Conventional Open Surgical Repair Research Articles

Endovascular Management of a Chronic Type A Aortic Dissection: Case Report.

Branched endograft exclusion of chronic type A dissections resulting from a TEVAR complication is a minimally-invasive approach to consider in very fragile patients to mitigate the potential risks associated with conventional open surgical repair.

Endovascular versus conventional open surgical repair for thoracoabdominal aortic aneurysms.

Thoracoabdominal aortic aneurysms (TAAAs) are a life-threatening condition which remain difficult to treat. Endovascular and open surgical repair (OSR) provide treatment options for patients, however, due to the lack of clinical trials comparing these, the optimum treatment option is unknown. To assess the effectiveness and safety of endovascular repair versus conventional OSR for the treatment of TAAAs. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 April 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations. We considered all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing endovascular repair to OSR for TAAAs for inclusion in the review. The main outcomes of interest were prevention of aneurysm rupture (participants without aneurysm rupture up to 5 years from intervention), aneurysm-related mortality (30 days and 12 months), all-cause mortality, spinal cord ischaemia (paraplegia, paraparesis), visceral arterial branch compromise causing mesenteric ischaemia or renal failure, and rate of reintervention. Two review authors independently screened all titles and abstracts identified from the searches to identify those that met the inclusion criteria. We planned to undertake data collection, risk of bias assessment, and analysis in accordance with Cochrane recommendations. We planned to assess the certainty of the evidence using GRADE. No RCTs or CCTs met the inclusion criteria for this review. Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of endovascular compared to OSR in patients with TAAAs and are unable to provide any evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs addressing this objective are necessary, however conducting such studies will be logistically and ethically challenging for this life-threatening disease.

Deep vein thrombosis as aprimary symptom of abdominal aortic aneurysm : Bilateral deep vein thrombosis caused by infrarenal abdominal aortic aneurysm (15 cm in diameter) with complete compression of the inferior vena cava

This article presents the case of a70-year-old obese patient with severe bilateral leg pain due to deep vein thrombosis. After unsuccessful venous recanalization, computed tomography angiography revealed an abdominal aortic aneurysm 15 cm in diameter with total compression of the inferior vena cava. For venous decompression as well as rupture prophylaxis, conventional open surgical repair was performed.

Conventional open versus hybrid aortic arch repair: a meta-analysis of propensity-matched studies.

BackgroundComparison of conventional (open) surgical versus hybrid aortic arch repair remains debatable. While the majority of previous comparative studies including meta-analyses contained primarily risk-unadjusted cohorts, those focusing on propensity-matched comparisons were limited by their small sample size. We aimed to compare outcomes of these two approaches through an up-to-date search and meta-analysis of the best evidence currently available in the literature.MethodsThe PubMed/MEDLINE, EMBASE, and Cochrane library from inception to September 2019 were searched to identify articles reporting propensity-score matching data on open versus hybrid aortic arch repair. Patients’ baseline characteristics and clinical outcomes were extracted from the articles and pooled for analysis. Heterogeneity and biases were assessed among the included studies.ResultsFive studies, including a total of 378 patients (189 pairs), were included in the study. The two groups were similar in patients’ baseline characteristics. Stroke rate favoured the open group [2.1% versus 14.3%, OR 0.18 (0.07, 0.46), P=0.0004, I2=0%]. There was no significant difference between the two groups with regard to paraplegia. The hybrid group had numerically higher short-term mortality, but lower rate of acute renal failure requiring dialysis. There was a statistically significant difference between the mid-term survivals of the open and hybrid groups, with lower pooled mortality seen for the open group at 1-year and 2-years (P=0.02).ConclusionsOpen and hybrid repairs do not offer equivalent outcomes. Compared with hybrid aortic arch repair, conventional surgical aortic repair could be associated with favourable outcomes including postoperative stroke. Hybrid repair does not appear to provide better survival. Operative approaches should be carefully selected in treating aortic arch pathology.

