Aortoiliac Aneurysms Research Articles

Unique Complications and Failure Modes of Iliac Branch Devices

Iliac branch devices (IBDs) are modular, bifurcated endografts designed to preserve hypogastric flow during endovascular aortoiliac aneurysm repair. We report our single center outcomes, and describe the unique complications of these devices: inability to cannulate the hypogastric artery (technical failure), occlusion of the internal branch, and type III endoleak from separation of components between the main body and IBD. A prospectively maintained institutional database of patients undergoing IBD implantation between 2014 and 2019 was reviewed. Technical and clinical outcomes were evaluated. We then identified patients having one of the IBD-specific complications and patient, anatomic, and procedural data were analyzed to identify factors associated with these failures. Sixty-four IBDs were placed in 59 patients during the study period. Mean age was 71.2 ± 8.6, and 92% were male. A 74.6% of patients had a current or prior abdominal aortic aneurysm, and 9.4% had a hypogastric aneurysm. Technical success was achieved in 60/64 cases (93.8%); prior endovascular aortic repair was associated with technical failure (P = 0.04). There were 5 instances of component separation between the main body and the IBD: 3 occurred intraoperatively and were repaired with additional bridging components, and 2 occurred on late follow-up and required reintervention. Increased tortuosity index of both aortoiliac (1.7 ± 0.4 vs. 1.3 ± 02, P = 0.04) and iliac-specific (3.9 ± 2.4 vs. 1.9 ± 0.9, P = 0.03) segments were significantly associated with component separation, as was the use of larger internal iliac components (13.9 ± 2.4 vs. 11.1 ± 2.3 mm, P = 0.04). Internal branch occlusions occurred in 4 patients (6.7%). Two were successfully reopened with endovascular procedures, with two being asymptomatic. No specific factors were found to be predictive of branch occlusion. IBD-specific complications occur rarely. History of prior endovascular aortic repair is associated with technical failure, while increased aortic and iliac tortuosity are predictive of component separation and type III endoleak. Severe tortuosity should be carefully considered when planning for IBD.

Hypogastric Preservation Using a Retrograde Endovascular Bypass in a Patient with Ruptured AAA and Concomitant Bilateral Common Iliac Aneurysms: A Feasible Option in the Acute Setting

Preservation of the hypogastric circulation is of major clinical importance in cases of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA). Pelvic ischemia can be detrimental and significantly increase post-operative morbidity and mortality. However, the application of a side branch device or a bell-bottom graft is not possible in ruptured aortoiliac aneurysms (due to off-the-shelf unavailability and/or prolonged operative time) and in most cases pelvic circulation may have to be sacrificed. We report a case of a rAAA with bilateral common iliac artery (CIA) aneurysms that was successfully repaired with an aorto-uni-iliac (AUI) endograft, a cross-femoral bypass, and an inverted-U shaped contralateral EIA to IIA endovascular bypass. The procedure is described in detail and certain technical points are further discussed. The steps in cases where the aneurysm has ruptured are different compared to elective repairs and vascular surgeons need to be aware of certain pitfalls. This strategy may be feasible in the acute setting and permits preservation of the hypogastric circulation with the combination of standard techniques and grafts that are readily available in most institutions.

Custom-Made Bifurcated Prosthetic Graft for Aortoiliac Aneurysm Repair.

Revascularization of the internal iliac artery during open repair of aortoiliac aneurysms can be challenging, especially if there is a significant distance between the orifices of the internal and external iliac arteries owing to common iliac aneurysmal dilatation. We describe a technique involving insertion of an 18-mm tube graft between the proximal aortic neck and aneurysmal common iliac artery bifurcation. Revascularization of the contralateral external iliac artery is accomplished through an 8-mm side arm graft.

