Endovascular Group Research Articles

Early and Mid-Term Outcomes of Open Repair, Fenestrated Stent Graft and Chimney Graft in Juxtarenal Abdominal Aortic Aneurysms

Introduction - Juxtarenal abdominal aortic aneurysm (JAAA) is defined as an infrarenal AAA that is adjacent to or involving the lower margin of the renal artery origins1. Recently, promising results have been reported in peer reviewed journals after fenestrated and chimney graft approaches to repair of JAAA2,3. Open repair, fenestrated endovascular aneurysm repair (FEVAR) and chimney endovascular aneurysm repair (Ch-EVAR) are effective methods to treat this condition, but the comparative effectiveness of these treatment modalities is unclear4. Upon completion of a hybrid vascular intervention room at our institution and careful planning and sizing, we started a prospective registry of all JAAA cases performed. Here we present our retrospectively analyzed results, including short and midterm follow-up results in patients with JAAA treated using either endovascular or open repair. Methods - We retrospectively reviewed patients with JAAA (n= 75) who underwent chimney grafts (Ch-EVAR, n = 23), fenestrated stent grafts (FEVAR, n = 20) or open repair (OR, n = 32) between January 2011 and December 2016 at a single institution. Our primary endpoint was peri-operative mortality. Secondary endpoints included renal function impairment, new-onset dialysis, procedural details and postoperative complications. Descriptive statistics are reported as mean ± standard deviation for continuous data and categorical data are presented as number and percentage. Kaplan-Meier analysis was used to estimate freedom from late re-intervention, primary patency of targeted vessel stent grafts and overall survival. Results - There were no statistically significant differences in baseline characteristics among the three groups. Perioperative mortality was not significantly different between groups: 4.3% (1/23) in the Ch-EVAR group, 0% in the FEVAR group and 3.1% (1/32) in the OR group(p = 0.532). Mean follow up time was 36.7 months. There were no statistically significant differences among the three groups in secondary endpoints, except for increased blood loss in the open repair group when compared to the endovascular groups. There were no statistically significant differences in overall survival among groups (p=0.282). Estimated targeted vessel stent patency at 1 and 4 years were 89.5% and 89.5% in the Ch-EVAR group and 93.8% and 93.8% in the FEVAR group, respectively. There were no statistically significant differences in estimated freedom from late re-intervention among groups (82.3% in the Ch-EVAR group, 77.2% in the FEVAR group and 96.4% in the OR group) Conclusion - We were unable to show a ststistically significant difference in outcomes among the treatment options for JAAA repair, which may be due to the size of our series. Nevertheless, our results show that after careful patient selection, we are able to offer our patients good results with fenestrated and chimney graft techniques that are comparable to open surgical procedures, but with a much faster recovery time. All three approaches (Ch-EVAR, FEVAR and open surgery) are effective treatment options for JAAA repair and have comparable short and mid-term outcomes in well-selected patients. Long term follow-up results are needed to determine the optimal management of JAAA. References·Jongkind V, Yeung KK, Akkersdijk GJ, Heidsieck D, Reitsma JB, Tangelder GJ, Wisselink W. Juxtarenal aortic aneurysm repair. J Vasc Surg. 2010;52:760-767·Verhoeven EL, Vourliotakis G, Bos WT, Tielliu IF, Zeebregts CJ, Prins TR, Bracale UM, van den Dungen JJ. Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: An 8-year single-centre experience. Eur J Vasc Endovasc Surg. 2010;39:529-536·Donas KP, Torsello GB, Piccoli G, Pitoulias GA, Torsello GF, Bisdas T, Austermann M, Gasparini D. The protagoras study to evaluate the performance of the endurant stent graft for patients with pararenal pathologic processes treated by the chimney/snorkel endovascular technique. J Vasc Surg. 2016;63:1-7·Katsargyris A, Oikonomou K, Klonaris C, Topel I, Verhoeven EL. Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: Are we ready for a paradigm shift? J Endovasc Ther. 2013;20:159-169

Amputation-Free Survival in Patients With Diabetes Mellitus and Peripheral Arterial Disease With Diabetic Foot Ulcer: Open Versus Endovascular Surgery

