Elective Endovascular Repair Research Articles

Outcomes of abdominal aortic aneurysm repair among patients with rheumatoid arthritis

ObjectiveIn the present study, we compared the outcomes of elective abdominal aortic aneurysm (AAA) repair in patients with and without rheumatoid arthritis (RA) stratified by the type of surgery. MethodsA retrospective population-based cohort study was conducted from 2003 to 2016. Linked administrative health data from Ontario, Canada were used to identify all patients aged ≥65 years who had undergone elective open or endovascular AAA repair during the study period. Patients were identified using validated procedure and billing codes and matching using propensity scores. The primary outcome was survival. The secondary outcomes were major adverse cardiovascular events (MACE)-free survival (defined as freedom from death, myocardial infarction, and stroke), reintervention, and secondary rupture. ResultsOf 14,816 patients undergoing elective AAA repair, a diagnosis of RA was present for 309 (2.0%). The propensity-matched cohort included 234 pairs of RA and control patients. The matched cohort was followed up for a mean ± standard deviation of 4.93 ± 3.35 years, and the median survival was 6.76 and 7.31 years for the RA and control groups, respectively. Cox regression analysis demonstrated no statistically significant differences in the hazards for death, MACE, reintervention, or secondary rupture. Analysis of the differences in outcomes stratified by repair approach also showed no statistically significant differences in the hazards for death, MACE, reintervention, or secondary rupture. ConclusionsWe found no statistically significant differences in survival, MACE, reintervention, or secondary rupture among patients with RA undergoing elective AAA repair compared with controls. Further studies are required to evaluate the impact of comorbidities and antirheumatic medications on the outcomes of elective AAA repair.

The Effect of Transfusion of Two Units of Fresh Frozen Plasma on the Perioperative Fibrinogen Levels and the Outcome of Patients Undergoing Elective Endovascular Repair for Abdominal Aortic Aneurysm

We aimed to investigate whether the transfusion of 2 units of fresh frozen plasma (FFP) immediately post aneurysm exclusion has any effect on the perioperative fibrinogen levels and the outcome of patients undergoing elective endovascular repair (EVAR) of abdominal aortic aneurysm (AAA). Consecutive infrarenal AAA patients undergoing elective EVAR with the bifurcated Endurant-II stent-graft (Medtronic) were recruited from 2 vascular units. The first unit has a routine policy of administering 2 units of FFP immediately upon aneurysm exclusion (FFP group), whereas the second unit has no such policy (control group). Serum fibrinogen levels were measured on admission and 24hr post-EVAR and the perioperative change in fibrinogen (Δfib) was calculated (24-hr postoperative minus preoperative fibrinogen). The 2 groups were compared with regards to the perioperative fibrinogen levels (preoperative, 24-hr postoperative, and Δfib) and the outcome (endoleaks, reinterventions, major adverse cardiovascular events, death) during follow up. A total of 70 patients (41 in the FFP group, 29 controls) were examined. There were 68 men, the mean age was 70±7years and the maximum AAA diameter was 63.3±13.8mm. During the follow up (34±19months), a total of 6 endoleaks were recorded (2 type Ia, 2 type Ib and 1 type II). Mean preoperative fibrinogen, 24-hr postoperative fibrinogen and Δfib was 391.1±92.8mg/dL, 367.7±97.8mg/dL and -23.5±51.02mg/dL, respectively. There was a trend for the fibrinogen to fall 24hr postprocedure, but this was not statistically significant (P=0.07). There was a weak negative association between Δfib and endoleaks (P=0.007, r=-0.29). Compared to controls, the FFP group had a higher 24-hr postoperative fibrinogen (401.8±112.9mg/dL vs. 319.3±34.9mg/dL, P<0.0001) and a lower Δfib (-3.00±56.01mg/dL vs. -52.48±21.15mg/dL, P<0.0001). No significant difference was observed between the 2 groups with regards to endoleaks, reinterventions, major adverse cardiovascular events, or deaths. Transfusion of 2 units of FFP postaneurysm exclusion prevents a significant drop in plasma fibrinogen 24hr post-EVAR, but the impact on clinical outcome has yet to be defined.

