients were matched according to propensity score to adjust for differences in patient characteristics. The cumulative incidence rates of abdominal aortic aneurysm–related mortality (p-T2EL: 52 of 4957 [1.0%] versus non-T2EL: 21 of 12 142 [0.2%]), rupture (p-T2EL: 38 of 4957 [0.8%] versus non-T2EL: 13 of 12 142 [0.1%]), sac enlargement (≥5 mm; p-T2EL: 1359 of 4957 [27.4%] versus non-T2EL: 332 of 12 142 [2.7%]), and reintervention (p-T2EL: 739 of 4957 [14.9%] versus non-T2EL: 91 of 12 142 [0.7%]) were significantly higher in the p-T2EL than the nonpT2EL group (P<0.001). Propensity score matching yielded higher estimated incremental risk, including abdominal aortic aneurysm–related mortality, rupture, sac enlargement (≥5 mm), and reintervention for p-T2EL (P<0.001). Cox regression analysis revealed older age (P=0.010), proximal neck diameter (P=0.003), and chronic kidney disease (P<0.001) as independent positive predictors and male sex as an independent negative predictor (P=0.015) of sac enlargement.Conclusions:The Japanese Committee for Stentgraft Management registry data show a correlation between p-T2EL and late adverse events, including aneurysm sac enlargement, reintervention, rupture, and abdominal aortic aneurysm–related mortality after endovascular aneurysm repair. Besides p-T2EL, older age, female sex, chronic kidney disease, and dilated proximal neck were associated with sac enlargement.

A meta-analysis of safety and efficacy of endovascular aneurysm repair in aneurysm patients with severe angulated infrarenal neck.

ObjectivesA growing number of abdominal aortic aneurysms with severe angulated neck anatomy is treated by endovascular means. However, contradictory early and late outcomes have been reported. Our review and outcome analysis attempted to evaluate the available literature and provide clinicians with a base for clinical implementation and future research.Materials and methodsA systematic review of the literature was undertaken to identify the outcomes of endovascular aneurysm repair in patients with severe infrarenal neck angulation (SNA ≥ 60°) vs non-severe neck angulation (NSNA). Outcome measures included perioperative complications, type 1a endoleak, neck-related secondary procedures, stent graft migration, aneurysm rupture, increase (>5mm) in sac diameter, all-cause and aneurysm-related mortality (PROSPERO Nr.: CRD42021233253).ResultsSix observational studies reporting on 5981 patients (1457 with SNA and 4524 with NSNA) with a weighted mean follow-up period of 1.8 years were included. EVAR in SNA compared with NSNA was associated with a higher rate of type 1a endoleak at 30 days (4.0% vs 1.8%; p< 0.00001), at 1 year (2.8% vs 1.9%; p<0.03), at 2 years (4.9% vs 2.1%; p< 0.0002), at 3 years (5.6% vs 2.6%; p< 0.0001). The rate of neck-related secondary procedures was significantly higher at 1 year (6.6% vs 3.9%; p<0.05) and at 3 years (13.1% vs 9%; p<0.05). Graft migration, aneurysm sack increase, aneurysm rupture and all-cause mortality were not statistically different at mid-term.ConclusionsThe use of EVAR in severely angulated infrarenal aortic necks is associated with a high rate of early and mid-term complications. However, aortic related and all-causes mortality are not higher compared to patients with NSNA. Therefore, EVAR should be cautiously used in patients with SNA.