Initial Clinical Experience With a New Conformable Abdominal Aortic Endograft: Aortic Neck Coverage and Curvature Analysis in Challenging Aortic Necks

Objectives: Aim of this work was to investigate precision of deployment and conformability of a new generation GORE EXCLUDER Conformable Endoprosthesis with active control system (CEXC Device, W.L. Gore and Associates, Flagstaff, AZ, USA) by analyzing aortic neck coverage and curvature. Methods: All consecutive elective patients affected by abdominal aortic aneurysm or aortoiliac aneurysm treated at our institution between November 2018 and June 2019 with the new CEXC Device were enrolled. Validated software was adopted to determine the available apposition surface area into the aortic neck, apposition of the endograft to the aortic wall, shortest apposition length (SAL), shortest distance between the endograft fabric and the lowest renal arteries (SFD) and between the endograft fabric and the contralateral renal artery (CFD). Pointwise centerline curvature was also computed. Results: Twelve patients (10 men, median age 78 years (71.75, 81.0)) with available pre- and postoperative computed tomography angiography (CTA) were included. Technical success was obtained in all the cases. Preoperative median length of the proximal aortic neck was 16.1 mm (10.7, 21.7) and suprarenal (α) and infrarenal (β) neck angulation were, respectively, 28.9° (15.7°, 47.5°) and 75.0° (66.9°, 81.4°). Postoperative median apposition surface coverage was 79% (69.25%, 90.75%) of the available apposition surface. SFD and CFD were 1.5 mm (0.75, 5.25) and 7 mm (4.5, 21.5), respectively. Average curvature over the infrarenal aorta decreased from 25 m−1 (21.75, 29.0) to 22.5 m−1 (18.75, 24.5) postoperatively (p=0.02). Maximum curvature did not decrease significantly from 64.5 m−1 (54.25, 92.0) to 62 m−1 (41.75, 71.5) (p=0.1). Conclusions: Our early experience showed that deployment of the CEXC Device is safe and effective for patients with challenging proximal aortic necks. Absence of significant changes between pre- and postoperative proximal aortic neck angulations and curvature confirms the high conformability of this endograft.

ISOLATED ILIAC ARTERY ANEURYSM- 10 YEARS INSTITUTIONAL EXPERIENCE

Objective: To review the experience of our institution in repairing isolated iliac artery aneurysm (isolated IAA) in the last 10 years. Introduction: Unlike abdominal and combined aortoiliac artery aneurysms, isolated iliac artery aneurysms (IIAAs) are uncommon. An isolated iliac artery aneurysm is dened as a twofold increase in the diameter of the iliac artery without a coexisting aneurysm at another location. IIAA was encountered infrequently in the past, comprising 0.9% to 4.7% of all intra-abdominal aneurysms according to a review of previous studies; however, in recent times, many asymptomatic IIAAs have been detected incidentally because of the widespread use of abdominal ultrasonography and computed tomography. Methods: The medical records of patients who underwent isolated IAA repair at Institute of vascular sciences, MMC and RGGGH, Chennai, India, were reviewed, to obtain information on patients' demographics, vascular risk factors, type of treatment and outcome Results: A total of 13 patients with 18 aneurysms, 11 men(84.6%) 2 women(15.4%), with a mean age of 58.1±6 years, and two paediatric patients of age 11yrs (Female) and 3 months (Male) were treated. The mean diameter was 4.6 ± 1.0 for non-ruptured at elective repair; 5.5±2.1 cm on the emergency cases. The majority of aneurysms were at the common iliac artery. All of them except one, underwent open repair.Ten (84%) had elective operations, and two (16%) emergency repair for ruptured aneurysm. Hypertension and diabetes were seen as the most common risk factors with most of the patients were smokers. One was a known case of CKD and the paediatric female was a known case of RHD. There was one postoperative death in this series, patient succumbed on POD 1. Conclusion: This case series reviews the literature with regard to the natural history, diagnostic workup, and treatment of iliac artery aneurysms. For patients undergoing elective repair, preoperative imaging with computed tomography or magnetic resonance is advocated. Repair is recommended for good-risk patients with aneurysms larger than 3.5 cm as there is high chances of rupture with increasing diameter.

Did Percutaneous Compared with Cutdown Access for Endovascular Aneurysm Repair Really Make a Difference?

Did Percutaneous Compared with Cutdown Access for Endovascular Aneurysm Repair Really Make a Difference?

Emergency endovascular repair of aortoiliac aneurysms in COVID-19 times.

