Emergency Abdominal Aortic Aneurysm Research Articles

Impact of Neck Morphology on Outcomes of Emergent Endovascular Abdominal Aortic Aneurysm Repair

Impact of Neck Morphology on Outcomes of Emergent Endovascular Abdominal Aortic Aneurysm Repair

Midterm Outcomes of Antegrade In Situ Laser Fenestration of Polyester Endografts for Urgent Treatment of Aortic Pathologies Involving the Visceral and Renal Arteries

Aortic endografting and antegrade in situ laser fenestration of visceral arteries (LFEVAR) may be considered as an alternative to open surgery for repair of emergent complex abdominal aortic aneurysms (AAA) in fragile patients. The aim of this article is to evaluate the midterm results of LFEVAR performed with polyester endografts. From August 2015 to December 2020, all consecutive LFEVAR performed for non-deferrable treatment of complex AAA were analysed. Polyester endografts were deployed and subsequently fenestrated using an atherectomy laser probe; the fenestrations were enlarged using cutting and semicompliant balloons before implantation of balloon expandable bridging stents into the target vessels. Prospectively collected midterm survival, patency, and re-intervention rates were analysed. Forty four procedures were performed for 11 T1a endoleaks, five thoracoabdominal aneurysms, 20 pararenal aneurysms, four segmental renal artery (RA) preservations, three anastomotic aneurysms, and one aortic dissection. One hundred and eight laser fenestrations were performed (26 for the superior mesenteric artery [SMA], 13 for the coeliac trunk, 33 and 31 for the right and left RA, respectively). Median ischaemia duration was 7, 48, 48, and 45 minutes, respectively. Technical success rate was 97%, with no open surgical conversions. The 30 day mortality was 4.5% (n = 2). No spinal cord events were observed nor early stent related complications. Kaplan-Meier overall survival at two years was 73%, the aortic related re-intervention free survival was 70%, and the stent related re-intervention free survival was 90.6%. Four target vessel thromboses were detected, of which three were rescued. Three type IIIC endoleaks, one RA false aneurysm, and one SMA stenosis, required re-intervention during a median follow up of 24.7 months. Antegrade LFEVAR is feasible, safe, and provides satisfactory early and midterm outcomes for non-deferrable treatment of aortic pathologies involving the visceral segment. Long term data are mandatory to confirm the usefulness of this promising off label technique.

A Novel Negative Pressure Therapy Technique to Manage a Colo-Cutaneous Fistula following Emergency Aortic Surgery

Negative pressure wound therapy (NPWT) is a well-established technique for managing the open abdominal wound. The decision to intentionally leave an abdominal incision open may be required in the aftermath of surgery for intra-abdominal sepsis or where there is concern regarding abdominal compartment syndrome (ACS). Untreated ACS following elective, or emergency abdominal aortic aneurysm repair (AAA) is associated with mortality rates of up to 60% [1]. Management of the open abdomen, particularly in obese patient, is challenging and labour-intensive. The aim of wound management in this setting is to contain drainage, manage the peri-wound skin and facilitate closure of the wound. This case report discusses the successful management of a complex abdominal wound in a morbidly obese patient complicated by a colo-cutaneous fistula following emergency abdominal aortic aneurysm repair.

Midterm Results of Physician-Modified Stent Grafts for Thoracoabdominal and Complex Abdominal Aortic Aneurysms Repair

