Endovascular Repair Group Research Articles

A comparative study on the medium-long term results of endovascular repair and open surgical repair in the management of ruptured abdominal aortic aneurysms

Background Although it is generally acknowledged that patients with ruptured abdominal aortic aneurysm (rAAA) obtain the greatest benefit from endovascular repair (EVAR), convincing evidence on the medium-long term effect is lacking. The aim of this study was to compare and summarize published results of rAAA that underwent EVAR with open surgical repair (OSR). Methods A search of publicly published literature was performed. Based on an inclusion and exclusion criteria, a systematic meta-analysis was undertaken to compare patient characteristics, complications, short term mortality and medium-long term outcomes. A random-effects model was used to pool the data and calculate pooled odds ratios and weighted mean differences. A quantitative method was used to analyze the differences between these two methods. Results A search of the published literature showed that fourteen English language papers comprising totally 1213 patients with rAAA (435 EVAR and 778 OSR) would be suitable for this study. Furthermore, 13 Chinese studies were included, including 267 patients with rAAA totally, among which 238 patients received operation. The endovascular method was associated with more respiratory diseases before treatment (OR=1.81, P=0.01), while there are more patients with hemodynamic instability before treatment in OSR group (OR=1.53, P=0.031). Mean blood transfusion was 1328 ml for EVAR and 2809 ml for OSR (weighted mean difference (WMD) 1500 ml, P=0.014). The endovascular method was associated with a shorter stay in intensive care (WMD 2.34 days, P <0.001) and a shorter total postoperative stay (WMD 6.27 days, P <0.001). The pooled post-operative complication rate of respiratory system and visceral ischemia seldom occurred in the EVAR group (OR=0.48, P <0.001 and OR=0.28, P=0.043, respectively). The pooled 30-day mortality was 25.7% for EVAR and 39.6% for OSR, and the odds ratio was 0.53 (95% confidence interval (CI) 0.41-0.70, P <0.001). There was not, however, any significant reduction in the medium-long all-cause mortality rate (HR=1.13, P=0.381) and re-intervention rate (OR= 2.19, P=0.243) following EVAR. In EVAR group, nevertheless, incidence of type I endoleak was significantly lower than type II endoleak (OR=0.33, P=0.039) at late follow-up period. Conclusions On the basis of this systematic review, rAAA EVAR results in less blood use for transfusion, shorter operation time, shorter intensive care unit and hospital stays, and lower 30-day mortality. However, in the medium-long term, it is not associated with a reduction in all-cause mortality.

Costs of Repair of Abdominal Aortic Aneurysm with Different Devices: Results of a Multicenter Randomized Trial

Prior analysis has demonstrated that survival, quality of life, and total healthcare costs are not significantly different between the two methods of repair of abdominal aortic aneurysm (AAA) in the Open Versus Endovascular Repair Veterans Affairs (VA) Cooperative Study. The device is a substantial portion of the cost of this method of repair, and the objective of this study is to evaluate the costs of AAA repair and total healthcare costs when different endograft systems are selected for the endovascular repair. Eight hundred and eighty-one subjects were randomized to open (437) or endovascular repair (444). Device selection was recorded before randomization; therefore open repair controls are matched to each device cohort. Data was excluded for two low volume devices, implanted in only 13 subjects. Mean device, hospitalization, and total healthcare costs from randomization to two years were compared. Health care utilization data were obtained from patients and national VA and Medicare data sources. VA costs were determined using methods previously developed by the VA Health Economics Resource Center. Non-VA costs were obtained from Medicare claims data and billing data from the patient's healthcare providers. Implant costs are 38% of initial hospitalization costs. Mean device, initial hospitalization and total health care costs at two years in the endovascular and open repair groups are not significantly different between device systems. Differences between endovascular and corresponding open repair cohorts show lower mean costs for endovascular repair but these are not statistically different. Endovascular aneurysm repair implant costs are substantial. When evaluating total healthcare system expenditures, there is large individual variability in costs, and there is no significant difference at two years between systems or when an individual system is compared to open repair.TableMean costs of AAA repairEVR device (n = 431) mean costs (SD)Zenith (n = 166)Excluder (n = 177)AneuRx (n = 88)P valueImplant14,395 (2552)13,582 (3820)14,262 (4191).08Initial hospitalization38,141 (27517)34,804 (31206)38,942 (24874).43Total at 2 years78,198 (60216)73,458 (65123)72,438 (42389).68Open repair (n = 423)(n = 175)(n = 150)(n = 98)Total at 2 years82,069 (113783)81,791 (84488)75,591 (84061).85P value: EVR vs Open.69.33.74 Open table in a new tab