Editor's Choice – Post-operative Surveillance and Long Term Outcome after Endovascular Aortic Aneurysm Repair in Patients with an Initial Post-operative Computed Tomography Angiogram Without Abnormalities: the Multicentre Retrospective ODYSSEUS Study

Lifelong imaging surveillance is recommended following endovascular aneurysm repair (EVAR). This study aimed to examine the association between adherence to post-operative surveillance and survival and secondary interventions in patients with an initial post-operative computed tomography angiogram (CTA) without abnormalities. All consecutive patients undergoing EVAR for intact abdominal aortic aneurysm (AAA) in 16 hospitals between 2007 and 2012 were identified retrospectively, with follow up until December 2018. Patients were included if the initial post-operative CTA showed no types I - III endoleak, kinking, infection, or limb occlusion. Discontinued follow up was defined as at least one 16 month period in which no imaging surveillance was performed. Primary outcomes were aneurysm related mortality and secondary interventions, and secondary outcome all cause mortality. Kaplan-Meier analysis was used to estimate survival, and Cox regression analyses to identify the association between independent variables and outcome. Sensitivity analyses were performed by varying the definition of continued yearly follow up. The study protocol was published (bmjopen-2019-033584). 1 596 patients (552 continued, 1 044 discontinued follow up) were included with a median (interquartile range) follow up of 89.1 months (52.6). Cumulative aneurysm related, overall, and intervention free survival was 99.4/94.8/96.1%, 98.5/72.9/85.9%, and 96.3/45.4/71.1% at 1, 5, and 10 years, respectively. American Society of Anesthesiologists (ASA) classification (ASA IV hazard ratio [HR] 3.810, 95% confidence interval [CI] 1.296 - 11.198), increase in AAA diameter (HR 3.299, 95% CI 1.408 - 7.729), and continued follow up (HR 3.611, 95% CI 1.780 - 7.323) were independently associated with aneurysm related mortality. The same variables and age (HR 1.063 per year, 95% CI 1.052 - 1.074) were significantly associated with all cause mortality. No difference in secondary interventions was observed between patients with continued vs. discontinued follow up (89/552; 16% vs. 136/1044; 13%; p= .091). Sensitivity analyses showed worse aneurysm related and overall survival in patients with continued follow up. Discontinued follow up is not associated with poor outcomes. Future prospective studies are indicated to determine in which patients imaging follow up can be safely reduced.

Fenestrated Aortic Aneurysm Repair in Patients Treated Inside Versus Outside of Instructions for Use

Objectives: The aim of this study was to compare outcomes of patients treated with the Cook Zenith Fenestrated (ZFEN) device for juxtarenal aortic aneurysms inside versus outside the IFU. Methods: We retrospectively reviewed our institutional ZFEN database for cases performed between 2012 and 2018, with analysis performed in 2020 in order to report midterm outcomes. The cohort was stratified based on treatment inside (IFU group) and outside (non-IFU group) the IFU for criteria involving the proximal neck: neck length 4 to 14 mm, neck diameter 19 to 31 mm, and neck angulation ≤45°. Patients with thoracoabdominal aneurysms or concurrent chimney grafting were excluded. The primary outcomes in question were mortality, type 1a endoleak, and reintervention. Univariate and multivariate analyses were performed to determine associations between adherence to IFU criteria and outcomes. Results: We identified 100 consecutive patients (19% female, mean age 73.6 years) for inclusion in this analysis. Mean follow-up was 21.6 months. Fifty-four patients (54%) were treated outside the IFU because of inadequate neck length (n=48), enlarged neck diameter (n=10), and/or excessive angulation (n=16). Eighteen patients were outside IFU for two criteria, and one patient was outside IFU for all three. Non-IFU patients were exposed to higher radiation doses (3652 vs 5445 mGy, p=0.008) and contrast volume (76 vs 95 mL, p=0.004). No difference was noted between IFU and non-IFU groups for 30-day mortality (0% vs 3.7%, p=0.18), or type 1a endoleak (0% vs 1.9%, p=0.41). Reintervention was also similar between cohorts (13% vs 27.8%, p=0.13). Being outside IFU for neck diameter or length was each borderline significant for higher reintervention on univariate analysis (p=0.05), but this was not significant on multivariate Cox proportional hazard modeling (HR 1.82 [0.53–6.25]; 2.03 [0.68–7.89]), respectively. No individual IFU deviations were associated with the primary outcomes on multivariate analysis, nor being outside IFU for multiple criteria. Conclusions: Patients with juxtarenal aortic aneurysms may be treated with the ZFEN device with moderate deviations from the IFU. While no differences were seen in mortality or proximal endoleak, larger studies are needed to examine the potential association between IFU nonadherence and reinterventions and close follow-up is warranted for all patients undergoing such repair.