Introduction: The number of people with diabetes mellitus (DM) is increasing worldwide with an estimated number of 422 million adults, according to WHO. The incidence of peripheral arterial disease (PAD) increases with both age and diabetes mellitus which in turn can lead to diabetic foot ulcers (DFU). Comparison of endovascular surgery vs open vascular surgery, in patients with DM, PAD and DFU has not been done in a randomized trial. Large cohort studies are therefore needed to address this issue. Methods: Between the years 1984-2006, 1151 limbs presented with DFU were admitted to a multidisciplinary foot centre. Among 1151 limbs, 478 went through vascular intervention, data on death and amputation was recorded up to 2019-01-01. Patients receiving hybrid intervention were excluded and because of loss of follow up the final study population was comprised to 408 limbs. Among the study population, 40% were women and the median follow up time was 2.7 years. Median time to intervention was 8.3 weeks. Retrospective comparative analysis between endovascular and open vascular surgery was performed. Results: Patients were treated with endovascular surgery first (n=289) or open vascular surgery first (n=119). Major amputation rate at 3 years was 17.0% and 16.8%, respectively (p=0.97) Mortality at 3 years was 42.6% and 46.2%, respectively (p=0.50). Compared to the endovascular group, patients in the open group had a lower ankle-brachial index (ABI) (p< 0.01), and there was a trend for higher HbA1c (p=0.08) and longer time to intervention (p=0.06). In a Cox regression analysis, no difference between endovascular surgery compared to open vascular surgery was found in regard to major amputation (p=0.62), mortality (p=0.23) or amputation-free survival (p=0.21). Longer time to intervention was associated with increased major amputation rate in the cox regression analysis (p=0.03). Conclusion: Endovascular sugary and open vascular surgery achieved similar long-term results in a large cohort of patients undergoing revascularization with foot ulcer, DM and PAD. Disclosure: Nothing to disclose

Endovascular thrombectomy versus open surgical thrombectomy for thrombosed arteriovenous hemodialysis graft

Objective: The aim of this study was to investigate the procedure success rate, one-year primary patency rate, one-year secondary patency rate, and complications compared between endovascular therapy and open surgical thrombectomy for treatment of thrombosed arteriovenous hemodialysis graft.Methods: This retrospective chart review included patients with thrombosed arteriovenous hemodialysis graft who were treated at the Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during January 2012 to December 2016. Demographic, graft type, time before treatment, thrombus removal technique, additional technique, procedure success rate, operative, primary and secondary patency, follow-up time, and complication data were collected.Results: Seventy-four thrombosed dialysis grafts were included. Twenty-five and 49 grafts underwent endovascular therapy and open surgical thrombectomy, respectively. There was no significant difference in demographic data, graft type, or adjunct procedure between groups. The procedure success rate was 92% and 98% in the endovascular group and thrombectomy group, respectively (p=0.262). The one-year primary patency rate was 26% in the endovascular group, and 33% in the thrombectomy group (p=0.054). One-year secondary patency rate was 82.6% in the endovascular group, and 56.3% in the thrombectomy group (p=0.122).Conclusion: No significant differences were observed between groups for procedure success rate or 1-year primary patency rate; however, the one-year secondary patency rate in the endovascular group was significantly better than in the thrombectomy group. No difference in complications was observed between groups.

Outcomes after endovascular versus open thoracoabdominal aortic aneurysm repair: A population-based study

ObjectiveWe sought to determine the early and late outcomes of endovascular versus open thoracoabdominal aortic aneurysm repair. MethodsWe performed a multicenter population-based study across the province of Ontario, Canada, from 2006 to 2017. The primary end point was mortality. Secondary end points were time to first event of a composite of mortality, permanent spinal cord injury, permanent dialysis, and stroke, the individual end points of the composite, patient disposition at discharge, hospital length of stay, myocardial infarction, and secondary procedures at follow-up. ResultsA total of 664 adults undergoing surgical repair of a thoracoabdominal aortic aneurysm (endovascular: n = 303 [45.5%] vs open: n = 361 [54.5%]) were identified using an algorithm of administrative codes validated against the operative records. Propensity score matching resulted in 241 patient pairs. Endovascular repairs increased during the study and currently comprise more than 50% of total repairs. In the matched sample, open repair was associated with a higher incidence of in-hospital death (17.4% vs 10.8%, P = .04), complications (26.1% vs 17.4%, P = .02), discharge to rehabilitation facilities (18.7% vs 10.0%, P = .02), and longer length of stay (12 [7-21] vs 6 [3-13] days, P < .01). Long-term mortality was not significantly different (hazard ratio, 1.09; 95% confidence interval, 0.78-1.50), nor were the other secondary end points, with the exception of secondary procedures, which were higher in the endovascular group (hazard ratio, 2.64; 95% confidence interval, 1.54-4.55). At 8 years, overall survival was 41.3% versus 44.6% after endovascular and open repair (P = .62). ConclusionsEndovascular repair was associated with improved early outcomes but higher rates of secondary procedures after discharge. Long-term survival after thoracoabdominal aortic aneurysm repair is poor and independent of repair technique.

