Elective Endovascular Aneurysm Repair Research Articles

Acute esophageal necrosis after endovascular abdominal aneurysm repair.

An 84-year-old man was referred to our hospital with an infrarenal abdominal aortic aneurysm (AAA). He had a history of hypertension and cerebral infarction but no diabetes or kidney disease. Computed tomography revealed an AAA that was 70 mm in diameter and diffuse, irregularly shaped thrombi in the descending thoracic aorta. He underwent elective endovascular aortic aneurysm repair. Subsequent thrombectomy with a Fogarty balloon catheter was required because of acute limb ischemia. Fresh thrombus was removed from the anterior tibial artery.

Postoperative imaging follow-up at 2 years as a predictor of long-term outcomes after endovascular aneurysm repair

ObjectiveLifelong imaging follow-up remains the reference standard after endovascular aneurysm repair (EVAR). Because the number of EVARs has been increasing, an individually optimized follow-up protocol is desirable. The aim of the present study was to investigate the possibility of creating such a protocol by evaluating patients' follow-up images and to compare the findings with their freedom from reintervention and abdominal aortic aneurysm (AAA) rupture. MethodsFrom 2000 to 2010, 282 patients with an AAA had undergone elective EVAR with the Zenith stent-graft. The patients were followed up annually until the end of 2019. The patients were categorized into two groups according to the presence of any endoleak or sac shrinkage at 2 years. Group A included those with no detectable endoleak plus aneurysm sac shrinkage of ≥5 mm (n = 137; 63%), and group B included those with any type of endoleak and/or no significant aneurysm sac shrinkage (<5 mm; n = 82; 37%). ResultsThe mean follow-up was 83 months (range, 0-229 months), and the overall survival at 2 years was 84% (n = 237). No significant difference was found in overall survival between groups A and B (P = .73). However, a significant difference was found in freedom from AAA rupture at 12 years, favoring group A (group A, 100%; group B, 91%; P = .002). Furthermore, in group A, the freedom from reintervention was 95% at 12 years compared with only 31% in group B (P < .001). The sensitivity of the categorization was 89% and the specificity was 74% for the finding of a complication requiring a reintervention during long-term follow-up. ConclusionsPatients without an endoleak and a reduction of ≥5 mm in aneurysm size at 2 years had significantly fewer late reinterventions and ruptures during long-term follow-up compared with their counterparts using the Zenith stent-graft (Cook Medical, Bloomington, Ind). This finding suggests that, for these patients, the follow-up interval can be personalized and safely extended after 2 years.

Outcomes in Octogenarians and the Effect of Comorbidities After Intact Abdominal Aortic Aneurysm Repair in the Netherlands: A Nationwide Cohort Study

Age is an independent risk factor for mortality after both elective open surgical repair (OSR) and endovascular aneurysm repair (EVAR). As a result of an ageing population, and the less invasive nature of EVAR, the number of patients over 80 years (octogenarians) being treated is increasing. The mortality and morbidity following aneurysm surgery are increased for octogenarians. However, the mortality for octogenarians who have either low or high peri-operative risks remains unclear. The aim of this study was to provide peri-operative outcomes of octogenarians vs. non-octogenarians after OSR and EVAR for intact aneurysms, including separate subanalyses for elective and urgent intact repair, based on a nationwide cohort. Furthermore, the influence of comorbidities on peri-operative mortality was examined. All patients registered in the Dutch Surgical Aneurysm Audit (DSAA) undergoing intact AAA repair between 2013 and 2018, were included. Patient characteristics and peri-operative outcomes (peri-operative mortality, and major complications) of octogenarians vs. non-octogenarians for both OSR and EVAR were compared using descriptive statistics. Multivariable logistic regression analyses were used to examine whether age and the presence of cardiac, pulmonary, or renal comorbidities were associated with mortality. This study included 12 054 EVAR patients (3 015 octogenarians), and 3 815 OSR patients (425 octogenarians). Octogenarians in both the EVAR and OSR treatment groups were more often female and had more comorbidities. In both treatment groups, octogenarians had significantly higher mortality rates following intact repair as well as higher major complication rates. Mortality rates of octogenarians were 1.9% after EVAR and 11.8% after OSR. Age ≥ 80 and presence of cardiac, pulmonary, and renal comorbidities were associated with mortality after EVAR and OSR. Because of the high peri-operative mortality rates of octogenarians, awareness of the presence of comorbidities is essential in the decision making process before offering aneurysm repair to this cohort, especially when OSR is considered.