To assess midterm results of physician-modified stent grafts (PMSG) for the treatment of emergent complex abdominal and thoracoabdominal aortic aneurysms (TAAA) in high-risk patients. All consecutive patients with emergent complex abdominal or TAAA undergoing PMSG technique between January 2012 and July 2019 were retrospectively included. Indications for PMSG were symptomatic aneurysms and rapidly growing aneurysms >70mm. Ruptured aneurysms were excluded. Thirty-three patients (mean age: 74 +/- 11years) were included. The mean aneurysm diameter was 76 +- 20mm. Patients presented with TAAA (n=20, 61%), complex abdominal aortic aneurysms (CAAA, n=9, 27%), type I endoleak after previous endovascular aneurysm repair (n=3, 9%) and intramural aortic hematoma (n=1, 3%). Chimney technique was performed in addition to PMSG in seven cases (21%). Intraoperative adverse events were recorded in seven cases (35%) in the TAAA group and one case (11%) in the CAAA group. In-hospital mortality rate was 15% (n=3) in the TAAA group and 11% (n=1) in the CAAA group. Moderate to severe complications were recorded in 45% of cases (n=15). Spinal cord ischemia occurred in two cases (6%, one case without residual deficit and one with minor motor deficit). One (3%) patient required transient hemodialysis. One patient presented with early aortic rupture and required an open conversion. The mean follow-up duration was 31months (1-79). Overall survival estimates were 81.4% (95% confidence interval [CI]: 63.1.-91.2) at 1year and 71.6% (95% CI: 52.6-84.1) at 2years. Freedom from reintervention rates at 1 and 2years were 61.2% (95% CI: 41.7-75.9) and 57.4% (95% CI: 37.9-72.8). Target vessel primary patency rates at 1 and 2years were 99.2% (95% CI: 94.2-99.9) and 97.7% (95% CI: 90.7-99.4). PMSG for high-risk patients with complex aneurysms provided acceptable technical success and excellent target vessel patency rates but were associated with a 12% in-hospital mortality rate. Reinterventions were frequent. This technique should be limited to selected high-risk patients for whom the risk of rupture in the short-term is deemed too high to wait for graft manufacturing of custom-made device.

O057 The association between computed tomography-based body composition metrics and outcomes after aortic aneurysm repair

Abstract Introduction Computed tomography-based body composition (CTBC) metrics can provide a reliable measure of muscle and fat distribution. Their role in predicting outcomes following abdominal aortic aneurysm (AAA) repair has yet to be investigated. This study explored the associations between CTBC and short-term postoperative outcomes after AAA repair. Methods This single-centre retrospective study included patients who had undergone either elective or emergency AAA repair, via open or endovascular routes, from 2015 to 2020. The cross-sectional surface areas of skeletal muscle (SMI), and intramuscular (IMAT), visceral (VAT), and subcutaneous (SAT) adipose tissues were measured at the L3 vertebral level of a preoperative CT scan. Sarcopaenia was defined as SMI ≤38.5cm2 in women and ≤52.4cm2 in men. Cut-points for IMAT, VAT, and SAT were defined as the sex-specific median or mean for this study population. Results In total, 265 patients were included. SMI was higher in the open surgery group compared to the endovascular group (p=0.011). For infrarenal aneurysms, IMAT was higher in the endovascular group (p=0.021), however, for juxtarenal aneurysms, it was higher in the open surgery group (p=0.002). 76.6% of all patients had sarcopaenia but this was not associated with mortality (p=0.259), Clavien-Dindo class ≥2 complications (p=0.559), or length of stay (p=0.920). IMAT, VAT, and SAT were not associated with any measured outcomes. Conclusion Body composition differences between open and endovascular patients highlight the potential for CTBC as a tool for patient stratification. However, at present, CTBC cannot predict short-term postoperative outcomes. Take-home message There are significant differences in body composition between patients undergoing open and endovascular aortic aneurysm repair, highlighting the potential for CTBC to be used as a tool for patient stratification. However, at present, CTBC cannot predict short term postoperative outcomes.

Endovascular aneurysm repair (EVAR) : UpdateD

Abdominal aortic aneurysms can either be treated by open surgery or endovascular repair. In both cases, prostheses are implanted to prevent potentially lethal aortic ruptures. Studies seeking to identify the optimal treatment came to diverging conclusions. The goal of this article is to shed light on the discussion of which treatment option is to be preferred. This article summarizes the relevant studies on elective and emergency abdominal aortic aneurysm repair. The presented studies are discussed, and results are interpreted and compared. While most studies indicate lower short-term mortality rates in endovascular aneurysm repair (EVAR), mortality rates converged in multiple trials and even showed alower mortality rate for open repair in mid-term analyses. Most recent studies indicate long-term equivalence in terms of mortality and ahigher rate of secondary interventions in EVAR patients. The current body of literature indicates no real advantage of one therapy over another. The choice of therapy should depend on anatomic, clinical, and logistic criteria.