A 14-year experience with blunt thoracic aortic injury

This study reviewed the natural history of blunt thoracic aortic trauma (BTAT) over a 14-year period at our level 1 trauma center and compared open vs endovascular treatment. All patients with BTAT presenting to a level 1 trauma center from 1998 to 2011 were included in a retrospective analysis. Multiple data points and short-term and midterm outcomes were ascertained through a retrospective record review. We identified 129 patients with BTAT. Of these, 32 (25%) were dead on arrival, 38 (29%) underwent a resuscitative thoracotomy and died, 33 (26%) underwent open repair, 14 (11%) underwent endovascular repair, 9 (7%) underwent simultaneous procedures, and 3 (2%) were managed nonoperatively. Mean Injury Severity Scores and Revised Trauma Scores were similar (P = .484, P = .551) between the open repair group (n = 36) and the endovascular repair group (n = 14). In the open repair group, there were 14 deaths (42%) ≤ 30 days of injury, 3 strokes (9%), 2 patients (6%) with paralysis, 2 myocardial infarctions (MIs; 6%), and 3 patients (9%) who required hemodialysis. In the endovascular group, there was 1 death (7%) ≤ 30 days of injury, 1 (7%) stroke, and 1 (7%) stent collapse. No paralysis, MI, or renal failure requiring hemodialysis was noted in the endovascular group. The average length of stay was 15 days for patients treated with endovascular repair vs 24 days for those treated with open repair (P = .003). The incidence of BTAT is low but the mortality associated with it is significant. During the 14-year period studied, there was a clear change in management preference from open repair to endovascular repair at our level 1 trauma center. Outcomes, including stroke, MI, renal failure, paralysis, length of stay, and death, appear to be reduced in the endovascular group.

Traumatic Aortic Injury: Single-center Comparison of Open versus Endovascular Repair

BackgroundConventional open repair is a suboptimal therapy for blunt traumatic aortic injury (BTAI) due to the high postoperative mortality and morbidity rates. Recent advances in the thoracic endovascular repair technique may improve outcomes so that it becomes an attractive therapeutic option.Materials and MethodsFrom August 2003 to March 2012, 21 patients (mean age, 45.81 years) with BTAI were admitted to our institution. Of these, 18 cases (open repair in 11 patients and endovascular repair in 7 patients) were retrospectively reviewed and the early perioperative results of the two groups were compared.ResultsAlthough not statistically significant, there was a trend toward the reduction of mortality in the endovascular repair group (18.2% vs. 0%). There were no cases of paraplegia or endoleak. Statistically significant reductions in heparin dosage, blood loss, and transfusion amounts during the operations and in procedure duration were observed.ConclusionCompared with open repair, endovascular repair can be performed with favorable mortality and morbidity rates. However, relatively younger patients who have acute aortic arch angulation and a small aortic diameter may be a therapeutic challenge. Improvements in graft design, delivery sheaths, and graft durability are the cornerstone of successful endovascular repair.

Long-Term Comparison of Endovascular and Open Repair of Abdominal Aortic Aneurysm