Risk factors for preoperative seizures in pediatric patients with intracranial aneurysms

ObjectiveSeizures are common complications following intracranial aneurysms and present a greater risk to pediatric patients than adults. Though the risk factors of seizures in adults with intracranial aneurysms have been well documented, the risk factors in pediatric patients remain unknown. The aim of this study was to evaluate the risk factors for preoperative seizures and the effect of the treatment approach on postoperative seizures in pediatric patients with intracranial aneurysms. Patients and methodsThe data of 64 pediatric patients (mean age 11.4 ± 5.7 years; 68.8 % of males) with intracranial aneurysms were retrospectively analyzed from January 2012 to April 2017. Comparisons were made between patients with preoperative seizures (case group) and those without (control group). ResultsTwenty-four patients (37.5 %) had preoperative seizures, and 15 patients (23.4 %) had postoperative seizures. Multiple logistic regression analysis revealed that younger age (0–5 years), head trauma history, ruptured aneurysms, lobe hematomas, modified Fisher grade 3–4, giant aneurysms, pseudoaneurysms and distal arterial aneurysms were independently associated with the increased risk of preoperative seizures. Patients in the surgical and endovascular groups did not differ significantly in the rates of preoperative seizures or early postoperative seizures (within 1 month) (P > 0.05). However, a significantly lower incidence of late postoperative seizures (1–3 months and 3–6 months) was observed in the surgical group compared with the endovascular group (P < 0.05). ConclusionPediatric patients with intracranial aneurysms are at high risk for seizures. Risk factors for preoperative seizures included younger age (0–5 years), head trauma history, lobe hematomas, modified Fisher grade 3–4, giant aneurysms, pseudoaneurysms and distal arterial aneurysms. Compared with the endovascular treatment, surgical intervention provided more benefits with regard to reducing the risk of late postoperative seizures.

Adverse Cardiac Events and Mortality in Patients with Critical Limb Ischemia

Both surgical and endovascular treatment in elderly patients with critical limb ischemia are associated with high mortality rates. Patients with critical limb ischemia are at increased risk of adverse cardiovascular events and subsequent cardiovascular death. Little is known about the incidence and consequences of these adverse events. The aim of this study was to investigate the effect of adverse cardiac events on mortality in patients with critical limb ischemia undergoing surgical or endovascular treatment. A retrospective cohort study including all patients with critical limb ischemia aged ≥65 undergoing surgical or endovascular treatment for critical limb ischemia between January 2013 and June 2018 was conducted. Data on adverse cardiac events were collected from medical records. The effect of an adverse cardiac event on mortality during 6months follow-up was analyzed with a multivariable cox proportional hazards model to adjust for confounders. Effects are displayed as hazard ratios (HR) with 95% confidence intervals (CI). A total number of 449 patients were included. Median age was 76years, 52.8% of patients were male. In total, 51 patients (11%) developed an adverse cardiac event, 31 patients (10%) in the surgical group and 20 patients (14%) in the endovascular group. After adjustment for confounders, adverse cardiac events were associated with an increased risk of mortality (HR 3.5 95% CI 2.1-5.9). This study showed that adverse cardiac events commonly occur in elderly patients with critical limb ischemia. Adverse cardiac events continue to occur even months after treatment and are associated with an increased mortality risk. These findings justify routine cardiac evaluation in both surgical and endovascular treatment. Additionally, frequent postdischarge cardiac follow-up in the outpatient clinic may be helpful in limiting the occurrence of adverse cardiac events.

Clipping versus Coiling in Ruptured Aneurysms of the Anterior Cerebral Circulation

Objective: To evaluate and compare the outcomes of microsurgical clipping and endovascular coiling of ruptured anterior cerebral circulation aneurysms. Methods: The current study retrospectively included 61 patients presented with subarachnoid hemorrhage (SAH), treated by clipping or coiling for ruptured aneurysms located in anterior circulation. Anatomic outcome and post-operative ischemic events were evaluated. The primary clinical outcomes were evaluated as operative complications while the secondary clinical outcome was evaluated by modified Rankin scale (mRS) at discharge. Results: Of 61 ruptured aneurysms, 47 and 14 were treated by surgery and coiling, respectively. The average follow-up duration was 19.1 ± 18.6 months for clipping and 21.7 ± 14.8 months for coiling. Complete occlusion was greater in surgery group (80.8%) than endovascular group (21.4%). Re-growth occurred in 2 cases of the coiling group only. Ischemic events were encountered in both groups; silent ones were higher in coiling group (21.4%) than in clipping group (6.3%), while symptomatic ones were higher in the clipping group (49%). Good outcome (mRS 0 - 2) was 51% and 71.4% after clipping and coiling respectively. Postoperative hospital period was longer after clipping (P = 0.04). Conclusions: For anterior circulation ruptured aneurysms, both treatments are feasible, coiling showed lower rate of morbidity while clipping results were better regarding durability and recurrence. Coil embolization may be preferred, which is the current point proved by the RCT like ISAT, but if you choose the patients carefully and find out the optimal candidate for the clipping, the clipping is still enough feasible as a mainstream.