Treatment of oral cancer with 3-vessel coronary artery disease and emergency abdominal aortic aneurysm

Treatment of oral cancer with 3-vessel coronary artery disease and emergency abdominal aortic aneurysm

Contemporary mortality after emergent open repair of complex abdominal aortic aneurysms

ObjectiveMortality after open repair for emergent complex abdominal aortic aneurysm (AAA) is poorly defined. This study evaluated the 30-day mortality of open complex AAA repair performed for rupture or other emergent indication using a national surgical registry. We subsequently identified factors associated with mortality. MethodsThe targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing open repair for juxtarenal and suprarenal AAAs or type IV thoracoabdominal aneurysms (TAAAs) for rupture or other emergent indication from 2011 to 2017. Univariate analyses were performed using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Multivariable logistic regression was performed to identify factors independently associated with mortality. ResultsWe included 374 patients who underwent an emergent complex open AAA repair during the study period. There were 142 (38%) cases performed for rupture with hypotension, 141 (38%) for rupture without hypotension, 40 (11%) for symptomatic AAA, and 51 (14%) for another indication. The distribution by aneurysm type was 224 juxtarenal AAAs, 122 suprarenal AAAs, and 28 type IV TAAAs. Overall, there was a 30-day mortality of 32% (118 deaths). For those with juxtarenal AAA repair, 67 (30%) patients died within 30 days; there were 38 (31%) deaths within 30 days in those with suprarenal AAA, and 13 (46%) deaths within 30 days in those with type IV TAAA. On univariate analysis, preoperative variables associated with death were increasing age, use of a transperitoneal surgical approach, lower preoperative estimated glomerular filtration rate, low baseline albumin concentration (<3.5 g/dL), need for preoperative transfusion, low body mass index (<18.5 kg/m2), and hypotension at presentation. Intraoperative variables associated with mortality were supraceliac clamp location and concurrent renal revascularization. On multivariable analysis, factors independently associated with death included rupture with associated hypotension (reference: other emergent indication; adjusted odds ratio [AOR], 3.28; confidence interval [CI], 1.75-5.41; P < .001), age >60 years (reference: <60 years; AOR, 1.59; CI, 1.18-2.13; P = .002), longitudinal laparotomy incision (reference: retroperitoneal; AOR, 3.28; CI, 1.75-6.16; P < .001), and supraceliac cross-clamp (reference: clamp above one renal artery; AOR, 2.14; CI, 1.31-3.50; P = .003). ConclusionsNearly one-third of patients die within 30 days of emergent open complex AAA repair. Mortality is particularly high for patients with type IV TAAAs, approaching 50%. Predictors of 30-day mortality include rupture with associated hypotension, increasing age, supraceliac clamp location, and longitudinal transperitoneal repair approach. These results will help inform surgical decisions preoperatively and intraoperatively.

Mortality for Open Abdominal Aortic Aneurysm Repair before and after Endovascular Aortic Repair (EVAR)

The purpose of this study was to determine whether endovascular aortic repair (EVAR) has impacted inhospital mortality for patients undergoing open repair (OR). From 1982 through 2016, 1572 repairs were performed for abdominal aortic aneurysms (AAAs). Both ORs and EVARs were performed by the author at two large, tertiary-care, community-based hospitals. In Period I (1982-1999, n = 863), all AAA repairs were performed open. In Period II (2000-2016; n = 709), repairs were performed both by ORs and EVARs. Demographics were similar between study groups. Mortality for elective repairs in Periods I and II were as follows: I = 1.2 per cent (open, n = 9/756) versus II = 1.7 per cent (open, n = 4/241) versus II = 1.2 per cent (EVAR, n = 5/420). Mortality for patients with ruptured AAAs in Periods I and II were as follows: I = 31.8 per cent (open, n = 34/107) versus II = 32 per cent (open, n = 8/25) versus II = 13 per cent (EVAR, n = 3/23). The results of this study demonstrate that the introduction of EVARs has not negatively impacted the inhospital mortality for elective ORs or emergent AAAs for one vascular surgeon who completed training before EVARs became available.

Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians

ObjectivePatients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up. MethodsRetrospective review of a prospectively collected vascular surgery database was performed to identify all patients who underwent elective repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared using univariate statistics. ResultsThe study cohort was composed of 314 patients 80 years of age or older (median, 83 years; interquartile range, 5 years) who underwent repair (96 open, 218 EVAR). The groups had similar comorbidities, except that EVAR patients were more likely to be male and open repair patients were more likely to have larger aneurysms. Compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (EVAR, 5.8 years; open repair, 5.8 years; P = .98). The 1-year survival was significantly higher for EVAR (92.9%) than for open repair (84.1%; P = .02). The 2-year survival (EVAR, 83.4%; open repair, 74.6%; P = .07) and 5-year survival (EVAR, 57.8%; open repair, 60.3%; P = .98) did not differ between EVAR and open repair. Reintervention rates (EVAR, 18%; open repair, 2%; P = .05) were higher in the endovascular treatment group. ConclusionsEVAR results in an improved 1-year mortality in octogenarians compared with open repair, although 5-year survival is similar between the groups. With average life expectancies of >5 years and an 18% reintervention rate, diligent follow-up is required after EVAR even in elderly patients.

Gender Differences in the Rates of Repair of Emergency Abdominal Aortic Aneurysm

Aim: We examined gender differences in the rate and type of repair for intact emergency and ruptured abdominal aortic aneurysm (AAA). Methods: Hospital episode statistic (HES) datasets from April 2002 to February 2015 were obtained. Clinical and administrative codes were used to identify patients who underwent primary definitive repair for ruptured and emergency-intact AAA and patients with AAA diagnosis who died in-hospital without repair. These three groups included all the patients with primary emergency AAA presentation. We examined gender differences between repair rates and type (EVAR versus open) over time. Results: In total 15,717 patients (83% male) received surgical intervention for ruptured AAA, 10,276 (81% male) for intact AAA and 12,767 (62% male) died in-hospital without attempted repair. The observed odds ratio for no repair for an emergency AAA presentation in men was 0.34 versus 0.9 for women. The adjusted odds ratio was 0.4 for men and 0.53 for women after adjustment for age, deprivation and co-morbidities. EVAR rates for increased over time but were lower for women compared to men; 22% versus 28% for ruptured AAA and 48% versus 50% for emergency intact repair, in the most recent year. Conclusions: The proportion of patients presenting as an emergency with AAA who do not undergo a repair is higher for women than for men. Although some of this can be explained by differences in age and co-morbidities, the differences persist after case mix adjustment. Reasons for the higher turndown rate for women warrant further investigation.

Sex differences in national rates of repair of emergency abdominal aortic aneurysm.

The aim of this study was to assess the sex differences in both the rate and type of repair for emergency abdominal aortic aneurysm (AAA) in England. Hospital Episode Statistics (HES) data sets from April 2002 to February 2015 were obtained. Clinical and administrative codes were used to identify patients who underwent primary emergency definitive repair of ruptured or intact AAA, and patients with a diagnosis of AAA who died in hospital without repair. These three groups included all patients with a primary AAA who presented as an emergency. Sex differences between repair rates and type of surgery (endovascular aneurysm repair (EVAR) versus open repair) over time were examined. In total, 15 717 patients (83·3 per cent men) received emergency surgical intervention for ruptured AAA and 10 276 (81·2 per cent men) for intact AAA; 12 767 (62·0 per cent men) died in hospital without attempted repair. The unadjusted odds ratio for no repair in women versus men was 2·88 (95 per cent c.i. 2·75 to 3·02). Women undergoing repair of ruptured AAA were older and had a higher in-hospital mortality rate (50·0 versus 41·0 per cent for open repair; 30·9 versus 23·5 per cent for EVAR). After adjustment for age, deprivation and co-morbidities, the odds ratio for no repair in women versus men was 1·34 (1·28 to 1·40). The in-hospital mortality rate after emergency repair of an intact AAA was also higher among women. Women who present as an emergency with an AAA are less likely to undergo repair than men. Although some of this can be explained by differences in age and co-morbidities, the differences persist after case-mix adjustment.

Physician-Modified Fenestrated Endografts for Managing the Ruptured or Symptomatic Aortic Aneurysm: Technique Overview and Clinical Outcomes.

