Elective Endovascular Abdominal Aortic Aneurysm Repair Research Articles

Octogenarians fare better under local anesthesia for elective endovascular aortic aneurysm repair

ObjectiveWith an aging patient population, an increasing number of octogenarians are undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) in the United States. Multiple studies have shown that, for the general population, use of local anesthetic (LA) for EVAR is associated with improved short-term and long-term outcomes as compared with performing these operations under general anesthesia (GA). Therefore, this study aimed to study the association of LA for elective EVARs with perioperative outcomes, among octogenarians. MethodsThe Vascular Quality Initiative database (2003-2021) was used to conduct this study. Octogenarians (Aged ≥80 years) were selected and sorted into two study groups: LA (Group I) and GA (Group II). Our primary outcomes were length of stay and mortality. Secondary outcomes included operative time, estimated blood loss, return to operating room, cardiopulmonary complications, and discharge location. ResultsOf the 16,398 selected patients, 1197 patients (7.3%) were included in Group I, and 15,201 patients (92.7%) were in Group II. Procedural time was significantly shorter for the LA group (114.6 vs 134.6; P < .001), as was estimated blood loss (152 vs 222 cc; P < .001). Length of stay was significantly shorter (1.8 vs 2.6 days; P < .001), and patients were more likely to be discharged home (LA 88.8% vs GA 86.9%; P = .036) in the LA group. Group I also experienced fewer pulmonary complications; only 0.17% experienced pneumonia and 0.42% required ventilator support compared with 0.64% and 1.02% in Group II, respectively. This finding corresponded to fewer days in the intensive care unit for Group I (0.41 vs 0.69 days; P < .001). No significant difference was seen in 30-day mortality cardiac, renal, or access site-related complications. Return to operating room was also equivocal between the two groups. Multivariate regression analysis confirmed GA was associated with a significantly longer length of stay and significantly higher rates of non-home discharge (adjusted odds ratio [AOR], 1.59; P < .001 and AOR, 1.40; P = .025, respectively). When stratified by the New York Heart Association classification system, classes I, II, III, and IV (1.55; P < .001; 1.26; P = .029; 2.03; P < .001; 4.07; P < .001, respectively) were associated with significantly longer hospital stays. ConclusionsThe use of LA for EVARs in octogenarians is associated with shorter lengths of stay, fewer respiratory complications, and home discharge. These patients also experienced shorter procedure times and less blood loss. There was no statistically significant difference in 30-day mortality, return to operating room, or access-related complications. LA for octogenarians undergoing EVAR should be considered more frequently to shorten hospital stays and decrease complication rates.

Abstract 14516: Combined Platelet Morphology and Clinicoradiological Features to Predict Type II Endoleaks Following Endovascular Abdominal Aortic Aneurysm Surgery

Introduction: Persistent endoleak and associated endotension following endovascular abdominal aortic aneurysm repair (EVAR) can compromise successful repair and lead to continued sac expansion and eventual life-threatening rupture event. Hypothesis: A risk-stratification algorithm of the inherent anatomical and systemic cellular characteristics of patients might predict the incidence of type II endoleaks on abdominal aortic aneurysm (AAA) patients undergoing EVAR or fenestrated endovascular aortic aneurysm repair (FEVAR) procedures. Methods: Single-center retrospective study includes 146 AAA patients undergoing primary elective EVAR and FEVAR procedures between September 2013 and July 2021. A review of institutional medical records was conducted for the analysis. Patients who or who did not developed a type II endoleaks were included in this study. Results: Mean platelet volume (MPV) was significantly increased in patients with type II endoleaks and was associated with lower endoleak-free survival. Receiver operating characteristic (ROC) curve analysis showed that MPV demonstrated satisfactory predictive performance in distinguishing patients who developed type II endoleaks, yielding an area under the curve (AUC) value of 0.64. A risk-stratification panel consisting of postoperative MPV, history of type II diabetes, and number of preoperative patent lumbar arteries achieved an AUC value of 0.72 and predicted endoleak-free survival rate with HR of 4.88. We built an easy-to-use nomogram for predicting the risk of postoperative type II endoleak and revealed that MPV had the highest scoring weight of any variable in our model. Conclusions: We refined the anatomical and systemic traits in the blood that identified MPV as a significant predictor for type II endoleaks, which might facilitate post-surgical monitoring using complete blood count (CBC) as a supplement to imaging practice.