BackgroundWhether elective endovascular repair of abdominal aortic aneurysm reduces long-term morbidity and mortality, as compared with traditional open repair, remains uncertain.MethodsWe randomly assigned 881 patients with asymptomatic abdominal aortic aneurysms who were candidates for both procedures to either endovascular repair (444) or open repair (437) and followed them for up to 9 years (mean, 5.2). Patients were selected from 42 Veterans Affairs medical centers and were 49 years of age or older at the time of registration.ResultsMore than 95% of the patients underwent the assigned repair. For the primary outcome of all-cause mortality, 146 deaths occurred in each group (hazard ratio with endovascular repair versus open repair, 0.97; 95% confidence interval [CI], 0.77 to 1.22; P=0.81). The previously reported reduction in perioperative mortality with endovascular repair was sustained at 2 years (hazard ratio, 0.63; 95% CI, 0.40 to 0.98; P=0.04) and at 3 years (hazard ratio, 0.72; 95% CI, 0.51 to 1.00; P=0.05) but not thereafter. There were 10 aneurysm-related deaths in the endovascular-repair group (2.3%) versus 16 in the open-repair group (3.7%) (P=0.22). Six aneurysm ruptures were confirmed in the endovascular-repair group versus none in the open-repair group (P=0.03). A significant interaction was observed between age and type of treatment (P=0.006); survival was increased among patients under 70 years of age in the endovascular-repair group but tended to be better among those 70 years of age or older in the open-repair group.ConclusionsEndovascular repair and open repair resulted in similar long-term survival. The perioperative survival advantage with endovascular repair was sustained for several years, but rupture after repair remained a concern. Endovascular repair led to increased long-term survival among younger patients but not among older patients, for whom a greater benefit from the endovascular approach had been expected. (Funded by the Department of Veterans Affairs Office of Research and Development; OVER ClinicalTrials.gov number, NCT00094575.)

Cost-effectiveness of open versus endovascular repair of abdominal aortic aneurysm in the OVER trial

This study was conducted to determine the costs and comparative cost-effectiveness of two methods of abdominal aortic aneurysm (AAA) repair in the Open Versus Endovascular Repair (OVER) Veterans Affairs (VA) Cooperative Study, a multicenter randomized trial of 881 patients. The primary outcomes of this analysis were mean total health care cost per life-year and per quality-adjusted life-year (QALY) from randomization to 2 years after. QALYs were calculated from EuroQol (EQ)-5D questionnaires collected at baseline and annually. Health care utilization data were obtained directly from patients and from national VA and Medicare data sources. VA costs were obtained from national VA sources using methods previously developed by the VA Health Economics Resource Center. Costs for non-VA care were determined from Medicare claims data or billing data from the patient's health care providers. After 2 years of follow-up, mean life-years were 1.78 in the endovascular repair group and 1.74 in the open repair group (difference, 0.04; 95% confidence interval [CI], -0.03 to 0.09; P = .29). Mean QALYs were 1.462 in the endovascular group and 1.461 in the open group (difference adjusting for baseline EQ-5D score, 0.006; 95% CI, -0.038 to 0.052; P = .78). Mean graft costs were higher in the endovascular group ($14,052 vs $1363; P < .001), but length of stay was shorter (5.0 vs 10.5 days; P < .001), resulting in a lower mean cost of the hospital admission for the AAA procedure in the endovascular repair group of $37,068 vs $42,970 (difference, -$5901; 95% CI, -$12,135 to -$821; P = .04). After 2 years, total health care costs remained lower in the endovascular group, but the difference was no longer significant (-$5019; 95% CI, -$16,720 to $4928; P = .35). The probability of endovascular repair being less costly and more effective was 70.9% for life-years and 51.4% for QALYs. In this multicenter randomized trial, endovascular AAA repair resulted in lower cost and better survival than open repair after the initial hospitalization for repair; but after 2 years, survival, quality of life, and costs were not significantly different between the two treatments.

Endovascular vs open repair for ruptured abdominal aortic aneurysm

Endovascular repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) has become first-line therapy at our institution and is performed under a standardized protocol. We compare perioperative mortality, midterm survival, and morbidity after EVAR and open surgical repair (OSR). Records were retrospectively reviewed from May 2000 to September 2010 for repair of infrarenal rAAAs. Primary end points included perioperative mortality and midterm survival. Secondary end points included acute limb ischemia, length of stay, ventilator-dependent respiratory failure, myocardial infarction, renal failure, abdominal compartment syndrome, and secondary intervention. Statistical analysis was performed using the t-test, χ(2) test, the Fisher exact test, and logistic regression calculations. Midterm survival was assessed with Kaplan-Meier analysis and Cox proportional hazard models. Seventy-four infrarenal rAAAs were repaired, 19 by EVAR and 55 by OSR. Despite increased age and comorbidity in the EVAR patients, perioperative mortality was 15.7% for EVAR, which was significantly lower than the 49% for OSR (odds ratio, 0.19; 95% CI, 0.05-0.74; P = .008). Midterm survival also favored EVAR (hazard ratio, 0.40; 95% CI, 0.21-0.77; P = .028, adjusted for age and sex). Mean follow-up was 20 months, and 1-year survival was 60% for EVAR vs 45% for OSR. Mean length of stay for patients surviving >1 day was 10 days for EVAR and 21 days for OSR (P = .004). Ventilator-dependent respiratory failure was 5% in the EVAR group vs 42% for OSR (odds ratio, 0.08; 95% CI, 0.01-0.62; P = .001). EVAR of rAAA has a superior perioperative survival advantage and decreased morbidity vs OSR. Although not statistically significant, overall survival favors EVAR. We recommend that EVAR be considered as the first-line treatment of rAAAs and practiced as the standard of care.

