Endovascular Versus Research Articles

PS34. Comparative Mortality of Ruptured Abdominal Aortic Aneurysm After Endovascular Versus Open Repair

PS34. Comparative Mortality of Ruptured Abdominal Aortic Aneurysm After Endovascular Versus Open Repair

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease

Cost-Effectiveness Analysis of Endovascular Versus Open Surgical Repair of Acute Abdominal Aortic Aneurysms Based on Worldwide Experience

To present an economic evaluation of endovascular versus open surgical repair of ruptured abdominal aortic aneurysms (AAA). Endovascular aneurysm repair (EVAR) is currently being appraised by the National Institute for Clinical Excellence. To aid in this appraisal, a health economic model developed to demonstrate the cost-effectiveness of EVAR for elective treatment of non-ruptured AAAs versus OSR was used for an analysis in the emergency setting. The base case data on 730 patients undergoing EVAR was extracted from our recently published 22-study meta-analysis of 7040 patients presenting with acute AAA (ruptured or symptomatic) treated with either emergency EVAR or OSR. These data reflected a patient population with an average age of 70 years. The base case model, which assumed a time horizon of 30 years and applied all-cause mortality rates, was subjected to a number of 1-way sensitivity analyses. A multivariate analysis was undertaken using 10,000 Monte-Carlo simulations. EVAR dominated OSR in the base case analysis, with a mean cumulative cost/patient of pound17,422 ($26,133) for EVAR and pound18,930 ($28,395) for OSR [- pound1508 ($2262) difference]. The mean quality-adjusted life years (QALYs)/patient was 3.09 for EVAR versus 2.49 for OSR (0.64 difference). EVAR was cost-effective compared with OSR at a threshold value of pound20,000 to pound30,000 ($30,000-$45,000)/QALY. In no single combination tested did open surgical repair provide the patient with more QALYs than EVAR. Sensitivity analyses demonstrated that the results were most sensitive to length of hospital and intensive care stays, use of blood products, and the cost of the evar device, which were the main cost drivers. While the UK's National Institute for Clinical Excellence does not set an absolute limit at which treatments would not be funded, pound30,000 ($45,000) is generally regarded as the upper limit of acceptability. At this level, there is almost a 100% probability that EVAR is a cost-effective treatment for ruptured AAA.

Analysis of Outcome after Using High-risk Criteria Selection to Surgery Versus Endovascular Repair in the Modern Era of Abdominal Aortic Aneurysm Treatment

Analysis of Outcome after Using High-risk Criteria Selection to Surgery Versus Endovascular Repair in the Modern Era of Abdominal Aortic Aneurysm Treatment

The link between volume and outcome in endovascular aneurysm repair

These data were based on OAR, however, which might be considered to be an increasingly historical procedure. The advent of EVAR has changed the provision of vascular surgery by allowing AAA repair at a lower mortality compared with OAR. For example, the EVAR 1 trial reported a reduction in 30-day mortality from 4.7% after OAR to 1.7% after EVAR [5], and these findings were mirrored in both the Dutch Randomised Endovascular Aneurysm Management (DREAM) trial and USA Open Versus Endovascular Repair (OVER) trial [6,7]. However, there has been debate as to how EVAR is best delivered and as to whether the same v olume–outcome relationships would be observed as with OAR.

Long-Term Results of Open Versus Endovascular Revascularization of Superficial Femoral Artery Occlusive Disease: A Case-Control Series

