Elective AAA Repair Research Articles

Fenofibrate in the management of AbdoMinal aortic anEurysm (FAME): study protocol for a randomised controlled trial

BackgroundAbdominal aortic aneurysm (AAA) is a slowly progressive destructive process of the main abdominal artery. Experimental studies indicate that fibrates exert beneficial effects on AAAs by mechanisms involving both serum lipid modification and favourable changes to the AAA wall.Methods/designFenofibrate in the management of AbdoMinal aortic anEurysm (FAME) is a multicentre, randomised, double-blind, placebo-controlled clinical trial to assess the effect of orally administered therapy with fenofibrate on key pathological markers of AAA in patients undergoing open AAA repair. A total of 42 participants scheduled for an elective open AAA repair will be randomly assigned to either 145 mg of fenofibrate per day or identical placebo for a minimum period of 2 weeks prior to surgery. Primary outcome measures will be macrophage number and osteopontin (OPN) concentration within the AAA wall as well as serum concentrations of OPN. Secondary outcome measures will include levels of matrix metalloproteinases and proinflammatory cytokines within the AAA wall, periaortic fat and intramural thrombus and circulating concentrations of AAA biomarkers.DiscussionAt present, there is no recognised medical therapy to limit AAA progression. The FAME trial aims to assess the ability of fenofibrate to alter tissue markers of AAA pathology.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12612001226897. Registered on 20 November 2012.

Effect of Day of the Week on Mortality and Cardiovascular Outcomes Following Elective AAA Repair and Lower Limb Revascularizations: A Population-Based Study

Effect of Day of the Week on Mortality and Cardiovascular Outcomes Following Elective AAA Repair and Lower Limb Revascularizations: A Population-Based Study

Patients with familial abdominal aortic aneurysms are at increased risk for endoleak and secondary intervention following elective endovascular aneurysm repair

A recent investigation has documented an increased risk of aneurysm-related complications after endovascular aneurysm repair (EVAR) of familial abdominal aortic aneurysms (fAAAs). We hypothesized that fAAA patients are not at increased risk for complications following open AAA repair or EVAR when compared with sporadic abdominal aortic aneurysm (spAAA) patients. To this end, we performed a single institution retrospective review. Epidemiologic data were collected through the electronic medical record. Family history data were obtained from a questionnaire administered at the initial vascular surgery consultation. Major adverse events were defined as myocardial infarction, respiratory failure, renal failure, bowel ischemia, limb ischemia, multisystem organ failure, intracranial hemorrhage, paraplegia, hemorrhage, or death. Endoleaks were classified in accordance with the standardized reporting practices of the Society for Vascular Surgery. AAA-related complications were defined as the need for a secondary intervention due to endoleak, limb ischemia, or postimplantation rupture. A total of 392 patients with complete clinical data underwent elective AAA repair from 2004 to 2014. Of these 392 patients, 89 (23%) were classified as fAAA patients and 303 (77%) were classified as spAAA patients. With the exception of increased rates of chronic obstructive pulmonary disease (P= .0009) and pack-years smoked (P= .03) in spAAA patients, demographics did not differ. Sixty-two percent (n= 55) of fAAA patients and 68% (n= 205) of spAAA patients underwent EVAR (P= .30). fAAA patients did not incur any significant difference in major adverse events following open AAA repair (fAAA, 9% vs spAAA, 11%; P= .75). Additionally, fAAA patients did not incur any significant difference in major adverse events following EVAR (fAAA, 4% vs spAAA, 5%; P= .70). Patients with fAAA did have a significantly increased rate of endoleak (fAAA, 24% vs spAAA, 12%; P= .03) and secondary intervention following EVAR (fAAA, 21% vs spAAA, 12%; P= .04). The current study shows that patients with fAAA do not have increased perioperative morbidity following open or endovascular AAA repair. However, patients with fAAA do have an increased risk of endoleak and secondary intervention following EVAR. These findings suggest that EVAR and open AAA repair are both safe and effective for fAAA patients. The increased rate of endoleak and secondary intervention in patients with fAAA suggests that this subpopulation may benefit from closer post-EVAR surveillance or open surgical repair in good risk patients.

A randomized clinical trial of ascorbic acid in open abdominal aortic aneurysm repair.