Development and Evaluation of an Enhanced Recovery Protocol to Reduce Length of Stay following Elective Endovascular Aneurysm Repair

Elective endovascular abdominal aortic aneurysm repair (EVAR) can be performed safely with a short postoperative length of stay (LOS). We aimed to develop and assess the impact of an enhanced recovery protocol (ERP) on LOS after elective EVAR. Pre-ERP development single center retrospective review of elective EVAR procedures from January 2012 to December 2019. ERP was developed by targeting factors associated with prolonged LOS (>2days) elucidated from semistructured interviews and Bayesian additive regression tree analysis. Post-ERP development, a subsequent retrospective review of elective EVAR performed from January 2018 to June 2021 was performed to evaluate LOS before and after ERP. Primary outcome was LOS. Two hundred sixteen patients underwent elective infrarenal EVAR from 2012 to 2019. Periprocedural factors identified as associated with LOS >2days included noncommercial insurance (43.6% vs. 26.5%; P=0.01), preoperative anemia (hemoglobin 12.56 g/dL vs. 13.57 g/dL; P=0.001), worse renal function (creatinine 1.31 mg/dL vs. 1.01/dL; P=0.004), open femoral access (74.4% vs. 26.5%; P<0.001), intensive care unit (ICU) stay (2.7days vs. 0.9days; P<0.001), postoperative anemia (9.8 g/dL vs. 11.9 g/dL; P<0.001), postoperative creatinine (1.55 mg/dL vs. 0.97 mg/dL; P<0.001), and beta blocker need on discharge (45.5% vs. 25%; P=0.003) as significant between patients with short and prolonged LOS groups. Semistructured interviews revealed postoperative day 1 complete blood count/chemistry, postoperative physical therapy evaluation, ICU admission, urinary retention, patient expectations, and unavailability of transportation home as modifiable factors that delayed early discharge. A 14-component ERP was created to target the factors identified from combined qualitative and quantitative results. Post-ERP development, 74 elective EVAR patients were reviewed from 2018 to 2021 (37 pre-ERP and 37 post-ERP). Following ERP development, the mean LOS was reduced from 2.6 (standard deviation: 1.9) to 1.3days (standard deviation: 1.3); P<0.01. There were no significant differences in 30-day readmission, postoperative complications, emergency room visits, or 90-day mortality before and after the ERP was used. Practice and procedural factors can be modified through an informed and safe process to reduce LOS after elective EVAR. LOS following elective EVAR was safely reduced following the use of a systematically developed ERP.

Patients’ Radiation Exposure During Endovascular Abdominal Aortic Aneurysm Repair

To investigate associations between patient characteristics, intraprocedural complexity factors, and radiation exposure to patients during endovascular abdominal aortic aneurysm repair (EVAR). Elective standard EVAR procedures between January 2015 and December 2020 were retrospectively analyzed. Patient characteristics and intraprocedural data (i.e., type of device, endograft configuration, additional procedures, and contralateral gate cannulation time [CGCT]) were collected. Dose area product (DAP) and fluoroscopy time were considered as measurements of radiation exposure. Furthermore, effective dose (ED) and doses to internal organs were calculated using PCXMC 2.0 software. Descriptive statistics, univariable, and multivariable linear regression were applied to investigate predictors of increased radiation exposure. The 99 patients were mostly male (90.9%) with a mean age of 74±7years. EVAR indications were most frequently abdominal aortic aneurysm (93.9%), penetrating aortic ulceration (2.0%), focal dissection (2.0%), or subacute rupture of infrarenal abdominal aortic aneurysm (2.0%). Median fluoroscopy time was 19.6minutes (interquartile range [IQR], 14.1-29.4) and median DAP was 86,311 mGycm2 (IQR, 60,160-130,385). Median ED was 23.2 mSv (IQR, 17.0-34.8) for 93 patients (93.9%). DAP and ED were positively correlated with body mass index (BMI) and CGCT. Kidneys, small intestine, active bone marrow, colon, and stomach were the organs that received the highest equivalent doses during EVAR. Higher DAP and ED values were observed using the Excluder endograft, other bi- and tri-modular endografts, and EVAR with ≥2 additional procedures. Multivariable linear regression analysis revealed that BMI, ≥2 additional procedures during EVAR, and CGCT were independent positive predictors of DAP and ED levels after accounting for endograft type. Patient-related and procedure-related factors such as BMI, ≥2 additional procedures during EVAR, and CGCT resulted predictors of radiation exposure for patients undergoing EVAR, as quantified by higher DAP and ED levels. The main intraprocedural factor that increased radiation exposure was CGCT. These data can be of importance for better managing radiation exposure during EVAR.

Factors associated with all-cause mortality following endovascular abdominal aortic aneurysm repair.