Introduction: We performed a case-control comparison of long-term results of femoral-popliteal bypass and superficial femoral artery (SFA) endovascular interventions to examine characteristics of patients and procedures to optimize results. Methods: Femoral-popliteal bypasses and SFA interventions performed for consecutive patients with symptoms (Rutherford 3 to 6) between 2001 and 2008 were reviewed. Time-dependent outcomes were assessed with Kaplan-Meier survival analyses. Log-rank analyses, univariate, and multivariate analyses were performed. Results: During the study period, 152 limbs in 141 patients (66% male; mean age, 66 ± 22 years) underwent femoral-popliteal bypass; 233 limbs in 204 patients (49% male; mean age, 70 ± 11 years) underwent SFA intervention. Surgery was performed less commonly for claudication (46% vs 56%) and more commonly for critical ischemia (54% vs 44%). Six-year primary, primary assisted, and secondary patency rates were 56%, 64%, and 75%, respectively, for bypass patients and 40%, 67%, and 85%, respectively, for SFA interventions. Six-year limb salvage was 80% for surgery and 92% for SFA interventions. Complications occurred in 21% of the surgery group and in 1.2% of the endovascular group. Reintervention was required in 24% of surgery patients and in 14% of endovascular patients. Failure of SFA intervention led to bypass in 5% of patients; however, prior failed intervention did not change the target artery. Predictors of failure for surgery and SFA interventions were female gender, diabetes, creatinine >1.8 mg/dL, and critical limb ischemia; however, limb salvage was no different for all groups. Conclusions: Although long-term patency and limb salvage were equivalent, reinterventions and complications occurred at a higher rate in the surgery group. Patients with critical limb ischemia, diabetes, or renal failure had decreased patency with both treatments; however, limb salvage was not disadvantaged for any group. SFA stent placement should therefore be the initial therapy for patients with SFA occlusive disease.

Analysis of Outcome after using High-risk Criteria Selection to Surgery Versus Endovascular Repair in the Modern Era of Abdominal Aortic Aneurysm Treatment

Introduction The concept of high-risk patients suggests that such patients will experience a higher rate of postoperative complications and worse short- and long-term outcomes, and should therefore benefit from the use of endovascular techniques for aortic abdominal aneurysm (AAA) repair. The primary goal of this study was to assess the relevance of the different high-risk criteria, defined by the French health agency Agence Française de Sécurité Sanitaire des Produits de Santé (AFSSAPS) in a single-centre continuous series. Secondary goals were to retrospectively compare the incidence of postoperative complications and short- and long-term survival in three groups of patients. Materials and methods Between January 1999 and December 2006, details of all the patients undergoing elective surgery for AAA in our hospital were recorded into a prospective registry ( n = 626). Three groups were considered according to the level of risk and type of repair defined by the AFSSAPS: endovascular aortic aneurysm repair (EVAR) high-risk (HR) (at least one high-risk factor and EVAR, n = 138), open HR (at least one high-risk factor and open repair, n = 134) and open low-risk (LR) (no high-risk factors and open repair, n = 344). None of the low-risk patients were treated using an endovascular approach. The demographics, preoperative risk factors, intra-, postoperative data and short- and long-term survival were compared between the groups. Interrelations among the set of high-risk criteria for mortality were calculated using multiple correspondence analysis (MCA). Results The distribution of high-risk criteria was similar in both high-risk groups, except for age, heart failure and hostile abdomen, which were significantly more frequent in EVAR HR. Operation time, blood loss and length of stay in an intensive care unit and hospital were significantly lower in the EVAR HR group. The 30-day mortality and survival rates at 5 years were 5.4 and 59.4% for EVAR HR, 3.7 and 70.4% for open HR and 2.3 and 83.7% for open LR, respectively, with no significant difference between the three groups for the mortality, but a significant higher survival at 5 years for the open LR versus both high-risk groups. Conclusion The high-risk AFSSAPS criteria were not predictive of postoperative mortality and should not be used to determine the choice of treatment technique. Other criteria therefore need to be established to determine whether open or EVAR repair should be used.