BackgroundOpen AAA repair is associated with ischaemia-reperfusion injury where systemic inflammation and endothelial dysfunction can lead to multiple organ injury including acute lung injury. Oxidative stress plays a role that may be inhibited by ascorbic acid.MethodsA double blind, allocation concealed, randomized placebo-controlled trial was performed to test the hypothesis that a single bolus dose (2g) of intra-operative parenteral ascorbic acid would attenuate biomarkers of ischaemia-reperfusion injury in patients undergoing elective open AAA repair.ResultsThirty one patients completed the study; 18 received placebo and 13 ascorbic acid. Groups were comparable demographically. Open AAA repair caused an increase in urinary Albumin:Creatinine Ratio (ACR) as well as plasma IL-6 and IL-8. There was a decrease in exhaled breath pH and oxygenation. Lipid hydroperoxides were significantly higher in the ascorbic acid group following open AAA repair. There were no other differences between the ascorbic acid or placebo groups up to 4 hours after removal of the aortic clamping.ConclusionsOpen AAA repair caused an increase in markers of systemic endothelial damage and systemic inflammation. Administration of 2g parenteral ascorbic acid did not attenuate this response and with higher levels of lipid hydroperoxides post-operatively a pro-oxidant effect could not be excluded.Trial registrationISRCTN27369400

Effect of Day of the Week on Mortality and Cardiovascular Outcomes Following Elective AAA Repair and Lower Limb Revascularizations: A Population-Based Study

Effect of Day of the Week on Mortality and Cardiovascular Outcomes Following Elective AAA Repair and Lower Limb Revascularizations: A Population-Based Study Luc Dubois, Jennifer Winick-Ng, Andrew McClure, Kelly Vogt, Chris Vinden, Adam Power, Guy DeRose, Amit Garg. Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, London, Ontario, Canada; LHSC Victoria Hospital, London, Ontario, Canada; University of Western Ontario, London Health Science Centre, London, Ontario, Canada; Institure for Clinical Evaluative Sciences Western, London, Ontario, Canada

Is a gap between perceived and actual practice in informed consent for elective AAA repair: An example of a wider problem in surgical practice?

Is a gap between perceived and actual practice in informed consent for elective AAA repair: An example of a wider problem in surgical practice?

Reintervention after EVAR and Open Surgical Repair of AAA

This study examined the frequency and reason for reinterventions and their impact on survival in contemporaneously treated cohorts of EVAR and open surgical repair (OSR) patients. EVAR has largely replaced OSR for anatomically appropriate AAA because of improved short-term outcomes. However, EVAR is associated with a notable reintervention rate. Data for patients undergoing elective AAA repair between 1996 and 2011 were collected and analyzed to assess time from initial procedure to reintervention and rate of reintervention. Patient demographics, comorbidities, number and type of reinterventions, graft type, and timing of reintervention were analyzed. A total of 1144 patients underwent AAA repair; 558 had EVAR and 586 had OSR. In 76 EVAR patients, 123 reinterventions were performed; 46 reinterventions were performed in 30 OSR patients (P < 0.0001). Endoleak was responsible for 66% of EVAR reinterventions; colonic ischemia, bleeding, and incisional hernias caused 30%, 22%, and 22% of OSR reinterventions, respectively. Time to first reintervention was shorter in OSR patients (P < 0.001) and was related to AAA size (P < 0.001). Early reintervention at the index procedure in OSR patients had a 23% mortality rate. If reinterventions were not required, survival curves were similar. Current endografts require fewer reinterventions than earlier generation endografts. Reintervention was more common with EVAR and occurred later. Early reintervention after OSR is associated with significant mortality. If early reintervention in OSR patients can be avoided, there is no early survival advantage to EVAR. Current endografts require fewer reinterventions than earlier devices.

Early and Late Outcomes Following Abdominal Aortic Aneurysm Repair Requiring a Suprarenal Cross-Clamp

METHODS: Patients from 1998-2011 who required a suprarenal aortic crossclamp during elective open AAA repair were reviewed. Data abstracted included demographics, comorbidities, preoperative, perioperative, and late renal function; late interventions related to AAA repair, and late mortality. A decrease in renal function was defined as a >30% decline in eGFR as compared to the preoperative value. Primary outcomes included renal function, intervention free survival and overall survival.