Background: Knowledge of factors that influence all-cause mortality after endovascular abdominal aortic aneurysm repair (EVAR) could improve therapeutic strategies post-EVAR and thus patient prognosis. Our study aimed to evaluate the association between sociodemographic information, comorbidities, laboratory parameters, treatment, selected anatomical and genetic factors and all-cause mortality post-EVAR. Patients and methods: We reviewed all patients who had undergone elective EVAR for non-ruptured abdominal aortic aneurysm (AAA) between January 2010 and December 2019. AAA size (maximum diameter and volume) was measured using CT-angiography. Sac expansion was defined as at least 5 mm increase, sac regression as at least 5 mm decrease in the sac diameter determined at 36±3 months post-EVAR in relation to pre-EVAR AAA diameter. Adjustments were performed for age, hypertension, diabetes mellitus, dyslipidaemia, sex, smoking, number of lumbar arteries, patency of inferior mesenteric artery and number of reinterventions post-EVAR. Results: One hundred and sixty-two patients (150 men, 12 women) with a mean age of 72.6±7.3 years were included in the analysis. Pre-EVAR AAA diameter (HR 1.07; 95% CI 1.03 - 1.12; p=0.001), pre-EVAR AAA volume (HR 1.01; 95% CI 1.002 - 1.011; p=0.008), post-EVAR sac diameter (HR 1.06; 95% CI 1.03 - 1.10; p=0.000), post-EVAR sac volume (HR 1.01; 95% CI 1.002 - 1.011; p=0.006) and anticoagulation therapy (HR 2.46; 95% CI 1.18 - 5.14; p=0.019) were associated with higher mortality in multivariate analysis. Sac regression (HR 0.42; 95% CI 0.22 - 0.82; p=0.011), and treatment with angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) (HR 0.71; 95% CI 0.36 - 0.97; p=0.047) were associated with lower mortality. Conclusions: Greater pre- and post-EVAR diameter and volume, failure of sac regression and anticoagulation were associated with higher mortality post-EVAR. Reduced mortality was observed in patients treated with ACE inhibitors or ARBs, and in patients with AAA sac regression.

Renal transplant recipients undergoing endovascular abdominal aortic aneurysm repair have increased risk of perioperative acute kidney injury but no difference in late mortality: Presented at the 2022 Vascular Annual Meeting of the Society for Vascular Surgery; Boston, Massachusetts, June 15-18, 2022.

Objective: Renal transplant is associated with substantial survival advantage in patients with end-stage renal disease. However, little is known about the outcomes of renal transplant recipients (RTRs) after endovascular abdominal aortic aneurysm repair (EVAR). This study aimed to study the effect of renal transplant on perioperative outcomes and long-term survival after elective infrarenal EVAR.

A Novel Preoperative Risk Assessment Tool to Identify Patients at Risk of Contrast-Associated Acute Kidney Injury After Endovascular Abdominal Aortic Aneurysm Repair

Contrast-associated acute kidney injury (CA-AKI) after endovascular abdominal aortic aneurysm repair (EVAR) is associated with mortality and morbidity. Risk stratification remains a vital component of preoperative evaluation. We sought to generate and validate a preprocedure CA-AKI risk stratification tool for elective EVAR patients. We queried the Blue Cross Blue Shield of Michigan Cardiovascular Consortium database for elective EVAR patients and excluded those on dialysis, with a history of renal transplant, death during procedure, and without creatinine measures. Association with CA-AKI (rise in creatinine > 0.5 mg/dL) was tested using mixed-effects logistic regression. Variables associated with CA-AKI were used to generate a predictive model via a single classification tree. The variables selected by the classification tree were then validated by fitting a mixed-effects logistic regression model into the Vascular Quality Initiative dataset. Our derivation cohort included 7,043 patients, 3.5% of whom developed CA-AKI. After multivariate analysis, age (odds ratio [OR] 1.021, 95% confidence interval [CI] 1.004-1.040), female sex (OR 1.393, CI 1.012-1.916), glomerular filtration rate (GFR) < 30 mL/min (OR 5.068, CI 3.255-7.891), current smoking (OR 1.942, CI 1.067-3.535), chronic obstructive pulmonary disease (OR 1.402, CI 1.066-1.843), maximum abdominal aortic aneurysm (AAA) diameter (OR 1.018, CI 1.006-1.029), and presence of iliac artery aneurysm (OR 1.352, CI 1.007-1.816) were associated with increased odds of CA-AKI. Our risk prediction calculator demonstrated that patients with a GFR < 30 mL/min, females, and patients with a maximum AAA diameter of > 6.9 cm are at a higher risk of CA-AKI after EVAR. Using the Vascular Quality Initiative dataset (N=62,986), we found that GFR < 30 mL/min (OR 4.668, CI 4.007-5.85), female sex (OR 1.352, CI 1.213-1.507), and maximum AAA diameter > 6.9 cm (OR 1.824, CI 1.212-1.506) were associated with an increased risk of CA-AKI after EVAR. Herein, we present a simple and novel risk assessment tool that can be usedpreoperatively to identify patients at risk of CA-AKI after EVAR. Patients with a GFR <30 mL/min, maximum AAA diameter > 6.9 cm, and females who are undergoing EVAR may be at risk for CA-AKI after EVAR. Prospective studies are needed to determine the efficacy of our model.