TAA 13. Comparing Results of Treating Infected Thoracic and Abdominal Aortic Aneurysms Between Open and Endovascular Repair

Infected aortic aneurysm is life-threatening if it is not treated properly, with high mortality rate when open repair is performed. The goal of treatment is to prevent rupture and to eliminate infection. The endovascular technique is accepted for bridging to definite repair. Our study compares the results of endovascular and conventional open repair for infected thoracic and abdominal aortic aneurysm. Retrospective data from January 2008 to December 2017 were analyzed. Collected data were categorized into three cohorts of infected thoracic, thoracoabdominal, and abdominal aortic aneurysms. The primary end point was the survival rate and the assessment of any associated factors. There were 99 patients presenting with infected aortic aneurysm who underwent surgery. Of 56 infected thoracic aortic aneurysms, 38 underwent thoracic endovascular aortic repair and 18 underwent open repair. Of 40 infected abdominal aortic aneurysms, 21 underwent endovascular aortic repair and 19 underwent open abdominal aortic aneurysm repair. Three infected thoracoabdominal aortic aneurysms and underwent open repair. Mean age was 67 years (range, 33-88 years), 74 (74.75%) were men, and 71 (71.72%) were immunocompromised. Mean follow-up was 24 months in the endovascular repair group and 38 months in the open repair group. The probability of survival rate in the endovascular repair group was 86%, 86%, 77%, and 51% at 1 year, 2 years, 5 years, and 10 years, respectively; in the open repair group, it was 81%, 81%, 76%, and 64% at 1 year, 2 years, 5 years, and 10 years, respectively. Endovascular repair for infected aortic aneurysms tends to play an important role in current practice as an alternative method or as a bridge to definitive open surgical repair.

Evolving Management of Distal Anastomotic Technical Issues During Open Aortic Aneurysm Repair

Thrombosis of the iliac anastomosis is an important complication of open aortic aneurysm repair. We evaluated our evolving management of this complication to an endovascular approach and compared it with open revision to the common femoral artery. Consecutive patients undergoing open aortic aneurysm repair from January 2009 through November 2016 at our institution were reviewed. Patients who developed iliac limb flow issues or thrombosis intraoperatively or within 48hrs postoperatively were identified. Patients were grouped by management strategies of either 1) an endovascular approach including iliac angiography, thrombectomy if needed, and stenting or 2) open surgical revision of the iliac anastomosis with or without bypass to the common femoral artery. Demographics, comorbidities, operative variables, and outcomes were retrospectively analyzed between groups. Primary patency and mortality were assessed by Kaplan-Meier estimates. There were 711 patients who underwent aortoiliac aneurysm repair during the study period. 43/711 patients (6.0%) developed early perioperative iliac limb flow issues including thrombosis. Twenty-nine patients (31 limbs) were managed by an endovascular approach, and 14 patients (15 limbs) were managed by open surgical revision. The mean age of the cohort was 69years, and 27 patients (62.8%) were male. Preoperative creatinine and diabetes frequency were higher in patients managed by an endovascular approach, although no other differences existed between preoperative comorbidities. Thrombosis or limb flow issues presented intraoperatively more commonly in the open surgical group and in the first 24hrs postoperatively in the endovascular group. All patients had complete restoration of outflow as a result of the rescue procedure. Transfusion requirements and crystalloid replacement were significantly higher in the open surgical group. Length of stay, perioperative complications, and mortality were similar between groups. Overall, 21/31 limbs in the endovascular group and 9/15 limbs in the open surgical group had postoperative imaging, with mean follow-up of 35.0 and 55.6months, respectively. Only one patient in the cohort lost patency: an iliofemoral jump graft that presented with late infection after postoperative wound infection, requiring staged extra-anatomic bypass and explant at 12months. Three-year primary patency was 100% for the endovascular group and 85.7% for the surgical group by Kaplan-Meier method (P=0.32). Endovascular management became our institution's primary salvage approach during the study. Whereas 8/15 limbs (53.3%) were managed by an endovascular approach from 2009-2011, 23/31 (74%) were managed by iliac stenting from 2012-2016. Endovascular management of iliac limb flow issues or thrombosis after open aneurysm repair is potentially a viable alternative to open surgical revision in the early postoperative period.