Hybrid repair versus conventional open repair for aortic arch dissection

A dissection of the aorta is a separation or tear of the intima from the media. This tear allows blood to flow not only through the original aortic flow channel (known as the true lumen), but also through a second channel between the intima and media (known as the false lumen). Aortic dissection is a life-threatening condition which can be rapidly fatal. There is debate on the optimal surgical approach for aortic arch dissection. People with ascending aortic dissection have poor rates of survival. Currently open surgical repair is regarded as the standard treatment for aortic arch dissection. We intend to review the role of hybrid and open repair in aortic arch dissection.To assess the effectiveness and safety of a hybrid technique of treatment over conventional open repair in the management of aortic arch dissection.The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 8 February 2021. We also undertook reference checking for additional studies.We included randomised controlled trials (RCTs) and clinical controlled trials (CCTs), which compared the effects of hybrid repair techniques versus open surgical repair of aortic arch dissection. Outcomes of interest were dissection-related mortality and all-cause mortality, neurological deficit, cardiac injury, respiratory compromise, renal ischaemia, false lumen thrombosis (defined by partial or complete thrombosis) and mesenteric ischaemia.Two review authors independently screened all records identified by the literature searches to identify those that met our inclusion criteria. We planned to undertake data collection and analysis in accordance with recommendations described in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of the evidence using GRADE.We identified one ongoing study and two unpublished studies that met the inclusion criteria for the review. Due to a lack of study data, we could not compare the outcomes of hybrid repair to conventional open repair for aortic arch dissection.This review revealed one ongoing RCT and two unpublished RCTs evaluating hybrid versus conventional open repair for aortic arch surgery. Observational data suggest that hybrid repair for aortic arch dissection could potentially be favourable, but conclusions can not be drawn from these studies, which are highly selective, and are based on the clinical status of the patient, the presence of comorbidities and the skills of the operators. However, a conclusion about its definitive benefit over conventional open surgical repair cannot be made from this review without published RCTs or CCTs. Future RCTs or CCTs need to have adequate sample sizes and follow-up, and assess clinically-relevant outcomes, in order to determine the optimal treatment for people with aortic arch dissection. It must be noted that this may not be feasible, due to the reasons mentioned.

Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms.

Thoracic aortic arch aneurysms (TAAs) can be a life-threatening condition due to the potential risk of rupture. Treatment is recommended when the risk of rupture is greater than the risk of surgical complications. Depending on the cause, size and growth rate of the TAA, treatment may vary from close observation to emergency surgery. Aneurysms of the thoracic aorta can be managed by a number of surgical techniques. Open surgical repair (OSR) of aneurysms involves either partial or total replacement of the aorta, which is dependent on the extent of the diseased segment of the aorta. During OSR, the aneurysm is replaced with a synthetic graft. Hybrid repair (HR) involves a combination of open surgery with endovascular aortic stent graft placement. Hybrid repair requires varying degrees of invasiveness, depending on the number of supra-aortic branches that require debranching. The hybrid technique that combines supra-aortic vascular debranching with stent grafting of the aortic arch has been introduced as a therapeutic alternative. However, the short- and long-term outcomes of HR remain unclear, due to technical difficulties and complications as a result of the angulation of the aortic arch as well as handling of the arch during surgery. To assess the effectiveness and safety of HR versus conventional OSR for the treatment of TAAs. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 March 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations. We considered for inclusion in the review all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing HR to OSR for TAAs. Two review authors independently screened all titles and abstracts obtained from the literature search to identify those that met the inclusion criteria. We retrieved the full text of studies deemed as potentially relevant by at least one review author. The same review authors screened the full-text articles independently for inclusion or exclusion. No RCTs or CCTs met the inclusion criteria for this review. Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of HR compared to OSR in people with TAAs, and we are unable to provide high-certainty evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs are necessary, addressing the objective of this review.

“Ring on Anastomosis” for Avoidance of Acute Proximal Anastomotic Leak after Open Surgical Repair of Abdominal Aortic Aneurysm

Acute proximal anastomotic leak is among severe complications after open surgical repair (OSR) of abdominal aortic aneurysm. We have proposed an approach of "ring on anastomosis" (ROA) as a technical improvement of conventional OSR to reinforce proximal anastomotic section. One hundred and nineteen abdominal aortic aneurysm patients admitted to Xiangya Hospital, Central South University were enrolled. Patients were randomly divided into conventional group (n=54) and ROA group (n=65). The ring is prepared by cutting out a 2-cm circle from the graft. Operative time, intraoperative blood loss, perioperative mortality, and retroperitoneal hematoma were recorded. Poisson distribution analysis was used between two groups. All methods were carried out in accordance with Declaration of Helsinki. No obvious difference in operative time or intraoperative blood loss was identified [(205.5±6.535) versus (195.6±6.034) minutes, P>0.05; (756±98.22) versus (673.1±98.93) ml, P>0.05, respectively]. Two patients in conventional group (2/54, 3.7%) died while no dead case was reported in ROA group (P=0.047). Three cases in conventional group experienced retroperitoneal hematoma while none was witnessed in ROA group (P=0.027). An average of 18months of follow-up was obtained in all patients, and no proximal anastomotic stenosis was reported. As a technical improvement of conventional OSR, ROA reinforces aorta graft anastomotic section and diminishes anastomotic leak as well as perioperative death without extra cost of time and money.

