Intact Abdominal Aortic Aneurysm Research Articles

The long-term implications of access complications during endovascular aneurysm repair

BackgroundAccess issues are one of the most common complications of endovascular aneurysm repair (EVAR). However, contemporary rates as well as risk factors for complications and the subsequent impact of access complications on mortality are poorly described. MethodsWe studied all EVAR for intact abdominal aortic aneurysms without prior aortic surgery in the Vascular Quality Initiative between 2011 and 2018. We studied factors associated with access complications (thrombosis, embolus, wound infection, hematoma, and conversion to cutdown), as well as the interaction with female sex and the impact on survival using multilevel logistic regression and propensity weighting. Multiple imputation was used for missing data. ResultsThere were 33,951 EVAR during the study period (91% elective, 9% symptomatic); most cases (70%) involved an attempt at percutaneous access on at least one side, with 30% bilateral cutdowns and 0.1% iliac conduits. There were 1553 patients (4.6%) who experienced at least one access complication. Access complications were almost twice as common in female patients (7.5% vs 3.9%; P < .001). The factors associated with access complications included female sex (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.0-3.6; P < .001), age (OR, 1.05 per 5 years; 95% CI, 1.02-1.1; P < .01), aortouni-iliac device (OR, 1.6; 95% CI, 1.1-2.3; P < .01), smoking (OR, 1.4; 95% CI, 1.1-1.7; P < .01), body mass index of less than 16 (OR, 1.8; 95% CI, 1.3-2.5; P = .001), dual antiplatelet therapy (1.3; 95% CI, 1.02-1.6 P = .03), prior infrainguinal bypass (OR, 1.8; 95% CI, 1.3-2.7; P < .01), and beta blocker use (OR, 1.2; 95% CI, 1.03-1.4; P = .02). Conversion from percutaneous access to open cutdown was associated with higher rates of complications than planned open cutdown (8.6% vs 2.9%; P < .001). In propensity-weighted analysis, percutaneous access was associated with significantly lower odds of access complications in women (OR, 0.6; 95% CI, 0.4-0.96; P = .03). Patients who experienced an access complication had more than four times the odds of perioperative death (OR, 4.2; 95% CI, 2.5-7.1; P < .001), and a 60% higher risk of long-term mortality (hazard ratio, 1.6; 95% CI, 1.2-2.1; P = .001). In addition to death, patients with access site complications had higher rates of other major complications, including reoperation during the index hospitalization (19% vs 1.2%; P < .001), myocardial infarction (3.5% vs 0.7%; P < .001), stroke (0.8% vs 0.2%; P < .001), acute kidney injury (12% vs 3%; P < .001), and reintubation (5.7% vs 0.8%). ConclusionsAlthough access complications are infrequent in the current era, they are associated with both perioperative and long-term morbidity and mortality. Female patients in particular are at high risk of access complications, but may benefit from percutaneous access.

Outcome analysis and risk factors for postoperative colonic ischaemia after aortic surgery

PurposeColonic ischaemia (CI) represents a serious complication after aortic surgery. This study aimed to analyse risk factors and outcome of patients suffering from postoperative CI.MethodsData of 1404 patients who underwent aortic surgery were retrospectively analysed regarding CI occurrence. Co-morbidities, procedural parameters, colon blood supply, procedure-related morbidity and mortality as well as survival during follow-up (FU) were compared with patients without CI using matched-pair analysis (1:3).ResultsThirty-five patients (2.4%) with CI were identified. Cardiovascular, pulmonary and renal comorbidity were more common in CI patients. Operation time was longer (283 ± 22 vs. 188 ± 7 min, p < 0.0001) and blood loss was higher (2174 ± 396 vs. 1319 ± 108 ml, p = 0.0049) in the CI group. Patients with ruptured abdominal aortic aneurysm (AAA) showed a higher rate of CI compared to patients with intact AAA (5.4 vs. 1.9%, p = 0.0177). CI was predominantly diagnosed by endoscopy (26/35), generally within the first 4 postoperative days (20/35). Twenty-eight patients underwent surgery, all finalised with stoma creation. Postoperative bilateral occlusion and/or relevant stenosis of hypogastric arteries were more frequent in CI patients (57.8 vs. 20.8%, p = 0.0273). In-hospital mortality was increased in the CI group (26.7 vs. 2.9%, p < 0.0001). Survival was significantly reduced in CI patients (median: 28.2 months vs. 104.1 months, p < 0.0001).ConclusionCI after aortic surgery is associated with considerable perioperative sequelae and reduced survival. Especially in patients at risk, such as those with rAAA, complicated intraoperative course, severe cardiovascular morbidity and/or perioperative deterioration of the hypogastric perfusion, vigilant postoperative multimodal monitoring is required in order to initiate diagnosis and treatment.