Fenestrated endovascular aneurysm repair (FEVAR) grafts have a 10- to 12-week manufacturing time and are generally not available for emergency cases of symptomatic or ruptured aortic aneurysm. In the absence of other alternatives, conventional off-the-shelf stent grafts can be modified by trained operators to treat these complex cases. The aim of this study is to present a single-center experience of physician-modified FEVAR. A retrospective review was performed of all physician-modified FEVAR identified from the hospital endovascular database at a single tertiary referral center between September 1996 and September 2017. Eight cases of urgent or emergency endovascular aneurysm repair (EVAR) with physician-modified grafts were identified. Mean follow-up was 44 weeks (range: 5-106 weeks). Outcomes for all implanted grafts (7/8 cases) included 100% technical success, 14% rate of endoleak, no procedure-related complications, no adverse visceral events, 0% 30-day mortality and 100% 1-year target vessel patency, and freedom from aneurysm-related death. There was a 14% (1/7 cases) per patient reintervention rate. Modifying EVAR grafts is a highly technical process requiring meticulous planning and extensive elective experience with FEVAR. The current series demonstrates that physician modification of endografts for urgent or emergency abdominal aortic aneurysm repair is feasible and a safe alternative to open surgical aneurysm repair.

PC018. Long-Term Outcomes Comparing Endovascular and Open Abdominal Aortic Aneurysm Repair in Octogenarians

Patients 80 years or older have significantly lower early mortality with endovascular aortic aneurysm repair (EVAR) when compared with open repair for abdominal aortic aneurysms (AAA). The long-term results in this older patient population remain poorly studied. We analyzed the results of emergent and elective AAA repair in patients 80 years or older who had at least 5 years of follow-up. A retrospective review of a prospectively collected vascular surgery database at a university-affiliated medical center was performed to identify all patients who underwent repair of an AAA between 2007 and 2012 and were 80 years of age or older at the time of surgery. Open and EVAR groups were compared for outcomes using univariate statistics. The study cohort comprised 314 patients (mean age, 83.5 ± 2.9 years) who underwent repair (96 open repair, 218 EVAR). Patients treated with open repair and EVAR had similar comorbidities, except that EVAR patients were more likely to be male, and open repair patients were more likely to have larger aneurysms. When compared with open repair, elective early postoperative mortality was significantly lower for EVAR patients (1% vs 14%; P < .001). Overall mean life expectancy was 5.9 years (5.8 years EVAR, 5.8 years open repair; P = .98). The 1-year survival was significantly higher for EVAR (92.9%) compared with open repair (84.1%; P = .02). Although 2-year survivals (83.4% EVAR, 74.6% open repair; P = .07), and 5-year survivals (57.8% EVAR, 60.3% open repair; P = .98) did not differ between EVAR and open repair (Fig 1). The most common causes of long-term mortality were malignant disease and cardiovascular events in both groups. Three patients (1.4%) initially treatment by endovascular intervention sustained a mortality related to their aneurysm, and no aneurysm-related mortalities occurred in the open group. Reintervention rates (14% EVAR, 2% open repair; P = .05) were higher in the endovascular treatment group (Fig 2). EVAR results in an improved 1-year mortality in octogenarians when compared with open repair, although 5-year survival is similar between the two groups. With average life expectancies over 5 years after surgery and a 14% reintervention rate, diligent follow-up is required after EVAR in these elderly patients.Fig 2Freedom from reintervention. Cum, Cumulative; EVAR, endovascular aortic aneurysm repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Short-term and midterm survival of ruptured abdominal aortic aneurysms in the contemporary endovascular era