Stress Testing Before Abdominal Aortic Aneurysm Repair Does Not Prevent Postoperative Cardiac Events

Stress testing is commonly used before abdominal aortic aneurysm (AAA) repair. Whether stress testing can prevent cardiac events after AAA repair remains unclear. Our objective was to study national stress test utilization rates and to compare perioperative outcomes between high-use centers and low-use centers. We examined patients who underwent elective endovascular (EVR) or open (OPEN) AAA repair in the Vascular Quality Initiative. We measured utilization rates of stress testing across centers and compared the Vascular Study Group of New England Cardiac Risk Index (VSG CRI) score of patients who underwent preoperative stress tests with those who did not. We determined the rate of major adverse cardiac events (MACEs), a composite of perioperative myocardial infarction, stroke, heart failure exacerbation, or death, across centers. We compared MACE and 1-year mortality of centers in the highest quintile of stress test utilization vs those in the lowest quintile. We studied 43,396 EVR patients and 8935 OPEN patients. The median stress test utilization before EVR was 35.9% and varied from 10.2% (5th percentile) to 73.7% (95th percentile), with similar variability for OPEN (median, 57.9%; range, 13.0%-86.0%). The mean VSG CRI score for patients who did not undergo stress testing was 5.4 (±2.1) for EVR and 4.8 (±2.1) for OPEN. Patients who underwent stress testing had a slightly higher VSG CRI score (EVR, 5.6 [±2.1]; OPEN, 5.1 [±2.0]; Fig). The rate of MACE was 1.8% after EVR and 11.6% after OPEN. One-year mortality was 4.6% for EVR and 6.6% for OPEN. Centers in the highest quintile of stress testing had a higher adjusted likelihood of MACE (EVR: odds ratio [OR], 1.78; 95% confidence interval [CI], 1.37-2.30; OPEN: OR, 1.92; 95% CI, 1.49-2.47) but similar 1-year mortality (EVR: OR, 1.18; 95% CI, 1.02-1.37; OPEN: OR, 0.86; 95% CI, 0.64-1.15) compared with centers in the lowest quintile. The VSG CRI score was not different between high-use (EVR, 5.5 ± 2.1; OPEN, 5.0 ± 2.0) and low-use centers (EVR, 5.5 ± 2.1; OPEN, 4.9 ± 2.0). Stress test utilization before AAA repair varies widely despite similar patient risk profiles. There was no observed reduction in MACE or 1-year mortality among high stress test-using centers. The value of routine stress testing before AAA repair should be reconsidered and used on a more judicious basis.

Thoracic Endovascular Aortic Repair With Left Subclavian Artery Coverage Is Associated With High 30-Day Stroke Incidence With or Without Concomitant Revascularization

Review of the National Surgical Quality Improvement Program registry from 2005 to 2017 The stroke incidence was 2% after elective thoracic endovascular aortic repair (TEVAR) without left subclavian artery (LSA) coverage compared with 5% with LSA coverage (P < .001). In TEVARs with LSA coverage, the stroke incidence was 7.5% when the LSA was concomitantly revascularized vs 4.4% without concomitant revascularization. LSA coverage was significantly associated with stroke both with and without concomitant revascularization. Stroke after TEVAR with LSA coverage occurs frequently in the real-world setting, and concurrent LSA revascularization was not associated with a lower stroke incidence.

Stress Testing Prior to Abdominal Aortic Aneurysm Repair Does Not Prevent Postoperative Cardiac Events