Suitability of the Aortic Neck Anatomy for Endovascular Aneurysm Repair in Korean Patients with Abdominal Aortic Aneurysm.

PurposeTo evaluate the aortic neck anatomy in Korean patients with abdominal aortic aneurysms (AAAs).Materials and MethodsWe examined computed tomography scans of 343 patients with AAAs (≥5.5 cm for men or ≥5 cm for women) between 2009 and 2018. Eligibility of neck anatomy for endovascular aneurysm repair (EVAR) was assessed with the standard instructions for use (IFU) (length ≥15 mm, suprarenal angulation (SRA) ≤45°, infrarenal angulation (IRA) ≤60°, and diameter 18-32 mm) and the extended IFU (length ≥10 mm, SRA ≤60°, IRA ≤75°, and diameter 17-32 mm).ResultsThere were 71 women (20.7%), and 61 patients (17.8%) with rupture. Women had smaller neck diameters (21.3 vs. 23.4 mm, P<0.001 for proximal neck; 22.2 vs. 24.5 mm, P<0.001 for distal neck), and higher angulations (51.5° vs. 37.8°, P<0.001 for SRA; 77.7° vs. 57.0°, P<0.001 for IRA) than men. However, the neck length was not significantly different. Patients with ruptured AAAs had shorter neck lengths (21.0 vs. 26.8 mm, P=0.005) than those with intact AAAs. However, the neck diameters and angulations were not significantly different. EVAR eligibility for standard and extended IFUs was found in 37.5% and 55.1% of men, and 11.3% and 25.4% of women (P<0.001 for both IFUs); neck anatomy was eligible in 34.0% of intact AAAs and 23.0% of ruptured AAAs (P=0.098).ConclusionA significant proportion of the Korean patients did not meet the IFU for EVAR, mainly due to the angulated neck. Women, and patients with ruptured AAAs, were less likely to meet the IFU criteria.

Meta-analysis of Phase-Specific Survival After Endovascular Versus Surgical Repair of Abdominal Aortic Aneurysm From Randomized Controlled and Propensity Score-Matched Studies

Although endovascular aneurysm repair (EVAR) is the treatment of choice for abdominal aortic aneurysm (AAA), we have not concluded superiority between EVAR and open surgical repair (OSR) beyond the perioperative period. The aim of this study was to compare phase-specific survival after EVAR vs OSR. Embase and MEDLINE were searched up to November 2019 to identify randomized controlled trials and propensity score-matched studies that investigated ≥2-year all-cause mortality (primary outcome) after EVAR vs OSR for intact infrarenal AAA. For each study, the hazard ratio (HR) with 95% confidence interval (CI) of mortality for EVAR vs OSR was calculated using survival curves for the following specific phases: early term (0-2 years after repair), midterm (2-6 years after repair), long term (6-10 years after repair), and very long term (≥10 years after repair). The risk ratio (RR) in the perioperative (in-hospital or 30-day) period was also extracted. Phase-specific HRs or RRs were separately pooled using the random effects model. Sensitivity analyses were performed by removing one study at a time to confirm that our findings were not derived from any single study. Funnel plot asymmetry was also examined using the linear regression test. Our search identified four randomized controlled trials and seven propensity score-matched studies enrolling a total of 106,243 AAA patients assigned to EVAR (n = 53,123) or OSR (n = 53,120). The mortality after EVAR compared with OSR was significantly lower in the perioperative period (RR, 0.39; 95% CI, 0.29-0.51; P < .00001) and similar in the early-term period (HR, 0.93; 95% CI, 0.84-1.03; P = .16). Notably, significantly higher mortality was observed in the EVAR group compared with the OSR group in the midterm period (HR, 1.15; 95% CI, 1.03-1.29; P = .01). However, similar mortality was observed between the EVAR group and the OSR group in the long-term (HR, 1.06; 95% CI, 0.96-1.17; P = .27) and very-long-term (HR, 1.17; 95% CI, 0.93-1.47; P = .19) periods. In sensitivity analyses, the significant benefit of EVAR in the perioperative period and that of OSR in the midterm period was not changed. No funnel plot asymmetry was identified in all analyses. Compared with OSR, EVAR was associated with lower perioperative mortality and higher mortality in the midterm period for intact infrarenal AAA. The superiority of EVAR was absent in the early-term period, and the inferiority of EVAR in the midterm period disappeared in the long-term and very-long-term periods.

