Conventional Open Repair Research Articles

Surgical Management of Mycotic Aortic Aneurysms.

Purpose: A mycotic aneurysm is an uncommon disease associated with a high mortality rate when managed surgically. This study reviewed our experiences in the surgical management of mycotic aortic aneurysms.Methods: In total, 26 patients who underwent surgery for a mycotic aneurysm were retrospectively reviewed. The mycotic aneurysms involved the thoracic aorta in 9 patients, the thoracoabdominal aorta in 4 patients, and the abdominal aorta in 13 patients. An overt aortic rupture in the mediastinum or retroperitoneal space was detected in 4 patients. Patients were classified into one of two groups, febrile or afebrile, and background characteristics, surgical intervention, and early and late mortalities were all compared.Results: There were 19 patients who underwent open surgery, and 7 patients underwent endovascular repair. No significant differences in the clinical characteristics were found between the two groups; however, the incidence of postoperative complications was significantly higher in the febrile group than in the afebrile group (P=0.024). Overall mortality was 15.4% (4/26), and 30-day mortality was 7.7% (2/26).Conclusion: Although febrile patients had a higher incidence of postoperative complications, surgical mortality from a mycotic aneurysm was within an acceptable range. Each patient should be thoroughly evaluated and treated on a case-by-case basis, using conventional open repair, endovascular repair, or a combination of both approaches.

Is Conventional Open Repair for Abdominal Aortic Aneurysm Feasible in Nonagenarians?

Background: Although endovascular repair for abdominal aortic aneurysm has been found to be beneficial in very elderly patients, some patients have contraindications to this procedure. For nonagenarians, the results of open repair remain unclear. The purpose of this study was to compare the outcomes of open vs. endovascular repair for abdominal aortic aneurysm in nonagenarian patients.Methods and Results: Fourteen patients undergoing open surgical repair and 24 undergoing endovascular repair for abdominal aortic aneurysm were evaluated. There was no significant difference in early mortality between the open and endovascular groups (0% vs. 4.1%, p=0.16). The open repair group required much longer hospital stays (26.4 vs. 10.6 days, respectively, p=0.003). Finally, 12 patients (86%) undergoing open repair vs. 21 (88%) undergoing endovascular repair returned home (p=0.49). During a mean follow-up period of 23.4±23.5 months, cumulative estimated 1- and 3-year survival rates were 90.0% and 48.0%, respectively in the open repair group and 90.6% and 54.9%, respectively in the endovascular repair group (p=0.51).Conclusion: Although endovascular repair for abdominal aortic aneurysm was superior in terms of recovery, the results of conventional open repair were acceptable even in nonagenarian patients. Open repair remains an alternative for patients with contraindications to endovascular repair.

Clinical outcomes of single incision laparoscopic surgery and conventional laparoscopic transabdominal preperitoneal inguinal hernia repair.

BACKGROUND:Laparoscopic surgery has been a frequently performed method for inguinal hernia repair. Studies have demonstrated that the laparoscopic transabdominal preperitoneal (TAPP) approach is an appropriate choice for inguinal hernia repair. Single-incision laparoscopic surgery (SILS) was developed to improve the cosmetic effects of conventional laparoscopy. The aim of this study was to evaluate the safety and feasibility of SILS-TAPP compared with TAPP technique.MATERIALS AND METHODS:A total of 148 patients who underwent TAPP or SILS-TAPP in our surgery clinic between December 2012 and January 2015 were enrolled. Data including patient demographics, hernia characteristics, operative time, intraoperative and postoperative complications, length of hospital stay and recurrence rate were retrospectively collected.RESULTS:In total, 60 SILS-TAPP and 88 TAPP procedures were performed in the study period. The two groups were similar in terms of gender, type of hernia, and American Society of Anesthesiologists (ASA) classification score. The patients in the SILS-TAPP group were younger when compared the TAPP group. Port site hernia (PSH) rate was significantly high in the SILS-TAPP group, and all PSHs were recorded in patients with severe comorbidities. The mean operative time has no significant difference in two groups. All SILS procedures were completed successfully without conversion to conventional laparoscopy or open repair. No intraoperative complication was recorded. There was no recurrence during the mean follow-up period of 15.2 ± 3.8 months.CONCLUSION:SILS TAPP for inguinal hernia repair seems to be a feasible, safe method, and is comparable with TAPP technique. However, randomized trials are required to evaluate long-term clinical outcomes.