In this paper, we describe a case series of four patients who were admitted with emergencies related to aortic aneurysms over a 3-day period and were treated with endovascular repair. The first patient was an 81-year-old female with a history of abdominal pain and a ruptured aortic aneurysm diagnosed by AngioCT-scan. The second patient was a 63-year-old male with a history of oral digestive bleeding and an AngioCT-scan showing an aortoenteric fistula. The third patient was a 77-year-old female with sudden-onset abdominal pain and ruptured right common iliac aneurysm. The fourth patient presented with abdominal pain and an AngioCT-scan showed aortic rupture. All four patients were discharged with no major complications or surgical mortality. These case series show that despite the Covid-19 pandemic situation, since elective surgeries decreased, vascular emergencies have increased.

Lower limb pain and swelling: is it sciatica, DVT, or else?

Background: Only 1% of all aortoiliac aneurysms could be presented with isolated internal iliac artery aneurysms with an incidence of 0.1% in the general population. Patients are mostly asymptomatic, yet they can present with clinical presentations related to aneurysm size and adjacent anatomical structures. Case Presentation: We report the case of a 76-year-old male patient with ruptured isolated internal iliac artery aneurysm presenting as ecchymosis and severe thigh pain with redness and discoloration. The patient was known hypertensive, diabetic type 2, and had end-stage renal disease but was not on regular hemodialysis. The patient's vital signs and systemic and abdominal examination were unremarkable, further laboratory tests were also normal. There was no sign of surrounding cellulitis and all the peripheral pulses were intact and normal. Because of unclear diagnosis and repeated visits to the emergency department, the patient was admitted for further investigation to rule out malignancy. CT abdomen was conducted and it revealed a ruptured internal iliac artery aneurysm with an extension into the gluteal region. Conclusion: Early diagnosis of isolated internal iliac artery aneurysm is difficult, as it is more easily detected when it is expanded or ruptured, which significantly increases morbidity and mortality rates and determines poor prognosis. Therefore, there are diagnostic as well therapeutic challenges. Surgical ligation is known as the most common management approach; however, the endovascular approach has shown promising outcomes, even in cases of a ruptured aneurysms.

Racial Differences in Isolated Aortic, Concomitant Aortoiliac, and Isolated Iliac Aneurysms: This is a Retrospective Observational Study.

Our aim was to describe the racial and ethnic differences in presentation, baseline and operative characteristics, and outcomes after aortoiliac aneurysm repair. Previous studies have demonstrated racial and ethnic differences in prevalence of abdominal aortic aneurysms and showed more complex iliac anatomy in Asian patients. We identified all White, Black, Asian, and Hispanic patients undergoing aortoiliac aneurysm repair in the VQI from 2003 to 2019. We compared baseline comorbidities, operative characteristics, and perioperative outcomes by race and ethnicity. In our 60,435 patient cohort, Black patients, followed by Asian patients, were most likely to undergo repair for aortoiliac (W:23%, B:38%, A:31%, H:22%, P < 0.001) and isolated iliac aneurysms (W:1.0%, B:3.1%, A:1.5%, H:1.6%, P < 0.001), and White and Hispanic patients were most likely to undergo isolated aortic aneurysm repair (W:76%, B:59%, A:68%, H:76%, P < 0.001). Black patients were more likely to undergo symptomatic repair and underwent rupture repair at a smaller aortic diameter. The iliac aneurysm diameter was largest in Black and Asian patients. Asian patients were most likely to have aortic neck angulation above 60 degree, graft oversizing above 20%, and completion endoleaks. Also, Asian patients were more likely to have a hypogastric artery aneurysm and to undergo hypogastric coiling. Asian and Black patients were more likely to undergo repair for aortoiliac and isolated iliac aneurysms compared to White and Hispanic patients who were more likely to undergo repair for isolated aortic aneurysms. Moreover, there were significant racial differences in the demographics and anatomic characteristics that could be used to inform operative approach and device development.

A Case of Giant Aortoiliac Aneurysm Rupture when Open Repair Seems a One-Way Street.

Giant aortoiliac aneurysm is a rare nosological entity. Owing to the increased diameter, the risk of rupture is extremely high and, similarly, the repair is extremely challenging. In this article, open surgical repair of a ruptured giant aortoiliac aneurysm in a 72-year-old male is described. A bifurcated Dacron graft was used with left internal iliac artery revascularization, while the contralateral internal iliac artery was ligated. The patient had an uneventful recovery.