Carotid to subclavian bypass and Amplatzer vascular plug subclavian endovascular occlusion before thoracic open or endovascular repair

ObjectiveThe aim of this study was to evaluate the safety and effectiveness of endovascular occlusion of the prevertebral subclavian artery (SA) using an Amplatzer vascular plug after prophylactic revascularization with carotid-subclavian bypass (CSB) in the setting of endovascular thoracic stent grafting or open arch repair with frozen elephant trunk. MethodsAll patients who underwent SA plug embolization (SAPE) and CSB from September 2009 to December 2018 were enrolled in a registered study (SAPE study: clinicaltrials.govNCT03620006). The primary end point was technical success, defined as complete occlusion of the origin of the SA, and how it was influenced by SA anatomy. The secondary end points were access vessel complications, cerebrovascular events, and CSB patency. ResultsThe 101 SAPE procedures were performed using a type I (35 patients) or a type II (66 patients) Amplatzer vascular plug. A percutaneous ipsilateral upper extremity access was used in 66% of patients and a radial artery access was used in 50% of procedures. The 30-day primary technical success rate was 95% (five patients received an additional plug during the index); five type IC endoleaks were observed and successfully treated either with surgical ligation (in open arch repair procedures) or secondary embolization procedure (thoracic endovascular aneurysm repair group). Three access vessel complications (3%) were recorded with percutaneous brachial approach. At a median follow-up time of 11 months (range, 2-19 months), no new-onset type IC endoleak was observed, and the CSB patency rate was 97%. ConclusionsSAPE after CSB is feasible and safe, and has low incidence of type IC endoleaks. Further device developments are needed to better adapt to the subclavian anatomy.

P6161The evaluation of the effectiveness of the treatment of patients with chronic thromboembolic pulmonary hypertension using subtraction CT pulmonary angiography

Abstract Introduction Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening delayed complication of acute pulmonary embolism. It is characterized by chronic obstruction of the branches of the pulmonary artery, arteriopathy and vasoconstriction of small vessels, that ultimately leading to right ventricular failure. Subtraction CT pulmonary angiography (CTPA) allows to perform a comprehensive the assessment of the state of the vascular bed and pulmonary perfusion, it is especially important for pathological changes in the distal branches of the pulmonary artery. Analysis of perfusion defects in combination with the standard protocol of CTPA can increase the diagnostic value of the method in examining patients with CTEPH that will select the optimal treatment strategy with the possibility of an objective assessment of its effectiveness. Purpose The aim of this work was to determine the possibilities of the method of subtraction CTPA in the evaluation of the effectiveness of the treatment of patients with CTEPH. Methods and materials Primary and repeated subtraction CTPA was performed 36 patients with the diagnosis of CTEPH (10 patients after surgical treatment, 13 patients after endovascular treatment and 13 patients after initiation of PAH-specific therapy) (figure).All patients were examined on 320-detector row CT scanner using the standard protocol Lung subtraction. Using subtraction CTPA was calculated of CT-scores of obstruction and perfusion defect. The data of primary and repeated CT studies were compared with the clinical and hemodynamic status of patients. CT color-coded iodine images were produced by subtraction of non-contrast from contrast images. Results According to repeated CTPA a decrease of the degree of obstruction was observed in 18 out of 36 (50%) patients: in 10 (100%) patients from the surgical treatment group and 8 (61.5%) patients from the endovascular treatment group. Subtraction CTPA was a good quality for interpreting perfusion maps in 28 of 36 (77.8%) patients.Evaluation of the dynamics of perfusion disorders was not performed in 8 patients: in 3 patients from the surgical treatment group and 5 patients from the endovascular treatment group. Improvement of lung perfusion according to perfusion maps was determined in 18 out of 28 (64.3%) patients: 7 (100%) patients from the surgical treatment group, 5 (62.5%) patients from the endovascular treatment group, and 6 (46.2%) patients from the group of drug treatment. Improvement of clinical and hemodynamic parameters was observed in all patients in the surgical and endovascular treatment groups. There was no statistically significant improvement in clinical and hemodynamic parameters in the drug treatment group. Conclusion The results of the study demonstrated the possibility of using subtraction CTPA for an objective assessment of the effectiveness of the treatment of patients with CTEPH.