Stress testing is commonly utilized prior to abdominal aortic aneurysm (AAA) repair. However, whether stress testing can prevent cardiac events after AAA repair remains unclear. Our objective was to study national stress test utilization rates and compare perioperative outcomes at high utilizing centers to low utilizing centers. We examined all patients who underwent elective endovascular (EVR) or open (OPEN) AAA repair in the Vascular Quality Initiative. We measured utilization rates of stress testing across centers and compared the Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) scores among patients who underwent preoperative stress tests to those who did not. Next, we determined the rate of major adverse cardiac events (MACE), a composite of perioperative myocardial infarction, stroke, heart failure exacerbation, or death across centers. To assess the impact of stress testing, we compared MACE and 1-year mortality among centers in the highest quintile of stress test utilization, versus those in the lowest quintile. We studied 43,396 patients who underwent EVR and 8935 patients who underwent OPEN. The median stress test utilization prior to EVR was 35.9% and varied across centers from 10.2% (5th percentile) to 73.7% (95th percentile), with similar variability for OPEN (median, 57.9%; 5th percentile, 13.0%; 95th percentile, 86.0%). The mean VSG-CRI score for patients who did not undergo stress testing was 5.4 ± 2.1 for EVR, and 4.8 ± 2.1 for OPEN. Patients who underwent stress testing had only a slightly higher VSG-CRI score, at 5.6 ± 2.1 for EVR and 5.1 ± 2.0 for OPEN (Figs 1 and 2). The absolute rate of MACE was 1.8% after EVR and 11.6% after OPEN. One-year mortality was 4.6% for EVR and 6.6% for OPEN. Centers in the highest quintile of stress test utilization had a paradoxically higher likelihood of age-, sex-, and race-adjusted MACE (EVR: odds ratio [OR], 1.78; 95% confidence interval [CI], 1.37-2.30; OPEN: OR, 1.92; 95% CI, 1.49-2.47), but nearly similar 1-year mortality (EVR: OR, 1.18; 95% CI, 1.02-1.37; OPEN: OR, 0.86; 95% CI, 0.64-1.15) compared to centers in the lowest quintile. The VSG-CRI was not different among high utilization (EVR: 5.5 ± 2.1; OPEN: 5.0 ± 2.0), and low utilization centers (EVR: 5.5 ± 2.1; OPEN: 4.9 ± 2.0). Stress test utilization prior to AAA repair varies widely across Vascular Quality Initiative centers, despite similar patient cardiac risk profiles. There was no observed reduction in MACE or 1-year mortality among high stress test utilizing centers. The overall value of preoperative stress testing prior to AAA repair should be reconsidered and used on a more judicious clinical basis.Fig 2Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) for patients who underwent preoperative stress testing versus those who did not: open repair (OPEN).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Early outcomes of elective and non-elective open and endovascular repair of distal arch, descending thoracic and thoracoabdominal aorta disease

Early outcomes of elective and non-elective open and endovascular repair of distal arch, descending thoracic and thoracoabdominal aorta disease

Elective Multistaged Endovascular Repair of Thoraco-abdominal Aneurysms with Fenestrated and Branched Endografts to Mitigate Spinal Cord Ischaemia

To evaluate the safety and effectiveness of a multistaged approach for elective thoraco-abdominal aneurysm (TAAAs) repair by means of endovascular fenestrated and/or branched (F/B-EVAR) grafts. Between 2013 and 2018, 80 high risk surgical patients received elective F/B-EVAR for TAAAs with a protocolled multistaged approach (thoracic, visceral, and limb steps) and were enrolled in an ambispective single centre study called STEAR (STaged Endovascular Aortic Repair - NCT03342755). Data regarding all study participants, single step mortality and morbidity (systemic complications) rates were recorded and the overall results were considered for statistical analysis. Previous aortic interventions (61/80 cases, 76.3%) combined with the TAAA extents resulted in different staging strategies: 58 patients (73%) had a thoracic step and 33 (41%) a limb step. The median TAAA treatment time was 77 days (50–107). The overall mortality was six cases (8%) and 30 day clinical success rate 64 cases (80%). The overall rate of grade 2 or 3 (including death) systemic complications was 19 cases (24%) and 20 patients (25%) experienced grade 1 complications. Three patients with type II or III TAAAs (4%) had permanent and fatal spinal cord (SC) impairment. On multivariable analysis, SC ischaemia was associated with an aortic coverage ≥350 mm (OR: 9.15, p = .03, 95% CI: 1.3–66.4) and bovine arch (OR: 10.6, p = .01, 95% CI: 1.6–68.6). The overall short term (six month) clinical success was 72 cases (90%) and none experienced SC ischaemia after late endoleak resolution or treatment. At mid term (mean follow up: 13.3 ± 15.4 months), the overall freedom from conversions, re-interventions, late rupture, or type I and III endoleaks was 57 of 72 survivors (79%). A multistaged approach with a third limb step in case of TAAAs is safe and technically feasible, with an acceptable rate of permanent spinal cord ischaemia. Different staging methods and protocols have been proposed and standardisation is required, especially for type I-II-III aneurysms.

The Effect of Mode of Anaesthesia on Outcomes After Elective Endovascular Repair of Abdominal Aortic Aneurysm