Patients with a Ruptured Abdominal Aortic Aneurysm Are Better Informed in Hospitals with an “EVAR-preferred” Strategy: An Instrumental Variable Analysis of the Dutch Surgical Aneurysm Audit

While several observational studies suggested a lower postoperative mortality after minimal invasive endovascular aneurysm repair (EVAR) in patients with a ruptured abdominal aortic aneurysm (RAAA) compared to conventional open surgical repair (OSR), landmark randomized controlled trials have not been able to prove the superiority of EVAR over OSR. Randomized controlled trials contain a selected, homogeneous population, influencing external validity. Observational studies are biased and adjustment of confounders can be incomplete. Instrumental variable (IV) analysis (pseudorandomization) may help to answer the question if patients with an RAAA have lower postoperative mortality when undergoing EVAR compared to OSR. This is an observational study including all patients with an RAAA, registered in the Dutch Surgical Aneurysm Audit between 2013 and 2017. The risk difference (RD) in postoperative mortality (30 days/in-hospital) between patients undergoing EVAR and OSR was estimated, in which adjustment for confounding was performed in 3 ways: linear model adjusted for observed confounders, propensity score model (multivariable logistic regression analysis), and IV analysis (two-stage least square regression), adjusting for observed and unobserved confounders, with the variation in percentage of EVAR per hospital as the IV instrument. 2419 patients with an RAAA (1489 OSR and 930 EVAR) were included. Unadjusted postoperative mortality was 34.9% after OSR and 22.6% after EVAR (RD 12.3%, 95% CI 8.5-16%). The RD adjusted for observed confounders using linear regression analysis and propensity score analysis was, respectively, 12.3% (95% CI 9.6-16.7%) and 13.2% (95%CI 9.3-17.1%) in favor of EVAR. Using IV analysis, adjusting for observed and unobserved confounders, RD was 8.9% (95% CI -1.1-18.9%) in favor of EVAR. Adjusting for observed confounders, patients with an RAAA undergoing EVAR had a significant better survival than OSR in a consecutive large cohort. Adjustment for unobserved confounders resulted in a clinical relevant RD. An "EVAR preference strategy" in patients with an RAAA could result in lower postoperative mortality.

Techniques and outcomes of total aortic arch repair with frozen elephant trunk for DeBakey I dissections.

Total aortic arch replacement (TAR) with frozen elephant trunk (FET) technique (FET) has been increasingly used to treat a variety of aortic pathologies over the past two decades. Because FET can effectively treat the diseased arch and cover the proximal entry tear in the distal arch, it is a valuable option in the treatment of DeBakey I aortic dissections. This report focuses on the techniques and outcomes of TAR with FET for acute/chronic aortic dissection. A review of pooled literature including 27 observational studies showed in-hospital mortality, permanent stroke, and spinal cord injury rates of 8.4%, 5.9% and 2.6% for acute aortic dissections, and 7.5%, 4.0% and 4.6% for chronic aortic dissections, respectively. In most of the studies, complete false lumen thrombosis rate was achieved in 80% of patients at the level of FET for acute and chronic aortic dissections. Mid-term outcomes are equally promising. For chronic aortic dissections, positive remodeling of the non-stented distal aortic segments is less frequent leading to secondary reinterventions within 3 to 5 years. However, most studies have not applied distal abdominal extensions of the repair using fenestrated and branched endografts. In the current endovascular era, TAR + FET should be considered as an alternative to conventional open surgical repair in centers of excellence.

Endovascular versus open repair of asymptomatic popliteal artery aneurysm.