Outcomes after EVAR in females are similar to males

IntroductionWomen are less likely to develop infrarenal abdominal aortic aneurysm; however, when they do, it is almost always associated with challenging anatomy, more rapid aneurysmal growth rate and earlier rupture. Women generally have poorer outcomes following open aneurysm repair; and in this respect, the present study aims to evaluate if it is so after endovascular repair.MethodsA retrospective analysis of our database was performed for patients underwent endovascular aneurysm repair (EVAR) between January 2013–March 2020. 249 elective EVAR patients were evaluated. Patients were categorized according to gender and 26 patients (10.4%) were female. Demographics and pre-peri-postoperative findings were compared. Propensity score matching (ratio 1:1) was performed to reduce selection bias.ResultsIn the overall unmatched cohort, female population had more diabetes mellitus (p = 0.016) and hypertension (p = 0.005). However, coronary artery disease (p = 0.005) and coronary artery bypass grafting (p = 0.006) were more in male gender. Non-IFU implantation was higher in female group (38.5% vs. 11.5%, p = 0.025). After propensity matching, even though it was not statistically significant, early mortality for female gender was higher when compared to male gender (7.7% and 0%, respectively, p = 0.490). In the follow-up period, no difference in all-cause mortality, secondary interventions or complications have been observed between the genders.ConclusionChallenging anatomy and subsequently treated patients outside IFU may be the reasons for higher morbidity and mortality in women. However, despite these factors female and male patients revealed equivalent early and late results.

Simultaneous Laparoscopic Cholecystectomy and Endovascular Infrarenal Aortic Aneurysm Repair.

Background/Aim: With the increasing use of endovascular aneurysm repair (EVAR) and the availability of laparoscopic cholecystectomy (LC) for treating abdominal aortic aneurysms (AAA) and cholelithiasis, respectively, the association between these elective treatments is not yet well-defined. Thus, this study aimed to evaluate the results of elective and simultaneous EVAR and LC.Methods: Thirteen patients (mean age, 72 years) with concomitant large and asymptomatic AAA and asymptomatic cholelithiasis underwent simultaneous EVAR and LC.Results: Post-operative mortality was absent, and the morbidity rate was 7%. The mean total duration of the procedure was 142 min. The mean duration of fluoroscopy was 19 min, and the mean radiation dose was 65 mGy. The mean amount of iodinated contrast injected was 49 mL. The timing of oral fluid intake was 28 h (range, 24–48 h) and that of the oral low-fat diet was 53 h (range, 48–72 h). No patient presented with an aortic graft infection during the entire follow-up period (mean duration, 41 months). The mean length of post-operative hospital stay was 6 days (range, 5–8 days). Late survival was 85%, and the exclusion of AAA was 100%.Conclusion: Simultaneous EVAR and LC can be performed safely, allowing effective and durable treatment under both AAA and cholelithiasis conditions.

Appropriateness of surgery performed for abdominal aortic aneurysm at tertiary hospitals in Spain.

The aim of this study was to analyze the appropriateness of the type of repair (open or endovascular) performed for abdominal aortic aneurysm (AAA) in five university hospitals in Spain, according to evidence-based recommendations. A multicenter, retrospective cross-sectional study of patients with AAA who underwent elective open surgical repair (OSR) or endovascular aneurysm repair (EVAR). Data were collected on demographic and clinical variables and type of surgical repair. A pair of vascular surgeons from each participating hospital performed a blinded assessment based on GRADE recommendations. The concordance between the two evaluators and the agreement between their evidence-based recommendation and the procedure performed were assessed. A total of 186 patients were selected; 179 were included. Mean age was 72.5 years (standard deviation [SD], 8.4), mean Charlson Comorbidity Index (CCI) was 2.04 (SD, 1.9). OSR was performed in 53.2% (N.=99) and EVAR in 46.8% (N.=87) of cases. Overall, 65.9% (118/179) of interventions performed were considered appropriate: 50% (47/94) of OSRs and 83.5% (71/85) of EVARs. The patient characteristics were similar for all the hospitals, but the chosen surgical technique did show significant differences among these centers. There were no significant differences among the hospitals in the proportion of cases judged as appropriate, either overall (P=0.346) or for each type of procedure (P=0.531 and P=0.538 for OSR and EVAR, respectively). In this study, most of the AAA repairs performed were appropriate according to GRADE recommendations. A higher proportion of EVARs were considered appropriate than OSRs. Choice of AAA repair should be standardized using evidence-based clinical practice guidelines, while incorporating patient preferences, to reduce the existing variability and ensure appropriate selection of AAA repair technique.