Racial and Ethnic Disparities in Patients With Ruptured Abdominal Aortic Aneurysm

The incidence of abdominal aortic aneurysm (AAA) continues to rise, and high morbidity and mortality exist among patients with ruptured AAA (rAAA). Therefore, screening and prevention are critical. Previous studies suggest that clinical presentation and treatment modalities for intact AAA vary among racial groups. The aim of our study was to assess racial and ethnic disparities in patients with rAAA. We performed a 2-year (2015-2016) retrospective analysis of the National Surgical Quality Improvement Program database including all patients with AAA undergoing surgical intervention. Patients were stratified as ruptured and nonruptured and on the basis of race and ethnicity. The primary outcomes were racial and ethnic disparities on presentation and in-hospital patient outcomes. Missing variable analysis was performed. Regression analysis was performed to assess outcome measures. A total of 7043 patients with AAA were included, of which 14% (n = 986) were rAAA; 18.7% (n = 1317) were open repair. African Americans (P = .01) and Hispanics (P = .04) were more likely to present with rupture, whereas whites were less likely to present with rupture (P = .01). There was no difference in open or endovascular treatment between racial and ethnic groups. The Fig demonstrates racial and ethnic distribution among patients. The Table demonstrates factors associated with presentation with rupture. Among rAAAs, African Americans were more likely to have complications (1.18 [1.02-3.7]; P = .04) and higher mortality (1.15 [1.05-4.2]; P = .048). Hispanics were more likely to have complications after intervention for rAAA (1.12 [1.09-2.5]; P = .036). However, there was no difference in mortality. There are racial and ethnic disparities among patients with AAA during initial presentation (intact vs ruptured) and in outcomes after intervention for rAAA. African American were 18% more likely and Hispanics were 8% more likely to present with rAAA. African Americans and Hispanics had a higher complication rate after intervention for rAAA. In our study, there was no difference in treatment modality offered. Further studies are warranted to help better understand the reasons for potential disparities in AAA screening and prevention of rupture among different racial and ethnic groups to provide effective and equitable health care to prevent a vascular emergency such as rAAA.TableFactors associated with presentation as ruptureaCharacteristicsOR [95%]P valueAfrican American1.18 [1.05 - 3.05].045Hispanics1.08 [1.04 - 4.2].04aControIIing for age, gender comorbidities, transfer status, type of hospital, insurance, Ethnicity. Open table in a new tab

Outcomes after aortic aneurysm repair in patients with history of cancer: a nationwide dataset analysis