Utilization of endovascular and open surgical repair in the United States: A 10-year analysis of the National Trauma Databank (NTDB)

BackgroundEndovascular therapy provides a less invasive alternative to open surgery for critically ill patients who have sustained arterial injuries. The purpose of this study was to evaluate recent trends in the management of arterial injuries in the United States with specific reference to the use of endovascular strategies and to examine the outcomes of endovascular vs open therapy for the treatment of civilian arterial traumatic injuries. MethodsWe performed a 10-year (2004–2014) analysis of ACS-NTDB and identified all adult trauma patients who had arterial injuries. Data regarding demographics, injury parameters, endovascular or open vascular repair and outcomes were extracted. Cochran-Armitage trend analysis and multivariate logistic regression analysis were performed. ResultsA total of 111,061 patients with arterial injuries were identified and included in our analysis. Mean age was 39 ± 19y, 82% were male and 79% were white. The most common artery injured was iliac artery followed by brachial artery and thoracic aorta. Overall 6.7% (7434) patients underwent endovascular repair while 38.8% (42,495) had open vascular repair. The rate of endovascular repair increased from 3.1% to 8.9% while the incidence of open vascular repair decreased from 47% to 32% over the study period. Patients in endovascular group had lower ISS compared to patients in open vascular repair group (17 + 10 vs 24 + 10, p < 0.001). Patients who underwent endovascular repair had shorter hospital length of stay (days: 10 + 17 vs 11 + 15, p < 0.001), lower mortality (8% vs 14%, p = 0.01). On multivariate regression analysis after controlling for confounding variables, endovascular repair was independently associated with improved survival (OR: 2.45[1.84–4.26], p = 0.01). ConclusionsThe use of endovascular modalities to repair arterial injuries in the setting of acute trauma is increasing in a dramatic fashion. Endovascular repair of trauma arterial injuries is associated with shorter length of stay and improved survival compared to open vascular procedures.

Surgery and Endovascular Management in Patients With Takayasu's Arteritis: A Ten-Year Retrospective Study

Takayasu's arteritis (TA) is an uncommon chronic vasculitis, and there is a lack of long-term large cohort studies regarding the optimal revascularization outcomes of patients with TA. One hundred and sixteen patients with TA who underwent surgery or endovascular repair over a 10-year period were studied retrospectively. One hundred and fifty-four vascular procedures were performed consisting of 69 open and 85 endovascular repairs. After a mean follow-up period of 48.5±38.5months, three cases each of cerebrovascular accident (CVA) and death occurred in the open repair group while two cases of CVA and 4 deaths were observed in the endovascular repair group. At 1, 3, 5, and 10years of follow-up, the primary patency rates were 97.3%, 86.2%, 70.5%, and 48.8% in the open repair group and 93.3%, 73.1%, 57.5%, and 31.8% in the endovascular repair group, respectively. The primary assisted patency rates were 98.2%, 90.3%, 73.2%, and 47.2% in the open repair group and 95%, 81%, 64.4%, and 35% in the endovascular repair group, respectively. The secondary patency rates were 98.2%, 96.1%, 83.5%, and 56.2% in the open repair group and 98.7%, 86%, 71.2%, and 44.9% in the endovascular repair group, respectively. The cumulative survival rates were 96.9%, 96.9%, 96.9%, and 90% in the open repair group and 97.4%, 97.4%, 88%, and 79.2% in the endovascular repair group, respectively. Both surgical repair and endovascular management are safe and efficient modes of treatment of TA. Surgical repair showed long-term durability, and it is suitable for complex lesions and failed cases of endovascular management.

Health Care Costs of Endovascular Compared With Open Thoracoabdominal Aortic Aneurysm Repair

To compare 1-year health care costs of open and endovascular thoracoabdominal aortic aneurysm (TAAA). Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and March 2017. All health care costs incurred by the Ministry of Health were included. Costs of the aortic endografts and devices for the index procedure were C$44,000 per case versus C$1000 for open cases. Costs (2017 Canadian $) were calculated in phases (1, 1-3, 3-6, 6-12 months) with censoring for death. Propensity score matching based on 26 preoperative characteristics was used. The association between preoperative characteristics and 1-month cost were characterized through multivariable analysis. Overall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]) and 241 open/endovascular propensity score-matched pairs were formed. At 1 month, the mean [median] total cost for the pre propensity score matched open TAAA group was C$46,575 [C$36,647] (77% hospital cost, 14% physician billings, 3% graft cost, 6% other), whereas for the endovascular group, total cost was C$72,581 [C$64,892] (67% graft cost, 27% hospital cost, 5% physician billings, 1% other; P < .01). At 1 to 3 months, 3 to 6 months, and 6 months to 1 year postprocedure intervals, there were no significant difference in health care costs between groups (Table). The mean [median] cumulative cost for patients alive at 1-year were C$91,571 [C$52,003] versus C$103,740 [C$83,242]; P < .01 for open (n = 264) and endovascular (n = 206) TAAA repair, respectively. On multivariable analysis, older age (P < .01), nonelective procedures (P < .01), and preoperative stroke (P = .05) were associated with increased costs at 1 month. While devices led to higher 1-month costs of endovascular TAAA repair, total cumulative health care costs after the first month and up to 1 year were not significantly different, including re-interventions. Higher 1-month costs occurred with older age, preoperative stroke, and nonelective procedures.TableHealth care costs of endovascular versus open thoracoabdominal aortic aneurysm (TAAA) repairCostBefore propensity score matchingAfter propensity score matchingOpenEndovascularP valueOpenEndovascularP valueMean [median]Mean [median]Mean [median]Mean [median]1 month46,575 [36,647]72,581 [64,892]<.0146,556 [33,605]72,786 [64,892]<.011-3 months19,826 [2024]11,292 [1977].6218,828 [1832]11,454 [1992].613-6 months12,289 [1173]11,453 [1508].169456 [1144]12,153 [1298].846 months-1 year11,985 [2427]12,087 [2998].978840 [2524]12,016 [3050].34 Open table in a new tab