Renal transplant recipients undergoing endovascular abdominal aortic aneurysm repair have increased risk of perioperative acute kidney injury but no difference in late mortality

ObjectiveRenal transplant is associated with substantial survival advantage in patients with end-stage renal disease. However, little is known about the outcomes of renal transplant recipients (RTRs) after endovascular abdominal aortic aneurysm repair (EVAR). This study aimed to study the effect of renal transplant on perioperative outcomes and long-term survival after elective infrarenal EVAR. MethodsThe Vascular Quality Initiative database was queried for all patients undergoing elective EVAR from 2003 to 2021. Functioning RTRs were compared with non-renal transplant recipients without a diagnosis of end-stage renal disease (non-RTRs). The outcomes included 30-day mortality, acute kidney injury (AKI), new renal failure requiring renal replacement therapy (RRT), endoleak, aortic-related reintervention, major adverse cardiac events, and 5-year survival. A logistic regression analysis was used to assess the association between RTRs and perioperative outcomes. ResultsOf 60,522 patients undergoing elective EVAR, 180 (0.3%) were RTRs. RTRs were younger (median, 71 years vs 74.5 years; P < .001), with higher incidence of hypertension (92% vs 84%; P = .004) and diabetes (29% vs 21%; P = .005). RTRs had higher median preoperative serum creatinine (1.3 mg/dL vs 1.0 mg/dL; P < .001) and lower estimated glomerular filtration rate (51.6 mL/min vs 69.4 mL/min; P < .001). There was no difference in the abdominal aortic aneurysm diameter and incidence of concurrent iliac aneurysms. Procedurally, RTRs were more likely to undergo general anesthesia with lower amount of contrast used (median, 68.6 mL vs 94.8 ml; P < .001) and higher crystalloid infusion (median, 1700 mL vs 1500 mL; P = .039), but no difference was observed in the incidence of open conversion, endoleak, operative time, and blood loss. Postoperatively, RTRs experienced a higher rate of AKI (9.4% vs 2.7%; P < .001), but the need for new RRT was similar (1.1% vs 0.4%; P = .15). There was no difference in the rates of postoperative mortality, aortic-related reintervention, and major adverse cardiac events. After adjustment for potential confounders, RTRs remained associated with increased odds of postoperative AKI (odds ratio, 3.33; 95% confidence interval, 1.93-5.76; P < .001) but had no association with other postoperative complications. A subgroup analysis identified that diabetes (odds ratio, 4.21; 95% confidence interval, 1.17-15.14; P = .02) is associated with increased odds of postoperative AKI among RTRs. At 5 years, the overall survival rates were similar (83.4% vs 80%; log-rank P = .235). ConclusionsAmong patients undergoing elective infrarenal EVAR, RTRs were independently associated with increased odds of postoperative AKI, without increased postoperative renal failure requiring RRT, mortality, endoleak, aortic-related reintervention, or major adverse cardiac events. Furthermore, 5-year survival was similar. As such, while EVAR may confer comparable benefits and technical success perioperatively, RTRs should have aggressive and maximally optimized renal protection to mitigate the risk of postoperative AKI.

Use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers increases the risk of postoperative acute kidney injury after elective endovascular abdominal aortic aneurysm repair.

Endovascular abdominal aortic aneurysm repair (EVAR) is the major treatment for abdominal aortic aneurysm (AAA); however, EVAR still carries a considerable risk of acute kidney injury (AKI). The present study aimed to investigate the risk factors for AKI after elective EVAR procedures. This was a retrospective observational study. Eligible patients who underwent EVAR from September 2011 to March 2019 in West China Hospital were included. The primary outcome was the occurrence of AKI within two days after EVAR, which was defined by the Kidney Disease Improving Global Outcomes Clinical Practice Guideline. Demographics, comorbidities, medications, laboratory tests, anatomical parameters of AAA, and relative operative details were collected as variables. Univariable and multivariable logistic regression analyses were applied to identify the risk factors among variables, and covariate interactions were further assessed. A total of 679 eligible patients were included. The incidence of postoperative AKI was 8.2% (56/679) in the whole cohort, and it was associated with a lower 5-year survival rate (63.5% vs . 80.9%; χ 2 = 4.10; P = 0.043). The multivariable logistic regression showed that chronic kidney disease (OR, 5.06; 95% CI: 1.43-17.95; P = 0.012), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) (OR, 2.60; 95% CI: 1.17-5.76; P = 0.019), and short neck (OR, 2.85; 95% CI: 1.08-7.52; P = 0.035) were independent risk factors for postoperative AKI. In the covariate interaction analysis, the effect of ACEIs/ARBs use on postoperative AKI was similar across all subgroups ( P > 0.05), thereby suggesting a robust effect of ACEIs/ARBs use in all patients undergoing elective endovascular abdominal aortic aneurysm repair. Postoperative AKI was associated with lower survival rate, and the use of ACEIs/ARBs was the only adjustable independent risk factor. Clinicians should consider withdrawing ACEIs/ARBs in high-risk patients undergoing elective endovascular abdominal aortic aneurysm repair to prevent postoperative AKI.

