Elective Infrarenal Aortic Aneurysm Repair Research Articles

Sex-specific differences in the standard of care for infrarenal abdominal aortic aneurysm repair, and risk of major adverse cardiovascular events and death.

This study investigated whether sex-specific differences in preoperative/perioperative standard of care (SOC) account for disparity in outcomes after elective infrarenal abdominal aortic aneurysm repair. This was a retrospective cohort study of elective infrarenal abdominal aortic aneurysm repairs (2013-2020) using depersonalized patient-level National Vascular Registry data. SOC was defined for waiting times, preoperative assessment (multidisciplinary/anaesthetic review), cardiovascular risk prevention, and perioperative medication. The primary outcome was major cardiovascular event and/or death (MACED). Some 21 810 patients with an infrarenal abdominal aortic aneurysm were included, 2380 women and 19 430 men. Women less often underwent aneurysm repair within SOC waiting times (51.5 versus 59.3 per cent; P < 0.001), but were equally likely to receive preoperative assessment (72.1 versus 72.5 per cent; P = 0.742). Women were less likely to receive secondary prevention for known cardiac disease (34.9 versus 39.6 per cent; P = 0.015), but more often met overall cardiovascular risk prevention standards (52.1 versus 47.3 per cent; P < 0.001). Women were at greater risk of MACED (open: 12.0 versus 8.9 per cent, P < 0.001; endovascular: 4.9 versus 2.9 per cent, P < 0.001; risk-adjusted OR 1.33, 95 per cent c.i. 1.12 to 1.59). A significant reduction in the odds of MACED was associated with preoperative assessment (OR 0.86, 0.75 to 0.98) and SOC waiting times (OR 0.78, 0.69 to 0.87). There was insufficient evidence to confirm a significant sex-specific difference in the effect of SOC preoperative assessment (women: OR 0.69, 0.50 to 0.97; men: OR 0.89, 0.77 to 1.03; interaction P = 0.170) or SOC waiting times (women: OR 0.84, 0.62 to 1.16; men: OR 0.76, 0.67 to 0.87; interaction P = 0.570) on the risk of MACED. SOC waiting times and preoperative assessment were not met for both sexes, which was associated with an increased risk of MACED. Sex-specific differences in SOC attenuated but did not fully account for the increased risk of MACED in women.

Major adverse cardiac events after elective infrarenal endovascular aortic aneurysm repair.

There is a significant cardiac morbidity and mortality after endovascular aneurysm repair (EVAR). However, information about long-term risk of cardiac events after EVAR and potential predictors is lacking. Therefore, the aim of this study was to determine incidence and predictors of major adverse cardiac events (MACE) at 1 and 5years after elective EVAR for infrarenal abdominal aortic aneurysms. Baseline, perioperative, and postoperative information of 320 patients was evaluated. The primary outcome was the incidence of MACE after EVAR, which was defined as acute coronary syndrome, unstable angina pectoris, de novo atrial fibrillation, hospitalization for heart failure, mitral valve insufficiency, revascularization (including percutaneous coronary intervention and coronary artery bypass grafting), as well as cardiovascular and noncardiovascular death. Kaplan-Meier analyses were performed to determine incidences of MACE, MACE excluding noncardiovascular death and cardiac events by excluding noncardiovascular and vascular death from MACE. Predictors of MACE were identified using univariate and multivariate binary regression analysis. Through 1 and 5years of follow-up after EVAR, freedom from MACE was 89.4% (standard error [SE], 0.018) and 59.8% (SE, 0.033), freedom from MACE excluding noncardiovascular death was 94.7% (SE, 0.013) and 77.5% (SE, 0.030) and freedom from cardiac events was 96.0% (SE, 0.011) and 79.1% (SE, 0.030), respectively. Predictors for MACE within 1year were American Society of Anesthesiologists (ASA) score of III or IV (odds ratio [OR], 3.17; 95% confidence interval [CI], 1.52-6.59) and larger abdominal aortic diameter (OR, 1.04; 95% CI, 1.01-1.08). A history of atrial fibrillation (OR, 0.14; 95% CI, 0.03-0.60) was a negative predictor factor. Predictors for MACE through 5years were a history of heart failure (OR, 4.10; 95% CI 1.36-12.32) and valvular heart disease (OR, 2.31; 95% CI, 0.97-5.51), American Society of Anesthesiologists score of 3 or 4 (OR, 1.66; 95% CI, 0.96-2.88), and older age (OR, 1.04; 95% CI, 1.01-1.08). MACE is a common complication during the first 5years after elective EVAR. Cardiac diseases at baseline are strong predictors for long-term MACE and potentially helpful in optimizing future postoperative long-term follow-up.