Long Term Results After Endovascular Aortic Aneurysm Repair in Patients with Infective Abdominal Aortic Aneurysm

Long Term Results After Endovascular Aortic Aneurysm Repair in Patients with Infective Abdominal Aortic Aneurysm

Analysis of Prognostic Factors for Postoperative Complications and Reinterventions After Open Surgical Repair and Endovascular Aneurysm Repair in Patients With Abdominal Aortic Aneurysm

A retrospective, single-center review was performed between 2006 and 2017. Although the operative mortality rate was the same (0.5%) for both groups, the 405 patients who had undergone endovascular aortic aneurysm repair (EVAR) had experienced significantly fewer postoperative complications (13%) than had the 176 patients who had undergone open surgical repair (OSR) for infrarenal abdominal aortic aneurysms (36%). Patients who had undergone hostile neck EVAR had a significantly lower 5-year reintervention-free survival rate (63%) than the patients who had undergone favorable neck EVAR (83%) and those who had undergone OSR (86%). Patients with hostile neck EVAR also had a significantly lower 5-year overall survival rate (52%) compared with favorable neck EVAR (73%) and OSR (79%). Age, hemodialysis, and modified frailty index (mFI) were the risk factors for complications, increased reintervention, and decreased 5-year survival on multivariate analysis. Age, mFI, hemodialysis, and hostile neck anatomy are useful predictors for reintervention and 5-year survival and could be useful for selecting treatment between OSR and EVAR.

Open aneurysm repair in patients with concomitant abdominal aortic aneurysm and aorto-iliac occlusive disease is associated with a high mortality and surgical complication rate.

To evaluate whether the outcome after open aneurysm repair combined with aorto-femoral bypass in patients with concomitant abdominal aortic aneurysm (AAA) and aorto-iliac occlusive disease (AIOD) is inferior to open aneurysm repair for isolated AAA or aorto-femoral bypass for isolated AIOD. We performed a retrospective analysis of 30-day mortality, 1-year mortality and surgical complications of consecutive patients undergoing elective aneurysm repair, aorto-femoral bypass or a combination of these at two vascular surgery departments from 2003 to 2013. Potential risk factors were investigated by multivariable analysis. Overall, 511 patients underwent open repair for isolated AAA, 104 aorto-femoral bypass for isolated AIOD and 46 open AAA repair combined with aorto-femoral bypass for concomitant AAA and AIOD. Surgical complications occurred in 17% of AAA, 23% of AIOD and 37% of combined patients (odds ratio [OR] combined vs AAA 2.76, 95% confidence interval [CI] 1.43-5.34; p = 0.003). Colon ischaemia occurred in 3.7% of AAA, 2.9% of AIOD and 13% of combined patients (incicidence rate ratio [IRR] combined vs AAA 3.27, 95% CI 1.37-7.81; p = 0.01). The 30-day mortality was 3.1% in AAA, 4.8% in AIOD, and 11% in combined patients (IRR combined vs AAA 3.17, 95% CI 1.26-7.96; p = 0.01). One-year mortality was 5.7% in AAA, 5.8% in AIOD and 15% in combined patients (IRR combined vs AAA 2.50, 95% CI 1.17-5.35; p = 0.02). Combined AAA repair and aorto-femoral bypass has a significantly higher 30-day mortality and postoperative complication rate than isolated AAA repair. Patients with concomitant AAA and AIOD thus represent a high-risk population, which should be considered when deciding on the indication for AAA treatment.