Endovascular aneurysm repair (EVAR) is the most commonly used method to repair abdominal aortic aneurysms. EVAR can be performed using a variety of anaesthetic techniques, including general anaesthetic (GA), regional anaesthetic (RA), and local anaesthetic (LA), but little is known about the effects that each of these anaesthetic modes have on patient outcome. The aim of this study was to assess the effect of anaesthetic technique on early outcomes after elective EVAR. Data from the UK's National Vascular Registry were analysed. All patients undergoing elective standard infrarenal EVAR between 1 January 2014 and 31 December 2016 were included. Patients with a symptomatic aneurysm treated semi-electively were excluded. The primary outcome was in hospital death within 30 days of surgery. Secondary outcomes included post-operative complications and length of hospital stay. Time to event outcomes were compared using Cox proportional hazards regression adjusted for confounders, including British Aneurysm Repair score (a validated aneurysm risk prediction score that is calculated using age, sex, creatinine, cardiac disease, electrocardiogram, previous aortic surgery, white blood cell count, serum sodium, abdominal aortic aneurysm diameter, and American Society of Anaesthesiologists grade) and chronic lung disease. A total of 9783 patients received an elective, standard infrarenal EVAR (GA, n=7069; RA, n=2347; and LA, n=367) across 89 hospitals. RA and/or LA was used in 82 hospitals. There were 64 in hospital deaths within 30 days, 50 (0.9% mortality at 30 days, 95% confidence interval [CI] 0.7-1.2) in the GA group, 11 (0.6%, 95% CI 0.3-1.1) in the RA group, and three (1.5%, 95% CI 0.5-4.7) in the LA group. The mortality rate differed between groups (p=.03) and was significantly lower in the RA group compared with the GA group (adjusted hazard ratio [aHR] RA/GA 0.37 [95% CI 0.17-0.81]; LA/GA 0.63 [95% CI 0.15-2.69]). The median length of stay was two days for all modes of anaesthesia, but patients were discharged from hospital more quickly in the RA and LA groups than the GA group (aHR RA/GA 1.10 [95% CI 1.03-1.17]; LA/GA 1.15 [95% CI 1.02-1.29]). Overall, 20.7% of patients experienced one or more complications (GA group, 22.1%; RA group, 16.8%; LA group, 17.7%) and pulmonary complications occurred with similar frequency in the three groups (overall 2.4%, adjusted odds ratio RA/GA 0.93 [95% CI 0.66-1.32]; LA/GA 0.82 [95% CI 0.41-1.63]). Thirty day mortality was lower with RA than with GA, but mode of anaesthesia was not associated with increased complications for patients undergoing elective standard infrarenal EVAR.

Impact of posthospital syndrome on outcomes of elective endovascular repair of abdominal aortic aneurysm

ObjectivePosthospital syndrome (PHS) is an acquired, transient period of health vulnerability after a hospital admission for acute illness. It is characterized by physiologic deconditioning secondary to stressors from disruption in circadian rhythm, depletion of nutritional and physiologic reserve as well as the pain and discomfort associated with hospitalization. PHS is reported as an independent risk factor for readmission and adverse postoperative outcomes. The aim of this study is to investigate whether preoperative hospitalization affects outcomes of elective endovascular repair of abdominal aortic aneurysm (EVAR). MethodsThe Healthcare Cost and Utilization Project State Inpatient Database for California (2009-2011) were queried using International Classification of Disease Codes, Ninth Edition, codes of 441.4 (abdominal aneurysm without mention of rupture), 397.1 (EVAR with graft), and 397.8 (EVAR with branching or fenestrated graft). PHS exposure is defined as any inpatient admission 30 or fewer days before elective EVAR. Primary outcomes are all-cause mortality and overall complications. Secondary outcomes include length of stay (LOS), 30-day readmission, and hospital charge. ResultsA total of 6155 patients were identified. of which 327 patients (5.6%) had more than one episode of hospital admission 30 days or less before elective EVAR. In-hospital mortality was comparable after PHS exposure (P = .09). However, PHS exposure was associated with increased 30-day readmission (9.5% vs 18.4%; P < .001), LOS (3.0 vs 4.5 days; P < .001), and overall complications (14.8% vs 24.5%; P < .001). Risk adjustment was made based on age, sex, race, baseline comorbidities, and reason for preoperative admission. Multivariate logistic regression analysis demonstrated that PHS exposure was a predictor for longer LOS (odds ratio [OR], 2.5; 95% confidence interval [CI], 2.0-3.2; P < .001), higher incidence of 30-day readmission (OR, 2.0; 95% CI, 1.4-2.6; P < .001), and overall complications (OR, 1.7; 95% CI, 1.3-2.2; P < .001). Additional cost associated with increased 30-day readmission attributable to PHS exposure was estimated at $448,302 per 100 cases. ConclusionsPHS is an independent risk-adjusted predictor for increased LOS, 30-day readmission, and overall complications after elective EVAR. Recent hospital admission should be assessed carefully before elective EVAR. Medical optimization with an attempt to delay elective surgery by up to 30 days may help to improve surgical outcomes and decrease unnecessary health care expenditures.

