Intact Abdominal Aortic Aneurysm Research Articles

Initial Experience of the Covered Endovascular Reconstruction of Iliac Bifurcation Technique.

The distal landing zone in iliac arteries represents an important issue during endovascular repair of abdominal aortic aneurysms (EVAR). The aim of this study is to present a case series for landing in the external iliac artery (EIA) during EVAR while preserving blood flow in the internal iliac artery (IIA) with the covered endovascular reconstruction of the iliac bifurcation (CERIB) technique. This is a single-center, retrospective analysis of prospectively collected data of patients that underwent EVAR either for intact abdominal aortic aneurysm (AAA) or previous failed EVAR from December 2022 up to September 2023. Indications for treatment were presence of common iliac artery aneurysm (CIAA), short CIA, or endoleak type Ib (ETIb). For the distal sealing zone, we used balloon-expandable covered stent (BXCS). Primary outcomes were technical success and first-month patency rate. Secondary outcomes were endoleak and re-intervention rate. Sixteen patients being treated with 20 CERIBs were included in the study. Four patients had a previous failed EVAR, while 3 patients were treated urgently for a symptomatic para-renal aneurysm. The indications for treatment were EIb (n=2), short CIA (n=4), CIAA with narrow lumen (n=3), and CIA aneurysm (n=11). Platforms that were used were the Cook Zenith Alpha (n=5), Gore C3 (n=2 and 3 limbs), Endurant IIs (n=2, and 3 limbs), and a t-branch device (n=3). Technical success rate was 100% with no adjunctive procedure. No death or re-intervention was recorded for all patients at postoperative 30-day period and at 6 months for 2 patients. At first-month CTA, patency rate was 100% (20/20), while in 2 patients that had 6-month CTA, the patency was also 100% (2/2). No kinking or stenosis was also noted. Two patients had ETIII after branched EVAR (BEVAR), 2 patients had ETII, and 1 patient had gutter ET in the area of the CERIB. The CERIB technique seems to be effective and safe in the early period. It is suitable with a variety of commercial endograft platforms. It may be a valuable alternative to iliac branch devices when there are anatomical considerations. Longer follow-up is needed to conclude for long-term patency and durability. The distal landing zone in iliac arteries represents an important issue during EVAR while it is important to preserve blood flow in the internal iliac artery. The covered endovascular reconstruction of the iliac bifurcation (CERIB) technique is a technique for the preservation of internal iliac arteries during EVAR, while it is suitable with a variety of commercial endograft platforms. The CERIB technique seems to be effective and safe in the early period. It may be valuable alternative to iliac branch devices when there are anatomical considerations.

Contemporary Age-stratified Outcomes After Endovascular Aortic Repair for Intact Abdominal Aortic Aneurysm in Medicare Beneficiaries

Contemporary Age-stratified Outcomes After Endovascular Aortic Repair for Intact Abdominal Aortic Aneurysm in Medicare Beneficiaries

A Core Outcome Set for Intact Abdominal Aortic Aneurysm Repair

Technology and advances in clinical care have changed the management of abdominal aortic aneurysms (AAAs) but the clinical effectiveness of continuing advances needs to be assessed. To facilitate rapid synthesis of new evidence and improve stakeholder representation, including patients, the concept of core outcome sets (COS) has been developed. COS, reflecting the needs of all stakeholders, have been established across several surgical specialties. This study aimed to develop an international core outcome set for intact AAA repair. Following COMET methodology, potential outcomes were identified from a systematic review of published outcomes and focus groups involving patients, carers, and nurses. A 38 question Delphi consensus survey in lay language was developed (with translation to local languages); this included 35 themes identified from the findings of the systematic review and three themes from the focus groups. All three of the themes identified by the focus groups (cognitive, physical, and social functioning) can be evaluated from quality of life instruments, with overall quality of life being identified from the systematic review. The survey was completed by patients, carers or family members, vascular nurses, vascular surgeons, trainees, interventional radiologists, anaesthetists, and industry partners from six European countries. After two rounds of the survey, the top outcomes were discussed at a face to face multistakeholder consensus meeting. The 38 item questionnaire was amended after piloting among all stakeholder groups. After the first round of the Delphi survey (98 respondents) 15 questions were eliminated, and 11 further questions were eliminated after round 2 (90 respondents). This left two outcome questions for discussion at the consensus meeting, where the top six outcomes were unanimously endorsed: death at 30 days (or in hospital if longer), secondary AAA rupture, overall quality of life and retention of cognitive functioning after recovery, five year survival, and continued sac growth. Six core outcomes are recommended for use as a minimum framework in all future studies and registries of intact open and endovascular AAA repair. Further work to select instruments for quality of life and to define instruments for cognitive functioning is needed.