Endovascular Versus Open Management of Blunt Traumatic Aortic Disruption at Two Military Trauma Centers: Comparison of In-Hospital Variables

Blunt traumatic aortic disruption (BTAD) carries significant mortality and morbidity. Traditional open repair has appreciable risks of perioperative mortality and spinal cord ischemic complications. Endovascular repair may reduce the incidence of these adverse outcomes. We present the experience at two military trauma centers with thoracic aortic endografting for trauma (TAET) and compare this with recent open experience. A review of inpatient records was performed. All patients undergoing open repair or TAET for acute BTAD were studied. Collected data included demographics, injury characteristics, and in-hospital variables. Descriptive statistics were calculated with two-tailed t-tests performed for comparison of continuous variables. Five open and eight TAET repairs were performed. Mean age was 32 years (range 28-50) in the TAET group and 35 (25-57) in the open group. All patients, except one TAET, had at least one associated injury with thoracic injuries predominating. Twelve BTAD were just distal to the left subclavian artery. One injury, treated with TAET, was just proximal to the celiac. Operative blood loss averaged 298 +/- 394 mL in the TAET group vs. 2,400 +/- 3,800 mL in the open group (p = 0.18). Crystalloid infusions were similarly reduced in TAET patients, 1,019 +/- 532 mL vs. 4,860 +/- 1,547 mL, p < 0.05), as were red blood cell transfusions, 1.6 units vs. 5.0 units (p = 0.12). The majority of patients [6/8 (75%) TAET, 5/5 (100%) open] experienced an inpatient complication (p = 0.09). All open patients had at least one infectious complication. There were no inpatient deaths related to aortic injury or spinal cord ischemic complications. TAET is feasible for the treatment of BTAD in military trauma centers. It is important for military centers to accomplish this with adequate results as endovascular technologies are now being taken to the battlefield. Decreased blood loss and resuscitation requirements compared to open repair are likely contributors to improved outcomes with TAET.

PP41. Long Term Results of Open Versus Endovascular Revascularization of Superficial Femoral Artery Occlusive DiseaseA Case Control Series

For patients with superficial femoral artery (SFA) occlusive disease the most appropriate treatment has yet to be determined. We performed a case control comparison of long term results of femoral popliteal bypass and SFA endovascular interventions to examine the characteristics of patients and procedures to optimize results.

Commentary on "Endovascular Abdominal Aortic Aneurysm Repair Versus Open Repair: Why and Why Not?"

Commentary on "Endovascular Abdominal Aortic Aneurysm Repair Versus Open Repair: Why and Why Not?"

The AAA With a Challenging Neck: Outcome of Open Versus Endovascular Repair With Standard and Fenestrated Stent-Grafts

To compare the outcome of endovascular aneurysm repair (EVAR) versus conventional open repair (OR) in patients with a short, angulated or otherwise challenging proximal neck. The definition of a challenging proximal neck was based on diameter (>or=28 mm), length (<or=15 mm), angulation (>or=60 degrees ), shape (reverse tapered or bulging), and thrombus lining (>50%). Between January 2005 and December 2007, 187 consecutive patients (159 men; mean age 73 years, range 48-92) operated for asymptomatic abdominal aortic aneurysm (AAA) were identified as having challenging proximal neck morphology. Of these, 61 patients were treated with OR at center I (group A), 71 with standard EVAR (group B; 45 center I, 29 center II) and 52 with fenestrated EVAR (group C) at center II. Clinical examination and computed tomography were performed at 1 month and yearly thereafter. There was no statistically significant difference between groups A, B, and C regarding primary technical success rate, 30-day mortality, or late AAA-related mortality. The mean length of follow-up was 19.5 months (range 0-40). Freedom from reintervention at 3 years was 91.8%, 79.7%, and 82.7% for groups A, B, and C, respectively (p = 0.042). The only statistically significant difference between standard and fenestrated EVAR was a higher incidence of late sac expansion [9 (12.2%) versus 1 (1.9%), p = 0.036] in the standard stent-graft group. Reinterventions were more frequent after EVAR (p = NS), but open reinterventions were more common after OR. Reinterventions after EVAR were related to the presence of an angulated (p = 0.039) or short neck (p = 0.024). The results of EVAR and OR were similar for AAAs with a challenging proximal neck. Endovascular reinterventions were more frequent after EVAR, particularly in patients with an angulated or short neck. Open reinterventions were more common after OR. More patients and long-term data are needed to confirm these findings.