Outcomes after Standalone Use of Gore Excluder Iliac Branch Endoprosthesis for Endovascular Repair of Isolated Iliac Artery Aneurysms

The aim of our study was to describe outcomes of stand-alone use (i.e., without concomitant implantation of an aortic stent graft) of the Gore Excluder iliac branch endoprosthesis (IBE) for elective endovascular repair of isolated iliac artery aneurysms. We evaluated all consecutive patients electively treated for isolated iliac artery aneurysms using standalone Gore Excluder IBE (January 2014-December 2018). Early (i.e., 30-day) endpoints were technical success, mortality, major adverse events (MAEs), and major access-site complications. Late endpoints were survival, freedom from aortic-related mortality (ARM), internal iliac artery (IIA) primary patency, IIA branch instability, graft-related adverse events (GRAEs), secondary interventions, endoleaks (ELs), aneurysm sac behavior, and new-onset buttock claudication (BC). A total of 11 consecutive patients (10 men; median age 75years) were included. The technical success rate was 100%. At 30days, mortality, MAEs, and major access-site complications were all 0%. Survival and freedom from ARM were 91% and 100%, respectively; only one nonaortic related death was recorded during follow-up. At a median follow-up of 14months, IIA primary patency, IIA branch instability, and GRAEs were 100%, 0%, and 0%, respectively. No instances of graft migration ≥10mm were detected. No graft-related secondary interventions were recorded, and 2 patients required a procedure-related secondary intervention 3months after the index procedure (1 common femoral artery endarterectomy and 1 external iliac artery stenting). Although new-onset type 1 or type 3 ELs were never noted, one patient developed a new-onset type 2 EL. Aneurysm sac regression ≥5mm was noted in 6 patients (55%), whereas in the remaining ones, the sac size was stable. No instances of new-onset BC were noted. Use of standalone Gore Excluder IBE for elective endovascular repair of isolated iliac artery aneurysms is a safe, feasible, and effective treatment option. These results may support use of the technique as an effective means of endovascular reconstruction in patients with suitable anatomy.

Incidence, predictors, and outcomes of spinal cord ischemia in elective complex endovascular aortic repair: An analysis of health insurance claims

ObjectiveThis study aimed to determine predictors and outcomes associated with spinal cord ischemia (SCI) after elective fenestrated or branched endovascular aneurysm repair (F/BEVAR) of thoracoabdominal aortic aneurysm (TAAA), abdominal aortic aneurysm (AAA), or aortic dissection. MethodsHealth insurance claims data of Germany's third largest insurance provider, DAK-Gesundheit, were used to investigate SCI in elective F/BEVAR performed between 2008 and 2017. The International Classification of Diseases and German Operation and Procedure Classification System were used. We stratified the results into F/BEVAR with one or two (AAA) vs three or more (TAAA) fenestrations or branches. ResultsA total of 877 patients (18.9% female; 5.8% with SCI) matching the inclusion criteria were identified during the study period. SCI occurred more often after F/BEVAR of TAAA vs AAA (10.7% vs 3.0%; P < .001). SCI was associated with female sex in the AAA group (odds ratio, 3.87; 95% confidence interval [CI], 1.25-11.15; P = .014) and with cardiac arrhythmias in the TAAA group (odds ratio, 2.98; 95% CI, 1.24-7.06; P = .013). Compared with patients without SCI, SCI patients were more likely to suffer from drug use disorders (eg, opioids, cannabinoids, sedatives) in the TAAA group (17.6% vs 2.1%; P < .05). After F/BEVAR of TAAA, the occurrence of SCI was associated with higher 90-day mortality (14.7% vs 1.1%; P < .05), longer postoperative hospital stay (22 vs 9 days; P < .05), and severe adverse events, such as acute respiratory insufficiency (44.1% vs 12.7%), acute renal failure (35.3% vs 11.3%), and pneumonia (29.4% vs 4.9%; all P < .05). In adjusted analyses, SCI was associated with worse long-term survival after F/BEVAR for TAAA (hazard ratio, 2.54; 95% CI, 1.37-4.73; P < .003). ConclusionsFemale AAA patients and TAAA patients with cardiac arrhythmias are at highest risk for development of SCI after F/BEVAR. The occurrence of this event was strongly associated with higher major complication rates and worse short-term and long-term survival. This emphasizes a need to further illuminate the value of spinal cord protection protocols in F/BEVAR.