Hospital Volume of Elective Abdominal Aortic Aneurysm Repair as a Predictor of Mortality After Ruptured Abdominal Aortic Aneurysm Repair

Registry data suggest that centralising abdominal aortic aneurysm (AAA) surgery decreases the mortality rate after AAA repair. However, the impact of higher elective volumes on ruptured AAA (rAAA) repair associated mortality rates remains uncertain. This study aimed to examine associations between intact AAA (iAAA) repair volume and post-operative rAAA death. Using data from official national registries between 2015 - 2019, all iAAA and rAAA repairs were separately analysed across 10 public hospitals. The following were assessed: 30 day and 12 month mortality rate following open surgical repair (OSR) and endovascular aneurysm repair (EVAR). Associations between the 5 year hospital iAAA repair volumes (organised into tertiles) and rAAA associated mortality rate were analysed, regardless of treatment modality. Receiver operating characteristic (ROC) curves were generated to identify iAAA volume thresholds for decreasing the rAAA mortality rate. Subanalysis by treatment type was conducted. Threshold analysis was repeated with the Markov chain Monte Carlo (MCMC) procedure to confirm the findings. A total of 1 599 iAAAs (80.2% EVAR, 19.8% OSR) and 196 rAAAs (66.3% EVAR, 33.7% OSR) repairs were analysed. The median and interquartile range of the volume/hospital/year for all iAAA repairs were 39.2 (31.2, 47.4). The top volume iAAA tertile exhibited lower rAAA associated 30 day (odds ratio [OR] 0.374; p= .007) and 12 month (OR 0.264; p < .001) mortality rates. The ROC analysis revealed a threshold of 40 iAAA repairs/hospital/year (EVAR+ OSR) for a reduced rAAA mortality rate. Middle volume hospitals for open iAAA repair had reduced 30 day (OR 0.267; p= .033) and 12 month (OR 0.223; p= .020) mortality rates, with a threshold of five OSR procedures/year. The MCMC procedure found similar thresholds. No significant association was found between elective EVAR volumes and ruptured EVAR mortality. Higher iAAA repair volumes correlated with a lower rAAA mortality rate, particularly for OSR. The recommended iAAA repair threshold is 40 procedures/year and five procedures/year for OSR. These findings support high elective volumes for improving the rAAA mortality rate, especially for OSR.

Outcomes Following Intact and Ruptured Aneurysm Repair across Nations: Analysis of International Registry Data from the VASCUNET Collaboration 2014 – 2019

To determine the peri-operative mortality rate for intact and ruptured abdominal aortic aneurysm (AAA) repair in 10 countries and to compare practice and outcomes over a six year period by age, sex, and geographic location. This VASCUNET study used prospectively collected data from vascular registries in 10 countries on primary repair of intact and ruptured AAAs undertaken between January 2014 and December 2019. The primary outcome was peri-operative death (30 day or in hospital). Logistic regression models were used to estimate the association between peri-operative death, patient characteristics, and type of procedure. Factors associated with the use of endovascular aortic aneurysm repair (EVAR) were also evaluated. The analysis included 50 642 intact and 9 453 ruptured AAA repairs. The proportion of EVARs for intact repairs increased from 63.4% in 2014 to 67.3% in 2016 before falling to 62.3% in 2019 (p < .001), but practice varied between countries. EVAR procedures were more common among older patients (p < .001) and men (p<.001). Overall peri-operative mortality after intact AAA repair was 1.4% (95% confidence interval [CI] 1.3- 1.5%) and did not change over time. Mortality rates were stable within countries. Among ruptured AAA repairs, the proportion of EVARs increased from 23.7% in 2014 to 35.2% in 2019 (p < .001). The average aortic diameter was 7.8 cm for men and 7.0 cm for women (p < .001). The overall peri-operative mortality rate was 31.3% (95% CI 30.4 - 32.2%); the rates were 36.0% (95% CI 34.9 - 37.2%) for open repair and 19.7% (95% CI 18.2 - 21.3%) for EVAR. This difference and shift to EVAR reduced peri-operative mortality from 32.6% (in 2014) to 28.7% (in 2019). The international practice of intact AAA repair was associated with low mortality rates in registry reported data. There remains variation in the use of EVAR for intact AAAs across countries. Overall peri-operative mortality remains high after ruptured AAA, but an increased use of EVAR has reduced rates over time.

The Role of Aortic Volume in the Natural History of Abdominal Aortic Aneurysms and Post-Endovascular Aortic Aneurysm Repair Surveillance.

There has been a debate about whether maximum diameter can be solely used to assess the natural history of abdominal aortic aneurysm. The aim of the present review is to collect all the available evidence on the role of abdominal aortic aneurysm (AAA) volume in the natural history of AAAs, including small untreated AAAs and AAAs treated by EVAR. The current literature appears to reinforce the role of volume as a supplementary measure for evaluating the natural history of AAA, in both intact AAAs and after EVAR. The clinical impact of AAA volume measurements remains unclear. Several studies show that volumetric analysis can assess changes in AAAs and predict successful endoluminal exclusion after EVAR more accurately than diameter. However, most studies lack strict standardized measurement criteria and well-defined outcome definitions. It remains unclear whether volumetry could replace diameter assessment in defining the risk of rupture of AAAs and identifying clinically relevant sac growth.