The relation between physical fitness, frailty and all-cause mortality after elective endovascular abdominal aortic aneurysm repair

BackgroundAccurate determination of probable surgical outcomes is fundamental in decision-making regarding appropriate abdominal aortic aneurysm treatment. These outcomes depend, among other factors, on patient-related factors such as physical fitness. The primary aim of this study was to evaluate the correlation between physical fitness, measured by the metabolic equivalent of task (MET) score and the five-factor Modified Frailty Index (MFI-5), and all-cause mortality. MethodsFour hundred twenty-nine patients undergoing elective endovascular treatment of an infrarenal aortic aneurysm (EVAR) from January 2011 to September 2018 were identified in an existing local abdominal aortic aneurysm database. Physical fitness was measured by the MFI-5 and the METs as registered during preoperative screening. The primary end point was 1-year all-cause mortality and secondary end points included 5-year all-cause mortality, freedom from aneurysm-related mortality and aneurysm-related reinterventions. Correlations were analyzed using Spearman's rho and survival was analyzed using Kaplan-Meier analyses. The effect of physical fitness on mortality was assessed by binary logistics regression analyses. ResultsThere was a positive correlation between the MFI-5 and 1-year all-cause mortality (Rho = 0.163; P = .001), but not between the METs and 1-year all-cause mortality (Rho = –0.083; P = .124). A significant correlation between both MFI-5 and METs and 5-year all-cause mortality was observed (Rho = 0.255; P < .001 and Rho = –0.154; P = .004). When stratified by the MFI-5, the 1- and 5-year follow-up survival rates were 95.1% and 85.9%, respectively, in the group with the lowest MFI-5 and 74.5% and 33.1% in the group with the highest MFI-5 score (P = .007 and P < .001). When stratified by METs categories for 1-year follow-up, no significant differences in survival between the groups were observed (P = .090). The 5-year follow-up survival rate was 39.4% in the lowest METs category and 76.3% in the highest METs category (P = .039). Logistic regression analysis, assessing the impact of age, sex, METs, and the MFI-5 on the risk of all-cause mortality, showed that only age and the MFI-5 made a significant contribution. ConclusionsThere is a significant positive association between the MFI-5 and both the 1- and 5-year all-cause mortality rates after EVAR; METs only correlated with the 5-year all-cause mortality. Only age and the MFI-5 contributed to predicting overall survival after EVAR; therefore, it could be recommended to add the MFI-5 for guidance in preoperative counselling.

Impact of frailty on acute outcomes of endovascular thoracic and abdominal aneurysm repair

BackgroundWhile coding-based frailty tools may readily identify at-risk patients, they have not been adopted into screening guidelines for endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic repair at the national level. We aimed to characterize the impact of frailty on clinical outcomes and resource use after endovascular aneurysm repair and thoracic endovascular aortic repair using a nationally representative cohort. MethodsThe 2005 to 2018 National Inpatient Sample was queried to identify all adults undergoing elective endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic repair. Patients were considered “frail” if they suffered from any frailty-defining diagnoses in the Johns Hopkins Adjusted Clinical Groups. Multivariable regression models were used to identify independent associations with outcomes of interest including in-hospital mortality, nonhome discharge, and hospitalization costs. ResultsOf an estimated 301,869 patients, 273,415 (90.6%) underwent endovascular aneurysm repair and the remainder thoracic endovascular aortic repair. Frailty prevalence was lower in the endovascular aneurysm repair cohort (2.3%) compared with thoracic endovascular aortic repair (4.7%). After adjustment, frailty was associated with higher in-hospital mortality (endovascular aneurysm repair odds ratio 4.0; thoracic endovascular aortic repair odds ratio 2.5), nonhome discharge rates (endovascular aneurysm repair odds ratio 7.2; thoracic endovascular aortic repair odds ratio 4.2), and predicted costs (endovascular aneurysm repair ß coefficient +$10.6K; thoracic endovascular aortic repair ß coefficient +$38.2K) for both cohorts. ConclusionGiven that frailty portends inferior outcomes for both endovascular aneurysm repair and thoracic endovascular aortic repair, its inclusion in existing risk models may better inform shared decision-making.

Outcomes in Octogenarians and the Effect of Comorbidities After Intact Abdominal Aortic Aneurysm Repair in the Netherlands: A Nationwide Cohort Study