Achilles Tendons Total Rupture, Open Surgical Treatment with PRF Augmentation: Clinical, Morphological and Functional Evaluation

Background: Changes in tendon structure after its rupture may also affect the likelihood of re-injury or strain injury to the musculotendinous complex of the plantar flexor.Purpose: The aim of our study is to investigate ankle biomechanical properties and clinical features of acute rupture of the Achilles tendon treated with open suture and PRF augmentation.Study design: Cohort study (NRS).Methods: This study has been conducted on twenty patients, divided in two groups; one group underwent conventional open repair of the Achilles tendon using the Krackow technique only, while the other group underwent surgery with Platelet-Rich-Fibrin (PRF) augmentation. We performed a clinical evaluation at 3 months, 6 months, and after 1 year. Morphological and functional tendons properties were analyzed by ultrasound and Gait Analysis.Results: The results obtained by the ultrasonographic assessment showed in the PRF group a statistically significant increasing of treated tendons the antero-posterior diameter, medio-lateral diameter. Statistically significant differences between the two groups have emerged in gait analysis performed with regard to network (Wnet). Furthermore, the network of healthy side and treated side was significantly different only in the group of patients not treated with PRF. Statistically significant values have emerged through the analysis of Pearson’s correlation between the diameter of the ultrasound treated tendon and the network, walking speed, swing speed and stride period.Conclusion: Treatment with suture and PRF shows significant morphological modifications and functional improvements compared to the results achieved with Achilles tendon suture without PRF.

Open Repair of Thoracoabdominal Aortic Aneurysm in Patients 50 Years Old and Younger

Evolving endovascular approaches to thoracoabdominal aortic aneurysm (TAAA) repair are attractive alternatives to the "gold standard" of conventional open TAAA repair. However, open repair may be more suitable for younger patients. We compared the outcomes of open TAAA repair in younger (≤50 years) and older (>50 years) patients to evaluate operative risk in younger patients. We analyzed retrospective and prospective data from 3,346 cases of open TAAA repair performed between 1986 and 2015. Of those patients, 445 (13.3%) were 50 years old or younger and 2,901 (86.7%) were older than 50 years at the time of repair. In the younger cohort, 237 patients (53.3%) had connective tissue disorder, and many (n= 359, 80.7%) had aortic dissection. Younger patients tended to be in good health, and rupture was uncommon (n= 11, 2.5%). The outcomes examined included adverse event, a composite endpoint that comprised operative death or persistent stroke, paraplegia, paraparesis, or renal failure requiring dialysis. Comparisons between the two age groups showed that younger patients underwent more extent II repairs, urgent/emergent repairs, and visceral artery bypass procedures and had longer aortic clamp times. Nevertheless, younger patients had better early outcomes than did older patients, including lower rates of operative death (3.2% vs 8.2%, p= 0.002) and adverse events (5.2% vs 15.9%, p < 0.001). Multivariable analyses determined age 50 years old or younger to be an independent predictor of reduced adverse events (relative risk ratio= 0.29, p < 0.001). Early outcomes of open TAAA repair were excellent for patients 50 years old or younger, despite the fact that these patients typically required extensive repairs.

Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts

PurposeThe study purpose was to review the outcomes of patients treated for thoracoabdominal aortic aneurysms using endovascular repair with fenestrated and branched stent-grafts in a single center. MethodsWe reviewed the clinical data of the first 185 consecutive patients (134 male; mean age, 75 ± 7 years) treated for thoracoabdominal aortic aneurysms using fenestrated and branched stent-grafts. Graft design evolved from physician-modified endografts (2007-2013) to off-the-shelf or patient-specific manufactured devices in patients enrolled in a prospective physician-sponsored investigational device exemption protocol (NCT 1937949 and 2089607). Outcomes were reported for extent IV and extent I to III thoracoabdominal aortic aneurysms, including 30-day mortality, major adverse events, patient survival, primary target vessel patency, and reintervention. ResultsA total of 112 patients (60%) were treated for extent IV thoracoabdominal aortic aneurysms, and 73 patients (40%) were treated for extent I to III thoracoabdominal aortic aneurysms. Demographics and cardiovascular risk factors were similar in both groups. A total of 687 renal-mesenteric arteries (3.7 vessels/patient) were targeted by 540 fenestrations and 147 directional branches. Technical success was 94%. Thirty-day mortality was 4.3%, including a mortality of 1.8% for extent IV and 8.2% for extent I to III thoracoabdominal aortic aneurysms (P = .03). Mortality decreased in the second half of clinical experience from 7.5% to 1.2%, including a decrease of 3.3% to 0% for extent IV thoracoabdominal aortic aneurysms (P = .12) and 15.6% to 2.4% for extent I to III thoracoabdominal aortic aneurysms (P = .04). Early major adverse events occurred in 36 patients (32%) with extent IV thoracoabdominal aortic aneurysms and 26 patients (36%) with extent I to III thoracoabdominal aortic aneurysms, including spinal cord injury in 2 patients (1.8%) and 4 patients (3.2%), respectively. Mean follow-up was 21 ± 20 months. At 5 years, patient survival (56% and 59%, P = .37) and freedom from any reintervention (50% and 53%, P = .26) were similar in those with extent IV and extent I to III thoracoabdominal aortic aneurysms. Primary patency was 93% at 5 years. ConclusionsEndovascular repair of thoracoabdominal aortic aneurysms can be performed with high technical success and low mortality and morbidity. However, the need for secondary reinterventions and continued graft surveillance represents major limitations compared with results of conventional open surgical repair. Long-term follow-up is needed before the widespread use of these techniques in younger or lower-risk patients.

Fenestrated Aortic Endografts in the Last 3 Years: An Update

Fenestrated endovascular aortic aneurysm repair (FEVAR) is an accepted treatment option for patients who are not suitable for conventional endovascular aortic aneurysm repair or open surgical repair (OSR). Five years ago, the FDA approved the use of FEVAR in patients with inadequate infrarenal aortic seal zones (short necks). This procedural paradigm continues to gain in popularity compared to OSR for complex aortic disease. We seek to define the current state of fenestrated endovascular repair by reviewing relevant literature over the past 3 years. FEVAR continues to prove to be efficacious with reasonable durability as a therapy for patients who are not candidates for OSR. As a second-line treatment, FEVAR is less morbid in the short-term with trade-off of high reintervention rates in the follow-up period. Mid- to long-term outcomes have proven to be comparable to OSR in selected patients with persistent excellent patency of the visceral target vessels. Recent publications have thrust FEVAR into consideration as the primary interventional modality in juxtarenal abdominal aortic aneurysms, a traditional indication for OSR. As FEVAR continues to evolve from surgeon-modified devices to custom built and eventually off-the-shelf grafts, it is anticipated to be employed widely for managing complex aortic aneurysms. Compared to OSR, FEVAR carries a low risk of perioperative morbidity while demonstrating continued safety and durability in early to mid-term reports.

Complementary roles of open and hybrid approaches to thoracoabdominal aortic aneurysm repair

Thoracoabdominal aortic aneurysm (TAAA) repair remains a significant challenge with considerable perioperative morbidity and mortality. A hybrid approach utilizing visceral debranching with endovascular aneurysm exclusion has been used to treat high-risk patients and therefore allow repair in more patients. Limited data exist regarding long-term outcomes with this procedure as well as comparison to conventional open repair. This study describes our institutional algorithmic approach to TAAA repair using both open and hybrid techniques. Hybrid and open TAAA repairs performed between July 2005 and August 2015 were identified from a prospectively maintained institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term and aorta-specific survival were calculated and compared between the two groups. During the study period, 165 consecutive TAAA repairs were performed, including 84 open repairs and 81 hybrid repairs. Patients in the hybrid repair group were significantly older, were more frequently female, and had a generally greater comorbid disease burden, including significantly more chronic kidney disease. Despite the older and sicker cohort, there was no difference in in-hospital mortality between the two groups (9.9% hybrid vs 7.1% open; P= .59). Major morbidity rates differed by procedure, with patients undergoing open repair having a significantly higher rate of postoperative stroke (9.5% open vs 0% hybrid; P= .017), whereas patients undergoing hybrid repair had a higher rate ofnew permanent dialysis (14.8% hybrid vs 3.6% open; P= .043). There was no difference between groups in the rate of postoperative permanent paraplegia/paresis (8.3% open vs 7.4% hybrid; P= .294). There was a significantly increased rate of reintervention in the hybrid repair group (12.3% hybrid vs 1.2% open, P= .004), with all hybrid reinterventions performed because of endoleak. One-year survival was similar between groups at 69% in hybrid repairs vs 77% in open repairs. Long-term survival was worse in the hybrid group (5-year survival, 32% hybrid vs 56% open), although late survival appeared to be influenced mainly by comorbid disease burden, given the similar long-term aorta-specific survival between groups. Use of an algorithmic approach whereby higher risk patients with TAAA are treated by a hybrid approach and lower risk patients with conventional open repair yields satisfactory short- and long-term outcomes. The availability of multiple options for TAAA repair within a single center likely allows repair in more patients with consequent decrease in the risk of aorta-related death, at the expense of increased reinterventions for endoleak.