QS441. Differing Interest in Open Versus Endovascular Surgery in a General Surgery Residency Program

QS441. Differing Interest in Open Versus Endovascular Surgery in a General Surgery Residency Program

The Immediate Management of the Patient with Rupture: Open Versus Endovascular Repair (IMPROVE) Aneurysm Trial-ISRCTN 48334791 IMPROVE trialists

Background: Systematic reviews have suggested a survival advantage for patients with ruptured abdominal aortic aneurysm (AAA), who are managed by endovascular repair. These reviews are based on single centre experiences of selected patients.Objective: To determine whether a policy of endovascular repair improves the survival of all patients with ruptured AAA.Methods: A randomized controlled trial, IMPROVE (ISRCTN 48334791) will randomize patients with a clinical diagnosis of rAAA, made in hospital, either to immediate CT scan and endovascular repair whenever anatomically suitable (endovascular first), or to open repair, with CT scan being optional (normal care), The trial is set on a background of guidelines for emergency care, CT scanning and anaesthesia, which incorporate the protocol of permissive hypotension. Recruitment started in October 2009 and 600 patients are required to show a 14% survival benefit at 30 days (primary outcome) for the endovascular first policy. Recruitment will be from the UK and Europe. Secondary outcomes include 24h, in-hospital and 1 year survival, complications, major morbidities, costs and quality of life. Discussion: This is a “real life” trial that will answer the fundamental relevant clinical dilemma, namely, do patients who present with ruptured AAA derive benefit from treatment in a system, which offers a preferential strategy of endovascular repair ? The trial addresses whether the anticipated reduced mortality and morbidity associated with endovascular repair is offset by the relatively greater ease of access and speed to conventional surgery. This issue is pivotal to future patient care and provision of services.

Endovascular Versus Open Mesenteric Revascularization: Immediate Benefits Do Not Equate with Short-Term Functional Outcomes

Endovascular Versus Open Mesenteric Revascularization: Immediate Benefits Do Not Equate with Short-Term Functional Outcomes

Comparison of the Incidences of Cardiac Arrhythmias, Myocardial Ischemia, and Cardiac Events in Patients Treated With Endovascular Versus Open Surgical Repair of Abdominal Aortic Aneurysms

This study examines differences in cardiac arrhythmias, perioperative myocardial ischemia, troponin T release, and cardiovascular events between endovascular and open repair of abdominal aortic aneurysms (AAAs). Of 175 patients, 126 underwent open AAA repair and 49 underwent endovascular AAA repair. Continuous 12-lead electrocardiographic monitoring, starting 1 day before surgery and continuing through 2 days after surgery, was used for cardiac arrhythmia and myocardial ischemia detection. Troponin T was measured on postoperative days 1, 3, and 7 and before discharge. Cardiac events (cardiac death or Q-wave myocardial infarction) were noted at 30 days and at follow-up (mean 2.3 years). New-onset atrial fibrillation, nonsustained ventricular tachycardia, sustained ventricular tachycardia, and ventricular fibrillation occurred in 5%, 17%, 2%, and 1% of patients, respectively. Myocardial ischemia, troponin T release, and 30-day and long-term cardiac events occurred in 34%, 29%, 6%, and 10% of patients, respectively. Significantly higher heart rates and less heart rate variability were observed in the open AAA repair group. Cardiac arrhythmias were less prevalent in the endovascular AAA repair group (14% vs 29%, p = 0.04). Endovascular repair was also significantly associated with less myocardial ischemia (odds ratio 0.14, 95% confidence interval 0.05 to 0.40, p <0.001) and troponin T release (odds ratio 0.10, 95% confidence interval 0.02 to 0.32, p <0.001) and lower 30-day mortality (zero vs 8.7%, p = 0.03) and 30-day cardiac event rates (zero vs 7.9%, p = 0.04). Long-term mortality and cardiac event rates were not significantly lower in the endovascular AAA repair group. In conclusion, endovascular AAA repair is associated with a lower incidence of perioperative cardiac arrhythmias, myocardial ischemia, troponin T release, cardiac events, and all-cause mortality compared with open AAA repair.