ObjectiveEndovascular aneurysm repair (EVAR) has been shown to reduce mortality in the emergent repair of ruptured abdominal aortic aneurysms (AAAs). However, long-term survival data for this group of patients are lacking with contemporary endovascular endografts. The purpose of this study was to evaluate both 30-day mortality rates and 1-year survival in patients undergoing emergent EVAR in a 43-facility hospital system with a quaternary referral center with an established ruptured aneurysm protocol. MethodsRetrospective analysis of patients captured prospectively in an Institutional Review Board-approved registry for patients treated emergently for AAA were reviewed between 2012 and 2017 was conducted. Primary outcome measures were 30-day mortality and 1-year survival for the entire group as well as for symptomatic and ruptured aneurysms. Data were analyzed using logistic regression survival curves, and a log-rank test was performed to compare survival between open and endovascular repair. Patients were evaluated on an intent-to-treat basis, and outcomes were evaluated in a multivariate model. ResultsA total of 249 patients were referred as part of the protocol. Of these, 102 (41%) were treated emergently. Kaplan-Meier estimates of 30-day and 1-year survival were 64% and 53% for all patients, 58% and 46% for ruptured patients, and 86% and 81% for symptomatic patients. EVAR resulted in improved 30-day survival (64% vs 31%; odds ratio, 4.0; P = .03) and 1-year survival (40% vs 23%; odds ratio, 2.3; P = .4) over open repair. Significant predictors for 30-day mortality included hypotension (P = .0003), blood transfusion (P < .0001), length of stay (P = .0005), extravasation (P = .01), preoperative cardiopulmonary resuscitation (P = .04), open repair (P = .007), aortouni-iliac reconstruction (P = .008), and abdominal compartment syndrome (P = .007). Significant predictors for 1-year mortality included advanced age (P = .04), hypotension (P = .01), blood transfusion (P = .006), extravasation (P = .03), reintubation (P = .03), and abdominal compartment syndrome (P = .03). There were no differences in outcomes based on race, gender, or outside transfer. Peripheral arterial disease (P = .04), hypertension (P = .04), coronary artery disease (P = .03), and familial history of aneurysms (P = .05) were related to increased 30-day mortality. Peripheral arterial disease (P = .06) and coronary artery disease (P = .07) were nearly significant, with increased 1-year mortality. ConclusionsEVAR is associated with improved survival compared with open repair in patients requiring emergent AAA repair. However, in the first year, there is a significant risk of death based on initial presentation as well as underlying comorbidities. To improve long-term survival, aggressive medical management and medical surveillance are warranted.

Is there an age limit for abdominal aortic aneurysm repair?

There is an increasing number of elderly in society and some of them may have an abdominal aortic aneurysm (AAA). The prevalence of AAA in octo- and nonagenarians indicates that this number could be substantial. The question is: is there an age limit for repair? This complex question incorporates ethical, political, economic and medical aspects. To answer part of this question a review of the outcome of elective and emergent AAA repair in those over 80 was done. A literature research was done in the PubMed and Embase databases between 2007 and 2017 for either emergent and/or elective repair of AAA in individuals older than 80 years of age. Ten of 663 studies were found eligible for the review. Elective AAA repair in individuals more than 80 years shows a very varying outcome with 30-day mortality between 0% and 20.1% and 1-year mortality between 7% and 26%. Length of procedure, hospital stay, and number of major adverse events are also more in those over 80 years of age. In ruptured AAA 30-day mortality is between 29 and 59 % and 1 one year between 45% and 63%. No definitive answer whether to perform a repair of AAA in the elderly can be given. The decision has to be individualized and will also vary depending on ethical, political, economic factors and type of healthcare system the individual lives in.

A registry-based rationale for discrete intervention thresholds for open and endovascular elective abdominal aortic aneurysm repair in female patients