Comparison of Survival Rates for Abdominal Aortic Aneurysm Treatment Methods

We compared relative survival rates of patients after various operative treatments for abdominal aortic aneurysm (AAA) to those for the general population. We calculated a point of "recovery," defined as the survival rate equal to that of the general population. Survival data were collected from patients who underwent open repair for a ruptured AAA (rAAA), elective open repair of an AAA (OPEN), and endovascular repair (EVAR) in our hospital between 1995 and 2005. The cumulative relative survival rate and time-specific relative survival rate were calculated for these patients compared to those for the general population. The point of "recovery" was defined as the cumulative relative survival rate equaling the survival rate for the population, and the time-specific relative survival rate reaching 1.0. The cumulative relative survival rate of the patients immediately after OPEN was lower than for the comparison group at the time the cumulative relative survival rate was regained. The time-specific relative survival rate of the rAAA reached 1.0 at 16months following emergency surgery, and for OPEN after 10months. The cumulative relative survival rate in the EVAR group had no impairment following intervention. The relative long-term survival rate in all three surgical groups was the same as that for the general German population. Patients treated successfully for AAA have the same relative long-term survival as the general population. The time required to reach the same survival, however, differs between the treatment groups and is longest in the group with a rAAA. The variable survival rates should be taken into consideration when treating patients with an AAA.

Residual Infrarenal Aortic Neck following Endovascular and Open Aneurysm Repair

BackgroundThe effectiveness of open and endovascular aneurysm repair of aortic abdominal aneurysms (AAAs) can be jeopardised by deterioration of the residual infrarenal neck of the aneurysm. ObjectiveThe study aims to determine the length of the residual infrarenal aortic segment after endovascular and open aneurysm repair. MethodsIn a multicentre randomised controlled trial comparing open and endovascular AAA repair, 165 patients were discharged after open AAA repair (OR) and 169 after endovascular repair (EVAR). Immediately after the operation, surgeons were asked to enter in the case record form whether the level of their anastomosis after open repair was within or beyond 10 mm of the caudal renal artery. Postoperative computed tomography (CT) scans that were obtained within 6 months after surgery were used for comparative analysis. The distance between the caudal renal artery and the proximal anastomosis of the (endo-) graft was measured using axial CT slices and a standardised protocol. CT images were available and suitable for analysis in 156 (95%) of 165 OR patients and in 160 (95%) of 169 EVAR patients. Data are presented as median (range). Differences were analysed using the Mann–Whitney test. ResultsThe distance from the caudal renal artery to the proximal anastomosis was 24 mm (16–30 mm) in the OR group versus 0 mm (0–6 mm) in the EVAR group (p < 0.0001, Mann–Whitney). In 140 of 156 (90%) patients, at least 1 cm of untreated infrarenal neck persisted after OR and in 17 of 160 (10%) after EVAR. In 84 of the 156 open repair patients (54%), the surgeon had indicated that the proximal anastomosis was within 10 mm of the caudal renal artery. Only five surgeons (6%) were accurate in this respect. ConclusionAfter open repair, a longer segment of the infrarenal aortic neck is left untreated compared with endovascular repair and this length is underestimated by most surgeons. Long-term studies are required to determine the consequences of this difference.