Major adverse cardiac events after elective infrarenal endovascular aortic aneurysm repair

Major adverse cardiac events after elective infrarenal endovascular aortic aneurysm repair

Five-year outcomes of elective infrarenal abdominal aortic aneurysm repair at a university hospital in Argentina

Few data about outcomes of elective infrarenal abdominal aortic aneurysm (AAA) repair in Latin America have been published. The objective of the present study is to address this aspect in our population.Retrospective cohort, in which patients with infrarenal AAA undergoing elective surgical or endovascular repair from January 2011 to May 2017 at a university hospital in Autonomous City of Buenos Aires were consecutively included. The primary endpoints were perioperative mortality and all-cause mortality during follow-up. Among the secondary endpoints, the requeriment of reinterventions was assessed.195 patients were included. Open surgery was performed in 72 patients (36.9%) and endovascular aortic repair (EVAR) in 123 (63.1%). Perioperative mortality in the surgery group was 2.8%, while no deaths were recorded in the endovascular group (p = 0.06). The median follow-up was 38 months. No statistically significant difference was found in long-term mortality incidence rate between patients who underwent EVAR and those who underwent open surgery (7% per year vs. 6.7% per year, p = 0.8). The requirement of reinterventions was significantly higher in the endovascular group (9.0% vs. 0%, p = 0.01).Survival analyses demonstrated no statistically significant differences in perioperative and long-term mortality for patients who underwent EVAR compared with those who underwent open surgery, while the former had a higher rate of reinterventions. The results observed in our population do not differ from those published in the United State or Europe.La evidencia surgida en Latinoamérica acerca de los resultados de la reparación electiva del aneurisma de aorta abdominal (AAA) es escasa, por lo que el objetivo de este estudio es abordar este aspecto en la población nacional.Cohorte retrospectiva en la cual se incluyó de forma consecutiva a pacientes con AAA infrarrenal sometidos a reparación quirúrgica o endovascular en forma electiva desde enero de 2011 hasta mayo de 2017 en un hospital universitario de la Ciudad Autónoma de Buenos Aires. Los puntos finales primarios fueron la mortalidad perioperatoria y la mortalidad por todas las causas durante el seguimiento. Entre los puntos finales secundarios se evaluó el requerimiento de reintervenciones.Se incluyó a 195 pacientes. La operación abierta se llevó a cabo en 72 pacientes (36.9%), mientras que el procedimiento endovascular se practicó en 123 (63.1%). La mortalidad perioperatoria en el grupo quirúrgico fue de 2.8%, sin registro de muertes en el grupo endovascular (p = 0.06). La mediana de seguimiento fue de 38 meses. La incidencia de mortalidad tardía fue de 7%/año en pacientes con reparación endovascular y de 6.7%/año en los quirúrgicos (p = 0.8). El requerimiento de reintervenciones fue significativamente mayor en el grupo endovascular (9.0% vs. 0%, p = 0.01).La mortalidad perioperatoria y la mortalidad tardía de los pacientes tratados de manera electiva por AAA en forma quirúrgica o endovascular fueron similares, en tanto que los pacientes sometidos a reparación endovascular requirieron mayor cantidad de reintervenciones. Los resultados observados en la población no difieren de los publicados en Estados Unidos o Europa.