Age is an independent risk factor for mortality after both elective open surgical repair (OSR) and endovascular aneurysm repair (EVAR). As a result of an ageing population, and the less invasive nature of EVAR, the number of patients over 80 years (octogenarians) being treated is increasing. The mortality and morbidity following aneurysm surgery are increased for octogenarians. However, the mortality for octogenarians who have either low or high peri-operative risks remains unclear. The aim of this study was to provide peri-operative outcomes of octogenarians vs. non-octogenarians after OSR and EVAR for intact aneurysms, including separate subanalyses for elective and urgent intact repair, based on a nationwide cohort. Furthermore, the influence of comorbidities on peri-operative mortality was examined. All patients registered in the Dutch Surgical Aneurysm Audit (DSAA) undergoing intact AAA repair between 2013 and 2018, were included. Patient characteristics and peri-operative outcomes (peri-operative mortality, and major complications) of octogenarians vs. non-octogenarians for both OSR and EVAR were compared using descriptive statistics. Multivariable logistic regression analyses were used to examine whether age and the presence of cardiac, pulmonary, or renal comorbidities were associated with mortality. This study included 12 054 EVAR patients (3 015 octogenarians), and 3 815 OSR patients (425 octogenarians). Octogenarians in both the EVAR and OSR treatment groups were more often female and had more comorbidities. In both treatment groups, octogenarians had significantly higher mortality rates following intact repair as well as higher major complication rates. Mortality rates of octogenarians were 1.9% after EVAR and 11.8% after OSR. Age ≥ 80 and presence of cardiac, pulmonary, and renal comorbidities were associated with mortality after EVAR and OSR. Because of the high peri-operative mortality rates of octogenarians, awareness of the presence of comorbidities is essential in the decision making process before offering aneurysm repair to this cohort, especially when OSR is considered.

Physician-modified fenestrated Navion endograft for the treatment of a symptomatic postdissection thoracoabdominal aneurysm.

We report the case of a physician-modified four-fenestration endograft for the emergent treatment of a 65-year-old patient with postdissection thoracoabdominal aneurysm deemed unfit for open surgery. The patient, after elective thoracic endovascular aneurysm repair as the first stage of a preplanned two-stage total thoracoabdominal endovascular repair, presented acute onset of dyspnea and thoracic pain. Computed tomography angiography (CTA) showed signs of contained rupture. The Valiant Navion thoracic endograft was used for the creation of a physician-modified four-fenestration stent graft. A diameter-reducing wire technique was used to constrain posteriorly the prosthetic graft and to allow intraprocedural partial deployment. The modified stent graft was finally folded into its original sheath and implanted; four balloon-expandable stent grafts were used as bridging components. Postoperative CTA showed a residual type IIIc endoleak that was treated with a relining procedure 4 months later. At the 20-month follow-up, the patient is alive and well and CTA shows complete seal of the thoracic aneurysm with persisting small type IIIc endoleak in the abdominal aneurysm. A physician-modified endograft can be considered a valuable option in case of urgent treatment of TAAA in patients deemed unfit for open surgery when off-the-shelf devices are not available or contraindicated.

Changes in Noninvasive Arterial Stiffness and Central Blood Pressure After Endovascular Abdominal Aneurysm Repair

Purpose: To evaluate the impact of elective endovascular aneurysm repair (EVAR) on the carotid-femoral pulse wave velocity (cfPWV) and central pressure waveform, through 1-year follow-up. Materials and Methods: A tonometric device was used to measure cfPWV and estimate the central pressure waveform in 20 patients with an infrarenal abdominal aortic aneurysm scheduled for elective EVAR. The evaluated central hemodynamic parameters included the central pressures, the augmentation index (AIx), and the subendocardial viability ratio (SEVR). AIx quantifies the contribution of reflected wave to the central systolic pressure, whereas SEVR describes the myocardial perfusion relative to the cardiac workload. Measurements were performed before EVAR, at discharge, and 6 weeks and 1 year after EVAR. Results: CfPWV was increased at discharge (12.4±0.4 vs 11.3±0.5 m/s at baseline; p=0.005) and remained elevated over the course of 1-year follow-up (6 weeks: cfPWV = 12.2±0.5 m/s; 1 year: cfPWV = 12.2±0.7 m/s, p<0.05). After an initial drop in systolic central pressure at discharge, all the central pressures increased thereafter up to 1 year, without significant differences compared with baseline. The same was observed for the AIx and SEVR. Conclusion: Endovascular aortic aneurysm repair caused an increase in pulse wave velocity compared with baseline, which remained elevated through 1 year follow-up, which may be related to an increased cardiovascular risk. However, no differences in central pressure, augmentation index, and subendocardial viability ration were observed during follow-up.

Renal function-adjusted contrast medium volume is a major risk factor in the occurrence of acute kidney injury after endovascular aneurysm repair.