BackgroundSynchronous cancer in patients with abdominal aortic aneurysm (AAA) increases morbidity and mortality after AAA repair. However, little is known about the impact of the history of cancer on mortality after AAA repair.MethodsPatients with intact AAA who were treated with endovascular aneurysm repair or open surgical repair were selected from the Health Insurance and Review Assessment data in South Korea between 2007 and 2016. Primary endpoints included the 30- and 90-day mortality and long-term mortality after AAA repair. The Cox proportional hazards models were constructed to evaluate independent predictors of mortality.ResultsA total of 1999 patients (17.0%, 1999/11785) were diagnosed with cancer prior to the AAA repair. History of cancer generally had no effect in short-term mortality at 30 and 90 days. However, short-term mortality rate of patients with a history of lung cancer was more than twice that of patients without it (3.07% vs. 1.06%, P = 0.0038, 6.14% vs. 2.69%, P = 0.0016). Furthermore, the mortality rate at the end of the study period was significantly higher in AAA patients with a history of cancer than in those without a history of cancer (21.21% vs. 17.08%, P < .0001, HR, 1.31, 95% CI, 1.17–1.46).ConclusionsThe history of cancer in AAA patients increases long-term mortality but does not affect short-term mortality after AAA repair. However, AAA repair could increase both short- and long-term mortality in patients with lung cancer history, and those cases should be more carefully selected.

Impact of Centralisation on Abdominal Aortic Aneurysm Repair Outcomes: Early Experience in Catalonia

Several studies have revealed high volume centres have better outcomes in the treatment of abdominal aortic aneurysms (AAAs), thus supporting centralisation of this procedure into selected centres based on volume. To date however, the real benefit of centralisation of this pathology has not been well demonstrated. The aim of this study was to analyse the impact of centralisation in to high volume centres (defined as those performing more than 30 cases per year) on AAA treatment outcomes carried out in Catalonia (Spain). Data were collected from official national registries (HDMBD) for AAA treated by endovascular aneurysm repair (EVAR) or open repair (OR) over a nine year period. Two time periods were selected for comparison: before centralisation (2009-2014) and after complete centralisation (2015-2017). The primary objective was to determine short term mortality (in hospital and 30 day mortality) and length of stay (LOS) after intact AAA (iAAA) and ruptured AAA (rAAA) repair, before and after centralisation. Uni- and multivariable analyses were performed in order to identify independent outcomes predictors. A total of 3 501 iAAAs, including 1 124 (32.1%) OR and 2377 (67.9%) EVAR, and 409 rAAAs, including 218 (53.3%) OR and 191 (46.7%) EVAR, were identified. After centralisation, there was a significant decrease in overall mortality in iAAA repair (4.7% vs. 2.0%, p<.001) and rAAA repair (53.1% vs. 41.9%, p=.028). Mortality reduction in iAAAs was significant for OR (8.7% vs. 3.6%, p=.005), but not for EVAR (2.2% vs. 1.5%, p=.25). Overall LOS decreased as well, mainly in iAAAs (9.49±10.84 vs. 7.44±12.23 days, p<.001), and in particular in elective EVAR (7.32±7.73 vs. 6.00±8.97 days, p<.001). Multivariable analysis was identified before the centralisation period as an independent predictor for both mortality (odds ratio 1.484, 95% CI 1.098-2.005, p=.010) and LOS (B coefficient 1.146, 95% CI 0.218-2.073, p=.016). The implementation of a country based centralisation programme for AAA treatment led to a significant reduction in short term mortality, for both iAAA and rAAA, and mainly for elective OR. LOS also significantly decreased, mainly for elective EVAR. These results support the benefit of centralisation of AAA repair procedures.

Midterm survival after endovascular repair of intact abdominal aortic aneurysms is improving over time