Risk Models for Mortality Following Elective Open and Endovascular Abdominal Aortic Aneurysm Repair: A Single Institution Experience

Objectives: To develop and validate an “in house” risk model for predicting perioperative mortality following elective AAA repair and to compare this with other models. Design: Multivariate logistics regression analysis was used to identify risk factors for perioperative-day mortality from one tertiary institution's prospectively maintained database. Materials and methods: Consecutive elective open (564) and endovascular (589) AAA repairs (2000–2010) were split randomly into development (810) and validation (343) data sets. The resultant model was compared to Glasgow Aneurysm Score (GAS), Modified Customised Probability Index (m-CPI), CPI, the Vascular Governance North West (VGNW) model and the Medicare model. Results: Variables associated with perioperative mortality included: increasing age (P = 0.034), myocardial infarct within last 10 years (P = 0.0008), raised serum creatinine (P = 0.005) and open surgery (P = 0.0001). The areas under the receiver operating characteristic curve (AUC) for predicted probability of 30-day mortality in development and validation data sets were 0.79 and 0.82 respectively. AUCs for GAS, m-CPI and CPI were poor (0.63, 0.58 and 0.58 respectively), whilst VGNW and Medicare model were fair (0.73 and 0.79 respectively). Conclusions: In this study, an “in-house” developed and validated risk model has the most accurate discriminative value in predicting perioperative mortality after elective AAA repair. For purposes of comparative audit with case mix adjustments, national models such as the VGNW or Medicare models should be used.

Risk Models for Mortality Following Elective Open and Endovascular Abdominal Aortic Aneurysm Repair: A Single Institution Experience

ObjectivesTo develop and validate an “in house” risk model for predicting perioperative mortality following elective AAA repair and to compare this with other models. DesignMultivariate logistics regression analysis was used to identify risk factors for perioperative-day mortality from one tertiary institution's prospectively maintained database. Materials and methodsConsecutive elective open (564) and endovascular (589) AAA repairs (2000–2010) were split randomly into development (810) and validation (343) data sets. The resultant model was compared to Glasgow Aneurysm Score (GAS), Modified Customised Probability Index (m-CPI), CPI, the Vascular Governance North West (VGNW) model and the Medicare model. ResultsVariables associated with perioperative mortality included: increasing age (P = 0.034), myocardial infarct within last 10 years (P = 0.0008), raised serum creatinine (P = 0.005) and open surgery (P = 0.0001). The areas under the receiver operating characteristic curve (AUC) for predicted probability of 30-day mortality in development and validation data sets were 0.79 and 0.82 respectively. AUCs for GAS, m-CPI and CPI were poor (0.63, 0.58 and 0.58 respectively), whilst VGNW and Medicare model were fair (0.73 and 0.79 respectively). ConclusionsIn this study, an “in-house” developed and validated risk model has the most accurate discriminative value in predicting perioperative mortality after elective AAA repair. For purposes of comparative audit with case mix adjustments, national models such as the VGNW or Medicare models should be used.

Risk Stratification Scores in Elective Open Abdominal Aortic Aneurysm Repair: Are They Suitable for Preoperative Decision Making?

Objectives: Risk indices help quantify the risk of cardiovascular events and death prior to making decisions about prophylactic AAA repair. This paper aims to study the predictive capabilities of 5 validated indices. Design and methods: A prospective observational multi-centre cohort study from August 2005 to September 2007 in Glasgow recruited 106 consecutive patients undergoing elective open AAA repair. The Glasgow Aneurysm Score (GAS), Vascular physiology only Physiological and Operative Severity Score for enUmeration of Mortality (V(p)-POSSUM), Vascular Biochemical and Haematological Outcome Model (VBHOM), Revised Cardiac Risk Index (RCRI) and Preoperative Risk Score of the Estimation of Physiological Ability and Surgical Stress Score (PRS of E-PASS) were calculated. Indices were compared using receiver operating characteristic (ROC) analysis and area under the curve (AUC) estimates. End points were all-cause mortality, Major Adverse Cardiac Events (MACE) and cardiac death. Results: GAS, VBHOM and RCRI did not predict outcome. V(p)-POSSUM predicted MACE (AUC = 0.681), cardiac death (AUC = 0.762) and all-cause mortality (AUC = 0.780), as did E-PASS (AUC = 0.682, 0.821, 0.703 for MACE, cardiac death and all-cause mortality respectively). Conclusion: Whilst V(p)-POSSUM and E-PASS predicted outcome, the less complex RCRI and GAS performed poorly which questions the utility of decision making based on these surgical risk indices.

PS118. Extent of COPD Is Associated with Short and Long-term Adverse Outcomes in Patients Undergoing Elective AAA Repair

PS118. Extent of COPD Is Associated with Short and Long-term Adverse Outcomes in Patients Undergoing Elective AAA Repair

Risk Stratification Scores in Elective Open Abdominal Aortic Aneurysm Repair: Are They Suitable for Preoperative Decision Making?