Sexual dysfunction after elective laparoscopic or endovascular abdominal aortic aneurysm repair in men

Infrarenal abdominal aortic aneurysm (AAA) repair can lead to ejaculation and erection troubles in men. There are few studies on sexual dysfunction after endovascular repair (EVAR) but they suggest less retrograde ejaculation than after open repair. We assessed the sexual dysfunction and ejaculation troubles after elective laparoscopic repair or EVAR. We conducted a monocentric prospective study on 124 patients undergoing AAA repair between 2013 and 2015. Sexual function was evaluated using the IIEF-15 questionnaire and questions on ejaculation. Only 45 patients (36.3%) accepted to complete the IIEF preoperatively with 20-37.8% having preoperative sexual dysfunction. Among them, 21 (46.7%) accepted to complete the questionnaire at 3, 6 and 12 months. Mean age at inclusion was 65±5.6 years in the laparoscopic group and 77±10.5 years in the EVAR group (P=0.003). Erectile and sexual function were slightly improved at 12 months in the laparoscopic group (+1.4 for erectile score and +4.6 for IIEF score) with no significant difference (P=0.83 and 0.74) whereas 8 patients (61.5%) had persistent ejaculation troubles at 3 months. In the EVAR group, patients had moderate sexual dysfunction at baseline without improvement at 12 months, but only one patient reported ejaculation troubles. Most patients eligible for AAA repair present with baseline erectile and sexual dysfunction. Laparoscopic AAA repair provides no onset of erectile or sexual dysfunction but a global improvement after surgery. Ejaculation troubles are frequent and persistent at 1 year. However, EVAR treatment, doesn't allow recovering of sexual function at 1 year. 4.

5-Year Outcome for Endoleak Type 2 after Endovascular Treatment in Abdominal Aortic Aneurysm in Songklanagarind Hospital

Objective: To study the incidence rate of endoleak type 2 in patients with abdominal aortic aneurysm treated with endovascular procedures. The results in Songklanagarind Hospital 5 years ago. Methods: Retrospective research studies in patients receiving abdominal aortic aneurysm treatment using elective endovascular repair, retrospective studies from Jan 2012- Dec 2016 and have followed up for 2 years to evaluate the incidence of endoleak type II and physical factors such as gender, age, weight, height, body mass index, and any underlying illnesses that are related to the occurrence of leaks. Results: In the year 2012-2016, there was a collection of data of patients diagnosed with aneurysm that had elective surgery. A total of 250 patients underwent surgery, with an average age was 76 (70,80) years, representing 194 males (77.6%). The average size of aneurysms is 6 centimeters and the incidence of endoleak type II was 73 people (29%). In related factors, Dyspilipidemia is likely to cause a significant endoleak type II (P <0.001). At the same time, it is found that in the first year after surgery, there is a chance of endoleak type II. Conclusion: From this study, it was found that at the Songklanagarind Hospital, there was an endoleak type II 29% and found that the risk of dyslipidemia is related to the endoleak type II.

Outcomes of Elective Endovascular Aneurysmal Repair for Abdominal Aortic Aneurysms in Jordan.

PurposeThe outcomes of endovascular aneurysmal repair (EVAR) for infrarenal abdominal aortic aneurysms (AAAs) in the Middle East have rarely been reported. We analyzed the outcomes of EVAR in a Jordanian population.Materials and MethodsWe conducted a retrospective review of the medical records of patients with infrarenal AAA who were treated with elective EVAR between January 2004 and January 2017 at a single center in Jordan. Patient characteristics, anatomical characteristics, procedural details, and early and late postoperative outcomes were analyzed.ResultsA total of 288 patients (mean age, 70 years; 77.8% males) underwent EVAR for infrarenal AAA (median aneurysm size, 64 mm). Bifurcated endografts were used in 265 patients, and aorto-uni-iliac devices were used in 22 patients. Successful endograft deployment was achieved in all patients with no open conversion. Early complications included localized groin hematoma in 15, femoral artery dissection in 4, wound infection in 3, and seroma in 3 patients. With a mean follow-up of 60 months, 50 endoleaks were detected, including 9 type I, 38 type II, and 3 type III. Seven patients had unilateral graft limb occlusion. The 30-day mortality was 1.7%, and long-term mortality was 7.0%, mostly due to non-AAA-related causes.ConclusionEVAR was safely performed in Jordanian patients with minimal complications. However, long-term surveillance is important due to the risk of endoleaks and consequent intervention.