A06] Sex Specific Differences in Pre-operative Standard of Care for Infrarenal AAA Repair and Association with Peri-operative Major Adverse Cardiovascular Events and Death

<h3>Objective</h3> Following elective infrarenal abdominal aortic aneurysm (IRAAA) repair, women have a higher rate of major adverse cardiovascular events and death (MACED). Disparity in pre-operative standard of care (SOC) may contribute. <h3>Methods</h3> Elective IRAAA repair data from the National Vascular Registry, 2013 – 2020 were analysed. SOC was defined for pre-operative assessment (multidisciplinary/anaesthetic review), waiting times, and cardiovascular risk prevention. Analyses and multivariable logistic regression were conducted according to a pre-specified plan. <h3>Results</h3> There were 21 810 patients (2 380 women; 19 430 men). Women were less often repaired within SOC waiting times (51.5% <i>vs</i>. 59.6%, <i>p</i> < .01), but received similar SOC pre-operative assessment (72.1% <i>vs</i>. 72.5%, <i>p</i> not significant). Women had ischaemic heart disease less often (29.0% <i>vs</i>. 37.7%, <i>p</i> < .01), but those with known cardiovascular co-morbidity received SOC risk prevention more often (52.1% <i>vs.</i> 47.3%, <i>p</i> < .01). Overall, women were less likely to receive antiplatelets (72.2% <i>vs</i>. 75.2%, <i>p</i> < .01) or statins (77.1% <i>vs</i>. 80.6%, <i>p</i> < .01). Women were at greater risk of MACED following open (12% <i>vs</i>. 8.9%, <i>p</i> < 0.01) and endovascular (4.9 % <i>vs.</i> 2.9%, <i>p</i> < .01) repair: overall odds ratio (OR) 1.51, adjusted for age and repair type; OR 1.28 following adjustment for demographics, co-morbidities and SOC. SOC waiting time was associated with a reduction in risk (OR 0.79) for both sexes. SOC pre-operative assessment reduced MACED risk for women (OR 0.80), but not men (OR 1.09). SOC cardiovascular risk prevention did not significantly influence MACED risk. <h3>Conclusion</h3> Treatment within SOC waiting time is independently associated with a reduction in MACED risk for both sexes, SOC pre-operative assessment is associated with risk reduction for women only.

Endovascular Aneurysm Repair May Provide a Survival Advantage in Patients Deemed Physiologically Ineligible for Open Abdominal Aortic Aneurysm Repair

Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity and fitness. It can be used to guide decision making prior to major vascular surgery. The EVAR-2 trial suggested that endovascular aneurysm repair (EVAR) in patients unfit for open repair failed to provide a significant survival advantage over nonsurgical management. The aim of this study is to assess contemporary survival differences between patients with poor CPET measures who underwent EVAR or were not offered surgical intervention. A prospectively maintained database of CPET results of patients considered for elective infrarenal aortic aneurysm repair were interrogated. Anaerobic threshold (AT) of <11mL/min/kg was used to indicate poor physical fitness. Hospital electronic records were then reviewed for perioperative, reintervention, and long-term outcomes. Between November 2007 and October 2017, 532 aortic aneurysm repairs were undertaken, of which 376 underwent preoperative CPET. Seventy patients were identified as having an AT <11mL/min/kg. Thirty-seven patients underwent EVAR and 33 were managed nonsurgically. All-cause survival at 1, 3, and 5years for those patients who underwent EVAR was 97%, 92%, and 81%, respectively. For those not offered surgical intervention survival at the same points was 72%, 48%, and 24% [hazard ratio, HR=5.13 (1.67-15.82), P=0.004]. Aneurysm-specific survival at 1, 3, and 5years for those patients who underwent EVAR was 97%, 94%, and 94%, respectively. Survival at the same time points for those not offered surgical intervention was 90%, 69%, and 39%, respectively [HR=7.48 (1.37-40.82), P=0.02]. In this small, retrospective, single-center, nonrandomized cohort, EVAR may provide a survival advantage in patients with poor physical fitness identified via CPET. Randomized studies with current generation EVAR are required to validate the results shown here.