ObjectivesRisk indices help quantify the risk of cardiovascular events and death prior to making decisions about prophylactic AAA repair. This paper aims to study the predictive capabilities of 5 validated indices. Design and methodsA prospective observational multi-centre cohort study from August 2005 to September 2007 in Glasgow recruited 106 consecutive patients undergoing elective open AAA repair. The Glasgow Aneurysm Score (GAS), Vascular physiology only Physiological and Operative Severity Score for enUmeration of Mortality (V(p)-POSSUM), Vascular Biochemical and Haematological Outcome Model (VBHOM), Revised Cardiac Risk Index (RCRI) and Preoperative Risk Score of the Estimation of Physiological Ability and Surgical Stress Score (PRS of E-PASS) were calculated. Indices were compared using receiver operating characteristic (ROC) analysis and area under the curve (AUC) estimates. End points were all-cause mortality, Major Adverse Cardiac Events (MACE) and cardiac death. ResultsGAS, VBHOM and RCRI did not predict outcome. V(p)-POSSUM predicted MACE (AUC = 0.681), cardiac death (AUC = 0.762) and all-cause mortality (AUC = 0.780), as did E-PASS (AUC = 0.682, 0.821, 0.703 for MACE, cardiac death and all-cause mortality respectively). ConclusionWhilst V(p)-POSSUM and E-PASS predicted outcome, the less complex RCRI and GAS performed poorly which questions the utility of decision making based on these surgical risk indices.

Ruptured AAA: Open Surgical Management

Ruptured abdominal aorta aneurysm (rAAA) is the 13th leading cause of death in the United States. Despite many advances in the field of vascular surgery, the improvement in mortality rates of rAAA have been very modest. Although endovascular repair has surpassed open repair for elective AAA repair in the United States, open rAAA repair remains the most common therapy for this devastating vascular emergency. In this article, we discuss open surgical management for rAAA. We also describe a fast-track algorithm we have developed at the University of Massachusetts where open and endovascular repairs play equally important roles in management of rAAA.

A randomised double-blind placebo-controlled trial of the impact of high-dose statins on the ischaemia-reperfusion injury in elective AAA repair

A randomised double-blind placebo-controlled trial of the impact of high-dose statins on the ischaemia-reperfusion injury in elective AAA repair

Perioperative Myocardial Injury after Elective Open Abdominal Aortic Aneurysm Repair Predicts Outcome

Objective: Myocardial injury, detected by rises in cardiac troponin I (TnI), is common and associated with decreased survival following open AAA surgery. We examined the relationship between perioperative myocardial injury and postoperative outcome. Design: Observational Cohort Study. Methods: Forty-three consecutive patients who underwent elective open AAA repair were screened for perioperative myocardial injury or infarction using serial TnI measurements (taken on days 1, 3, and 7), ECG and clinical assessment. The primary outcome was survival free of cardiac failure, or myocardial infarction (MI) at follow-up. Results: Twenty (47%) of the 43 patients had a TnI elevation. Of these, 11 (26%) patients met the criteria for MI. At a mean (±SD) follow-up of 1.5 ± 0.8 years, 12 (28%) subjects had experienced at least one endpoint event. Survival free of cardiac failure or MI was 55% in patients who had TnI rises compared to 87% in those without (P = 0.02). Logistic regression revealed that TnI elevation was an independent predictor of outcome with an odds ratio of 5.4 (95% CI 1.2–2.4, P = 0.03). Conclusion: Perioperative myocardial injury after elective open AAA repair predicts outcome after surgery. Routine TnI measurement should be considered in all patients, especially in those with high cardiovascular risk.

Similar Cost for Elective Open and Endovascular AAA Repair in a Population-Based Setting

To compare cost differences between elective open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysm in a population-based setting. Clinical data and hospital-related costs (pre-, peri-, and postoperative) were analyzed for 109 consecutive AAA procedures (98 men; mean age 73 years, range 48-95; mean aneurysm diameter 61 mm, range 42-120) performed from 2001 to 2005 (58 OR, 51 EVAR) in our primary catchment area. Data were obtained through case records and hospital accounting systems. Nonparametric bootstrap was used for cost comparison. EVAR patients were older (76 versus 70 years, p<0.001) and had more comorbidities (ASA class 2.6 versus 2.3, p = 0.025). OR patients more often had anatomically complex aneurysms (52% versus 14%, p<0.001). Comparison of data with diagnosis-based reimbursement levels nationally and internationally indicated adequate cost level in the study. No difference was observed in total cost between OR and EVAR (euro29,786 versus euro26,382; p = 0.336). Preoperative cost was lower for OR compared to EVAR (euro661 versus euro1494, p = 0.002). OR patients had higher cost of intensive care [36% (euro8921) of perioperative cost versus 7% (euro1460), p = 0.001], while EVAR had higher implant cost [36% (euro7468) versus 2% (euro448), p<0.001]. Mean follow-up was 2.5 years (range 0.5-5.4). Mean postoperative cost was similar (OR euro4613 versus EVAR euro4403, p = 0.209; 16% and 17% of total cost, respectively). Postoperative cost after OR was high early on, with lower cost thereafter. Postoperative cost after EVAR was more homogeneously distributed, leveling off at euro500 to euro1000 annually over 5 years. In a population-based setting, total cost was similar for OR and EVAR. There were, however, important differences in patient characteristics and cost structure.