Safety and effectiveness of the TREO stent graft for the endovascular treatment of abdominal aortic aneurysms

ObjectiveThe short- and mid-term outcomes of endovascular aortic aneurysm repair have made it a standard treatment of abdominal aortic aneurysms. However, newer generation devices have yet to demonstrate improved long-term rates for complications, reinterventions, and survival. The TREO stent graft is a latest generation device and was evaluated for approval in the United States. MethodsIn a multicenter, nonrandomized, investigational device exemption clinical trial, we assessed the safety and effectiveness of the TREO device, with core laboratory assessment of the imaging studies and an independent adjudication of safety. The primary effectiveness endpoint was successful aneurysm treatment at 1 year. The primary safety endpoint was the incidence of major adverse events (MAE) at 30 days. ResultsA total of 150 patients (132 men; 88.0%) with infrarenal abdominal aortic (87.3%) or aortoiliac (12.7%) aneurysms were enrolled. The data were normally distributed. The mean age was 71.7 ± 7.4 years. The MAE incidence at 30 days was 0.7%. One subject experienced two MAE: myocardial infarction and procedural blood loss of 1000 mL. The proportion of successful aneurysm treatment at 1 year was 93.1%. Longer term follow-up continues, with no aneurysm-related mortality at the latest follow-up. At 3 years, the cumulative all-cause mortality and incidence of type I and type III endoleaks was 10.7% (n = 16), 2.7% (n = 4), and 0% (n = 0), respectively. In addition, aneurysm sac shrinkage >5 mm at 3 years had occurred in 54.3% of patients, and 9.3% had required a secondary intervention (n = 14). ConclusionsThe safety and effectiveness of endovascular repair of abdominal aneurysms with TREO were demonstrated, with 93.1% successful aneurysm treatment at 1 year and aneurysm sac shrinkage >5 mm at 3 years in 54.3% of patients. Long-term follow-up continues to determine whether these favorable outcomes will be sustained.

Early results of expanding the anatomical indications for using a Gore Iliac branch endoprosthesis to treat aortoiliac and iliac aneurysms.

To assess the safety and anatomical suitability of using a Gore Iliac Branch Endoprosthesis (IBE) in aortoiliac and iliac aneurysm repair. Between 2017 and 2020, 20 patients underwent endovascular aneurysm repair (EVAR) with a Gore IBE device (bilateral IBE, n = 1) after expanding the instructions for use (IFU) criteria. We evaluated the early clinical outcomes and suitability of the IFU criteria, retrospectively. Six patients (30%) met all the IFU criteria. Anatomical suitability according to the IFU criteria for the collective total of 21 IBE limbs was confirmed for 10 (47.6%) proximal common iliac arteries, 21 (100%) external iliac arteries, 18 (85.7%) internal iliac arteries, and in the length from the lowest renal artery to the iliac bifurcation in 15 (71.8%) patients. Assisted primary technical success was achieved in all patients with various bail-out techniques. One patient (5%) required a bare-stent insertion 7days after EVAR for severe stenosis in the ipsilateral limb caused by a small terminal aorta. There was no case of occlusion of an iliac branch component device. Gore IBEs were implanted safely and effectively with various bail-out techniques to repair aortoiliac and iliac aneurysms in our Japanese patients with a low rate of inclusion IFU criteria.

Pelvic collateral pathway during endovascular aortoiliac aneurysm repair with internal iliac artery interruption: a retrospective observational study

BackgroundIpsilateral branches of the deep femoral artery (DFA) are qualitatively identified as collateral arteries based on angiography after internal iliac artery (IIA) interruption. The purpose of this study was to quantitatively identify the major collateral pathway after unilateral IIA interruption during endovascular aortoiliac aneurysm repair to preserve the pelvic circulation and reduce the risk of ischemic complications.MethodsThe study population included 28 patients (mean age 76.3 years) with aortoiliac aneurysm who underwent endovascular aneurysm repair with unilateral IIA interruption from August 2012 to January 2020. The diameters of the bilateral preoperative and postoperative DFA, lateral femoral circumflex artery (LFCA), medial femoral circumflex artery (MFCA) and obturator artery (ObA) were measured on contrast-enhanced computed tomography using a 3-dimensional image analysis system. The measured values were evaluated and analyzed with a repeated measures two-way analysis of variance and Dunnett’s test.ResultsThe postoperative diameters of the MFCA (P = 0.051) and ObA (P = 0.016) were observed to be larger than the preoperative diameters. Such increases in the MFCA (P < 0.001) and ObA (P < 0.001) diameters were only found to be significant on the unilateral side of the IIA interruption, and the diameter of the ipsilateral LFCA (P < 0.001) was also found to have significantly increased in size. However, no significant arterial extension was found on the contralateral side.ConclusionsThe ipsilateral MFCA-ObA pathway might therefore be a major collateral pathway arising from the DFA to preserve pelvic circulation after unilateral IIA interruption.