Volumetric Nephrogram Represents Renal Function and Complements Aortic Anatomic Severity Grade in Predicting EVAR Outcomes.

Chronic kidney disease (CKD) is a predictor of poor outcomes for patients undergoing endovascular aortic aneurysm repair (EVAR). Anatomic severity grade (ASG) represents a quantitative mechanism for assessing anatomical suitability for endovascular aortic repair. Anatomic severity grade has been correlated with repair outcomes and resource utilization. The purpose of this study was to identify a novel renal perfusion metric as a way to assist ASG with predicting EVAR outcomes. Retrospective review of a prospectively maintained database identified elective infrarenal aortic aneurysm repair cases. Anatomic grading was undertaken by independent reviewers. Using volumetric software, kidney volume, and a novel measure of kidney functional volume, the volumetric nephrogram (VN) was recorded. Systematic evaluation of the relationship of kidney volume and VN to CKD and ASG was undertaken using linear regression and receiver-operator statistical tools. A total of 386 cases with patient and anatomic data were identified and graded. Mean age was 72.9 ± 0.4 years. Renal volume <281 mL correlated with CKD (area under the curve [AUC] = .708; P ≤ .0001). Volumetric nephrogram <22.5 HU·L correlated with CKD (AUC = 0.764; P ≤ .0001). High (≥15) ASG scores correlated with both renal volume (AUC = .628; P ≤ .0001) and VN (AUC = .628; P ≤ .0001). Regression analysis demonstrated a strong, inverse relationship between ASG and VN ( R2 = .95). These data demonstrate that VN is a strong predictor of CKD in a large database of patients undergoing elective aneurysm repair. We demonstrate an inverse relationship between renal function and ASG that has not been previously described in the literature. Additionally, we have shown that VN complements ASG as a model of overall cardiovascular health and atherosclerotic burden. Outcomes in patients with poor renal function may be related to anatomical issues in addition to well-described systemic ramifications.

Aspirin use is associated with decreased radiologically-determined thrombus sac volume in abdominal aortic aneurysms.

Introduction Formation and renewal of intramural thrombus is associated with inflammation, and contributes to the complexity of aneurysm repair. Current cardiovascular pharmacotherapy includes several inflammatory modulators such as aspirin, statins, clopidogrel, and angiotensin-converting enzyme inhibitors. The purpose of our study was to investigate the effect of these inflammatory modulators on radiographically-determined thrombus sac volume. Methods Pre-operative computed tomography scans were reviewed in patients who underwent elective infrarenal aortic aneurysm repair. Thrombus sac volume was obtained using a Hounsfield unit restricted region growth algorithm. Co-morbid conditions such as diabetes mellitus and post-operative complications were evaluated compared to thrombus sac volume. Receiver-operator characteristic curves were generated for thrombus sac volume and patients on the various cardiovascular pharmacotherapies. Results A total of 266 patients (mean age = 72.6 ± 0.6 years; mean thrombus sac volume = 58.7 (34.4-89.0) cm3) were identified. Acetylsalicylic acid use was associated with a decreased thrombus sac volume ≤50 cm3 (AUC = 0.616, p = 0.013) whereas statins ( p = 0.26), angiotensin-converting enzyme inhibitors ( p = 0.46), and clopidogrel ( p = 0.62) had no correlation to thrombus sac volume. Diabetes mellitus was not associated with thrombus sac volume ( p = 0.31). Conclusion Acetylsalicylic acid use is associated with decreased thrombus sac volume in a patient population undergoing elective abdominal aortic aneurysms repair. The effect of acetylsalicylic acid over other anti-inflammatory and anti-platelet agents is possibly attributable to its distinct mechanism of cyclooxygenase-1 inhibition. Diabetes mellitus, a known correlate of aneurysm incidence, is not associated with thrombus burden. The potential to alter aneurysm thrombus volume, thereby affecting aneurysm morphology, may yield a more favorable aneurysmal repair.