Stationäre Frührehabilitation nach endovaskulärer und offener Versorgung eines Bauchaortenaneurysmas bei über 65-Jährigen: Indikation und langfristiges Outcome

BackgroundIn Germany, there is no data available on the frequency of inpatient rehabilitation (IR) after elective endovascular (EVAR) and open (OAR) abdominal aortic aneurysm (AAA) repair. ObjectiveTo report for the first time on the outcome of patients 65 years and older and thus of retirement age with and without IR after AAA repair in a retrospective analysis of routine data from all eleven regional companies of the AOK health insurance fund (AOK-Gesundheit). MethodsAnonymized data of 16,358 patients 65 years and older with intact abdominal aortic aneurysm treated with EVAR (n = 12,960) or OAR (n = 3,398) between 01/01/2010 and 12/31/2016 were analyzed. Patients with postoperative IR (n = 1,531) were compared to those without postoperative IR (n = 14,827) with respect to general patient characteristics, comorbidities, perioperative and postoperative outcomes, and survival. The average follow-up of patients with postoperative and without postoperative IR was 49.9 months and 51.8 months, respectively. Results5.4% of EVAR patients, but 24.6% of OAR patients were referred to IR (p < 0.001). Patients with IR were sicker than those without IR. Parameters significantly influencing the use of IR included OAR vs EVAR (Odds Ratio [OR] 6.03), condition after cerebral infarction (OR 1.53), and women vs men (OR 1.49). Perioperative influencing parameters were cerebral infarction (OR 2.40), blood transfusions (OR 2.21) and complex critical care (OR 2.15). After nine years, the Kaplan-Meier estimated survival was 41.9% for patients with vs 43.4% for those without IR in the EVAR group (p = 0.178). For OAR, it was 50.2% for patients with IR vs 49.8% for patients without IR (p = 0.006). In multivariate regression analysis, postoperative IR had a significant effect on long-term survival in OAR but not in EVAR patients. ConclusionThere are no generally binding guidelines for the indication of IR after AAA repair. It should therefore be a requirement for the future that the fitness of each patient with elective AAA repair be determined with a score before and after the procedure in order to make indications for AHB more comparable. The score should be documented in the hospital discharge letter.

Association of polypharmacy scores with the long-term survival of patients with intact aortoiliac aneurysms and indication for repair

Objective/BackgroundOur study analyzed the relationship between two polypharmacy scores (addition of chronic prescribed drugs [ACPDs] and Rx-Risk Comorbidity Index) and survival in patients with an intact abdominal aortic and/or common iliac aneurysm (AAA). MethodsConsecutive retrospective, single-center cohort of patients attended for an intact AAA with indication for repair from 2008 to 2021. Demographic data, Charlson Comorbidity Index, AAA treatment, ACPD, and Rx-Risk polypharmacy scores were recorded at baseline. Main outcomes were the 5-year and long-term survival rates. The statistical analysis included Cox regression, area under the curve, and continuous net reclassification index. ResultsA total of 424 patients with AAA were evaluated (median age: 76 years; 92.2% male, median Charlson index 2), of whom 314 (74.1%) underwent intervention (80% endovascular and 20% open) and 110 (25.9%) did not. During follow-up (mean 4.6 years), 245 patients (57.8%) died, with 1-month, 1-year, and 5-year survival rates of 98.1%, 86.3%, and 52.7%, respectively. ACPD and Rx-Risk indices (median [interquartile range]: 6 [4-9] and 3 [0-5], respectively) were significantly and linearly associated (P < .001) with survival, with the best cutoff points at 5 and 0, respectively. An ACPD >5 (patients with >5 chronically prescribed drugs at baseline) and an Rx-Risk >0 were associated with a 45.2% (P = .038) and 102% (P = .002) increase in 5-year mortality, respectively, after adjustment for age, sex, Charlson index, and type of AAA treatment. Both polypharmacy indices improved significantly the discriminative power of the Charlson Comorbidity Index in predicting survival. ConclusionsBoth ACPD and Rx-Risk polypharmacy scores are independently related to survival among patients with an intact AAA and indication for repair. Their behavior is similar, so the simple ACPD >5 appears to be sufficient to identify patients with lower survival rates.