Female sex is associated with reintervention and mortality following elective endovascular abdominal aortic aneurysm repair.

Although sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes have been increasingly reported, the determination of contributing factors has not reached a consensus. We investigated the disparities in sex-specific outcomes after elective EVAR at our institution and evaluated the factors that might predispose women to increased morbidity and mortality. We performed a retrospective medical record review of all patients who had undergone elective EVAR from 2011 to 2020 at a suburban tertiary care center. The primary outcomes were 5-year survival and freedom from reintervention. The Fisher exact test, t tests, and Kaplan-Meier analysis using the rank-log test were used to investigate the associations between sex and outcomes. A multivariable Cox proportional hazard model controlling for age and common comorbidities evaluated the effect of sex on survival and freedom from reintervention. A total of 273 patients had undergone elective EVAR during the study period, including 68 women (25%) and 205 men (75%). The women were older on average than were than the men (76years vs 73years; P ≤ .01) and were more likely to have chronic obstructive pulmonary disease (38% vs 23%; P= .01), require home oxygen therapy (9% vs 2%; P=.04), or dialysis preoperatively (4% vs 0%; P= .02). The distribution of other common vascular comorbidities was similar between the sexes. The 30-day readmission rate was greater for the women than for the men (18% vs 8%; P= .02). The women had had significantly lower survival at 5years (48%± 7.9% vs 65%± 4.3%; P< .01) and significantly lower 1-year (women, 89%± 4.1%; vs men, 94%± 1.7%; P= .01) and 5-year (women, 69%± 8.9%; vs men, 84%± 3.3%; P= .02) freedom from reintervention. On multivariable analysis, female sex (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.1-2.9), congestive heart failure (HR, 2.2; 95% CI, 1.2-3.9), and older age (HR, 1.1; 95% CI, 1.0-1.1) were associated with 5-year mortality. Female sex remained as the only variable with a statistically significant association with 5-year reintervention (HR, 2.4; 95% CI, 1.1-4.9). Female sex was associated with decreased 5-year survival and increased 1- and 5-year reintervention after elective EVAR. Data from our institution suggest that factors beyond patient age and baseline health risk likely contribute to greater surgical morbidity and mortality for women after elective EVAR.

A Novel Risk Calculator To Identify Patients At Risk Of Contrast Associated Acute Kidney Injury After Endovascular Abdominal Aortic Aneurysm Repair

Contrast-associated acute kidney injury (CA-AKI) after endovascular abdominal aortic aneurysm repair (EVAR) is common and associated with mortality and morbidity. Risk stratification remains a vital component of preoperative evaluation. We sought to generate and validate a pre-procedure CA-AKI prevention algorithm for elective EVAR patients.

Development and Comparison of Multimodal Models for Preoperative Prediction of Outcomes After Endovascular Aneurysm Repair.

ObjectiveThe aim of this study was to develop and compare multimodal models for predicting outcomes after endovascular abdominal aortic aneurysm repair (EVAR) based on morphological, deep learning (DL), and radiomic features.MethodsWe retrospectively reviewed 979 patients (January 2010—December 2019) with infrarenal abdominal aortic aneurysms (AAAs) who underwent elective EVAR procedures. A total of 486 patients (January 2010–December 2015) were used for morphological feature model development and optimization. Univariable and multivariable analyses were conducted to determine significant morphological features of EVAR-related severe adverse events (SAEs) and to build a morphological feature model based on different machine learning algorithms. Subsequently, to develop the morphological feature model more easily and better compare with other modal models, 340 patients of AAA with intraluminal thrombosis (ILT) were used for automatic segmentation of ILT based on deep convolutional neural networks (DCNNs). Notably, 493 patients (January 2016–December 2019) were used for the development and comparison of multimodal models (optimized morphological feature, DL, and radiomic models). Of note, 80% of patients were classified as the training set and 20% of patients were classified as the test set. The area under the curve (AUC) was used to evaluate the predictive abilities of different modal models.ResultsThe mean age of the patients was 69.9 years, the mean follow-up was 54 months, and 307 (31.4%) patients experienced SAEs. Statistical analysis revealed that short neck, angulated neck, conical neck, ILT, ILT percentage ≥51.6%, luminal calcification, double iliac sign, and common iliac artery index ≥1.255 were associated with SAEs. The morphological feature model based on the support vector machine had a better predictive performance with an AUC of 0.76, an accuracy of 0.76, and an F1 score of 0.82. Our DCNN model achieved a mean intersection over union score of more than 90.78% for the segmentation of ILT and AAA aortic lumen. The multimodal model result showed that the radiomic model based on logistics regression had better predictive performance (AUC 0.93, accuracy 0.86, and F1 score 0.91) than the optimized morphological feature model (AUC 0.62, accuracy 0.69, and F1 score 0.81) and the DL model (AUC 0.82, accuracy 0.85, and F1 score 0.89).ConclusionThe radiomic model has better predictive performance for patient status after EVAR. The morphological feature model and DL model have their own advantages and could also be used to predict outcomes after EVAR.