Perioperative Myocardial Injury after Elective Open Abdominal Aortic Aneurysm Repair Predicts Outcome

Myocardial injury, detected by rises in cardiac troponin I (TnI), is common and associated with decreased survival following open AAA surgery. We examined the relationship between perioperative myocardial injury and postoperative outcome. Observational Cohort Study. Forty-three consecutive patients who underwent elective open AAA repair were screened for perioperative myocardial injury or infarction using serial TnI measurements (taken on days 1, 3, and 7), ECG and clinical assessment. The primary outcome was survival free of cardiac failure, or myocardial infarction (MI) at follow-up. Twenty (47%) of the 43 patients had a TnI elevation. Of these, 11 (26%) patients met the criteria for MI. At a mean (+/-SD) follow-up of 1.5+/-0.8 years, 12 (28%) subjects had experienced at least one endpoint event. Survival free of cardiac failure or MI was 55% in patients who had TnI rises compared to 87% in those without (P=0.02). Logistic regression revealed that TnI elevation was an independent predictor of outcome with an odds ratio of 5.4 (95% CI 1.2-2.4, P=0.03). Perioperative myocardial injury after elective open AAA repair predicts outcome after surgery. Routine TnI measurement should be considered in all patients, especially in those with high cardiovascular risk.

Have Endovascular Procedures Negatively Impacted General Surgery Training?

Technological advances in vascular surgery have changed the field dramatically over the past 10 years. Herein, we evaluate the impact of endovascular procedures on general surgery training. National operative data from the Residency Review Committee for Surgery were examined from 1997 through 2006. Total major vascular operations, traditional open vascular operations and endovascular procedures were evaluated for mean number of cases per graduating chief general surgery resident (GSR) and vascular surgery fellow (VSF). As endovascular surgical therapies became widespread, GSR vascular case volume decreased 34% over 10 years, but VSF total cases increased 78%. GSR experience in open vascular operations decreased significantly, as evidenced by a 52% decrease (P < 0.0001) in elective open AAA repair. VSFs have also seen significant decreases in open vascular procedures. Experience in endovascular procedures has increased for both general surgery and vascular residents, but the increase has been much larger in absolute number for VSFs. GSR experience in open vascular procedures has significantly decreased as technology has advanced within the field. Unlike VSFs, this loss has not been replaced by direct experience with endovascular training. These data demonstrate the impact technology can have on how we currently train general surgeons. New educational paradigms may be necessary in which either vascular surgery as an essential component is abandoned or training in catheter-based interventions becomes required.

POSSUM Models in Open Abdominal Aortic Aneurysm Surgery

This study evaluated the Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM), Portsmouth (P) POSSUM and Vascular (V) POSSUM. The primary aim was to assess the validity of these scoring systems in a population of patients undergoing elective and emergency open AAA repair. The secondary intention was in the event that these equations did not fit all patients with an aneurysm; a new model would be developed and tested using logistic regression from the local data (Cambridge POSSUM). POSSUM data items were collected prospectively in a group of 452 patients undergoing elective and emergency open AAA repair over an eight-year period. The operative mortality rates were compared with those predicted by POSSUM, P-POSSUM, V-POSSUM and Cambridge POSSUM. All models except V-POSSUM (physiology only) showed significant lack of fit when predicting mortality after open AAA surgery. It was found that the locally generated single unified model (Cambridge POSSUM) could successfully describe both elective and ruptured AAA mortality with good discrimination (chi(2)=9.24, 7 d.f., p=0.236, c-index=0.880). POSSUM, V-POSSUM and P-POSSUM may not be robust tools for comparing mortality between populations undergoing elective and emergency open AAA repair as once thought. The development and successful validation of Cambridge POSSUM provides a unified model to describe both elective and emergency AAAs together and should be validated in other geographical settings.