Popliteal artery aneurysm (PAA) is a focal dilatation and weakening of the popliteal artery. If left untreated, the aneurysm may thrombose, rupture or the clot within the aneurysm may embolise causing severe morbidity. PAA may be treated surgically by performing a bypass from the arterial segment proximal to the aneurysm to the arterial segment below the aneurysm, which excludes the aneurysm from the circulation. It may also be treated by a stent graft that is inserted percutaneously or through a small cut in the groin. The success of the procedure is gauged by the ability of the graft to stay patent over an extended duration. While surgical treatment is usually preferred in an emergency, the evidence on first line treatment in a non-emergency setting is unclear. This is an update of a review first published in 2014. To assess the effectiveness of an endovascular stent graft versus conventional open surgery for the treatment of asymptomatic popliteal artery aneurysms (PAA) on primary and assisted patency rates, hospital stay, length of the procedure and local complications. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 29 January 2019. We included all randomised controlled trials (RCTs) comparing endovascular stent grafting versus conventional open surgical repair in patients undergoing unilateral or bilateral prophylactic repair of asymptomatic PAAs. We collected data on primary and assisted primary patency rates (primary endpoints) as well as operating time, the length of hospital stay, limb salvage and local wound complications (secondary endpoints). We presented results as risk ratio or mean difference with 95% confidence intervals and assessed the certainty of the evidence using GRADE. No new studies were identified for this update. A single RCT with a total of 30 PAAs met the inclusion criteria. There was a low risk of selection bias and detection bias. However, the risks of performance bias, attrition bias and reporting bias were unclear from the study. Despite being an RCT, the certainty of the evidence was downgraded to moderate due to the small sample size, resulting in wide confidence intervals (CIs); only 30 PAAs were randomised over a period of five years (15 PAAs each in the groups receiving endovascular stent graft and undergoing conventional open surgery). The primary patency rate at one year was 93.3% in the endovascular group and 100% in the surgery group (RR 0.94, 95% CI 0.78 to 1.12; moderate-certainty evidence). The assisted patency rate at one year was similar in both groups (RR 1.00, 95% CI 0.88 to 1.13; moderate-certainty evidence). There was no clear evidence of a difference between the two groups in the primary or assisted patency rates at four years (13 grafts were patent from 15 PAA treatments in each group; RR 1.00, 95% CI 0.76 to 1.32; moderate-certainty evidence); the effects were imprecise and compatible with the benefit of either endovascular stent graft or surgery or no difference. Mean hospital stay was shorter in the endovascular group (4.3 days for the endovascular group versus 7.7 days for the surgical group; mean difference (MD) -3.40 days, 95% CI -4.42 to -2.38; P < 0.001; moderate-certainty evidence). Mean operating time was also reduced in the endovascular group (75.4 minutes in the endovascular group versus 195.3 minutes in the surgical group; MD -119.90 minutes, 95% CI -137.71 to -102.09; P < 0.001; moderate-certainty evidence). Limb salvage was 100% in both groups. Data on local wound complications were not published in the trial report. Evidence to determine the effectiveness of endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs is limited to data from one small study. At one year there is moderate-certainty evidence that primary patency may be improved in the surgery group but assisted primary patency rates were similar between groups. At four years there was no clear benefit from either endovascular stent graft or surgery to primary or assisted primary patency (moderate-certainty evidence). As both operating time and hospital stay were reduced in the endovascular group (moderate-certainty evidence), it may represent a viable alternative to open repair of PAA. A large multicenter RCT may provide more information in the future. However, difficulties in recruiting enough patients are likely, unless it is an international collaboration including a number of high volume vascular centres.

Efficacy of Unibody Bifurcated Endovascular Stent-Graft Repair in the Treatment of Abdominal Aortic Aneurysm.

To compare the clinical efficacy of unibody bifurcated endovascular stent-graft repair versus conventional open surgery for abdominal aortic aneurysm (AAA). Interventional study. Department of Vascular Surgery, Gansu Province People's Hospital, China, from January 2015 to December 2016. A total of 80 patients with AAA were randomly divided into Group A and Group B, with 40 cases in each group. Group A was treated with conventional open surgical repair, and Group B was treated with unibody bifurcated endovascular stent-graft repair. The efficacy of the two groups was compared. The operation time, intraoperative blood loss, postoperative ambulation time, and postoperative hospital stay in Group B were all lower than those in Group A (all p <0.001). The incidence of pulmonary complications and electrolyte imbalance in Group B were lower than those in Group A (p=0.026 and p <0.001, respectively). The survival rate of patients in Group B at 6 months, 12 months and 24 months after operation was higher than that of Group A (p=0.002, 0.002 and 0.005, respectively). Unibody bifurcated endovascular stent-graft repair for abdominal aortic aneurysm has advantages of short operation time, little trauma, short recovery time, high safety and efficacy compared with the conventional open surgery.