Ultrasound Surveillance is Feasible After Endovascular Aneurysm Repair

IntroductionSurveillance after endovascular aneurysm repair (EVAR) is traditionally done with computed tomography angiography (CTA) scans that exposes patient to radiation, nephrotoxic contrast media, and potentially increased risk for cancer. Ultrasound (US) is less labor intensive and expensive and might thus provide a good alternative for CTA surveillance. The aim of this study was to evaluate in real-life patient cohorts whether US is able to detect post-EVAR aneurysm-related complications similarly to CTA. MethodsThis retrospective study compared the outcome of consecutive patients who underwent EVAR for intact abdominal aortic aneurysm (AAA) and were surveilled solely by CTA (CTA-only cohort, n= 168) in 2000-2010 or by combined CTA and US (CTA/US cohort, n= 300) in 2011-2016, as a standard surveillance protocol in department of vascular surgery, Helsinki University Hospital. The CTA-only patients were imaged at 1, 3, and 12 months and annually thereafter. The CTA/US patients were imaged with CTA at 3 and 12 months, US at 6 months and annually thereafter. If there were suspicion of >5 mm aneurysm growth, CTA scan was performed. The patients were reviewed for imaging data, reinterventions, aneurysm ruptures, and death until December 2018. The two groups were compared for secondary rupture, aneurysm- and cancer-related death, reintervention related to AAA, and maximum aneurysm diameter increase >5 mm. The mean follow-up in the CTA-only cohort was 67 months and in CTA/US cohort 43 months. ResultsThe two cohorts were alike for basic characteristics and for the mean aneurysm diameter. The total number of CT scans for detecting aneurysm was 84.1/100 patient years in the CTA-only cohort compared to 74.5/100 patient years for US/CTA-cohort. 40 % of patients under combined CTA/US surveillance received one or more additional CTA scans. The two cohorts did not differ for 1-, 5- and 8-year freedom from aneurysm related death, secondary sac rupture, nor the incidence of rupture preventing interventions. ConclusionBased on the follow up data of this real-life cohort of 468 patients, combined surveillance with US and additional CTA either per protocol or due to suspicion of aneurysm-related complications had comparable outcome with sole CTA-surveillance. Thus, US can be considered a reasonable alternative for the CTA. However, our study showed also that the need of additional CTAs due to suspicion of endoleak or aneurysm non-related reasons is substantial.

One-year aneurysm-sac dynamics are associated with reinterventions and rupture following infrarenal endovascular aneurysm repair

ObjectiveOne-year aneurysm sac changes have previously been found to be associated with mortality and may have the potential to guide personalized follow-up following endovascular aneurysm repair (EVAR). In this study, we examined the association of these early sac changes with long-term reintervention and rupture. MethodsWe identified all patients undergoing first-time EVAR for intact abdominal aortic aneurysm between 2003 and 2018 in the Vascular Quality Initiative with linkage to Medicare claims for long-term outcomes. We included patients with an imaging study at 1 year postoperatively. Aneurysm sac behavior was defined as per the Society for Vascular Surgery guidelines: stable sac (<5 mm change), sac regression (≥5 mm), and sac expansion (≥5 mm). Outcomes included mortality, reintervention, and rupture within 8 years, which were assessed with Kaplan-Meier methods and multivariable Cox regression analysis. Secondarily, we utilized polynomial spline interpolation to demonstrate the continuous relationship of diameter change to 8-year hazard of reintervention, rupture, or mortality as a composite outcome. ResultsOf 31,185 EVAR patients, 16,102 (52%) had an imaging study at 1 year and were included in this study. At 1 year, 44% of sacs remained stable, 49% regressed, and 6.2% displayed expansion. Following risk adjustment, compared with a stable sac at 1 year, sac regression was associated with lower 8-year mortality (49% vs 53%; hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.85-0.99; P = .036), reintervention rate (8.9% vs 15%; HR, 0.58; 95% CI, 0.50-0.68; P < .001), and rupture rate (2.0% vs 4.0%; HR, 0.45; 95%CI, 0.29-0.69; P < .001). Conversely, compared with a stable sac, sac expansion was associated with higher 8-year mortality (64% vs 53%; HR, 1.31; 95% CI, 1.14-1.51; P < .001) and reintervention rate (27% vs 15%; HR, 1.98; 95% CI, 1.57-2.51; P < .001), but similar risk of rupture (7.2% vs 4.0%; HR, 1.61; 95% CI, 0.88-2.96; P = .12). Polynomial spline interpolation demonstrated that, compared with no diameter change at 1 year, increased sac regression was associated with an incrementally lower risk of late outcomes, whereas increased sac expansion was associated with an incrementally higher risk of late outcomes. ConclusionsFollowing EVAR, compared with a stable sac at 1-year imaging, sac regression and expansion are associated with a lower and higher risk respectively of long-term mortality, reinterventions, and ruptures. Moreover, the amount of regression or expansion seems to be incrementally associated with these late outcomes, too. Future studies are needed to determine how to improve 1-year sac regression, and whether it is safe to extend follow-up intervals for patients with regressing sacs.

Oxidative stress-related genetic variation and antioxidant vitamin intake in intact and ruptured abdominal aortic aneurysm: a Swedish population-based retrospective cohort study.