Risk Management of Aneurysmal Subarachnoid Hemorrhage by Age and Treatment Method from a Nationwide Database in Japan

There has been no precise guide for treatment management of aneurysmal subarachnoid hemorrhage (aSAH) based on the patient's age and treatment method. This study clarifies each risk management for aSAH according to age and treatment method listed in a nationwide database. We compared 2 groups of patients (nonelderly, <65 years; elderly, ≥65 years) who underwent surgical clipping or endovascular coiling and were registered in a nationwide database in Japan from 2010 to 2015. The odds ratio (OR) and 95% confidence interval (CI) of each risk factor were calculated through multivariate logistic regression analysis for poor outcome according to a modified Rankin Scale score >2 at discharge for each group. In all groups, the risk factors for poor outcome were older age, male sex, neurologic grade on admission, diabetes mellitus, and use of anticoagulation drugs. Inverse risk factors were a high-volume hospital, academic hospital, hypertension, and use of an antiplatelet drug (OR, 0.63-0.81; 95% CI, 0.56-0.88). Chronic heart disease was also a risk factor, but use of a statin drug (OR, 0.85-0.87; 95% CI, 0.76-0.97) and location other than on the anterior communicating artery (OR, 0.74-0.80; 95% CI, 0.67-0.91) were inverse risks in both the elderly and the endovascular coiling groups. Management for patients with aneurysmal subarachnoid hemorrhage was recommended in high-volume and academic institutes with the administration of antiplatelet drugs and consideration of several risk factors. Elderly patients undergoing endovascular coiling might be better given a statin drug, and patients with chronic heart failure or an anterior communicating artery aneurysm should be treated more carefully.

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.

Open and Endovascular Management of Acute Mesenteric Ischaemia: A Systematic Review.

Acute mesenteric ischaemia (AMI) is a life-threatening surgical emergency resulting from thromboembolic occlusion of the mesenteric vasculature. Traditional management of AMI has been open revascularisation with or without bowel resection-a procedure which carries considerable morbidity and mortality in an already unwell, compromised patient. Endovascular and more minimally invasive management approaches to AMI have been reported. Proponents of endovascular management suggest this approach may be associated with reduced morbidity and mortality compared with open surgery. To assess the impact of endovascular approach for AMI on mortality and need for subsequent laparotomy and/or bowel resection. The search bodies PubMed and Medline were interrogated. All studies in English with greater than 10 patients examining outcomes for patients undergoing endovascular intervention for acute mesenteric ischaemia were included. All patients over 18years presenting with a diagnosis of acute mesenteric ischaemia secondary to an arterial thromboembolic source were included. Studies examining endovascular intervention alone or endovascular and open intervention were selected. The 30-day mortality for endovascular approach from all 13 studies was 16-42%. Of the 7 comparative studies including results of open revascularisation, the 30-day mortality for patient treated with an endovascular approach was 15-39% versus 33-50% for open revascularisation. Laparotomy rates post-initial endovascular intervention ranged from 13 to 73%. Bowel resection post-endovascular therapy ranged from 14 to 40% among studies. Concerning 7 comparative studies for open versus endovascular revascularisation, the rate of bowel resection in the endovascular group ranged 14-28% and 33-63% in the open cohort. Endovascular intervention also demonstrated lower median length (s) of bowel resected. Heterogeneity of studies and patient populations studied including selection bias. Endovascular management may be associated with reduced mortality and need for/length of bowel resection compared with the traditional open approach, but there remains a paucity of robust data to support this. The available literature illustrates that a subgroup of patients without haemodynamic compromise and more insidious onset may garner benefit from endovascular intervention.