Female Sex Predicts for Five-Year Reintervention and Mortality After Elective Endovascular Abdominal Aortic Aneurysm Repair

Although sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes have been increasingly reported, the causes have remained ill-defined. We investigated the disparities in sex-specific outcomes after elective EVAR at our institution and evaluated the factors that might predispose women to increased morbidity and mortality.

Non-guideline-compliant endovascular abdominal aortic aneurysm repair in women is associated with increased mortality and reintervention compared with men.

Sex-based disparities in surgical outcomes have emerged as an important focus in contemporary healthcare delivery. Likewise, the appropriate usage of endovascular abdominal aortic aneurysm repair (EVAR) in the United States remains a subject of ongoing controversy, with a significant number of U.S. EVARs failing to adhere to the Society for Vascular Surgery (SVS) clinical practice guideline (CPG) diameter thresholds. The purpose of the present study was to determine the effect of sex among patients undergoing EVAR that was not compliant with the SVS CPGs. All elective EVAR procedures for abdominal aortic aneurysms without a concomitant iliac aneurysm (≥3.0cm) in the SVS Vascular Quality Initiative were analyzed (2015-2019; n= 25,112). SVS CPG noncompliant repairs were defined as a size of<5.5cm for men and<5.0cm for women. The primary endpoint was 30-day mortality. The secondary endpoints were all-cause mortality, complications, and reintervention. Logistic regression was performed to control for surgeon- and patient-level factors. Freedom from the endpoints was determined using the Kaplan-Meier method. Noncompliant EVAR was performed in 9675 patients (38.5%). Although men were significantly more likely to undergo such procedures (90% vs 10%; odds ratio [OR], 3.1; 95% confidence interval [CI], 2.9-3.4; P< .0001), the 30-day mortality was greater for the women than the men (1.8% vs 0.5%; P= .0003). Women also experienced significantly higher rates of multiple complications, including postoperative myocardial infarction (1% vs 0.3%; P= .006), respiratory failure (1.4% vs 0.6%; P= .01), intestinal ischemia (0.7% vs 0.2%; P= .003), access vessel hematoma (3% vs 1.2%; P= .0006), and iliac access vessel injury (2.4% vs 0.8%; P< .0001). Additionally, women experienced increased overall 1-year reintervention rates (11.5% vs 5.8%; P< .0001). In the adjusted analysis, 30-day mortality and any in-hospital complication risk remained significantly greater for the women (30-day death: OR, 3.1; 95% CI, 1.6-5.8; P= .0005; in-hospital complication: OR, 1.9; 95% CI, 1.4-2.6; P< .0001). Women also experienced increased reintervention rates over time compared with men (OR, 1.5; 95% CI, 1.1-2.2; P= .02). Although men were more likely to undergo non-CPG compliant EVAR, women experienced increased short-term morbidity and 30-day mortality and higher rates of reintervention when undergoing non-CPG compliant EVAR. These unanticipated findings necessitate increased scrutiny of current U.S. sex-based EVAR practice and should caution against the use of non-CPG compliant EVAR for women.

Factors Associated With Noninfectious Fever After Endovascular Aortic Aneurysm Repair

Purpose: The post–endovascular abdominal aortic aneurysm repair (EVAR) inflammatory response, which is very often associated with fever, has been ascribed to a wide range of proinflammatory mediators and operative events. The aim of this study was to evaluate the impact of such factors in the development of fever of noninfectious origin after elective EVAR. Materials and Methods: A retrospective analysis of prospectively collected data of patients treated with standard elective EVAR between February 2017 and December 2020 was undertaken. The database included patients’ demographics and comorbidities, as well as laboratory inflammatory markers (white blood cell count, neutrophils, and C-reactive protein [CRP]) and anatomical characteristics (sac diameter, inferior mesenteric artery [IMA] patency and diameter, number of patent lumbar arteries, internal iliac artery [IIA] patency or occlusion). Intraoperative details, such as type of stent graft material and IIA overstenting, were also analyzed. Patients with infectious postoperative complications or previously receiving systemic anti-inflammatory medication were excluded. Statistical analysis was performed by SPSS 22.0 for Windows software (IBM Corp, Armonk, New York). Results: From 332 patients treated with elective EVAR between 2017 and 2020, 268 patients (all men) were included in the analysis. The mean age was 72.1±7.5 years and the mean aneurysm diameter was 59.1±12.1 mm. Seventeen patients were excluded due to a known infection site. From the study cohort, 114 (42.5%) patients presented with fever. Multivariate regression analysis confirmed that the occlusion of IMA ≥5 mm (p<0.008) and higher CRP (p<0.001) were independent factors associated with postoperative fever. A subanalysis was performed only on patients with patent IMA before EVAR. In the multivariate regression analysis of this subgroup, IMA ≥5 mm (p=0.008), presence of dyslipidemia (p=0.037), and higher CRP (p<0.001) were related to fever. Conclusion: Occlusion of an existing wide (≥5 mm) and patent IMA prior to EVAR may contribute to the development of post-EVAR pyrexia. The CRP is a reliable marker for post-EVAR fever. Further prospective studies are needed to corroborate these findings.