The Effect of Manufacturer's Instructions for Use Compliance on Cook ZBIS Iliac-Branched Endograft Long-Term Outcomes

Current guidelines indicate iliac-branched endografts (IBDs) as the ideal means to preserve pelvic perfusion during endovascular aortic repair. Because patient vascular anatomy represents the main limitation to extensive use of these devices, off-label application may be considered to expand the number of patients being treated. The aim of this study is to evaluate long-term outcomes obtained using the Cook ZBIS endograft in the treatment of aortoiliac aneurysms as per or outside manufacturer's instruction for use (IFU). Data from all patients who underwent IBD implant in a single center were reviewed. Study population was divided into two subgroups: Group I treated as per manufacturer's IFU and group II treated outside IFU. During the study period (2008-2018), 119 patients were treated with 130 IBDs. Eighty-six patients were treated as per IFU (group I) and 44 outside IFU (group II). Overall technical success was 99.2%. Mean follow-up was of 63.5±38.3months for group I and 58.3±35.9months for group II (P=0.45). Freedom from reintervention at ten years was 79.8% in group I and 69.6% in group II (P=0.29). Freedom from IBD-related reintervention rate was 98.7% and 95.3% in groups I and II, respectively (P=0.240). Iliac-branched module thrombosis occurred significantly more in patients treated outside IFU with 4 cases in group I (4.7%) and 10 cases in group II (22.7%), (P=0.005). Cox regression analysis identified hypogastric artery aneurysm as the only independent predictor for both IBD thrombosis and hypogastric artery occlusion during follow-up. When used by an experienced team, Cook IBDs are safe and effective in the treatment of aortoiliac aneurysms both inside and outside IFU. Anyway a lower target hypogastric patency rate should be expected when treating patients with hypogastric aneurysms.

Accuracy evaluation of patient-specific 3D-printed aortic anatomy

Introduction3D printing has a wide range of applications in medicine. In surgery, this technique can be used for preoperative planning of complex procedures, production of patient specific implants, as well as training. However, accuracy evaluations of 3D vascular models are rare. ObjectivesAim of this study was to investigate the accuracy of patient-specific 3D-printed aortic anatomies. MethodsPatients suffering from aorto-iliac aneurysms and with indication for treatment were selected on the basis of different anatomy and localization of the aneurysm in the period from January 1st 2014 to May 27th 2016. Six patients with aorto-iliac aneurysms were selected out of the database for 3D-printing. Subsequently, computed tomography (CT) images of the printed 3D-models were compared with the original CT data sets. ResultsThe mean deviation of the six 3D-vascular models ranged between −0.73 mm and 0.14 mm compared to the original CT-data. The relative deviation of the measured values showed no significant difference between the 3D-vascular and the original patient CT-data. ConclusionOur results showed that 3D printing has the potential to produce patient-specific 3D vascular models with reliable accuracy. This enables the use of such models for the development of new endovascular procedures and devices.

Contemporary Analysis of Senior Level Case Volume Variation Between Traditional Vascular Surgery Fellows and Integrated Vascular Surgery Chief Residents