ObjectiveThere is a growing body of literature raising concerns about the long-term durability of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs), suggesting that long-term outcomes may be better after open AAA repair. However, the data investigating these long-term outcomes largely originate from early in the endovascular era and therefore do not account for increasing clinical experience and technologic improvements. We investigated whether 4-year outcomes after EVAR and open repair have improved over time. MethodsWe identified all EVARs and open repairs for intact infrarenal AAA within the Vascular Quality Initiative database (2003-2018). We then stratified patients by procedure year into treatment cohorts of four years: 2003-2006, 2007-2010, 2011-2014, and 2015-2018. We used Kaplan-Meier analysis and Cox proportional hazards models to assess whether the survival after EVAR or open repair changed over time. In addition, we propensity matched EVAR and open repairs for each time cohort to investigate whether the relative survival benefit of EVAR over open repair changed over time. ResultsWe included 42,293 EVARs (increasing from 549 performed between 2003 and 2006 to 25,433 between 2015 and 2018) and 5189 open AAA repairs (increasing from 561 to 2306). Four-year survival increased for the periods 2003-2006, 2007-2010, 2011-2014, and 2015-2018 after both EVAR (76.6% vs 79.7% vs 83.5% vs 87.3%; P < .001) and open repair (82.2% vs 85.8% vs 87.7% vs 88.9%; P = .026). After risk adjustment, compared with 2003-2006, hazard of mortality up to 4 years after EVAR was lower for those performed between 2011 and 2014 (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.59-0.87; P = .001) and for those performed between 2015 and 2018 (HR, 0.56; 95% CI, 0.46-0.68; P < .001). In contrast, the risk-adjusted hazard of mortality was similar between open repair cohorts (2011-2014: HR, 0.81 [95% CI, 0.61-1.08; P = .15]; and 2015-2018: HR, 0.86 [95% CI, 0.64-1.17; P = .34]). Finally, in matched EVAR and open repairs, there was no difference in mortality in the first three cohorts, whereas the hazard of mortality was lower for the 2015-2018 cohort (HR, 0.65; 95% CI, 0.51-0.84; P = .001). ConclusionsFour-year survival improved in more recent years after EVAR but not after open repair. This finding suggests that midterm outcomes after EVAR are improving, perhaps because of technologic improvements and increased experience, information that should be considered by surgeons and policymakers alike in evaluating the value of contemporary EVAR and open AAA repair.

Nationwide Analysis of Intact Abdominal Aortic Aneurysm Repair in Portugal from 2000 to 2015

Results on the management of infrarenal abdominal aortic aneurysm (AAA) from Mediterranean countries are scarce. The aim of this study was to evaluate trends in rate of and mortality after repair of intact AAA (iAAA) in Portugal. iAAA repairs registered in the hospitals administrative database of the National Health Service from 2000 to 2015 were retrospectively analyzed regarding demographics (age and gender) and type of repair (open surgery [OS] or endovascular repair [EVAR]). Rate and mortality were compared among three time periods: 2000-2004, 2005-2009 and 2010-2015. Age-standardized rate of iAAA repair increased consistently across the time periods under analysis from 3.6±0.6/100,000/year in 2000-2004, to 5.6±0.4/100,000/year in 2005-2009 and to 7.1±0.9/100,000/year in 2010-2015 (p<0.001). The percentage of EVAR among all iAAA repairs rose steeply from 0 to 21±19% and then to 58±7% (p<0.001). The rate of OS also increased from the first to the second period, but there was a decrease in the third period (p<0.001). The in-hospital mortality after iAAA repair decreased from 7.5±1.3% to 6.6±1.6% and then to 5.1±1.9% (p<0.001). This variation corresponded to a decrease in in-hospital mortality after EVAR (from 4.0±3.5% to 2.8±0.9%, p<0.001) and increased in-hospital mortality after OS (7.5±1.3% to 7.4±1.1% to 8.3±3.7%, p<0.001). Low-volume centers (<15 repairs/year) did not present higher mortality rates. The number of EVARs per year in a centre presented a positive association with EVAR mortality (Spearman correlation of 0.696, p=0.004). The rate of repair of iAAA continues to grow, especially in patients ≥ 75 years old, and did not reach an inflection point yet. This is happening along with decreased repair mortality mainly due to the increased use of EVAR. Hospital mortality for iAAA repair is still a matter of concern, warranting further investigation and planning of vascular surgical services.