Ten-Year Single-Center Results of Abdominal Aortic Aneurysm Treatment: Endovascular versus Open Repair

The purpose of the present study was to compare the long-term survival in matched cohorts of patients with infrarenal abdominal aortic aneurysm (AAA) undergoing an elective open repair (OR) or an endovascular aneurysm repair (EVAR). Patients with a primary elective repair of an infrarenal aortic aneurysm between 1998 and 2006 were identified in a retrospective review of our single-center database. EVAR and OR patients were matched with respect to age, gender, renal disease, tobacco use, hypertension, chronic obstructive pulmonary disease, and coronary artery disease. The primary end points were the early mortality and all-cause mortality during follow-up. A total of 465 patients with elective infrarenal aortic aneurysm repair were identified in the database. The EVAR and OR patients were matched according to the above-mentioned characteristics, and finally, 108 patients were included in each group. The early mortality encountered was only one death in the open group (P=0.316). The Kaplan-Meier survival analysis by the log-rank test showed no difference in cumulative survival between OR group and EVAR group (P=0.458). Seventeen reinterventions (16.7%) in the EVAR group vs. 7 (6.5%) in the OR group (P=0.018) were necessary during follow-up. OR and EVAR can be performed safely for elective treatment of AAA. The reintervention rate is, as expected, significantly higher in the EVAR group, but the long-term survival remains equal in both groups.

Accurate Clinical Data is Vital in the Age of Surgeon Level Outcome Reporting

Data are only as good as the system that collects them. It is crucial to have good healthcare data to draw robust and accurate conclusions, not only for individual clinician feedback but also to better inform patients. Venermo and Lees have shown the Swedish data collection for the SWEDVASC Registry to be on the whole highly accurate. It seems that most of the discrepancies found in external validation were a result of administrative errors, and the main issue in internal validation was one hospital not recording pre-operative risk factors of diabetes and smoking, which was attributed to a poor administrative culture. This is a robust database and the Swedish vascular surgeons and patients alike can be confident in its accuracy. The accuracy of clinical data recording has become of increasing importance in the UK. Since the NHS Commissioning Board’s publication “Everyone Counts: Planning for Patients 2013/14,” the UK government have been pushing for individual surgeon outcomes to be published, to better inform the public. This is following the lead of cardiac surgery, in which there are well-established index procedures and a culture of recording outcomes, to allow comparisons between colleagues and improve skills. In June 2013, the National Vascular Registry published consultant-level statistics on stroke and peri-operative mortality for carotid endarterectomy, and peri-operative mortality in elective infra-renal abdominal aortic aneurysm (AAA) repair. However, a surgeon is much more than just an individual, and here the argument lies. Should surgical outcomes be expressed at surgeon or at unit level? The latter would take into account the whole surgical episode, including multidisciplinary team decision-making, the anaesthetic team, high dependency and ward-based care. Concerns that the reporting of surgeon-level outcomes may lead to risk-adverse behaviour, with surgeons becoming reluctant to offer intervention in high-risk cases, may have been borne out in the UK outcome data reported in 2014. These data demonstrated a fall of 4.5% in the number of elective AAA repairs performed in the UK, between 2012 and 2013, the first year of surgeon-level outcome reporting. Another aspect to consider following the publication of surgeonspecific outcomes is the impact on training. The Association of Surgeons in Training (ASiT) in the UK has expressed concerns about this,

Systematic Review and Meta-analysis of Long-term survival After Elective Infrarenal Abdominal Aortic Aneurysm Repair 1969–2011: 5 Year Survival Remains Poor Despite Advances in Medical Care and Treatment Strategies

Systematic Review and Meta-analysis of Long-term survival After Elective Infrarenal Abdominal Aortic Aneurysm Repair 1969–2011: 5 Year Survival Remains Poor Despite Advances in Medical Care and Treatment Strategies

An analysis of the influence of intra-operative blood salvage and autologous transfusion on reducing the need for allogeneic transfusion in elective infrarenal abdominal aortic aneurysm repair.