A Simplified Arch Debranching Technique for Hybrid Repair of Complicated Type B Aortic Dissection

Convenient procedures and fewer postoperative adverse events of an arch debranching technique are important factors that need to be considered for assured outcomes of hybrid repair. In this report we describe our hybrid repair with a simplified arch debranching technique. It was used for patients with complicated type B aortic dissection who had undergone previous operations for type A aortic dissection. With this technique, the treatment for complicated type B aortic dissection becomes easier and less invasive, which is especially advantageous for patients with high surgical risk for conventional open repair.

Thoracic stent graft versus surgery for thoracic aneurysm.

Thoracic aortic aneurysm (TAA) is an uncommon disease with an incidence of 10.4 per 100,000 inhabitants. It occurs mainly in older individuals and is evenly distributed among both sexes. There are no signs or symptoms indicative of the presence of the disease. Progressive but unpredictable enlargement of the dilated aorta is the natural course of the disease and can lead to rupture. Open chest surgical repair using prosthetic graft interposition has been a conventional treatment for TAAs. Despite improvements in surgical procedures perioperative complications remain significant. The alternative option of thoracic endovascular aneurysm repair (TEVAR) is considered a less invasive and potentially safer technique, with lower morbidity and mortality compared with conventional treatment. Evidence is needed to support the use of TEVAR for these patients, rather than open surgery. This is an update of the review first published in 2009. This review aimed to assess the efficacy of TEVAR versus conventional open surgery in patients with thoracic aortic aneurysms. For this update the Cochrane Vascular Information Specialist searched the Specialised Register (last searched January 2016) and CENTRAL (2015, Issue 12). Randomised controlled trials in which patients with TAAs were randomly assigned to TEVAR or open surgical repair. Two review authors independently identified and evaluated potential trials for eligibility. Excluded studies were further checked by another author. We did not perform any statistical analyses as no randomised controlled trials were identified. We did not find any published or unpublished randomised controlled trials comparing TEVAR with conventional open surgical repair for the treatment of thoracic aortic aneurysms. Stent grafting of the thoracic aorta is technically feasible and non-randomised studies suggest reduction of early outcomes such as paraplegia, mortality and hospital stay. High quality randomised controlled trials assessing all clinically relevant outcomes including open-conversion, aneurysm exclusion, endoleaks, and late mortality are needed.

Laparoscopic Repair of Inguinal Hernia : Early Experience in A Tertiary Care Hospital

Background : The introduction of laparoscopic techniques has added a new dimension to groin hernia surgery. The laparoscopic repair of inguinal hernia has had a staggering beginning in the surgical arena. Laparoscopic repairs have had to compete with the current gold standard for inguinal hernia repair ie Liechtenstein repair. This study shows the results of laparoscopic inguinal hernia repair in comparison to open repair in a similar group of patients.Methods and materials : This is a prospective study done on 50 male patient of inguinal hernia aging from 18- 65years. Among 50 patients selected for study 25 patient underwent open hernioplasty and 25 patient underwent laparoscopic hernioplasty. In the laparoscopic group, in 20 patients (80%) TAPP procedure was done &amp; in 5 patients (20%) TEP procedure was done.Aims and Objective : The aim of this study is to compare the effectiveness and safety of laparoscopic and conventional open repair, in the treatment of inguinal hernia.Results : Average operating time in open procedure was 55±12 minutes, and in laparoscopic procedure 65±10 minutes. Opoid analgesics were required in 36% patient in open group and 16% in laparoscopy group. Within 7 days most of the patient (76%) in laparoscopic group returned to their normal activity, but in the open group 92% patient required more than 7 days to return to normal activity. Post operative complication like hematoma formation (8%), Testicular pain (8%), retention of urine (3%), and mesh infection (4%) was more in open repair than in laparoscopic repair. In Laparoscopic group 1patient (5%) had bladder injury, and 1 patient (5%) developed illeus.Conclusion : Early results of laparoscopic inguinal hernia repair are encouraging, but the chance of organ injury like bladder, or major vessel injury are more. So laparoscopic repair of inguinal hernia should only be practiced with adequate training and experience in laparoscopic surgery.Bangladesh Crit Care J March 2016; 4 (1): 19-22

Multivariate Analysis of Risk Factors of Cerebral Infarction in 439 Patients Undergoing Thoracic Endovascular Aneurysm Repair.