ObjectiveAn evidence-based consensus for a female-specific intervention threshold for abdominal aortic aneurysms (AAAs) is missing. This study aims to analyze sex-related differences in the epidemiology of ruptured AAA to establish an intervention threshold for women. MethodsThe Dutch Surgical Aneurysm Audit (DSAA) is a compulsory, nation-wide registry of AAA repairs in The Netherlands. All patients with emergency or elective AAA repair between January 1, 2013, and December 31, 2015, were included in the analysis. The main outcomes were age, sex, AAA diameter at time of rupture, and 30-day postoperative mortality. ResultsA total of 1561 ruptured AAA repairs (14.7% women) and 7063 cases of elective AAA repair (13.7% women) were included in the analysis. Women had significantly smaller mean ± standard deviation AAA diameter at time of rupture than men; 70.5 ± 14.4 mm and 78.6 ± 17.5 mm, respectively. In male patients, 8% of ruptures occurred at diameters below the 55 mm intervention threshold. The female equivalent of this eighth percentile is 52 mm. Female patients had significantly higher 30-day mortality after emergency repair, namely, 33% for women versus 24.2% for men, but were also significantly older, mean ± standard deviation age 76.7 ± 7.1 years and 73.9 ± 8.3 years for women and men, respectively. Correcting for age reduced the 30-day mortality risk for women after ruptured AAA repair from 1.53 (95% confidence interval, 1.14-2.04) to 1.27 (95% confidence interval, 0.92-1.73). Outcome after open elective repair was significantly worse for women compared with men, with a 30-day mortality of 7.97% 30 for women and 4.27% for men (P < .01). ConclusionsThe equivalent of the 55-mm intervention threshold for elective endovascular AAA repair in men is 52 mm in women. The almost doubled mortality risk for elective open repair in women implies that the optimal point for open repair is at higher diameters, very possibly at least 55 mm.

Mortality rates and risk factors for emergent open repair of abdominal aortic aneurysms in the endovascular era.

The background of this paper is to report the mortality at 30 and 90 days and at mean follow-up after open abdominal aortic aneurysms (AAA) emergent repair and to identify predictive risk factors for 30- and 90-day mortality. Between 1997 and 2002, 104 patients underwent emergent AAA open surgery. Symptomatic and ruptured AAAs were observed, respectively, in 21 and 79% of cases. Mean patient age was 70 (SD 9.2) years. Mean aneurysm maximal diameter was 7.4 (SD 1.6) cm. Primary endpoints were 30- and 90-day mortality. Significant mortality-related risk factor identification was the secondary endpoint. Open repair trend and its related perioperative mortality with a per-year analysis and a correlation subanalysis to identify predictive mortality factor were performed. Mean follow-up time was 23 (SD 23) months. Overall, 30-day mortality was 30%. Significant mortality-related risk factors were the use of computed tomography (CT) as a preoperative diagnostic tool, AAA rupture, preoperative shock, intraoperative cardiopulmonary resuscitation (CPR), use of aortic balloon occlusion, intraoperative massive blood transfusion (MBT), and development of abdominal compartment syndrome (ACS). Previous abdominal surgery was identified as a protective risk factor. The mortality rate at 90 days was 44%. Significant mortality-related risk factors were AAA rupture, aortocaval fistula, peripheral artery disease (PAD), preoperative shock, CPR, MBT, and ACS. The mortality rate at follow-up was 45%. Correlation analysis showed that MBT, shock, and ACS are the most relevant predictive mortality factor at 30 and 90days. During the transition period from open to endovascular repair, open repair mortality outcomes remained comparable with other contemporary data despite a selection bias for higher risk patients. MBT, shock, and ACS are the most pronounced predictive mortality risk factors.

Influence of Gender on Abdominal Aortic Aneurysm Repair in the Community

Women have been shown to experience inferior outcomes following intact and ruptured abdominal aortic aneurysm (AAA) treatment in endovascular aneurysm repair (EVAR) and open surgical repair (OSR) groups. The goal of our study was to compare gender-specific presentation, management, and early outcomes after AAA repair using a statewide registry. We utilized the Washington State's Vascular Interventional Surgical Care and Outcomes Assessment Program registry data collected in 19 hospitals from July 2010 to September 2013. Demographics, presentation, procedural data, and outcomes in elective and emergent AAA repair groups were analyzed. We identified 1,231 patients (19.6% women) who underwent intact (86.4%) or ruptured AAA (13.6%) repairs. Nine thousand seventy-two (79.0%) patients had EVAR and 259 (21.0%) had OSR. Men and women were of equivalent age and had similar comorbidities,except that women had less coronary artery disease (P<0.01) and were more likely to suffer from chronic obstructive pulmonary disease (P=0.05). Women had smaller aneurysm diameters (5.8±1.1 vs. 6.2±1.8cm, P<0.01) at the time of presentation and men had slightly higher incidence of rupture at larger aneurysm size. Men were more likely to undergo EVAR, with significant differences in elective (82.1% vs. 74.1%, P=0.01), but not ruptured repair. Women had significantly higher mortality rates following elective EVAR (3.1% vs. 0.6%, P=0.01), but not after ruptured or elective open repair. Following elective EVAR, women were less likely to be discharged to home after longer hospital stays (3 vs. 2days, P<0.01). Despite presentation at a similar age, with a smaller aneurysm diameter, and similar medical comorbidities, women experience substantially worse hospital outcomes primarily driven by elective endovascular procedures. Utilization of endovascular techniques in women still remains lower compared with men. Improvement of elective outcomes in women will likely depend on technical advancements in repair techniques and management strategies that may differ between genders.