Early Institutional Experience of Management of Ruptured Intracranial Aneurysms: Our Team Approach

Introduction: Intracranial aneurysms are relatively common, with a prevalence of approximately 4%. Rupture of an intracranial aneurysm (IA) causing subarachnoid haemorrhage (SAH) is a devastating event that is still associated with a 50% case fatality rate, despite major improvements in surgical techniques, diagnosis and interventional treatment. While patient subgroups may clearly qualify for either surgical or endovascular treatment some patients could benefit from multimodal therapy. In this article we will show our team approach experience of management of ruptured intracranial aneurysms.&#x0D; Methods: Cross-sectional descriptive study of 52 patients of ruptured intracranial aneurysm who got admitted into Combined Military Hospital, Dhaka in the period from Jan 2016 to Dec 2018. Patients were evaluated according to their demographic data, analysis of risk factors, radiological location of aneurysms, World Federation of Neurological Surgeon (WFNS) scale, procedural options for aneurysm treatment, post procedural complications. We excluded unruptured cases and those patients who were treated conservatively. General outcome was assessed through the Glasgow out-come (GOS) scale. Data analysis was done by using computer software SPSS version 25.0. Patients studied were mainly middle-aged with mean age 44 ±5.2 years and predominantly female. Most of the patients had previous history of hypertension 45 (86.53%). WFNS scale 2 was observed in 34 (65.38%). Anterior communicating (Acom) artery aneurysm was more frequent which is found in 16 (30.77%) cases. 37 (71.15%) patients underwent microsurgical clipping whereas 13 (25%) patients underwent endovascular intervention and 2 (3.85%) patients needed combined approach. Complications were more in microsurgical clipping group 38 (73.08%) in comparison to endovascular group 13 (25%). GOS scale 5 was observed in 30 (57.70%) cases.&#x0D; Conclusion: Our experience of management of ruptured intracranial aneurysms together with their outcome have been reflected in this small study. For better outcome of ruptured intracranial aneurysms decision can be made on an individual case by case basis. Hybrid treatment option of staged endovascular and open microsurgical proceduresare sometimes needed as a combined approach.&#x0D; Bang. J Neurosurgery 2019; 9(1): 39-43

Characteristics, treatments, and outcomes among patients with abdominal aortic injury in Japan: a nationwide cohort study.

BackgroundAbdominal aortic injury (AAI) is a life-threatening condition that occurs in only 0.1% of all trauma admissions. Because of its rarity, the clinical features of AAI remain unclear. We investigated the characteristics, treatments, and clinical outcomes among patients with AAI.MethodsThis retrospective cohort study was performed using the Japanese Diagnosis Procedure Combination database. We identified patients with a confirmed diagnosis of AAI with emergency admission from 1 July 2010 to 31 March 2017. Eligible patients were divided into three groups: those who were treated with no surgery or endovascular treatment (non-repair group), those who underwent surgery without endovascular treatment (open repair group), and those who received endovascular treatment without surgery (endovascular repair group).ResultsA total of 238 patients met the inclusion criteria during the study period. Of these, 191 (80.3%) were allocated to the non-repair group, 20 (8.4%) were allocated to the open repair group, and 27 (11.3%) were allocated to the endovascular repair group. The proportions of patients in the non-repair group from July 2010 to March 2012, April 2012 to March 2014, April 2014 to March 2016, and April 2016 to March 2017 were 93.5%, 75.9%, 80.6%, and 73.2%, respectively. The crude in-hospital mortality rate was 26.2%, 35.0%, and 18.5% in the non-repair, open repair, and endovascular repair group, respectively.ConclusionsIn this cohort, the proportion of non-repair for AAI decreased from 2010 to 2017, whereas the proportion of endovascular repair increased. Younger patients were more likely to undergo open repair, whereas older patients were more likely to undergo endovascular repair.

Life is about so much more: Patients' experiences of health, well-being, and recovery after operation of abdominal aortic aneurysm with open and endovascular treatment—A prospective study

Different surgical treatments for abdominal aortic aneurysm can lead to different perceptions of health and well-being. The aim of this study was to describe patients' well-being, sense of coherence (SOC), and experiences of surgery after open and endovascular treatment one month and one and 2 years after the procedure. Seventy six patients participated (40 open repair; 36 endovascular aneurysm repair). The study was conducted using the SOC questionnaire, and specific questions about patients' experiences of the surgical treatment and well-being. After 2 years, no patient regretted the operation or considered it to be the most difficult experience they had ever had. Twenty percent of the patients were worried about complications one month after the operation. Both groups experienced difficulty in returning to normal activity after surgery at one month. At one and 2 years after the surgery, patients in both groups stated that it was other things in life that affected their well-being. The endovascular aneurysm repair group reported a significant decrease in SOC from baseline until one year (P=.012) and 2 years (P=.033). The open repair group reported a significant decrease after one year (0.033). The operation did not affect patients' way of thinking about the disease. Patients in both groups stated that it was other circumstances in life that affected their well-being one and 2 years after the treatment, which could indicate that long-term follow-up would not be necessary from a patient perspective. The operation affects patients' well-being a short time after the operation.