The aim of this study is to investigate how genetic variations in genes related to oxidative stress, intake of antioxidant vitamins, and any potential interactions between these factors affect the incidence of intact abdominal aortic aneurysm (AAA) and its rupture (rAAA), accounting for sex differences where possible. The present retrospective cohort study (n = 25 252) uses baseline single-nucleotide polymorphisms (SNPs) and total antioxidant vitamin intake data from the large population-based, Malmö Diet and Cancer Study. Cumulative incidence of intact AAA was 1.6% and of rAAA 0.3% after a median follow-up of 24.3 years. A variant in NOX3 (rs3749930) was associated with higher rAAA risk in males [adjusted hazard ratio (aHR): 2.49; 95% confidence interval (CI): 1.36-4.35] and the overall population (aHR: 1.88; 95% CI: 1.05-3.37). Higher intakes of antioxidant vitamins, riboflavin, and folate were associated with 20% and 19% reduced intact AAA incidence, respectively. Interestingly, the inverse associations between riboflavin and vitamin D intake with intact AAA incidence were stronger in the individuals carrying the NOX3 variant as compared with the wild-type recessive genotype, i.e. by 60% and 66%, respectively (P for interaction < 0.05). Higher riboflavin intake was associated with a 33% male-specific intact AAA risk reduction, while higher intake of vitamin B12 intake was associated with 55% female-specific intact AAA risk increase; both these associations were significantly modified by sex (P for interaction < 0.05). Our findings highlight the role of oxidative stress genetic variations and antioxidant vitamin intake in AAA. Although a low AAA/rAAA sample size limited some analyses, especially in females, our findings highlight the need for future randomized controlled trials and mechanistic studies, to explore the potential benefits of antioxidant vitamins while accounting for genetic and sex differences.

Systematic Review With Meta-Analysis of Endovascular Versus Open Repair of Abdominal Aortic Aneurysm Repair in the Young.

The purpose of this study was to investigate which treatment method for abdominal aortic aneurysm (AAA), endovascular or open repair, has better outcomes in young patients. A systematic review was conducted to identify observational studies or randomized controlled trials (RCTs) that compared endovascular and open repair of intact AAA in young patients. MEDLINE, EMBASE, and CENTRAL were searched up to March 2022 using the Ovid interface. The risk of bias was assessed with the Newcastle-Ottawa scale (NOS), with a maximum score of 9, or version 2 of the Cochrane risk of bias tool. The certainty of evidence was assessed with the GRADE framework. Primary outcomes were perioperative, overall, and aneurysm-related mortality. Secondary outcomes were reintervention, hospital length of stay, and perioperative complications. Effect measures in syntheses were the odds ratio (OR), risk difference (RD), mean difference (MD), or hazard ratio (HR) and were calculated with the Mantel-Haenszel or inverse variance statistical method and random-effects models. Fifteen observational studies and 1 RCT were included, reporting a total of 48 976 young patients. Definitions of young ranged from 60 to 70 years. The median score on the NOS was 8 (range: 4-9), and the RCT was judged to be high risk of bias. The perioperative mortality was lower after EVAR (RD: -0.01, 95% CI: -0.02 to -0.00), but the overall and aneurysm-related mortality was not significantly different between EVAR and open repair (HR: 1.38, 95% CI: 0.81 to 2.33; HR: 4.68, 95% CI: 0.71 to 31.04, respectively), as was the hazard of reintervention (HR: 1.50, 95% CI: 0.88 to 2.56). The hospital length of stay was shorter after EVAR (MD: -4.44 days, 95% CI: -4.79 to -4.09), and the odds of cardiac (OR: 0.22, 95% CI: 0.13 to 0.35), respiratory (OR: 0.17, 95% CI: 0.11 to 0.26), and bleeding complications were lower after EVAR (OR: 0.26, 95% CI: 0.11 to 0.64). The level of evidence was low or very low. Patient preferences and perspectives should be considered during shared decision-making process considering the available evidence. EVAR may be considered in young and fit patients with a suitable anatomy. PROSPERO, CRD42022325051. Uncertainty surrounds the optimal treatment strategy for abdominal aortic aneurysm in young patients. Meta-analysis of some 48,976 young patients showed that endovascular aneurysm repair (EVAR) has a lower perioperative mortality and morbidity and a shorter hospital and intensive care unit stay than open surgical repair, but the overall and aneurysm-related mortality in the short to medium term are not significantly different between EVAR and open repair. EVAR can be considered in young patients.

Long-Term Outcome of Intact Abdominal Aortic Aneurysm After Endovascular or Open Repair.