Predictors of Decline in Renal Function 5 Years after EVAR.

While there exists copious short-term data regarding renal function following infra-renal endovascular abdominal aortic aneurysm repair (EVAR), long-term analysis is sparse. This is a single institution retrospective review of predictors of renal function decline 5 years after elective EVAR. All EVAR between 2007 and 2015 were queried. Patients in whom renal function was documented 5 years postoperatively were included in analysis. Exclusion criteria were ruptured aneurysm, mortality before 56 months, lack of follow-up, ESRD status, and concomitant renal intervention. The primary outcome investigated was a 20% or greater drop in glomerular filtration rate (GFR) 5 years postoperatively. The following variables at the time of surgery were investigated as potential predictors: age, gender, hypertension, hyperlipidemia, diabetes, CAD or prior MI, COPD, prior stroke, baseline eGFR under 60mL/min/1.73m2, supra-renal fixation, infra-renal fixation, neck diameter, neck length, and number of contrast CT. 354 EVAR were identified of which 143 met inclusion criteria (211 excluded). Univariate analysis revealed female gender (OR 2.7), hypertension (OR 9.4), baseline renal insufficiency (OR 3.8), larger neck diameter, and supra-renal fixation (OR 2.32) all predictive (P < .05) of GFR drop at 5 years. Multivariate binary logistic regression analysis found female gender (multivariate OR 3.9, P = .023) and baseline renal insufficiency (multivariate OR 3.0, P = .029) as significant predictors of greater than 20% GFR drop at 5 years. Only 2 patients of the 143 progressed to dialysis requirement at 5 years. Females and patients with baseline renal insufficiency are more vulnerable to significant decline in renal function 5 years following EVAR. Consistent with analogous literature, supra-renal fixation appears moderately deleterious toward renal function with no clinical significance in those with baseline normal renal function. The potential benefit of avoidance of supra-renal fixation in female patients with baseline renal insufficiency is worth further investigation in a more robust multi-center study.

Female Sex Predicts Reintervention After Elective Endovascular Abdominal Aortic Aneurysm Repair

Sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes have been increasingly reported, although the factors influencing this disparity are not well-defined. We investigated the sex differences for elective EVAR outcomes at our institution and evaluated the factors potentially predisposing women to increased morbidity and mortality. A retrospective medical record review of all patients who had undergone elective EVAR from 2011 to 2016 at a suburban tertiary care center was performed. The primary outcomes were survival and freedom from reintervention at 1 and 5 years postoperatively. The secondary outcomes included the postoperative intensive care unit stay and 30-day readmission rate. The Fisher exact test, t test, and Kaplan-Meier analysis using the rank-log test were used to investigate the associations between sex and outcomes. A multivariate Cox proportional hazard model was used to evaluate the effect of sex on survival and freedom from reintervention. A total of 185 patients had undergone elective EVAR, including 46 women (25%) and 139 men (75%). On average, the women were older than were the men (76 years vs 73 years; P = .04) and were more likely to have chronic obstructive pulmonary disease (41% vs 21%; P = .01) and to require home oxygen therapy (11% vs 3%; P = .04). Other common vascular comorbidities were distributed similarly between the sexes. The intensive care unit level of postoperative care (13% vs 5%; P = .09) and 30-day readmission rate (20% vs 9%; P = .06) showed a trend toward a greater incidence in the women. Survival was similar between the men and women at 1 year (95% vs 91%; P = .34) and 5 years (67% vs 55%; P = .12). The freedom from reintervention rate was significantly lower for the women than for the men at 1 year (96% vs 86%; P = .02) and 5 years (86% vs 69%; P < .03; Fig). Although female sex did not significantly predict for 5-year survival (hazard ratio, 1.4; 95% confidence interval, 0.8-2.6; P = .26) on multivariate analysis controlling for age and common comorbidities, female sex persisted as the only significant outcome predictor among the covariates using a similar analysis for 5-year freedom from reintervention (hazard ratio, 2.8; 95% confidence interval, 1.2-6.6; P = .02). Female sex was independently associated with 1- and 5-year reintervention, but not survival, after controlling for age and comorbidities. These findings suggest that sex-specific factors, in addition to age at presentation and baseline health risk, contribute to greater surgical morbidity for women after elective EVAR.