The aim of the study is to identify the potential risk factors of cerebral infarction associated with thoracic endovascular aneurysm repair (TEVAR).TEVAR was developed as a less invasive surgical alternative to conventional open repair for thoracic aortic aneurysm treatment. However, outcomes following TEVAR of aortic and distal arch aneurysms remain suboptimal. Cerebral infarction is a major concern during the perioperative period.We included 439 patients who underwent TEVAR of aortic aneurysms at a high-volume teaching hospital between July 2006 and June 2013. Univariate and multivariate logistic regression analyses were performed to identify perioperative cerebral infarction risk factors.Four patients (0.9%) died within 30 days of TEVAR; 17 (3.9%) developed cerebral infarction. In univariate analysis, history of ischemic heart disease and cerebral infarction and concomitant cerebrovascular disease were significantly associated with cerebral infarction. “Shaggy aorta” presence, left subclavian artery coverage, carotid artery debranching, and pull-through wire use were identified as independent risk factors of cerebral infarction. In multivariate analysis, history of ischemic heart disease (odds ratio [OR] 6.49, P = 0.046) and cerebral infarction (OR 43.74, P = 0.031), “shaggy aorta” (OR 30.32, P < 0.001), pull-through wire use during surgery (OR 7.196, P = 0.014), and intraoperative blood loss ≥800 mL (OR 24.31, P = 0.017) were found to be independent risk factors of cerebral infarction.This study identified patient- and procedure-related risk factors of cerebral infarction following TEVAR. These results indicate that patient outcomes could be improved through the identification and management of procedure-related risk factors.

Thoracoabdominal aortic aneurysm (extent II) repair in a patient with systemic vasculitis.

Conventional open repair is a gold standard for treating thoracoabdominal aortic aneurysm (TAAA) in patients with connective tissue disorders or systemic vasculitis. In a 42-year-old male patient with systemic vasculitis, TAAA extent II open repair was performed at our hospital. Here, we present the case with a video clip and technical tips.

Endovascular repair or open repair for ruptured abdominal aortic aneurysm: a Cochrane systematic review

ObjectivesEmergency endovascular aneurysm repair (eEVAR) may improve outcomes for patients with ruptured abdominal aortic aneurysm (RAAA). The study aim was to compare the outcomes for eEVAR with conventional open surgical...

National trends in utilization and outcome of thoracic endovascular aortic repair for traumatic thoracic aortic injuries

Endovascular repair of traumatic thoracic aortic injuries (TTAI) is an alternative to conventional open surgical repair. Single-institution studies have shown a survival benefit with thoracic endovascular aortic repair (TEVAR), but whether this is being realized nationally is not clear. The purpose of our study was to document trends in the increase in use of TEVAR and its effect on outcomes of TTAI nationally. Patients admitted with a TTAI between 2005 and 2011 were identified in the National Inpatient Sample. Patients were grouped by treatment into TEVAR, open repair, or nonoperative management. Primary outcomes were relative use over time and in-hospital mortality. Secondary outcomes included postoperative complications and length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality. Included were 8384 patients, with 2492 (29.7%) undergoing TEVAR, 848 (10.1%) open repair, and 5044 (60.2%) managed nonoperatively. TEVAR became the dominant treatment option for TTAI during the study period, starting at 6.5% of interventions in 2005 and accounting for 86.5% of interventions in 2011 (P< .001). Nonoperative management declined concurrently with the widespread of adoption TEVAR (79.8% to 53.7%; P< .001). In-hospital mortality after TEVAR decreased during the study period from 33.3% in 2005 to 4.9% in 2011 (P< .001), and an increase in mortality was observed for open repair from 13.9% to 19.2% (P< .001). Procedural mortality (TEVAR or open repair) decreased from 14.9% to 6.7% (P< .001), and mortality after any TTAI admission declined from 24.5% to 13.3% during the study period (P< .001). In addition to lower mortality, TEVAR was followed by fewer cardiac complications (4.1% vs 8.5%; P< .001), respiratory complications (47.5% vs 54.8%; P< .001), and shorter length of stay (18.4 vs 20.2days; P= .012) compared with open repair. In adjusted mortality analyses, open repair proved to be associated with twice the mortality risk compared with TEVAR (odds ratio, 2.1; 95% confidence interval, 1.6-2.7), and nonoperative management was associated with more than a fourfold increase in mortality (odds ratio, 4.5; 95% confidence interval, 3.8-5.3). TEVAR is now the dominant surgical approach in TTAI, with substantial perioperative morbidity and mortality benefits over open aortic repair. Overall mortality after admission for TTAI has declined, which is most likely the result of the replacement of open repair by TEVAR as well as the broadened eligibility for operative repair.