Acute kidney injury (AKI) is a complication that can occur during endovascular aneurysm repair (EVAR), increasing postoperative mortality and disease-related death. We therefore evaluated the incidence of AKI after elective EVAR, as well as related factors affecting AKI occurrence, investigating the volume of contrast medium (CV)/estimated glomerular filtration rate (eGFR) ratio as a predictive factor.We retrospectively reviewed the data of patients who underwent EVAR for infrarenal abdominal aorta aneurysm at a single center between April 2011 and December 2018. AKI was defined according to the Kidney Disease: Improving Global Outcomes criteria. We evaluated the occurrence of AKI within the first 7 days postoperatively, comparing serum creatinine levels, eGFR, CV, CV/eGFR ratio, fluid input and output, and morbidity between the AKI and no-AKI groups.The data of 147 patients were analyzed, of which 131 (89.1%) were males (mean age: 72.10±7.40 years); the incidence of AKI was 4.1% (6/147 patients). The mean dose of contrast agents used was greater in the AKI group than in the no-AKI group (249.17 ± 83.21 mL vs 179.43 ± 84.32 mL, respectively; P = .05). The baseline eGFR was 42.69 ± 22.08 mL/kg/1.73 m2 in the AKI group and 77.96 ± 18.92 mL/kg/1.73 m2 in the no-AKI group (P = .001). The CV/eGFR ratio was significantly higher in the AKI group (8.21 ± 6.13 vs 2.46 ± 1.44; P = 0.003). Baseline eGFR (odds ratio [OR] = 0.922, P = .001) and the CV/eGFR ratio (OR = 2.049, P = .008) were observed to be factors related to the occurrence of AKI in the logistic regression analysis for patients’ characteristics, operation-related factors, and renal outcomes. In the receiver operating characteristic curve analysis, the area under the curve of the CV/eGFR ratio was 0.856, indicating the greatest influence. A CV/eGFR ratio cutoff value of 3.84 was considered the most appropriate, with an 83.3% sensitivity and 83.0% specificity.The CV/eGFR ratio, rather than the absolute amount of contrast agents, was associated with the development of AKI after EVAR. The CV/eGFR ratio could be used as a possible indicator to limit the amount of contrast media required for the procedure.

Update of a Model to Predict Outcomes after Endovascular Aneurysm Repair

Risk assessment models must be continuously validated and updated to ensure that predictions remain valid. Here, the Endovascular Aneurysm Repair Risk Assessment Model, developed in 2008, is updated and improved. We used prospectively collected data from Australian patients who underwent elective endovascular aneurysm repair between 2009 and 2013 (n = 695). Data were provided by treating surgeons and the National Death Index. Key outcomes were early and midterm survival, early complications (endoleak, operative, and graft-related) and late complications (endoleak and graft-related). Multinomial logistic regression determined which preoperative variables best predicted each outcome. Area under Receiver Operating Characteristic curve (AUROC), model P-value and internal validation statistics were used to select the best model. Ten preoperative variables were included in the modeling for 10 key outcomes. The most valid outcomes with AUROC>0.7 were 1- and 3-year survival, 30 and 90-day mortality, early and late endoleak (types I, III and IV) and type II endoleak (with an increase in sac size ≥5 mm). The 10 preoperative variables that contributed to outcome models were self-reported fitness, American Society of Anesthesiologists physical status score, history of stroke/transient ischemic attack, age, aneurysm angle, infrarenal neck length, white cell count, respiratory assessment, diabetes and statin therapy. Fitness alone statistically significantly predicted 30 and 90-day deaths better than any other preoperative variable; achieving high AUROCs (0.78 and 0.80), and high odds ratios (12.8 [95% CI: 1.5-110.4] and 18.1 [95% CI: 2.2-149]). An updated interactive predictive model of outcomes after endovascular aneurysm repair has been created. Many of the variables used in the 2008 model continued to be significant, however, new variables including fitness and respiratory assessment, improved the model. The new model uses variables routinely collected preoperatively, and hence can better support surgeon-patient discussions prior to operation. Informing patients of potential risks or likely outcomes following elective surgery can assist with preoperative shared decision-making.

The Administrative Risk Analysis Index (RAI-A) Does Not Predict Reintervention or Mortality Within 30 Days in Patients Who Undergo Elective Open or Endovascular Abdominal Aortic Aneurysm Repair