Female Gender: A Leading Predictor of Decline in Renal Function 5 Years After Endovascular Abdominal Aortic Aneurysm Repair

Although copious short-term data exist regarding renal function after infrarenal endovascular abdominal aortic aneurysm repair (EVAR), long-term data are sparse. We performed a single-institution retrospective review to identify the predictors of renal function 5 years after elective EVAR. All EVAR cases performed at a single institution from 2007 to 2015 were queried. Patients for whom renal function was documented 5 years postoperatively were included in present analysis. The exclusion criteria were ruptured aneurysms, mortality before 56 months, lack of follow-up, end-stage renal disease status, and concomitant renal intervention. The primary outcome was a ≥20% decrease in the glomerular filtration rate (GFR) at 5 years postoperatively. The following variables at surgery were investigated as potential predictors: age, gender, hypertension, hyperlipidemia, diabetes, coronary artery disease or prior myocardial infarction, chronic obstructive pulmonary disease, prior stroke, baseline estimated GFR <60 mL/min/1.73 m2, suprarenal fixation, infrarenal fixation, neck diameter, neck length, and number of contrast computed tomography scans. A total of 354 EVARs were identified, of which 143 met the inclusion criteria (211 were excluded). Univariate analysis revealed that female gender, hypertension, baseline renal insufficiency, larger neck diameter, and suprarenal fixation (relative to infrarenal fixation) were all predictive (P < .05) of a GFR decrease at 5 years postoperatively. Multivariate binary logistic regression analysis found female gender and baseline renal insufficiency were significant predictors (P = .02 for both) of a >20% GFR decrease at 5 years (Table). Only 2 of the 143 patients in the present study had required to dialysis at 5 years. Women and patients with baseline renal insufficiency are more vulnerable to a significant decline in renal function at 5 years after EVAR. Consistent with analogous literature, suprarenal fixation appeared moderately deleterious toward renal function. The potential benefit of avoiding suprarenal fixation in female patients with baseline renal insufficiency is worth further investigation in a more robust multicenter study.Tabled 1Table. Predictors of greater than 20% drop in GFR 5 years after EVARVariableGreater than 20% drop in GFR at 5 years (n = 32)No drop in GFR >20% at 5 Years postop (n = 111)Univariate odds ratioUnivariate P valueMultivariate odds ratio (95% CI)Multivariate P valueFemale gender28% (n = 9)13% (n = 14)2.7.0353.9 (1.2-12.3).023Male gender72% (n = 23)87% (n = 97)Mean age75.25 (SD 7.6)72.6 (SD 8.28).1.351Diabetes mellitus25% (n = 8)30% (n = 33)0.78.61.3 (0.5-3.7).552Hypertension97% (n = 31)77% (n = 85)9.4.015.0 (0.5-50.3).172Hyperlipidemia84% (n = 26)70% (n = 78)1.3.222.2 (.64-7.4).211COPD16% (n = 5)11% (n = 17)1.02.970.8 (.22-.79).733CAD or Hx of MI56% (n = 18)60% (n = 67)0.84.681.4 ( .54-3.5).497Hx of prior stroke13% (n = 5)11% (n = 12)1.52.461.5 (.31-7.3)0.61Baseline eGFR less than 6050% (n = 16)21% (n = 23)3.8.0013.0 (1.1-7.9).029Mean neck diameter, mm28.3 (SD 4.08)24.1 (SD 3.87)<.001.825Mean neck length, mm28.3 (SD 12.3)31.67 (SD 14).22.491Mean number contrast CT Scan at 5 years postop3.4 (SD 2.56)4.74 (SD 3.48).95.356Suprarenal fixation69% (n = 22)49% (n = 54)2.32.042.2 (.83-5.6).102Infrarenal fixation31% (n = 10)51% (n = 57)Nominal Variables : Chi-Squared Test for UnivariateOrdinal Variables : T-test for UnivariateMultivariate Analysis : Binary Logistic Regression Analysis Open table in a new tab

Effect of Ischemic Cardiomyopathy on Perioperative Mortality After Endovascular Abdominal Aortic Aneurysm Repair

One in five patients undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) will have left ventricular dysfunction. Yet, little is known about the perioperative risks of the different types of cardiomyopathy. We compared the outcomes of patients with ischemic cardiomyopathy (ICM) undergoing EVAR with those of patients with non-ICM (NICM).

Female Sex Predicts for Risk of Reintervention After Elective Endovascular Abdominal Aortic Aneurysm Repair

Sex differences in outcomes after endovascular abdominal aortic aneurysm repair (EVAR) have been increasingly reported, although the factors influencing this disparity have not been well-defined. We investigated the sex differences for elective EVAR outcomes at our institution and evaluated the factors that might predispose women to increased morbidity and mortality.