Comparison of aortic neck dilatation after open and endovascular repair of abdominal aortic aneurysm

This study evaluated the changes of the aortic diameter at the suprarenal and infrarenal segment after open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). This was a retrospective analysis of all patients undergoing AAA repair between 1997 and 2008. Inclusion criteria were at least 3 months of follow-up at our institution, elective aneurysm repair, and absence of false, mycotic, or inflammatory aneurysms. For EVAR, standard computed tomography (CT) scans from follow-up were used; in the OR group, CT scans performed for unrelated nonvascular indications were used. Diameters of the aorta were measured at the first slice below the lowest renal artery and at the first slice above the highest renal artery. A 2-mm change was defined as measurable aortic neck dilatation. Inclusion criteria were met by 46 patients in the OR group and 103 in the EVAR group. After a follow-up of 34.1 months (range, 5.5-131.7 months) in the OR group and 39.4 months (range, 3-108.9 months) in the EVAR group, the mean changes were 1.75 ± 3.50 mm (OR) and 0.9 ± 2.3 mm (EVAR; P = .305) in the suprarenal diameters and 0.8 ± 2.9 mm (OR) and 1.2 ± 2.5 mm (EVAR; P = .311) in the infrarenal diameters. The absolute suprarenal vs infrarenal sizes were 29.7 ± 7.1 and 28.7 ± 6.8 mm in the OR group and 28.7 ± 3.2 and 28.5 ± 3.6 mm, respectively, in the EVAR group (suprarenal, P = .749; infrarenal, P = .273). Increase of the aortic diameter >2 mm, defined as aortic neck dilatation, was found in 23 of 103 EVAR patients (22.3% ± 0.862%), and in nine of 46 OR patients (19.57% ± 0.484%; P = .870). Increase in the suprarenal change >2 mm occurred in 21 of 103 EVAR patients (20.39% ± 1.04%) and in 14 of 46 OR patients (30.4% ± 0.446%; P = .260). Reintervention rate of patients with an increase >2 mm was 31% (seven of 23) in EVAR and 11.1% (one of nine) in the OR group (P = .386). The AAA groups treated with EVAR or OR demonstrated similar increases of aneurysmal neck diameters. This suggests that aortic neck dilatation may be caused by a natural progression of the disease rather than by deviating therapeutic strategies.

Long-Term Outcomes of Endovascular Repair versus Open Repair of Abdominal Aortic Aneurysm

To compare the long-term outcomes of endovascular repair (EVAR) versus open repair for abdominal aortic aneurysm (AAA). We retrospectively reviewed consecutive AAA patients treated with EVAR (n = 89) or open repair (n = 136) from January 1998 to December 2008. More patients in the open repair group had a longer duration of hospital stay. The operation time was significantly longer in open surgery than in EVAR (p <0.001), and the percentage of patients requiring a transfusion was higher in the open repair group than in EVAR. Patients in the open repair group had a higher incidence of cardiac insufficiency after surgery than did those in the EVAR group. Kaplan-Meier analysis indicated that the proportion of patients without complications in the EVAR group was significantly less than that in the open repair group (68.1% vs. 91.1%; p <0.0001), and the long-term survival rate in EVAR group was similar to open surgery group (87.5% vs. 91.1%; p = 0.555). Thrombosis was found inside of the aneurysm; postoperative complications in the EVAR group included ischemic legs, graft stenosis, and endoleaks that required further endoluminal treatment. Endovascular repair of abdominal aortic aneurysm causes less trauma in patients with AAAs in the short term, and patients treated with EVAR have similar survival rate with open repair in the long term, but have postoperative complications requiring further interventional treatment.

Early Outcomes of Open Abdominal Repair Versus Endovascular Repair for Abdominal Aortic Aneurysm: Report from National Hospital Organization Network Study in Japan

Early outcomes of open abdominal repair (OS) versus endovascular repair (EVAR) for abdominal aortic aneurysm were retrospectively analyzed, after commercialized devices for EVAR had become available in Japan. A total of 781 consecutive patients (OS, n = 522; EVAR, n = 259) were treated at ten medical centers between January 2008 and September 2010. The OS group comprised patients with preoperative shock (SOS, n = 34) and without shock (NOS, n = 488). Patients in the EVAR group were 3 years older than those in the NOS group. There was greater prevalence of hostile abdomen, on dialysis, chronic obstructive pulmonary disease on inhaled drug, and cerebrovascular disease in the EVAR group than in the NOS group. Surgical mortality was 16 cases (2.0% in all patients, EVAR: 0.8%, NOS: 1.4%, SOS: 21%). Hospital stay >30 days was documented in 52 (11%) with NOS, 11 (33%) with SOS, and 8 (3%) with EVAR. Thirty late deaths included 6 aneurysm related death and 14 cardiovascular causes at a mean follow up of 1.0 year. The survival rates freedom from all cause death at one year, were 95 ± 1% in NOS and 94 ± 2% in EVAR respectively. Though significant differences in patient characteristics among three groups were noted, early results were satisfactory.