Laparoscopic versus open repair of duodenal perforation: a comparative study in tertiary care hospital in Uttarakhand, India

Background: Duodenal ulcer perforation is a common cause of emergency laparotomy. Minimal access surgery is opted with hesitation in most surgical units. The present study was conducted to determine the feasibility of laparoscopic repair of duodenal perforation and to compare it with the conventional open repair in our set-up. Methods: The patients admitted in a single unit of surgery department during a two year period were included in the study. All the patients were admitted in emergency with the diagnosis of duodenal perforation. These were subjected to either laparotomy or laparoscopic repair of duodenal perforation. Results were analyzed and compared. Results: Result analysis indicated laparoscopic approach to be associated with less post-operative complications and morbidity with better patient recovery. Conclusions: We concluded that minimal access approach to duodenal ulcer perforation is safe and should be offered in properly selected cases.

A comparative study on trans-umbilical single-port laparoscopic approach versus conventional repair for incarcerated inguinal hernia in children.

PURPOSE:The purpose of this study is to determine whether singleport laparoscopic repair (SLR) for incarcerated inguinal hernia in children is superior toconventional repair (CR) approaches.METHOD:Between March 2013 and September 2013, 126 infants and children treatedwere retrospectively reviewed. All the patients were divided into three groups. Group A (48 patients) underwent trans-umbilical SLR, group B (36 patients) was subjected to trans-umbilical conventional two-port laparoscopic repair (TLR) while the conventional open surgery repair (COR) was performed in group C (42 patients). Data regarding the operating time, bleeding volume, post-operative hydrocele formation, testicular atrophy, cosmetic results, recurrence rate, and duration of hospital stay of the patients were collected.RESULT:All the cases were completed successfully without conversion. The mean operative time for group A was 15 ± 3.9 min and 24 ± 7.2 min for unilateral hernia and bilateral hernia respectively, whereas for group B, it was 13 ± 6.7 min and 23 ± 9.2 min. The mean duration of surgery in group C was 35 ± 5.2 min for unilateral hernia. The recurrence rate was 0% in all the three groups. There were statistically significant differences in theoperating time, bleeding volume, post-operative hydrocele formation, cosmetic results and duration hospital stay between the three groups (P < 0.001). No statistically significant differences between SLR and TLR were observed except the more cosmetic result in SLR.CONCLUSION:SLR is safe and effective, minimally invasive, and is a new technology worth promoting.

Treatment of Abdominal Aortic Aneurysms in Cancer Patients

The aim of this study was to analyze the outcomes of oncologic patients with associated aneurysm of the abdominal aorta (AAA), treated at a specialized cancer (Ca) hospital more than a 10-year period. This was a retrospective study, and the data were obtained from our institution's prospective database. Between September 2003 and 2013, a total of 36 consecutive patients with AAA in association with Ca underwent surgical repair. Of these, 9 patients were excluded because the Ca treatment was performed at another service. Most of the patients were male (22) and the most frequent form of neoplasia was prostate Ca. Surgery for AAA repair was performed after the Ca treatment in 19 cases, before Ca treatment in 7 cases and concomitantly in 1 case. The intraoperative characteristics, treatment technique used, complications, patients' clinical evolution, and survival outcomes were analyzed. Endovascular aneurysm repair (EVAR) was used in 19 cases (70.4%) and conventional open repair (OR) in 8 cases (29.6%). Surgical treatment was uneventful in 19 cases, however, when present, postoperative complications occurred more frequently with EVAR (36.84% vs. 12.5%). There were no cases of death related to the aneurysm surgery. Most of the patients in both groups were alive at the end of the study. The probability of survival in our study was 65.8% at 3 years and 53% at 5 years, with no statistically significant difference between the EVAR and OR groups. The main cause of death was progression of the neoplastic disease. Patients who present Ca in association with AAA benefit from surgical treatment of both conditions, simultaneously or not. In these cases, it is important for the treatment to be individualized, and the disease of greater severity should be treated first. The endovascular and conventional open techniques were shown to be equivalent.