A review was performed of Accreditation Council for Graduate Medical Education integrated vascular surgery, vascular surgery fellowship, and general surgery case logs for trainees graduating between 2013 and 2018. The 5+2 trainees performed a significantly greater mean volume of vascular cases compared with the 0+5 trainees by the time they had completed training. These included open repair of suprarenal aortic aneurysms (2.4 vs 1.4), thoracic aortic aneurysms (0.5 vs 0.3), endovascular repair of abdominal aortoiliac aneurysms (45 vs 28), thoracic aortic aneurysms (TEVAR; 15 vs 8), femoral-popliteal (10 vs 6) and infrapopliteal (14 vs 9) vein bypasses, carotid artery endarterectomy (47 vs 29), carotid artery stenting (10 vs 5), celiac/superior mesenteric artery endarterectomy or bypass (4 vs 2), renal artery balloon angioplasty/stenting (5 vs 3), thoracic outlet decompression (5 vs 2), arteriovenous fistulas (31 vs 16), and arteriovenous grafts (11 vs 5). The 5+2 trainees logged significantly more “senior” vascular cases than did the 0+5 trainees.

The Effect of Hypogastric Artery Revascularization on Ischemic Colitis in Endovascular Aneurysm Repair

BackgroundThe objective of the study was to examine the effect of hypogastric revascularization maneuvers on the rate of postoperative ischemic colitis among patients undergoing endovascular aortoiliac aneurysm repair. MethodsUsing the 2011-2018 Endovascular Aneurysm Repair Procedure-Targeted American College of Surgeons National Surgical Quality Improvement Program Participant Use Files, we analyzed patients undergoing elective endovascular infrarenal aortoiliac aneurysm repairs. Using multivariable modeling techniques, a cohort of patients at high risk for postoperative ischemic colitis was identified. The outcomes of this group were then compared using Pearson's chi-square testing in accordance with whether or not they underwent hypogastric revascularization. ResultsOf 4753 patients undergoing endovascular aortoiliac aneurysm repair in the National Surgical Quality Improvement Program cohort, 1161 had concomitant hypogastric revascularization procedures. High-risk predictors of ischemic colitis included chronic obstructive pulmonary disease and concurrent renal artery or external iliac artery stenting. There was not a significant association between pelvic revascularization and postoperative ischemic colitis [1.0% with versus 0.5% without pelvic revascularization; adjusted odds ratio of ischemic colitis with revascularization 2.07 (0.96, 4.46); P = 0.06] after adjustment for patient- and procedure-related factors. In a subgroup analysis of patients with a distal aneurysm extent beyond the common iliac artery, the incidence of ischemic colitis was significantly lower in patients without pelvic revascularization (0.1% versus 1.6%, P = 0.004). ConclusionsOur analysis of patients undergoing elective endovascular repair of infrarenal aortoiliac aneurysmal disease did not find a reduced incidence of postoperative ischemic colitis in patients who received a concomitant pelvic revascularization procedure, suggesting instead that such procedural adjuncts may actually increase risk for this complication.

Parallel Placement of Excluder Legs to Treat Abdominal Aortic Aneurysms with Aortoiliac Occlusive Lesion.

The effectiveness of endovascular aneurysm repair (EVAR) has been proven, but anatomical limitations, including narrow access route, may obstruct procedure of EVAR and cause serious complications. Parallel placement of Excluder legs (W. L. Gore & Associates, Inc., Newark, DE, USA) was established to treat patients with type IIIb endoleak or those with a narrow aorta, who could not be treated using a standard main body. In this report, we applied this technique in two patients with aortoiliac aneurysms with occlusive lesion.