A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients

Several studies, including three randomized controlled trials (RCTs), have shown that endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) offered better early results than open surgical repair (OSR) but a similar medium-term to long-term mortality and a higher incidence of reinterventions. Thus, the role of EVAR, most notably in low-risk patients, remains debated. The ACE (Anevrysme de l'aorte abdominale: Chirurgie versus Endoprothese) trial compared mortality and major adverse events after EVAR and OSR in patients with AAA anatomically suitable for EVAR and at low-risk or intermediate-risk for open surgery. A total of 316 patients with >5 cm aneurysms were randomized in institutions with proven expertise for both treatments: 299 patients were available for analysis, and 149 were assigned to OSR and 150 to EVAR. Patients were monitored for 5 years after treatment. Statistical analysis was by intention to treat. With a median follow-up of 3 years (range, 0-4.8 years), there was no difference in the cumulative survival free of death or major events rates between OSR and EVAR: 95.9% ± 1.6% vs 93.2% ± 2.1% at 1 year and 85.1% ± 4.5% vs 82.4% ± 3.7% at 3 years, respectively (P = .09). In-hospital mortality (0.6% vs 1.3%; P = 1.0), survival, and the percentage of minor complications were not statistically different. In the EVAR group, however, the crude percentage of reintervention was higher (2.4% vs 16%, P < .0001), with a trend toward a higher aneurysm-related mortality (0.7% vs 4%; P = .12). In patients with low to intermediate risk factors, open repair of AAA is as safe as EVAR and remains a more durable option.

Anesthesia Literature Review

Anesthesia Literature Review

The study of different operative style for abdominal aortic aneurysm during surrounding operation

To compare the the similarities and differences during the surrounding operation of endovascular repair (EVAR) and open surgical repair (OSR) for abdominal aortic aneurysm. 112 patients with abdominal aortic aneurysms (AAA) were selected from 2004 to 2009: among them, 66 patients were treated with EVAR, 46 patients with OSR. Data of two groups were collected and analyzed during surrounding operation. Compared to OSR group, the mean blood lost, blood transfusion and intra-operative fluid in EVAR group were significantly less than OSR group (P < 0.05). The mean time of operation, observation period in ICU and being in hospital in EVAR group were shorter than OSR group (P < 0.05). But the cost of hospitalization in EVAR was far higher than that of OSR group (P < 0.05). In short term postoperative complications the OSR group was higher than the EVAR (P < 0.05), however, there was no statistically significant difference in death rate of the two groups during surrounding operation (P > 0.05). EVAR has the advantages of mild trauma, less blood loss, quicker recovery after operation, and less disturbance to internal environment. Especially, it is suitable for the patients who can not undergo open surgery repair, but its cost is still higher.

Endovascular versus Open Repair of Abdominal Aortic Aneurysm

Few data are available on the long-term outcome of endovascular repair of abdominal aortic aneurysm as compared with open repair. From 1999 through 2004 at 37 hospitals in the United Kingdom, we randomly assigned 1252 patients with large abdominal aortic aneurysms (> or = 5.5 cm in diameter) to undergo either endovascular or open repair; 626 patients were assigned to each group. Patients were followed for rates of death, graft-related complications, reinterventions, and resource use until the end of 2009. Logistic regression and Cox regression were used to compare outcomes in the two groups. The 30-day operative mortality was 1.8% in the endovascular-repair group and 4.3% in the open-repair group (adjusted odds ratio for endovascular repair as compared with open repair, 0.39; 95% confidence interval [CI], 0.18 to 0.87; P=0.02). The endovascular-repair group had an early benefit with respect to aneurysm-related mortality, but the benefit was lost by the end of the study, at least partially because of fatal endograft ruptures (adjusted hazard ratio, 0.92; 95% CI, 0.57 to 1.49; P=0.73). By the end of follow-up, there was no significant difference between the two groups in the rate of death from any cause (adjusted hazard ratio, 1.03; 95% CI, 0.86 to 1.23; P=0.72). The rates of graft-related complications and reinterventions were higher with endovascular repair, and new complications occurred up to 8 years after randomization, contributing to higher overall costs. In this large, randomized trial, endovascular repair of abdominal aortic aneurysm was associated with a significantly lower operative mortality than open surgical repair. However, no differences were seen in total mortality or aneurysm-related mortality in the long term. Endovascular repair was associated with increased rates of graft-related complications and reinterventions and was more costly. (Current Controlled Trials number, ISRCTN55703451.)