Thoracic endovascular repair (TEVAR) versus open surgery for blunt traumatic thoracic aortic injury.

Blunt traumatic thoracic aortic injury (BTAI) is a life-threatening surgical emergency associated with mortality up to 8000 per year, most commonly caused by rapid acceleration/deceleration injury sustained through motor vehicle accident and/or blunt thoracic trauma. BTAI has high pre-hospital mortality following the primary injury, with only 10% to 15% of patients surviving long enough to reach the hospital. Open surgical repair had remained the standard treatment option for BTAI since successfully introduced in 1959. However, with technological advances, thoracic endovascular repair (TEVAR) offers an alternative treatment option for BTAI. TEVAR is a less invasive surgical approach for management of these already critical patients; many reports have described favourable early outcomes.Thoracic endovascular repair may appear to be superior to open repair for treatment of BTAI. However, its long-term results and efficacy remain unknown. No randomised controlled trials (RCTs) have provided evidence to support the superiority of the endovascular approach versus open repair in the treatment of BTAI. This review aims to address this matter. To determine whether use of TEVAR for treatment of BTAI is associated with reduced mortality and morbidity when compared with conventional open surgery. The Cochrane Vascular Trials Search Co-ordinator searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 7) and clinical trials databases for details of ongoing and unpublished studies. We considered all published and unpublished randomised controlled trials (RCTs) comparing TEVAR and open surgery for BTAI. Two review authors independently reviewed all RCTs identified by the Trials Search Co-ordinator. We found no RCTs that met the inclusion criteria for this review. We found no RCTs conducted to determine whether use of TEVAR for the treatment of BTAI is associated with reduced mortality and morbidity when compared to conventional open repair. Hence, we are unable to provide any evidence to guide the treatment option for this life-threatening condition. To perform a randomised controlled trial to clarify the optimal management of BTAI would be highly challenging due to the natural history of the condition. Despite the lack of RCT evidence, clinicians are moving forward with endovascular treatment of BTAI on the basis of meta-analyses and large clinical series.

Is Conventional Open Repair Still a Good Option for Aortic Arch Aneurysm in Patients of Advanced Age?

Although thoracic endovascular aortic repair has advantages in elderly patients, it is not always applicable, and some elderly patients require open surgical repair. Between 2008 and 2014, 157 patients (11 men) older then 75 years (mean age, 79.3 ± 3.3 years) underwent conventional total arch replacement, of which 39 were emergency operations. Coexisting diseases included remote stroke in 54 patients, coronary artery disease in 64, chronic obstructive pulmonary disease in 25, and chronic kidney disease in 112. Concomitant procedures were performed in 46 patients. Mean follow-up time was 2.9 ± 1.8 years. Mean cardiopulmonary bypass time was 251.1 ± 68.4 minutes. Mean lowest nasopharyngeal temperature was 23.2° ± 3.4 °C. The hospital mortality rate was 7.6% (12 of 157) overall, 5.1% in elective cases, and 15.4% in emergency cases. Postoperative complications included permanent neurologic dysfunction in 5.7% of patients and prolonged ventilation time exceeding 72 hours in 13.4%. No spinal cord complications occurred. The 1-year and 5-year survival rates were 88.2% and 69.2% in all cases and 91.3% and 77.0% in elective cases, respectively. Univariate analysis demonstrated that risk factors for hospital death in elective cases were chronic kidney disease (odds ratio, 4.00; p = 0.028) and ventilation time exceeding 72 hours (odds ratio, 13.3; p = 0.001). Even in patients older than 75 years, recent surgical results of conventional open arch repair were acceptable, especially in elective cases. Thus, conventional open surgical aortic arch replacement remains a good option, especially in patients with preserved renal function.