Predictors of Operative Mortality of 928 Intact Aortoiliac Aneurysms

The aim of this study is to identify preoperative and intraoperative factors associated with in-hospital mortality of intact abdominal aortoiliac aneurysm repair. In this observational study, prospectively collected information included demographics, risk factors, comorbidities, aneurysm characteristics (including special aneurysm presentation, i.e., inflammatory, mycotic/infected, aortocaval fistula), investigations, and operative variables. Receiver operating characteristic) curve analysis of the Glasgow aneurysm score (GAS) and the Vascular Study Group of New England (VSGNE) score was performed in the subgroup of bland aneurysms undergoing isolated elective repair. A total of 928 cases with intact aortoiliac aneurysms had an elective (n=882) or urgent (n=46) repair, associated with an in-hospital mortality of 1.7% and 8.7%, respectively (P=0.01). Open repair (n=514) was a predictor of higher mortality (3.3% vs. 0.5% for endovascular aneurysm repair [EVAR], n=414, odds ratio [OR] 7.1, P=0.003), and so was the pre-EVAR era (4.8% vs. 1.3% in the EVAR era, OR 4.0, P=0.004). Other significant predictors included the presence of abdominal/back pain (7.5% vs. 1.3%, OR=6.0, P=0.001), preoperative angiography (7% vs. 1.6%, OR=4.5, P=0.01), special aneurysm presentation (10.9% vs. 1.5%, OR=8.1, P<0.001), concomitant major procedures (19% vs. 1.7%, OR=14.0, P<0.001), serious intraoperative complications (9.1% vs. 1.5%, OR=6.6, P=0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, P<0.001), and procedure duration (270 and 150min for cases with and without mortality, respectively, P<0.001). Open repair (OR=4.5, P=0.05), special aneurysm presentation (OR=6.58, P=0.001), and concomitant major procedures (OR=14.3, P<0.001) were independent predictors of higher mortality. ROC curve analysis for the GAS (P=0.87) and VSGNE score (P=0.10) failed to demonstrate statistical significance in the subgroup of bland aneurysms undergoing isolated elective repair. Our study has demonstrated independent risk factors for mortality, which should be considered when contemplating aortoiliac aneurysm repair. We failed to externally validate the GAS and VSGNE score.

A new randomized controlled trial on abdominal aortic aneurysm repair is needed

Guidelines from societies are based on selected literature and scientific evidence preferably derived from randomized controlled trials (RCTs). Recent Society for Vascular Surgery guidelines 1 Chaikof E.L. Dalman R.L. Eskandari M.K. Jackson B. Lee W.A. Mansour A. et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg. 2018; 67: 2-77.e2 Abstract Full Text Full Text PDF PubMed Scopus (957) Google Scholar on the care of patients with abdominal aortic aneurysm (AAA) recommend an assessment of operative risk and life expectancy in contemplating open repair or endovascular aneurysm repair (EVAR) using the patients' Vascular Quality Initiative perioperative mortality risk score (level 2, evidence C). The European Society for Vascular Surgery guidelines 2 Wanhainen A. Verzini F. Van Herzeele I. Allaire E. Bown M. Cohnert T. et al. European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2019; 57 ([published correction appears in Eur J Vasc Endovasc Surg 2020;59:494]): 8-93 Abstract Full Text Full Text PDF PubMed Scopus (957) Google Scholar recommend that in most patients with suitable anatomy and reasonable life expectancy, EVAR should be considered the preferred treatment modality (recommendation 60, class IIa; evidence level B). However, in patients with long life expectancy, these guidelines recommend that open surgical repair (OSR) of AAA should be considered the preferred treatment modality (recommendation 61, class IIa, evidence level B). These recommendations are based on previous RCTs comparing OSR with EVAR for AAA. 3 EVAR Trial ParticipantsEndovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005; 365: 2179-2186 Abstract Full Text Full Text PDF PubMed Scopus (1314) Google Scholar , 4 Prinssen M. Verhoeven E.L. Buth J. Cuypers P.W. van Sambeek M.R. Balm R. et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004; 351: 1607-1618 Crossref PubMed Scopus (1634) Google Scholar , 5 Becquemin J.P. The ACE trial: a randomized comparison of open versus endovascular repair in good risk patients with abdominal aortic aneurysm. J Vasc Surg. 2009; 50: 222-224 Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar , 6 Lederle F.A. Freischlag J.A. Kyriakides T.C. Padberg Jr., F.T. Matsumura J.S. Kohler T.R. et al. Outcomes following endovascular vs open repair of abdominal aortic aneurysm: a randomized trial. JAMA. 2009; 302: 1535-1542 Crossref PubMed Scopus (837) Google Scholar New randomized controlled trials for abdominal aortic aneurysm treatment should focus on younger, good-risk patientsJournal of Vascular SurgeryVol. 73Issue 6PreviewIn their editorial, Spanos et al1 concluded that new randomized controlled trials (RCTs) are needed to compare endovascular aneurysm repair (EVAR) with open surgical repair (OSR). They observed that current surgical society guidelines depend on outdated RCTs showing perioperative superiority for EVAR that is lost during the long-term follow-up period. The shortcomings of those trials included the learning curve in the early days of EVAR, evolving approaches to reintervention, and advances in technology leading to improvements in EVAR durability. Full-Text PDF