Endovascular aortic aneurysm repair (EVAR) has been established as a standard treatment option for intact abdominal aortic aneurysm (iAAA) and gained importance due to a lower perioperative mortality than open repair (OAR). However, whether this survival advantage can be maintained or if OAR is beneficial in terms of long-term complications and reinterventions remains questionable. In this retrospective cohort study data from patients undergoing elective EVAR or OAR for iAAAs in the years 2010-2016 was analyzed. The patients were followed through 2018. In the propensity score matched cohorts the perioperative and long-term outcomes of the patients were assessed. We identified 20683 patients undergoing elective iAAA repair (76.4% EVAR). The propensity matched cohorts included 4886 pairs of patients. The perioperative mortality was 1.9% for EVAR and 5.9% for OAR (P = <.001). The perioperative mortality was mainly influenced by patients age (Odds-Ratio (OR):1.073, confidence interval (CI):1.058-1.088, P ≤ .001) and OAR (OR:3.242, CI:2.552-4.119, P ≤ .001). The early survival benefit after endovascular repair persisted for approximately 3 years (estimated survival EVAR 82.3%, OAR 80.9%, P = .021). After that time the estimated survival curves were similar. After 9 years the estimated survival was 51.2% after EVAR as compared to 52.8% after OAR (P = .102). The operation method didn't influence long-term survival significantly (Hazard-Ratio (HR): 1.046, CI: .975-1.122, P = .211). The vascular reintervention rate was 17.4% in the EVAR cohort and 7.1% in the OAR cohort (P ≤ .001). EVAR has a significantly lower perioperative mortality than OAR, a survival benefit that lasts up to 3years after intervention. Thereafter, no significant difference in survival was observed between EVAR and OAR. The decision between EVAR or OAR may depend on patient preference, surgeons' experience, and the institutions' ability to handle complications.

Demographic and Socioeconomic Disparities in Long-term Outcomes After Endovascular Abdominal Aortic Aneurysm Repair Among Medicare Beneficiaries

Age, sex, and race-related disparities in outcomes following abdominal aortic aneurysm (AAA) repair have been described, but the impact of socioeconomic factors on these outcomes is poorly understood. We examined 5-year outcomes after endovascular abdominal aortic aneurysm repair (EVAR) for intact AAA stratified by demographic and socioeconomic factors and explored potential mechanisms underlying outcome disparities. All Medicare fee-for-service beneficiaries ≥66 years of age who underwent EVAR for intact AAA between January 1, 2011, and December 31, 2019, were identified and stratified by the following disparity measures: age category (66-75 years/76-85 years/>85 years), sex, race (White/Black/other), Medicare/Medicaid dual enrollment, distressed communities index (distressed >80th percentile/nondistressed ≤80th percentile), and residential location (urban/rural). The primary outcome was a composite endpoint of late aneurysm rupture, aortic reintervention (graft relining or endograft extension), conversion to open repair, or all-cause mortality. Kaplan-Meier and Cox regression analyses were used to examine outcomes by each disparity measure. A total of 113,261 beneficiaries were identified. Mean age was 77 years, and most beneficiaries were male (79%), White (93%), enrolled in Medicare only (91%), and resided in urban locations (95%; Table). Median follow-up time was 3.2 years. At 5 years, compared with beneficiaries aged 66 to 75, incidence of the composite endpoint was higher in those aged 76 to 85 years (38% vs 25%, unadjusted hazard ratio [uHR], 1.7l 95% confidence interval [CI], 1.6-1.7) and in those aged >85 years (52% vs 25%; uHR, 2.6; 95% CI, 2.5-2.7) (Table). Higher incidence of the composite endpoint was also observed in female vs male beneficiaries (37% vs 32%; uHR, 1.2, 1.2-1.3), Black vs White beneficiaries (38% vs 33%; uHR; 1.2; 95% CI, 1.2-1.3), dual-enrolled vs Medicare-only beneficiaries (42% vs 32%; uHR, 1.4; 95% CI, 1.4-1.4), and in beneficiaries residing in distressed vs non-distressed communities (35% vs 33%; uHR, 1.1; 95% CI, 1.1-1.1). In adjusted analyses, these outcome disparities were partly explained by a higher burden of comorbid conditions in beneficiaries who were older, female, Black, dual-enrolled, or residing in distressed communities. Among Medicare fee-for-service beneficiaries who underwent EVAR for intact AAA, we observed significant 5-year outcome disparities by demographic and socioeconomic measures. These disparities seem to be driven, in part, by a higher burden of comorbidities in beneficiaries who are older, female, Black, or socioeconomically disadvantaged. These findings highlight the need for early identification and management of comorbid conditions to reduce outcome disparities following EVAR. Further work to examine other potential contributing factors, including healthcare utilization and imaging surveillance after EVAR, is ongoing and may highlight additional actionable targets for improvement.TableBaseline rates of disparity measures and associated cumulative incidence of the composite endpoint of late aneurysm rupture, aortic reintervention (graft relining or endograft extension), conversion to open repair, or all-cause mortality in Medicare beneficiaries who underwent EVAR for intact AAADisparity measureNo. (%)5-Year event rate (%)uHR (95% CI)Age category, years 66-7553,009 (47)25Ref 76-8548,084 (42)381.7 (1.6-1.7) >8512,168 (11)522.6 (2.5-2.7)Sex Male89,219 (79)32Ref Female24,042 (21)371.2 (1.2-1.3)Race White105,158 (93)33Ref Black4289 (3.8)381.2 (1.2-1.3) Other3814 (3.4)280.84 (0.79-0.89)Medicare/Medicaid enrollment Medicare only103,095 (91)32Ref Dual10,166 (9.0)421.4 (1.4-1.4)Distressed communities index Nondistressed90,074 (80)33Ref Distressed23,187 (20)351.1 (1.1-1.1)Residential location Urban107,305 (95)33Ref Rural5956 (5.3)320.97 (0.93-1.0)AAA, Abdominal aortic aneurysm; CI, confidence interval; EVAR, endovascular abdominal aortic aneurysm repair; Ref, reference; uHR, unadjusted hazard ratio.aEvent rates (%) at 5 years were estimated using Kaplan-Meier methods, and Cox regression was used to determine the uHRs at each time point. Open table in a new tab