Elective Multistaged Endovascular Repair of Thoraco-abdominal Aneurysms with Fenestrated and Branched Endografts to Mitigate Spinal Cord Ischaemia

To evaluate the safety and effectiveness of a multistaged approach for elective thoraco-abdominal aneurysm (TAAAs) repair by means of endovascular fenestrated and/or branched (F/B-EVAR) grafts. Between 2013 and 2018, 80 high risk surgical patients received elective F/B-EVAR for TAAAs with a protocolled multistaged approach (thoracic, visceral, and limb steps) and were enrolled in an ambispective single centre study called STEAR (STaged Endovascular Aortic Repair - NCT03342755). Data regarding all study participants, single step mortality and morbidity (systemic complications) rates were recorded and the overall results were considered for statistical analysis. Previous aortic interventions (61/80 cases, 76.3%) combined with the TAAA extents resulted in different staging strategies: 58 patients (73%) had a thoracic step and 33 (41%) a limb step. The median TAAA treatment time was 77 days (50-107). The overall mortality was six cases (8%) and 30 day clinical success rate 64 cases (80%). The overall rate of grade 2 or 3 (including death) systemic complications was 19 cases (24%) and 20 patients (25%) experienced grade 1 complications. Three patients with type II or III TAAAs (4%) had permanent and fatal spinal cord (SC) impairment. On multivariable analysis, SC ischaemia was associated with an aortic coverage ≥350mm (OR: 9.15, p=.03, 95% CI: 1.3-66.4) and bovine arch (OR: 10.6, p=.01, 95% CI: 1.6-68.6). The overall short term (six month) clinical success was 72 cases (90%) and none experienced SC ischaemia after late endoleak resolution or treatment. At mid term (mean follow up: 13.3±15.4 months), the overall freedom from conversions, re-interventions, late rupture, or type I and III endoleaks was 57 of 72 survivors (79%). A multistaged approach with a third limb step in case of TAAAs is safe and technically feasible, with an acceptable rate of permanent spinal cord ischaemia. Different staging methods and protocols have been proposed and standardisation is required, especially for type I-II-III aneurysms.

Long-term Outcomes of Elective Endovascular Repair of Asymptomatic Infrarenal Aortic Aneurysms with the Zenith Stentgraft

Long-term Outcomes of Elective Endovascular Repair of Asymptomatic Infrarenal Aortic Aneurysms with the Zenith Stentgraft

Survival After Elective Endovascular or Open AAA Repair: A Systematic Review and Meta-analysis

Introduction - Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective AAA repair. However, superiority of EVAR has recently been challenged by reports of impaired longevity in patients who underwent elective endovascular repair. (1, 2) In this context we considered a systematic review and meta-analysis of the available survival data relevant. Possible confounding by age differences between patients receiving EVAR or open surgical repair (OSR) was addressed by estimating relative survival. Methods - A search using PubMed, Embase, Web of Science and Cochrane for the 1993-2018 interval identified 53 eligible papers that reported short-term and/or long-term mortality of EVAR and OSR. Identified studies included 4 randomized controlled trials (RCTs), 20 reports based on administrative registries, and 29 cohort studies. Pooled overall survival estimates (Hazard ratios with corresponding 95% CIs for EVAR versus OSR) were calculated using a random-effects model. For each study expected survival was calculated based on the matched (age, sex, year of operation and country) general population. Relative survival was consequently calculated as the ratio between observed and expected survival, according to EVAR or OSR. (3, 4) Results - The analysis includes data of 189.022 patients: 102.053 EVARs and 86.969 OSRs. Pooled 30-day mortality for EVAR was 1.16% (95% CIs 0.92 – 1.39) and 3.27% (95% CIs: 2.71 – 3.83) for OSR. Combined (overall) 3, 5, and 10-year survival rates were similar for EVAR and OSR. However, data from cohort studies indicated superior survival after OSR at 3 years and a trend towards superior survival at 5 and 10 years. Yet, EVAR patients included in these cohort studies were older (73.7 years) compared to OSR patients (71.4 years). Correction of age inequality through relative survival analysis showed comparable 3, 5, and 10 years survival for EVAR and OSR among all types of studies. Conclusion - Pooled data confirm superior 30-day survival of EVAR over OSR, but long-term survival up to 10 years is equivalent, when corrected for age inequality. Asymmetrical medical decision making with regard to EVAR and OSR may result in confounding by indication in the cohort and registry studies. Although relative survival estimates reduce the impact of age differences, it is plausible that fitter patients or patients with more complex AAA morphologies are more likely to receive OSR. Published data do not allow for extension beyond the 10-year survival window or for analysis of specific subgroups (women, young patients).