An intra-operative cell salvage machine, commonly known as a "cell saver", aspirates, washes, and filters patient's blood during an operation so that the blood can be returned to the patient's circulation instead of being discarded. This procedure could significantly reduce the risks related to the use of allogeneic blood and blood products in surgery. The aim of this study was to analyse the influence of intra-operative cell salvage on reducing the need for allogeneic blood in patients with asymptomatic infrarenal abdominal aortic aneurysm undergoing elective repair of the aneurysm. We retrospectively collected data from the clinical records of patients who underwent elective infrarenal abdominal aortic aneurysm repair. Two groups were formed: the "cell saver" group, in which intra-operative cell salvage was used, and the control group, in which a cell saver was not used. Thirty patients underwent abdominal aortic aneurysm repair with the use of a cell saver, while 32 underwent the same operation without cell salvage. We found a significant association between use of the cell saver and a reduced need for allogeneic blood in these patients. Operations performed with the use of a cell saver lasted, on average, less time than those performed without it. The difference between pre-operative and post-operative haemoglobin levels was significantly greater in the group of patients who underwent repair with the use of a cell saver than in the control group. The use of a cell saver in elective abdominal aortic aneurysm repair significantly reduces the need for intra-operative use of allogeneic blood.

Combined general-epidural anesthesia with continuous postoperative epidural analgesia preserves sigmoid colon perfusion in elective infrarenal aortic aneurysm repair

Background:In elective open infrarenal aortic aneurysm repair the use of epidural anesthesia and analgesia may preserve splanchnic perfusion. The aim of this study was to investigate the effects of epidural anesthesia on gut perfusion with gastrointestinal tonometry in patients undergoing aortic reconstructive surgery.Methods:Thirty patients, scheduled to undergo an elective infrarenal abdominal aortic reconstructive procedure were randomized in two groups: the epidural anesthesia group (Group A, n=16) and the control group (Group B, n=14). After induction of anesthesia, a transanally inserted sigmoid tonometer was placed for the measurement of sigmoid and gastric intramucosal CO2 levels and the calculation of regional–arterial CO2 difference (ΔPCO2). Additional measurements included mean arterial pressure (MAP), cardiac output (CO), systemic vascular resistance (SVR), and arterial lactate levels.Results:There were no significant intra- and inter-group differences for MAP, CO, SVR, and arterial lactate levels. Sigmoid pH and PCO2 increased in both the groups, but this increase was significantly higher in Group B, 20 min after aortic clamping and 10 min after aortic declamping.Conclusions:Patients receiving epidural anesthesia during abdominal aortic reconstruction appear to have less severe disturbances of sigmoid perfusion compared with patients not receiving epidural anesthesia. Further studies are needed to verify these results.

Postoperative Pulmonary Function After Open Abdominal Aortic Aneurysm Repair in Patients With Chronic Obstructive Pulmonary Disease: Epidural Versus Intravenous Analgesia

We reviewed our experience to determine the effect of epidural versus intravenous analgesia on postoperative pulmonary function and pain control in patients with chronic obstructive pulmonary disease (COPD) undergoing open surgery for abdominal aortic aneurysm. A retrospective study with prospective collection of data of 30 COPD patients undergoing open abdominal aortic aneurysm repair, during a 5-year period. Group I (n = 16) was operated under combined general and epidural anesthesia and epidural analgesia; group II (n = 14), under general anesthesia and intravenous analgesia. All patients performed pulmonary function tests (PFTs) preoperatively and during postoperative days 1 and 4. Pain assessment was performed on all patients during rest and activity on postoperative days 1, 2, and 4 by using the visual analog scale. Data were recorded for PFTs, postoperative pain, length of hospital stay, length of ICU stay, and postoperative pulmonary morbidity, including atelectasis and pulmonary infections. There was no in-hospital mortality. Hospital stay was similar between the two groups (group I: 7.1 ± 1.0, group II: 7.5 ± 1.1). Group I patients showed significantly increased postoperative PFT values compared with group II patients at all time points (postoperative day 1: FEV(1)(%): 32.3 ± 4.4 vs. 27.1 ± 1.6, p = 0.007, FVC(%): 35.4 ± 8,5 vs. 28.3 ± 2.3, p = 0.035; postoperative day 4: FEV(1)(%): 50.4 ± 6.8 vs. 41.9 ± 6.8, p = 0.017, FVC(%): 51.3 ± 8.3 vs. 43.0 ± 7.9, p = 0.046). However, postoperative clinical pulmonary morbidity was not different between groups. Group I patients showed significantly reduced postoperative pain at all time points compared with group II patients. These differences were more pronounced during postoperative days 1 and 2, both at rest (visual analog score: 1.1 ± 0.9 vs. 2.6 ± 1.6, p = 0.02 and 0.7 ± 0.8 vs. 1.9 ± 1.1, p = 0.021, respectively) and during activity (2.3 ± 0.8 vs. 4.0 ± 1.7, p = 0.013 and 1.6 ± 0.7 vs. 2.8 ± 1.2, p = 0.019, respectively). Epidural anesthesia and postoperative epidural analgesia improve the postoperative respiratory function, compared with general anesthesia and systemic analgesia, and reduce postoperative pain as well, in COPD patients undergoing elective infrarenal abdominal aortic aneurysm repair.