Outcomes Following Endovascular vs Open Repair of Abdominal Aortic Aneurysm&lt;subtitle&gt;A Randomized Trial&lt;/subtitle&gt;

Limited data are available to assess whether endovascular repair of abdominal aortic aneurysm (AAA) improves short-term outcomes compared with traditional open repair. To compare postoperative outcomes up to 2 years after endovascular or open repair of AAA in a planned interim report of a 9-year trial. A randomized, multicenter clinical trial of 881 veterans (aged > or = 49 years) from 42 Veterans Affairs Medical Centers with eligible AAA who were candidates for both elective endovascular repair and open repair of AAA. The trial is ongoing and this report describes the period between October 15, 2002, and October 15, 2008. Elective endovascular (n = 444) or open (n = 437) repair of AAA. Procedure failure, secondary therapeutic procedures, length of stay, quality of life, erectile dysfunction, major morbidity, and mortality. Mean follow-up was 1.8 years. Perioperative mortality (30 days or inpatient) was lower for endovascular repair (0.5% vs 3.0%; P = .004), but there was no significant difference in mortality at 2 years (7.0% vs 9.8%, P = .13). Patients in the endovascular repair group had reduced median procedure time (2.9 vs 3.7 hours), blood loss (200 vs 1000 mL), transfusion requirement (0 vs 1.0 units), duration of mechanical ventilation (3.6 vs 5.0 hours), hospital stay (3 vs 7 days), and intensive care unit stay (1 vs 4 days), but required substantial exposure to fluoroscopy and contrast. There were no differences between the 2 groups in major morbidity, procedure failure, secondary therapeutic procedures, aneurysm-related hospitalizations, health-related quality of life, or erectile function. In this report of short-term outcomes after elective AAA repair, perioperative mortality was low for both procedures and lower for endovascular than open repair. The early advantage of endovascular repair was not offset by increased morbidity or mortality in the first 2 years after repair. Longer-term outcome data are needed to fully assess the relative merits of the 2 procedures. clinicaltrials.gov Identifier: NCT00094575.

Prospective follow-up of sexual function after elective repair of abdominal aortic aneurysms using open and endovascular techniques

Surgical intervention in the treatment of abdominal aortic aneurysms (AAA) can affect sexual functions, resulting in a negative impact on the quality of life. The aim of this study was to investigate the preoperative information given about sexual functions and to compare the functional changes after open (OR) and endovascular repair (EVAR) for patients with AAA during one year after treatment. Seventy-six patients participated in the study (40 OR and 36 EVAR). A questionnaire was used to measure the sexual function preoperatively, and then after one month and one year following surgical interventions. Four aspects related to sexual function were studied: interest in sex, quality of erection, ability to achieve orgasm, and ejaculation. Two questions about the preoperative information covering the sexual function and another two questions about the patients concern for their sexual activities were also added. Fisher's exact test was used to test for significant relative changes within each group of treatment for the variables studied. Ninety-one percent reported that they did not receive any preoperative information about the risk for any possible negative impact on the sexual function. None of the EVAR patients were given such information. Forty-two percent of all patients felt some anxiety about having sex before the operation, which decreased to 7% after one year. About 22% reported having strong/moderate ability of their erection and 54% reported this as being weak/very weak preoperatively. Patients who preoperatively had reported some form of sexual interest had experienced a significant impairment in sex (P < .039) one year after the interventions. Patients treated with EVAR reported a significant impairment in the quality of erection (P < .033) and their ability to achieve ejaculation (P < .047) one year after the operation. A similar tendency was seen in the OR group, but did not achieve statistical significance. Few patients were given or understood any preoperative information concerning the risk and possibility of a negative impact on their sexual function following surgical interventions. This was especially reported by patients in the EVAR group. Following the operation, the reported sexual interest and ability was decreased among patients in both groups. When only those patients who had reported some form of interest in sexual activity before the intervention were analyzed, a small significant impairment in quality of erection and achieving ejaculation could be found during the one year follow-up in the EVAR group.