ObjectiveFrailty scores are increasingly utilized to predict postoperative complications. The purpose of this study is to determine whether the administrative risk analysis index (RAI-A) can be used to predict reintervention or mortality within 30 days in patients who undergo elective open or endovascular abdominal aortic aneurysm (AAA) repair. MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was used to query data from elective open or endovascular aortic aneurysm repairs from 2011 to 2018. The administrative risk analysis index (RAI-A) score was calculated for each patient using two approaches (conservative versus liberal) due to discrepancies in NSQIP data categorization. Multivariable regression analysis was performed to determine whether there were statistical or clinical significance for incremental increases of RAI-A for both the open and endovascular repair group. Outcome measures were re-intervention or death within 30 days. ResultsData from 4106 and 11,733 patients who underwent open and endovascular repair, respectively, were included in the analysis. The number of reinterventions within 30 days was 9.1% (375 out of 4106 patients) in the open repair group and 4.0% (463 out of 11,685 patients) in the endovascular group. Thirty-day mortality was 4.7% (192 out of 4106 patients) in the open repair group, and 0.9% (109 out of 11,685 patients) in the endovascular group.In the conservative calculation of RAI-A scores, the open and endovascular repair groups had median RAI-A scores of 7 (mean 8.31) and 9 (mean 9.51), respectively. There was no significant association between RAI-A scores and outcome measures in either group. For predicting 30 d reintervention, the C statistic was 0.535 (OR 1.02) for the open repair group and 0.532 (OR 1.02) for endovascular repair. For predicting 30-day mortality, the C statistic was 0.626 (OR 1.07) in the open repair group and 0.701 (OR 1.09) in the endovascular repair group.In the liberal calculation of RAI-A scores, the open and endovascular repair groups had median RAI-A scores of 6 (mean 6.19) and 7 (mean 7.65), respectively. There was no significant association between RAI-A scores and outcome measures in either group. For predicting 30 d reintervention, the C statistic was 0.527 (OR 1.02) for open repair and 0.529 (OR 1.02) for endovascular repair. For predicting 30-day mortality, the C statistic was 0.625 (OR 1.07) in the open repair group and 0.695 (OR 1.08) in the endovascular repair group. ConclusionsThe RAI-A is not useful in predicting 30 d reintervention or mortality in patients who undergo elective open or endovascular AAA repair.

Limb Occlusion Rate after EVAR With Individualized Graft Limb Selection and a Liberal Protocol of Primary Relining

This study analyses limb occlusion rates after endovascular aneurysm repair (EVAR) with a strategy including stent-graft limb selection and liberal primary stenting (relining) in anatomies at higher risk for occlusion with uncovered self-expandable or balloon-expandable stents. All patients undergoing elective EVAR with a bifurcated stent-graft between January 2010-August 2018 were included. A protocol involving personalized stent-graft selection and liberal primary relining based on preoperative imaging was followed during the whole period. Primary endpoints were technical success and primary limb patency during follow-up. Secondary endpoints included mortality and limb reintervention rates. Risk factors associated to limb patency and reintervention rates were analyzed. Six hundred and fifteen patients (548 males; mean age 72.9 ± 9 years) were included. Overall technical success was 98.5% (606/615). One (0.16%) patient died during the first 30 days. Of the 1230 limbs, 96 (8%) were deemed at risk for occlusion in view of the anatomy, and primarily relined in 62 patients. Estimated primary limb patency at 6 months, 1 year and 3 years was 99.5 ± 0.2%, 99.2 ± 0.3% and 98.5 ± 0.5%, respectively. Freedom from limb-related reintervention at 6 months, 1 year and 3 years was 98.1 ± 0.4%, 97.4 ± 0.5% and 95.6 ± 0.7%, respectively. Only one (1%) of the 96 relined limbs occluded during follow-up. No differences were found in terms of patency or freedom from reintervention between limbs at risk that were primary stented and limbs without adjunctive stents. Gore Excluder stent-grafts presented better patency (Breslow P = 0.005) and lower reintervention rates (Breslow P = 0.001) than other devices during follow-up. Peripheral artery disease was also a risk factor for reintervention (Breslow P = 0.015). Liberal use of primary limb relining in patients with iliac anatomy at higher risk for occlusion appears to be a safe and effective strategy to preserve limb patency after EVAR. Gore Excluder graft limbs present better patency and lower reintervention rates than other stent-graft types.

Platelet Count Recovery after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm.

Objective: To find a new predictor of endoleak (EL) and aneurysm sac expansion after endovascular aneurysm repair (EVAR), we evaluated the platelet count recovery (PCR) process after EVAR.Materials and Methods: Two hundred five patients treated with elective EVAR from 2007 to 2015 were retrospectively analyzed. We compared the platelet count ratio until postoperative day (POD) 7 to the presurgical baseline between patients with and without persistent EL (≥ 6 months). Subsequently, we calculated the optimal platelet count ratio for distinguishing persistent EL using receiver-operating characteristics analysis. A platelet count ratio on POD7 ≥118% was defined as the PCR. We evaluated the PCR’s influence on the cumulative aneurysm sac expansion rate.Results: The average platelet count ratio on POD7 rose above baseline (112%), and the ratio was attenuated by persistent EL (103%). Of 205 patients, 126 (61%) were assigned to the disturbed PCR group (PCR(−) group). Cumulative aneurysm sac expansion rate was higher in the PCR(−) group than the PCR(+) group (34.4% vs. 12.8% in 5 years, p=0.01).Conclusion: Disturbed PCR after EVAR may be associated with ELs and eventual aneurysm sac expansion.

Ten-year single center experience in elective standard endovascular abdominal aortic aneurysm repair.