Commentary on "Mid-term Results of a Multicenter Study of Thoracic Endovascular Aneurysm Repair Versus Open Repair"

Commentary on "Mid-term Results of a Multicenter Study of Thoracic Endovascular Aneurysm Repair Versus Open Repair"

Endovascular Versus Open Mesenteric Revascularization: Immediate Benefits Do Not Equate with Short-Term Functional Outcomes

Endovascular Versus Open Mesenteric Revascularization: Immediate Benefits Do Not Equate with Short-Term Functional Outcomes

A Summary of the Contributions of the VA Cooperative Studies on Abdominal Aortic Aneurysms

The Department of Veterans Affairs Cooperative Studies Program has completed two studies on abdominal aortic aneurysm (AAA) and is currently conducting a third. The first, the Aneurysm Detection and Management (ADAM) Study, consisted of both a screening program, which provided information on the prevalence and associations of AAA, and a randomized trial, which found that survival is not improved by repair of small AAA. The second was a prospective observational study to determine the incidence of rupture in patients with large AAA for whom elective repair was not planned due to medical contraindications or patient refusal. AAA in this population had a high risk of rupture, about 10% per year for AAA > 5.5 cm, and 25% within 6 months for AAA larger than 8.0 cm. The third, the Open Versus Endovascular Repair (OVER) Trial, is a multicenter randomized trial comparing long-term survival following two methods of elective AAA repair.

Endovascular Versus Open Mesenteric Revascularization: Immediate Benefits Do Not Equate with Short-Term Functional Outcomes

Percutaneous therapy for symptomatic visceral occlusive disease is rapidly gaining popularity in many centers. This study evaluates the anatomic and functional outcomes of open and endovascular therapy for chronic mesenteric ischemia at an academic medical center. We performed a retrospective review of patients who underwent endovascular or open mesenteric arterial revascularization for chronic mesenteric ischemia between January 1989 and September 2003. Indications for revascularization included postprandial abdominal pain (92%) or weight loss (54%). All had atherosclerotic visceral occlusive disease with a median of 2 vessels with more than 50% stenosis or occlusion on angiography. Sixty patients (44 women, mean age 66 years) underwent 67 interventions (43 vessels bypassed, 23 vessel endarterectomies, 22 vessel angioplasty and stents). The median numbers of vessels revascularized were two in the open group and one in the endovascular group. Thirty-day mortality and cumulative survival at 3 years were similar (open, 15% and 62% +/- 9%; endovascular, 21% and 63%+/-14%, respectively; p=NS). Cumulative patencies at 6 months were 83%+/-7% and 68%+/-14% in the open and endovascular groups, respectively (p=NS). Major morbidity, median postoperative length of stay, and cumulative freedom from recurrent symptoms at 6 months were significantly greater in the open group (open, 46%, 23 days, and 71%+/-7%, respectively; endovascular, 19%, 1 day, and 34%+/-10%, respectively; p < 0.01). Endovascular revascularization is attractive because it carries equivalent patency to open revascularization. Symptomatic benefit of endovascular revascularization is not achieved, probably as a result of incomplete revascularization. Despite incomplete revascularization, endovascular therapy has equivalent survival and lower morbidity compared with open revascularization. Complete endovascular revascularization needs further evaluation to determine if it is superior to open revascularization. In the interim, endovascular therapy should be reserved for the patient unable to undergo open revascularization.

Rupture of Abdominal Aortic Aneurysm: Concurrent Comparison of Outcome of Those Occurring After Endovascular Repair Versus Those Occurring Without Previous Treatment in an 11-Year Single-Center Experience

Rupture of Abdominal Aortic Aneurysm: Concurrent Comparison of Outcome of Those Occurring After Endovascular Repair Versus Those Occurring Without Previous Treatment in an 11-Year Single-Center Experience