Fast track management reduces the systemic inflammatory response and organ failure following elective infrarenal aortic aneurysm repair

Systemic inflammatory response syndrome (SIRS) is common after abdominal aortic aneurysm (AAA) repair. The aim of this study was to analyze the impact of a multimodal fast track (FT) regimen on incidence rates of SIRS after elective infrarenal AAA repair. Post hoc analysis of a randomized controlled trial including 99 patients after either traditional (TC) or FT care. Basic FT elements were no bowel preparation, reduced preoperative fasting, patient controlled epidural analgesia, enhanced postoperative feeding and mobilization. The presence of SIRS, organ failure and mortality, length of stay (LOS) on intensive care unit (ICU) were analyzed during the postoperative course. The incidence of SIRS in the FT treatment arm was significantly lower as compared to TC: 28% vs. 50%, P = 0.04. The rate of any organ failure (AOF) and multiple organ failure (MOF) was lower in the FT group: AOF: 16% vs. 36%, P = 0.039; MOF: 2% vs. 12%; P = 0.112. LOS on ICU showed a slight advantage for FT care: 20 hours vs. 32 hours (P = 0.183). An optimized patient care program in elective open AAA repair significantly decreases the postoperative incidence of SIRS as well as rates of organ failure.

Midterm results of adjunctive neck therapies performed during elective infrarenal aortic aneurysm repair

This study evaluated the durability of adjunctive endovascular neck procedures, including aortic cuffs, Palmaz stents (Cordis, Miami Lakes, Fla), and high-pressure balloon angioplasty, at managing intraoperative proximal neck complications during endovascular aortic aneurysm repair (EVAR). This was a single-center retrospective review of EVARs. The primary outcome variable studied was survival free of a graft-related event (GRE). GRE was defined by the occurrence of one of the following: type I endoleak, sac enlargement, aneurysm rupture, death, or procedure related to the aortic neck. These outcome variables were assessed relative to the preoperative anatomic neck variables (neck length, diameter, degree of angulation, degree of circumferential thrombus, and presence of conicity), procedural variables (manufacturing type of graft, use of a Palmaz stent), and patient characteristics (age and presence of medical comorbidities). Outcomes were assessed by t tests, Pearson χ(2), and Kaplan-Meier analysis, when appropriate. A total of 174 EVARs performed between January 2005 and December 2007 were evaluated. Fifty-six adjunctive procedures were performed, with a 97% primary-assisted exclusion rate. Patients who received an adjunctive therapy had similar freedom from a GRE compared with EVARs that did not require adjunctive therapy (35.5 ± 2.6 vs 34.8 ± 1.5 months, P = .31, log-rank test). Subset analysis identified a significant association between Palmaz stent placement at the time of EVAR and decreased freedom from GREs (hazard ratio, 2.87; 95% confidence interval, 1.21-6.77; P = .02). Midterm results suggest that adjunctive therapies to manage intraoperative proximal neck complications do not compromise durability. The subset of patients requiring aortic neck Palmaz stent placement at the time of EVAR are among those at highest risk for subsequent GRE.