Endovascular aneurysm repair (EVAR) has become the treatment of choice for abdominal aortic aneurysm (AAA), demonstrating excellent early outcomes. However, EVAR durability has been questioned in the long-term period. The aim of this study was to assess EVAR outcomes in terms of survival and freedom from re-intervention during a long-term period. All consecutive patients being treated, with elective standard EVAR, in a single tertiary center, were included between 2008 and 2018. Outcomes were defined as survival and freedom from re-intervention and were reported using Kaplan-Meyer lifetables. In subgroup analyses, sex, age (threshold at 65 and 80 years), neck diameter>28mm and type of fixation were also analyzed. Type of re-intervention and endoleak type I (ETIa) were also reported. Five hundred and eight patients (94% males, mean age 72±7.3, mean AAA diameter 59±9mm) were included. The median follow-up was 3 years (range 0-10 years). The survival rate was 92.8% (SE 1.5%), 76.5% (SE 3.1%) and 41.6% (SE 6%), at 2, 5 and 10 years of follow-up, respectively. In total, 78 patients died; 8 deaths (8/75, 10%) were aneurysm related. In multivariate regression analysis, age (CI. 1.02-1.14; p=0.006) and ever tobacco use (CI. 1.02-6.12, P=0.045) were associated with the long-term mortality. Freedom from re-intervention was 96% (SE 1.1%), 93% (SE 1.8%), 85.5% (SE 5%) at 2, 5 and 9 years of follow-up. Limb occlusion was a common complication (n/n; 30% of re-intervention), particularly within the first 2 postoperative years. Six patients presented with rupture and were treated with open conversion. EVAR cases with supra-renal fixation graft presented lower rates of ETIa (CI. 76-87.27, P<0.001). Elective standard EVAR is associated with good long-term survival showing low aneurysm-related mortality. Common risk factors such as advanced age and smoking are associated to higher mortality. The procedure presents low re-intervention rates, while limb occlusion is a complication presented within the first 2 postoperative years.

Late outcomes after endovascular and open repair of large abdominal aortic aneurysms

ObjectiveThe risk of aortic abdominal aneurysm (AAA) rupture increases with an increasing aneurysm diameter. However, the effect of the AAA diameter on late outcomes after aneurysm repair is unclear. Therefore, we assessed the association of a large AAA diameter with late outcomes for patients undergoing open and endovascular AAA repair. MethodsWe identified all patients who had undergone elective open or endovascular infrarenal aneurysm repair from 2003 to 2016 in the Vascular Quality Initiative linked to Medicare claims for long-term outcomes. A large AAA diameter was defined as a diameter >65 mm. We assessed the 5-year reintervention, rupture, mortality, and follow-up rates. We constructed propensity scores and used inverse probability-weighted Kaplan-Meier estimations and Cox proportional hazard models to identify independent associations between large AAA repair and our outcomes. ResultsOf the 21,119 aneurysm repairs identified, 15.2% were for large AAAs. Of the 21,119 repairs, 19,017 were endovascular and 2102 were open. The large AAA cohort was less likely to have undergone endovascular aneurysm repair (EVAR; 84.9% vs 91%; P < .001), more likely to be older (median age, 76 vs 75 years; P < .001), and were less likely to be women (16.2% vs 21.7%; P < .001). After EVAR, patients with large AAAs had had lower adjusted 5-year freedom from reintervention (73.9% vs 84.6%; P < .001), freedom from rupture (88.5% vs 93.6%; P < .001), survival (58.0% vs 66.4%; P < .001), and freedom from loss to follow-up (77.7% vs 83.3%; P < .001) compared with patients with smaller AAAs. However, after open repair, the adjusted 5-year freedom from reintervention (95.8% vs 93.3%; P = .11), freedom from rupture (97.4% vs 97.8%; P = .32), survival (70.4% vs 74.0%; P = .13), and loss to follow-up (60.5% vs 62.8%; P = .86) were similar to the results for patients with smaller AAAs. For patients with large AAAs, the adjusted 5-year survival was lower after EVAR than that after open repair (55.3% vs 63.7%) but not after smaller AAA repair (67.3% vs 70.6%). ConclusionsThe 5-year adjusted reintervention, ruptures, mortality, and loss to follow-up rates for patients who had undergone large AAA EVAR were higher than those for patients who had undergone small AAA EVAR and large AAA open repair. Therefore, for patients with large AAAs who are medically fit, open repair should be strongly considered. Furthermore, these findings highlight the necessity for rigorous long-term follow-up after EVAR.