Use of Chimney Technique Does Not Improve the Outcome of Endovascular Aneurysm Repair in Patients With a Hyperangulated and Short Proximal Aortic Neck

Purpose: We hypothesized that extending the proximal landing zone with the chimney technique could be beneficial in patients with a hyperangulated proximal aortic neck, defined as more > 60 degrees. Material and Methods: We retrospectively analyzed the outcome of prospectively collected data of patients treated by endovascular aneurysm repair (EVAR) for infrarenal aortic aneurysm with a hyperangulated proximal aortic neck. In all, 104 out of 130 patients were treated without (Group A) and 24 with the chimney endovascular aortic repair (ChEVAR, Group B). Primary outcome was technical and clinical success according to the reporting standards of the Society of Vascular Surgery. Results: The use of the chimney technique was associated with a significantly longer operation duration (167 vs. 93 min, p < .001), longer fluoroscopy time (44 vs.30 min, p = < .001), and larger amount of contrast medium used (149 vs. 127 ml, p = .03) but did not significantly improve technical (79.2% vs. 87.7%) and clinical success (54.2% vs. 68.9%). Aneurysm-related mortality was higher in group B (8.3% vs. = 0%, p < .001). Type IA endoleak was high in both groups at completion angiography (11.3% in Group A vs. 12.5% in Group B) and at follow-up (10.4% in Group A vs. 4.5% in Group B) without significant difference between the groups. Conclusions: Our data did not show a benefit of the primary use of the chimney technique in patients with a hyperangulated and short neck, although more studies are required to support this conclusion. Other strategies or new technologies are required for improving EVAR results in aneurysm patients with severe angulated proximal and short neck.

INCREASED TRAVEL TIME TO THE TERTIARY CENTRE IS ASSOCIATED WITH DECREASED LONG-TERM SURVIVAL FOLLOWING ASCENDING AORTIC OPERATIONS

<h3>BACKGROUND</h3> The association between travel time from the tertiary care centre and outcomes after aortic surgery is unknown. Our objective was to determine the effect of estimated travel time from tertiary care centre on outcomes in ascending aortic repair in Nova Scotia. <h3>METHODS AND RESULTS</h3> A retrospective analysis of all elective and emergent ascending thoracic aortic operations, performed either in isolation or in combination with other cardiac surgery procedures, from 2005 and 2015 was carried out. Clinical characteristics as well as in-hospital outcomes were recorded. Patient's residential geographical coordinates were used to calculate estimated driving time using geographic information system software (ArcMAP, ESRI). Socioeconomic deprivation quintiles were derived from the 2006 Census based on the patient's residential postal code. Long-term survival was identified through Vital Statistics database. Multivariable logistic regression was performed to determine the independent effect of estimated travel time ≥1 hour on in-hospital outcomes. Cox-proportional hazard modeling and Kaplan-Meier survival estimates were created to determine the independent effect of estimated travel time on long-term survival. A total of 476 patients underwent ascending thoracic aortic surgery from 2005 to 2015. Mean age was 59.1 (±13.3) years and 107 (22.5%) were female. Compared to patients at < 1 hour from the tertiary care centre, patients who lived ≥1 hour did not experience higher rates of in-hospital mortality (OR 1.51, 95% CI 0.45-5.00), composite in-hospital complications (OR 1.09, 95% CI 0.62-1.91), discharge disposition to another institution or nursing home (OR 1.33, 95% CI 0.56-3.14), or prolonged hospital length of stay (OR 1.15, 95% CI 0.68-1.93). Kaplan-Meier survival estimates (Figure) and adjusted Cox proportional hazard modeling revealed that patients who lived ≥1 hour from the tertiary centre had increased long-term mortality (HR 2.19, 95% CI 1.13-4.28, p=0.02). In a sensitivity analysis of only elective ascending aortic aneurysm repair patients (n=380), there was a persistent finding of increased mortality in patients who lived ≥1 hour from the tertiary centre (HR 2.56, 95% CI 1.14-5.75, p=0.02). Statistical analysis was performed using Stata, version 14 (College Station, TX). <h3>CONCLUSION</h3> Compared to patients who live in close proximity to the tertiary centre, patients at increased travel time experience equivalent in-hospital outcomes but decreased long-term survival following ascending aortic operations. Resource expansion to improve follow-up monitoring of patients who live remotely is needed.