Elective infrarenal abdominal aortic aneurysm repair - transperitoneal, retroperitoneal, endovascular?

We retrospectively analyzed the peri-operative outcome of 210 consecutive patients undergoing elective infrarenal abdominal aortic aneurysm (AAA) repair according to the surgical approach: transperitoneal (TP; 63 patients), retroperitoneal (RP; 81 patients) and endovascular (EV; 66 patients) repair. Concerning gender, AAA diameter and classification of the American Society of Anesthesiologists (ASA score) all groups were comparable; the median age in the EV group was significantly higher (78 years vs. 68 years and 67 years, respectively, P=0.001). Mortality rates were 0% for TP, 1.2% for RP and 3% for EV repair (n.s.). Morbidity rates did not significantly differ between the groups. In specialized centres mortality rates of elective infrarenal aneurysm repair are low - regardless of the surgical approach. In such centres the best treatment options for each patient as to the surgical approach as well as peri-operative management can be provided individually.

The retroperitoneal approach combined with epidural anesthesia reduces morbidity in elective infrarenal aortic aneurysm repair

In elective open infrarenal aortic aneurysm repair the surgical approach and the use of epidural anesthesia (EDA) may determine patients' outcome. Hence we analyzed our results after elective open aneurysm repair in the light of the surgical approach and the use of EDA. Retrospective analysis of a prospective data base. From December 2005 to April 2008, 125 patients with infrarenal aortic aneurysm underwent elective open repair. Patients were divided into four groups: retro- and transperitoneal approach with and without epidural anesthesia (RP+/-EDA and TP+/-EDA). In terms of age, sex, aneurysm diameter, ASA score and clamping time all groups were comparable. In the retroperitoneal groups significantly more tube grafts were implanted (63 vs. 27; P=0.001). The rate of surgical complications did not differ between the groups. The RP+EDA group had the lowest rate of postoperative assisted mechanical ventilation (5.1% vs. 35.7%; P=0.002) and medical complications (17.9% vs. 42.8%; P=0.032). Concerning frequency of surgical complications, the retroperitoneal incision was comparable to the transperitoneal approach in infrarenal aortic reconstruction. Supplementation with EDA resulted in a decreased rate of postoperative assisted mechanical ventilation and in lower morbidity rates.

待期的腹部大動脈瘤術後に脊髄虚血による対麻痺を発症した 1 例

待期的腹部大動脈瘤術後に脊髄虚血による対麻痺を発症した 1 例

Hormonal Stress Response and Hemodynamic Stability in Patients Undergoing Endovascular vs. Conventional Abdominal Aortic Aneurysm Repair

To investigate the effect of two different surgical techniques with different anesthetic modes on intraoperative and postoperative hormonal stress response, hemodynamic stability, fluid loading and renal function in patients scheduled for elective infrarenal abdominal aortic aneurysm (AAA) repair. Forty consecutive patients scheduled for elective infrarenal AAA repair were allocated without randomizing into two groups: an endovascular (EVAR, n = 20) and a conventional (CAR, n = 20) aneurysm repair group according to aneurysm morphology as determined by preoperative computed tomography and angiography. The EVAR group were operated under spinal anesthesia and the CAR group using general anesthesia with epidural blockade. Patients undergoing CAR showed lower intraoperative mean arterial pressure and significantly higher plasma norepinephrine before aortic cross-clamping and significantly higher lactate after aortic declamping and postoperatively than patients in the EVAR group. Postoperatively, vasopressin and serum cortisol were also significantly higher in the CAR group. Fluid loading and estimated blood loss were more excessive in the CAR group. Stress response was lower and hemodynamic stability and lower body perfusion superior and renal function also better maintained in patients undergoing EVAR under spinal anesthesia as compared to those undergoing CAR using general anesthesia with epidural blockade.