Women with large intact abdominal aortic aneurysms remain untreated

ObjectiveA lower elective repair rate among women with abdominal aortic aneurysms (AAAs) has been a consistent finding. Reasons behind this gender gap have not been thoroughly outlined. MethodsThis was a retrospective multicenter cohort study (ClinicalTrials.gov: NCT05346289) at three European vascular centers in Sweden, Austria and Norway. Patients in surveillance with AAAs were consecutively identified starting from January 1, 2014, until reaching a total sample size of 200 women and 200 men. All individuals were followed for 7 years through medical records. Final treatment distributions and the proportion of “truly untreated” (surgically untreated despite reaching guideline-directed thresholds: 50 mm for women and 55 mm for men) were determined. In a complementary analysis, a universal 55-mm threshold was used. Gender-specific primary reasons behind untreated statuses were clarified. Eligibility for endovascular repair among the truly untreated was assessed in a structured computed tomography analysis. ResultsWomen and men had similar median diameters at inclusion (46 mm; P = .54) and at treatment decisions (55 mm; P = .36). After 7 years, the repair rate was lower among women (47% vs 57%). More women were truly untreated (26% vs 8%; P < .001) despite similar mean ages as for male counterparts (79.3 years; P = .16). With the 55-mm threshold, 16% women still classified as truly untreated. Similar reasons for nonintervention were captured for women and men (50% due to comorbidities alone, 36% morphology and comorbidity). The endovascular repair imaging analysis revealed no gender differences. Among truly untreated women, ruptures were common (18%), and mortality was high (86%). ConclusionsSurgical AAA management differed between women and men. Women could be underserved in terms of elective repairs: one in every four women was untreated with over-the-threshold AAAs. The lack of obvious gender differences in eligibility analyses could imply unmeasured discrepancies (eg, in disease extent or patient frailty).

Comparison of Outcomes for Major Contemporary Endograft Devices Used for Endovascular Repair of Intact Abdominal Aortic Aneurysms

Comparison of Outcomes for Major Contemporary Endograft Devices Used for Endovascular Repair of Intact Abdominal Aortic Aneurysms

Incidence and Outcomes of Abdominal Aortic Aneurysm Repair in New Zealand from 2001 to 2021.

The burden of abdominal aortic aneurysms (AAA) has changed in the last 20 years but is still considered to be a major cause of cardiovascular mortality. The introduction of endovascular aortic repair (EVAR) and improved peri-operative care has resulted in a steady improvement in both outcomes and long-term survival. The objective of this study was to identify the burden of AAA disease by analysing AAA-related hospitalisations and deaths. All AAA-related hospitalisations in NZ from January 2001 to December 2021 were identified from the National Minimum Dataset, and mortality data were obtained from the NZ Mortality Collection dataset from January 2001 to December 2018. Data was analysed for patient characteristics including deprivation index, repair methods and 30-day outcomes. From 2001 to 2021, 14,436 patients with an intact AAA were identified with a mean age of 75.1 years (SD 9.7 years), and 4100 (28%) were females. From 2001 to 2018, there were 5000 ruptured AAA with a mean age of 77.8 (SD 9.4), and 1676 (33%) were females. The rate of hospitalisations related to AAA has decreased from 43.7 per 100,000 in 2001 to 15.4 per 100,000 in 2018. There was a higher proportion of rupture AAA in patients living in more deprived areas. The use of EVAR for intact AAA repair has increased from 18.1% in 2001 to 64.3% in 2021. The proportion of octogenarians undergoing intact AAA repair has increased from 16.2% in 2001 to 28.4% in 2021. The 30-day mortality for intact AAA repair has declined from 5.8% in 2001 to 1.7% in 2021; however, it has remained unchanged for ruptured AAA repair at 31.6% across the same period. This study highlights that the incidence of AAA has declined in the last two decades. The mortality has improved for patients who had a planned repair. Understanding the contemporary burden of AAA is paramount to improve access to health, reduce variation in outcomes and promote surgical quality improvement.