Contemporary imaging methods for the follow-up after endovascular abdominal aneurysm repair: a review.

Abdominal aortic aneurysm (AAA) is defined as a localized enlargement of the aortic cross-section where the diameter is greater than 3 cm or more than 50% larger than the diameter in a normal segment. The most important complication of AAA is rupture, which, if untreated, results in mortality rates of up to 90%. Conventional open surgical repair is associated with significant 30-day mortality. Endovascular aneurysm repair (EVAR) is a significantly less invasive procedure; it is related to a lower early mortality rate and a lower number of perioperative complications. Although EVAR is a minimally invasive technique, lifelong follow-up imaging is necessary due to possible late complications including endoleak, recurrent aneurysm formation, graft infection, migration, kinking and thrombosis. The total rate of complications after EVAR is estimated at approximately 30%, and the rate of complications that require intervention is 2–3%. Early detection and progression analysis of such situations is crucial for proper intervention.

Aberrant subclavian: new face of an old disease.

An aneurysm of an aberrant subclavian artery is un usual prevalence of anomalies of aortic arch, with a literature reported prevalence of 2%. Timely elective intervention is of paramount. The advancement in stenting techniques has promoted this practice to be an alternative to conventional open surgical repair which is associated with high rates of perioperative complications including mortality outcomes. However, new faces of this old disease are emerging as we move to novelty and innovation era. We discuss in this review the advancements in this disease entity highlighting and collecting the world experiences.

Endovascular versus conventional open surgical repair for thoracoabdominal aortic aneurysms

Endovascular versus conventional open surgical repair for thoracoabdominal aortic aneurysms

Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms

BACKGROUND Thoracic aortic arch aneurysms (TAAs) can be a life-threatening condition due to the potential risk of rupture. Treatment is recommended when the risk of rupture is greater than the risk of surgical complications. Depending on the cause, size and growth rate of the TAA, treatment may vary from close observation to emergency surgery. Aneurysms of the thoracic aorta can be managed by a number of surgical techniques. Open surgical repair (OSR) of aneurysms involves either partial or total replacement of the aorta, which is dependent on the extent of the diseased segment of the aorta. During OSR, the aneurysm is replaced with a synthetic graft. Hybrid repair (HR) involves a combination of open surgery with endovascular aortic stent graft placement. Hybrid repair requires varying degrees of invasiveness, depending on the number of supra-aortic branches that require debranching. The hybrid technique that combines supra-aortic vascular debranching with stent grafting of the aortic arch has been introduced as a therapeutic alternative. However, the short- and long-term outcomes of HR remain unclear, due to technical difficulties and complications as a result of the angulation of the aortic arch as well as handling of the arch during surgery. OBJECTIVES To assess the effectiveness and safety of HR versus conventional OSR for the treatment of TAAs. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 March 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations. SELECTION CRITERIA We considered for inclusion in the review all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing HR to OSR for TAAs. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts obtained from the literature search to identify those that met the inclusion criteria. We retrieved the full text of studies deemed as potentially relevant by at least one review author. The same review authors screened the full-text articles independently for inclusion or exclusion. MAIN RESULTS No RCTs or CCTs met the inclusion criteria for this review. AUTHORS' CONCLUSIONS Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of HR compared to OSR in people with TAAs, and we are unable to provide high-certainty evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs are necessary, addressing the objective of this review.

Epidemiology and contemporary management of abdominal aortic aneurysms.