PC030. Clinical Outcomes of Open and Endovascular Abdominal Aortic Aneurysm Repair Over a 15-Year Period in the Veteran Population

Disease acuity and perioperative morbidity amongst Veterans is considered to be greater than in the general U.S. population. The reduced morbidity and mortality associated with endovascular aneurysm repair (EVAR) hold promise of improving safety of management of abdominal aortic aneurysms (AAA) in this population. We examine the outcomes of open repair and EVAR, over a 15-year period, in a Veteran population at our regional VA Medical Center. With IRB approval, a retrospective review was conducted of all patients who underwent open infrarenal open AAA repair and EVAR at a single VA hospital between 2000 and 2015. Emergency AAA repairs were excluded. Open and EVAR groups were compared. Variables reviewed include demographics, medical history, surgical details, complications (perioperative and late), and mortality. The primary end points were 30-day, 6-month, 1-year, and 2-year mortality. Survival was estimated using actuarial life-table method. During the 15-year study period, 212 patients (mean age, 71.44 years) underwent 91 open (70.37 years) and 121 endovascular (72.56 years) AAA repairs (Table). Perioperative (30-day) complications, including pneumonia, creatinine elevation, and surgical site infection, were significantly increased in the open group. Need for dialysis, graft infection, pulmonary embolism, cardiac enzyme elevation were not different between groups. Mortality was greater in the open group (3) than the EVAR group (0), but this was not statistically significant. Late morbidity was not significantly different between groups ,with exception of endoleaks and aortic enlargement after EVAR. The EVAR group had 27 (22.73%) endoleaks (7 type I and 24 type II), 20 (18.2%), and 15 (12.3%) required interventions. Our study is consistent with the national trend toward EVAR as the preferred approach for AAA repair. Overall perioperative mortality for AAA repairs (0% EVAR, 2% open) was below the national average. Mortality at 2 years was similar for the open and EVAR groups. Our study supports EVAR as a safe elective operation with low mortality and few complications in a group of patients who are characterized by greater disease acuity and elevated complication rates. With lower perioperative mortality and shorter recovery time, EVAR has become the preferred method of AAA management in the Veteran population.TableOpen repair and endovascular aneurysm repair (EVAR) in 212 patientsPerioperative complications (30-day mortality)Open repairEVARP valuen = 91 (42.9%), No. (%)n = 121 (57%), No. (%)Creatinine elevation6 (6.6)0 (0.0).003Dialysis2 (2.2)1 (0.8).38Creatine kinase elevation3 (3.2)0 (0.0).39Surgical site infection6 (6.6)2 (1.6).036Graft infection1 (1.1)1 (0.8).812Pneumonia10 (10.9)0 (0.0).001Late morbidity (>30 days) Claudication4 (4.4)10 (8.3).305 Incisional hernia5 (5.4)1 (8.2).016 Graft infection0 (0.0)0 (0.0) Erectile dysfunction4 (4.4)5 (4.1).807 AAA enlargement2 (2.1)20 (16.5).002 Migration0 (0.0)1 (0.8).008 Rupture0 (0.0)0 (0.0)Mortality 30 days2 (2.2)0 (0.0).099 6 months5 (5.4)2 (16.5).116 1 year8 (8.7)4 (3.3).081 2 years11 (12.1)6 (4.9).030 5 years24 (26.1)17 (14.0).013 10 years38 (41.8)19 (15.8)<.001Endoleak (>30 days)27 (22.73) Type I7 Type II24AAA, Abdominal aortic aneurysm. Open table in a new tab