Effect of Body Mass Index on Early Outcomes of Endovascular Abdominal Aortic Aneurysm Repair

This study compares the presentation, management, and outcomes of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR), based on their weight status as defined by their body mass index (BMI). Patients with primary EVAR for ruptured and intact abdominal aortic aneurysm (AAA) were identified in the National Surgical Quality Improvement Program database (2016-2019). Patients were categorized by weight status (underweight: BMI < 18.5kg/m2, normal weight: 18.5-24.9kg/m2, overweight: 25-29.9kg/m2, Obese I: 30-34.9kg/m2, Obese II: 35-39.9kg/m2, Obese III: > 40kg/m2). Preoperative characteristics and 30-day outcomes were compared. Of 3,941 patients, 4.8% were underweight, 24.1% normal weight, 37.6% overweight, and 22.5% with Obese I, 7.8% Obese II, and 3.3% Obese III status. Underweight patients presented with larger (6.0 [5.4-7.2] cm) and more frequently ruptured (25.0%) aneurysms than normal weight patients (5.5 [5.1-6.2] cm and 4.3%, P<0.001 for both). Pooled 30-day mortality was worse for underweight (8.5%) compared to all other weight status (1.1-3.0%, P<0.001), but risk-adjusted analysis demonstrated that aneurysm rupture (odds ratio [OR] 15.9, 95% confidence interval [CI] 8.98-28.0) and not underweight status (OR 1.75, 95% CI 0.73-4.18) accounted for increased mortality in this population. Obese III status was associated with prolonged operative time and respiratory complications after ruptured AAA, but not 30-day mortality (OR 0.82, 95% CI 0.25-2.62). Patients at either extreme of the BMI range had the worst outcomes after EVAR. Underweight patients represented only 4.8% of all EVARs, but 21% of mortalities, largely attributed to higher incidence of ruptured AAA at presentation. Severe obesity, on the other hand, was associated with prolonged operative time and respiratory complications after EVAR for ruptured AAA. BMI, as an independent factor, was however not predictive of mortality for EVAR.

Shared Decision Making for Abdominal Aortic Aneurysm: Patients Want It But Are Not Getting It

Shared Decision Making in and Management of Intact Abdominal Aortic Aneurysm: A Scoping Review of the LiteratureEuropean Journal of Vascular and Endovascular SurgeryPreviewThe aim of this study was to summarise the current knowledge of shared decision making (SDM) in patients facing a treatment decision about an intact abdominal aortic aneurysm (AAA), and to identify where further evidence is needed. Full-Text PDF Open Access

An abdominal aortic aneurysm rupture risk score: a pilot study for combining precise aortic measurements and clinical factors

ObjectiveCurrent screening and management for abdominal aortic aneurysms (AAAs) are based on maximal aortic diameter criteria. This study sought to compare anatomic and clinical factors between ruptured and intact AAAs to identify predictors of rupture. MethodsPatients treated for AAAs at Thomas Jefferson University Hospital from 2010 to 2021 were reviewed from intact AAAs (iAAAs), ruptured AAAs (rAAAs), and no aortic pathology (NP) groups. Preoperative computed tomography angiography (CTA) studies were retrospectively measured with Aquarius iNtuition (TeraRecon Inc). Maximal diameter, length, mural thrombus volume (MTV), and calcification volume were measured from the lowest renal artery to the femoral artery. A rupture risk score was calculated using AAA diameter (1 point), percent ≥MTV 50% (1 point), number of antihypertensive agents <2 (1 point), not on cholesterol-lowering medication (1 point), and active smoking (1 point) for a 5-point total score. ResultsCTAs from 48 patients (age, 69.5 ± 8.1 years; 87.5% male) were measured (23 iAAAs, 15 rAAAs, and 10 controls). When compared with iAAAs, the maximal AAA diameter (rAAA, 7.71 cm; iAAA, 6.02 cm; P = .005) and %MTV (rAAA, 66.1%; iAAA, 45.3%; P = .0001) were greater in patients with rAAAs. Mean AAA rupture risk score was greater in patients with rAAAs than those with iAAAs (rAAA, 3.40 ± 1.12; iAAA, 1.78 ± 1.44; P < .001) with 100% of rAAAs and 47.8% of iAAAs having a score 2 or greater. ConclusionsThis study demonstrates that AAA diameter, percent MTV, blood pressure control, and active smoking are significant risk factors for AAA rupture. Patients with multiple risk factors (risk score ≥2) were more likely to rupture and should be considered high risk.