Women have similar mortality but higher morbidity than men after elective endovascular abdominal aortic aneurysm repair

ObjectiveSex disparities regarding outcomes for women after open and endovascular abdominal aortic aneurysm repair have been well-documented. The purpose of this study was to review whether these disparities were also present at our institution for elective endovascular aneurysm repair (EVAR) and whether specific factors predispose female patients to negative outcomes. MethodsAll elective EVARs were identified from our three sites (Florida, Minnesota, and Arizona) from 2000 to 2018. The primary outcome was in-hospital mortality and three-year mortality. Secondary outcomes included complications requiring return to the operating room, length of hospitalization (LOH), intensive care unit (ICU) days, and location of discharge after hospitalization. Multivariable logistic regression models were used to assess for the risk of complications. ResultsThere were 1986 EVARs; 1754 (88.3%) were performed in male and 232 (11.7%) in female patients. Female patients were older (79 years [interquartile range (IQR), 72-83 years] vs 76 years [IQR, 70-81 years]; P < .001), had a lower body mass index (median, 26.1 kg/m2 [IQR, 22.1-31.0 kg/m2] vs 28.3 kg/m2 [IQR, 25.3-31.6 kg/m2]; P < .001 and hematocrit (median, 37.6% [IQR, 33.4%-40.6%] vs 39.4% [IQR, 35.6%-42.6%]; P < .001) and had higher glomerular filtration rate (median, 84.4 mL/min per 1.73m2 [IQR, 62.3-103 mL/min/1.73 m2] vs 51.1 mL/min/1.73 m2 [IQR, 41.8-60.8 mL/min/1.73 m2]; P < .001. Female patients were also more likely to be active smokers (15.3% vs 13.1%; P < .001) and have chronic obstructive pulmonary disease (24.7% vs 15.3%; P = .001). They were less likely to have coronary artery disease (31.6% vs 45.6%; P < .001). Aneurysms in women were slightly smaller in size (median, 54 mm [IQR, 50.0-58.0 mm] vs 55 mm [IQR, 51.0-60.0 mm]; P = .004). In-hospital mortality and mortality at the 3-year follow-up was not significant between female and male patients (0.86% vs 0.17%; P = .11 and 38.4% vs 36.2%; P = .57). However, female patients returned to the operating room with a greater frequency than male patients (3.9% vs 1.4%; P = .011). LOH (mean, 3.4 ± 3.8 days vs 2.5 ± 2.4 days; P < .001) and ICU days (mean, 0.3 ± 2.0 days vs 0.1 ± 0.5 days; P < .001) were longer for female patients. After hospitalization, female patients were discharged to rehabilitation facilities in greater proportion (12.7% vs 3.1%; P < .001) than their male counterparts. On multivariable analysis, female sex was associated with a return to the operating room (odds ratio, 6.4; 95% confidence interval [CI], 1.4-3.5; P = .02), longer LOH (Coef 4.0; 95% CI, 1.0-2.5; P = .00007), more ICU days (Coef 2.8; 95% CI, 1.1-3.0; P = .005), and a greater likelihood of posthospitalization rehabilitation facility placement (odds ratio, 5.8; 95% CI, 1.5-2.4; P = .0001). ConclusionsOur three-site, single-institution data support sex disparities to the detriment of female patients regarding return to the operating room after EVAR, LOH, ICU days, and discharge to rehabilitation facility. However, we found no differences for in-hospital or 3-year mortality.

Examining the impact of psychological distress on short-term postoperative outcomes after elective endovascular aneurysm repair (EVAR)

PurposePreoperative psychological factors have an impact on postoperative outcomes and there is a paucity of research in vascular surgery. The objective of this study was to examine the impact of preoperative psychological factors on short-term postoperative outcomes in an infrarenal endovascular aneurysm repair (EVAR) cohort. MethodsA prospective, multi-centre observational study was conducted across three vascular units in England. English-speaking participants who were older than 18 years, able to provide informed consent and awaiting an elective standard infrarenal EVAR were eligible for the study. A total of 46 patients undergoing elective infrarenal AAA repair were assessed preoperatively with the State Trait Anxiety Inventory (STAI), Beck's Depression Inventory (BDI-II) and Life Orientation Test-Revised (LOT-R). Data on five short-term postoperative outcomes was collected and analysed using Spearman's rank correlations. ResultsHigher preoperative anxiety levels (ρ = 0.38, p = 0.01), and depression scores (ρ = 0.36, p = 0.02) were moderately correlated with an increased length of postoperative critical care stay. Higher levels of preoperative depression were moderately correlated with greater postoperative opioid analgesia use (ρ = 0.34, p = 0.02). No correlation was witnessed between optimism scores and postoperative outcomes. No correlation was witnessed with respect to total length of stay, number of complications, or time to mobilisation. ConclusionsThere is a potential link between preoperative psychological well-being and short-term postoperative outcomes in an EVAR cohort. Further work is necessary to validate this link and examine the role of preoperative interventions in optimising the psychological well-being of patients undergoing EVAR.