Blunt Thoracic Aortic Injury: Open or Stent Graft Repair?

Conclusion: There are no significant differences between endovascular and open repair of blunt aortic injury with respect to morbidity or mortality. Summary: Endovascular stent grafting has nearly become the standard of care for treatment of blunt thoracic aortic injury. This is despite the lack of any randomized data to support this paradigm change in the treatment of blunt aortic injury. The authors sought to determine whether the use of endovascular stent grafting has actually improved outcome of treatment of blunt thoracic aortic injury. This was a retrospective review of the patients from single institution that were treated for blunt thoracic aortic injury from October 1999 to May 2007. Patients were identified from the University of Wisconsin's level I trauma registry and included in this study if they had computed tomography scan or angiographic evidence of a thoracic aortic injury distal to the left subclavian artery after blunt trauma. Patients were separated into those who underwent open repair (OR) and those who underwent endovascular repair (ER). Patients were assessed for demographics, mechanism of injury, injury severity score (ISS), associated injuries, known comorbid conditions, intraoperative findings, postoperative complications, and hospital stay. Outcomes in patients treated with OR and ER were compared. During this 8-year period, 26 consecutive patients (20 men) were treated for blunt aortic injury, of which 12 were treated with OR and 14 with ER. The mean age was 36 years. There were no differences between the ER and OR groups with respect to mechanism of injury, ISS score, or number of associated injuries upon presentation. ER was technically successful in 100%, with no procedurally related mortality. One patient in the OR group had a presumed recurrent laryngeal nerve palsy postoperatively. There was no treatment-related paraplegia in either group. One-year survival for OR and ER patients was 93% and 92% respectively. At 1 year, 25% of patients in the OR group and 18% in the ER group required reintervention. Intraoperative blood product administration was greater in the OR group (P = .055). However, total blood products transfused in the initial hospital stay did not differ between the two groups. Duration of hospital stay was also similar, at 13 days for the OR group and 13.9 days for the ER group. Patients in the ER group tended to have delayed repair vs those in the OR group, with an average time from injury to repair of 0.3 days for the OR group and 12.2 days for the ER group. Comment: ER of thoracic aortic injury has its problems, but most articles on this subject have concluded ER of blunt thoracic injury has advantages over OR. This report will not significantly detract from the trend for ER of blunt thoracic aortic injury. The number of patients treated here was relatively small, averaging only about three patients per year. In addition, the patients treated with OR had a mean cross-clamp time of 27 minutes (these are quick surgeons), and half of the patients could be treated with primary repair (favorable injuries). Overall survival of the OR group was higher than is usually seen in reports of OR of thoracic aortic injury. This suggests a relatively favorable group of patients treated with OR for blunt thoracic injury at the University of Wisconsin. More data are clearly needed, but despite this report, the trend for ER of blunt thoracic aortic injury will continue.

Thoracic endovascular aortic repair - a Brazilian experience in 255 patients over a period of 112 months

The aim of this study is to analyze the immediate and late evolution for death and reintervention in a thoracic endovascular aortic repair (TEVAR) group, over a follow-up period of 112 months. Retrospective data of 255 patients, from 1998 to 2007, were obtained. The most prevalent diseases were thoracic aortic aneurysms (89), thoracic and abdominal aneurysms (85) and thoracic aortic dissections (61). The mean age was 63.2 years and 67.1% were male. Three hundred and three endoprostheses were used. Causes of morbidity, in the immediate postoperative period, were hyperthermia (45.9%), endoleaks (9.8% - being 7.1% type I), vascular complications (5.2%), renal insufficiency (3.1%) and neurological complications (3.1%). There were two (0.8%) hospital deaths and 17 (6.7%) late deaths. Time of follow-up was up to 112 months (mean of 60 months). The Kaplan-Meier curve analysis showed an increase of reintervention, compared with death, after a follow-up period of 42 months. Freedom from death at 36, 60 and 112 months was 96%, 89.1%, 85.1% and for reintervention, for the same periods was 93.6%, 82.7%, 57.2%, respectively. This study showed low incidence of prostheses related morbidity and immediate mortality. After a period of 42 months there was an increase on the percentual tax of reintervention.