Optimizing Surveillance and Re-intervention Strategy Following Elective Endovascular Repair of Abdominal Aortic Aneurysms.

EVAR for abdominal aortic aneurysm has an initial survival advantage over OR, but more frequent complications increase costs and long-term aneurysm-related mortality. Randomized controlled trials of EVAR versus OR have shown EVAR is not cost-effective over a patient's lifetime. However, in the EVAR-1 trial, postoperative surveillance may have been sub-optimal, as the importance of sac growth as a predictor of graft failure was overlooked. Real-world data informed a discrete event simulation model of postoperative outcomes following EVAR. Outcomes observed EVAR-1 were compared with those from 5 alternative postoperative surveillance and re-intervention strategies. Key events, quality-adjusted life years and costs were predicted. The impact of using complication and rupture rates from more recent devices, imaging and re-intervention methods was also explored. Compared with observed EVAR-1 outcomes, modeling full adherence to the EVAR-1 scan protocol reduced abdominal aortic aneurysm (AAA) deaths by 3% and increased elective re-interventions by 44%. European Society re-intervention guidelines provided the most clinically effective strategy, with an 8% reduction in AAA deaths, but a 52% increase in elective re-interventions. The cheapest and most cost-effective strategy used lifetime annual ultrasound in primary care with confirmatory computed tomography if necessary, and reduced AAA-related deaths by 5%. Using contemporary rates for complications and rupture did not alter these conclusions. All alternative strategies improved clinical benefits compared with the EVAR-1 trial. Further work is needed regarding the cost and accuracy of primary care ultrasound, and the potential impact of these strategies in the comparison with OR.

A Frailty-Based Risk Score Predicts Morbidity and Mortality After Elective Endovascular Repair of Descending Thoracic Aortic Aneurysms

Thoracic endovascular aortic repair (TEVAR) has expanded access to descending thoracic aortic aneurysm (DTAA) repair particularly for elderly and frail patients. This high-risk population has limited long-term overall survival, such that appropriate patient selection is required to optimize patient benefit and resource utilization. Our objective is to develop and validate a frailty-based, procedure-specific risk score for patients undergoing elective TEVAR for DTAA. Patients undergoing nonemergent TEVAR for DTAA during 2005-2016 were identified in the National Surgical Quality Improvement Program database. Those with concurrent cardiac or open aortic surgery, abdominal visceral intervention, or Zone 0 deployment were excluded. Patients were randomly divided between derivation and validation samples. The primary outcome was 30-day major adverse events (MAE), including mortality and major systemic complications. Using the derivation cohort, variables associated with MAE were identified by univariable analyses. Those with P<0.05 were included in multivariable logistic regression analysis. Independent procedure-specific and frailty-related risk factors for MAE were used to develop a pragmatic score to assess risk for TEVAR. Overall, 1,784 patients were included. 14% of the derivation patients had MAE (14% major complications, 4% mortality). Independent risk factors for MAE were primarily associated with markers of frailty and TEVAR extent and complexity and included functional dependence (OR 2.9, 95% CI 1.6-5.4), pulmonary disease (1.6, 1.1-2.4), thoracoabdominal extent (2.2 (1.4-3.4), need for iliac access (2.1, 1.1-3.8), and Zone I or II deployment (OR 1.7, 1.1-2.5). According to their respective beta coefficients, each variable was assigned a single point. Based on total points, patients were stratified as low- (0 points), intermediate- (1 point), or high-risk (≥2 points), with stepwise increases in mortality (0%, 4%, and 9%) and major complications (7%, 11%, and 23%) between strata. Validation patients had similar characteristics, risk strata distribution, and outcomes as the derivation patients, and the risk model had similar performance in both groups. Markers of frailty and procedure complexity strongly predict MAE after TEVAR for DTAA and can improve patient selection by enabling patient and procedure-specific risk stratification. While TEVAR is safe in low-risk patients, intermediate-risk patients warrant careful discussion of the risks and benefits of aortic intervention; under certain circumstances, high-risk patients may not benefit. Further study is required to define the association between frailty and long-term outcomes.

The effects of anesthesia types on early postoperative results in elective endovascular repair of aortic aneurysms

The effects of anesthesia types on early postoperative results in elective endovascular repair of aortic aneurysms