Abdominal aortic aneurysm (AAA) is most commonly defined as a maximal diameter of the abdominal aorta in excess of 3 cm in either anterior-posterior or transverse planes or, alternatively, as a focal dilation ≥1.5 times the diameter of the normal adjacent arterial segment. Risk factors for the development of AAA include age >60, tobacco use, male gender, Caucasian race, and family history of AAA. Aneurysm growth and rupture risk appear to be associated with persistent tobacco use, female gender, and chronic pulmonary disease. The majority of AAAs are asymptomatic and detected incidentally on various imaging studies, including abdominal ultrasound, and computed tomographic angiography. Symptoms associated with AAA may include abdominal or back pain, thromboembolization, atheroembolization, aortic rupture, or development of an arteriovenous or aortoenteric fistula. The Screening Abdominal Aortic Aneurysms Efficiently (SAAAVE) Act provides coverage for a one-time screening abdominal ultrasound at age 65 for men who have smoked at least 100 cigarettes and women who have family history of AAA disease. Medical management is recommended for asymptomatic patients with AAAs <5 cm in diameter and focuses on modifiable risk factors, including smoking cessation and blood pressure control. Primary indications for intervention in patients with AAA include development of symptoms, rupture, rapid aneurysm growth (>5 mm/6 months), or presence of a fusiform aneurysm with maximum diameter of 5.5 cm or greater. Intervention for AAA includes conventional open surgical repair and endovascular aortic stent graft repair.

Endovascular treatment for ruptured abdominal aortic aneurysm.

An abdominal aortic aneurysm (AAA) (pathological enlargement of the aorta) is a condition that can occur as a person ages. It is most commonly seen in men older than 65 years of age. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, which is fatal unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. Endovascular aneurysm repair (EVAR), a minimally invasive technique, has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. More recently emergency endovascular aneurysm repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in select patients; however, it is unclear if eEVAR will lead to significant improvements in outcomes for these patients or if indeed it can replace conventional open repair as the preferred treatment for this lethal condition. This is an update of the review first published in 2006. To assess the advantages and disadvantages of emergency endovascular aneurysm repair (eEVAR) in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm (RAAA). This will be determined by comparing the effects of eEVAR and conventional open surgical repair on short-term mortality, major complication rates, aneurysm exclusion (specifically endoleaks in the eEVAR treatment group), and late complications. For this update the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (last searched June 2016), CENTRAL (2016, Issue 5), and trials registries. We also checked reference lists of relevant publications. Randomised controlled trials in which participants with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair. Two review authors independently assessed studies identified for potential inclusion for eligibility. Two review authors also independently completed data extraction and quality assessment. Disagreements were resolved through discussion. We performed meta-analysis using fixed-effect models with odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data and mean differences with 95% CIs for continuous data. We included four randomised controlled trials in this review. A total of 868 participants with a clinical or radiological diagnosis of RAAA were randomised to receive either eEVAR or open surgical repair. Overall risk of bias was low, but we considered one study that performed randomisation in blocks by week and performed no allocation concealment and no blinding to be at high risk of selection bias. Another study did not adequately report random sequence generation, putting it at risk of selection bias, and two studies were underpowered. There was no clear evidence to support a difference between the two interventions for 30-day (or in-hospital) mortality (OR 0.88, 95% CI 0.66 to 1.16; moderate-quality evidence). There were a total of 44 endoleak events in 128 participants from three studies (low-quality evidence). Thirty-day complication outcomes (myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation, and respiratory failure) were reported in between one and three studies, therefore we were unable to draw a robust conclusion. We downgraded the quality of the evidence for myocardial infarction, renal complications, and respiratory failure due to imprecision, inconsistency, and risk of bias. Odds ratios for complications outcomes were OR 2.38 (95% CI 0.34 to 16.53; 139 participants; 2 studies; low-quality evidence) for myocardial infarction; OR 1.07 (95% CI 0.21 to 5.42; 255 participants; 3 studies; low-quality evidence) for renal complications; and OR 3.62 (95% CI 0.14 to 95.78; 32 participants; 1 study; low-quality evidence) for respiratory failure. There was low-quality evidence of a reduction in bowel ischaemia in the eEVAR treatment group, but very few events were reported (OR 0.37, 95% CI 0.14 to 0.94), and we downgraded the evidence due to imprecision and risk of bias. Six-month and one-year outcomes were evaluated in three studies, but only results from a single study could be used for each outcome, which showed no clear evidence of a difference between the interventions. We rated six-month mortality evidence as of moderate quality due to imprecision (OR 0.89, 95% CI 0.40 to 1.98; 116 participants). The conclusions of this review are currently limited by the paucity of data. We found from the data available moderate-quality evidence suggesting there is no difference in 30-day mortality between eEVAR and open repair. Not enough information was provided for complications for us to make a well-informed conclusion, although it is possible that eEVAR is associated with a reduction in bowel ischaemia. Long-term data were lacking for both survival and late complications. More high-quality randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.

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.

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.