Factors Associated With Lower Incidence of Rupture in Abdominal Aortic Aneurysms

Introduction: The only current standard in international guidelines for estimating rupture risk of an abdominal aortic aneurysm (AAA) is the maximum diameter. The aim of this study was to evaluate anatomical factors in large (>80mm) AAA, in which the impact of diameter on rupture incidence is similar and profound, that may be associated with lower incidence of rupture. Methods: This was a retrospective study including patients with large (>80mm) aneurysms. Total of 62 patients were included in the study; matched 1:1 for age, and smoking (31 elective; 92±9.7mm vs. 31 ruptures; 95.7±12mm; p=0.5). Pre-operative computed tomography angiography was analyzed with a dedicated workstation and AAA anatomical characteristics were compared. The prognostic utility of several factors on rupture occurrence was also examined with receiver operating characteristic (ROC) curves. Results: Significantly different anatomical characteristics between elective vs ruptures were infra-renal aortic neck diameter at 5mm, 10mm and 15mm, neck length and calcification, common iliac length (CIA), pelvic artery index, left CIA and external iliac artery, total and true lumen volume. Intraluminal thrombus (ILT) volume did not differ (elective vs. ruptures; 233cc vs 245cc, p=0.76), although its form did (elective vs. ruptures; no thrombus 0% vs 20%, p=0.025; circular thrombus 63.3% vs 44%, p=0.03, respectively). After multivariate analysis, shorter left CIA (OR 1.07, CI. 1.01- 1.1, p=0.016) and smaller total aneurysm volume (OR 1.007, CI. 1.001-1.014, p=0.016) were associated with intact AAA. After a ROC curve analysis, left CIA < 50mm demonstrated lower incidence of rupture with sensitivity 60% and specificity 78%, while for total aneurysm volume of < 380cc the sensitivity and the specificity was 60% and 60%, retrospectively. Conclusion: Anatomical characteristics other than maximum diameter AAAs seem to be associated with incidence of rupture. Lower total aneurysm volume, but not ILT volume, and shorter left CIA may be associated with lower incidence of AAA rupture, even in large diameter AAA. Disclosure: Nothing to disclose

Nationwide Analysis of Intact Abdominal Aortic Aneurysm Repair In a Mediterranean Country from 2000-2015

Introduction: The incidence of and mortality due to abdominal aortic aneurysm (AAA) have experienced an epidemiological transition in Western countries with reports of decreasing rates from several countries. However, the evidence available from Mediterranean countries, where national AAA screening is not throughout implemented, is insufficient. The aim of this study was to evaluate trends in incidence and mortality after repair due to intact AAA (iAAA) in a Mediterranean country. Methods: iAAA repairs registered in the hospital-based National Health Service database from 2000 to 2015 were analyzed regarding demographics (age and gender) and type of repair (open surgery [OS] or endovascular repair [EVAR]). Incidence and mortality were compared among three time periods: 2000-2004, 2005-2009 and 2010-2015. To adjust for multiple testing due to subgroup analysis p < 0.01 was considered significant. Results: Incidence of iAAA repair increased consistently across the time periods under analysis from 4.2±0.7/100,000/year in 2000-2004, to 6.7±0.5/100,000/year in 2005-2009 and to 8.6±1.0/100,000/year in 2010-2015 (p< 0.001). The increasing incidence of iAAA repair was verified in both gender subgroups being significant in men (p< 0.001) but not in women (p=0.024). The rise in the incidence of iAAA repair was present in both age-bands < 75 and ≥ 75 years-old, being more evident in the last one (6.0±1.3/100,000/year in 2000-2004, 11.6±1.2/100,000/year in 2005-2009 and 15.0±1.1/100,000/year in 2010-2015 (p< 0.001) (Table 1). The percentage of EVAR among all iAAA repairs rose steeply from 0 to 21±19% and then to 58±7% (p< 0.001). The incidence of OS also increased from the first to the second period, but there was a decrease in the third period (p< 0.001). In hospital mortality after iAAA repair decreased from 7.5±1.3% to 6.6±1.6% and then to 5.1±1.9% (p< 0.001) (Table 2). This variation corresponded to a decrease in hospital mortality after EVAR (from 4.0±3.5% to 2.8±0.9%, p< 0.001) and an increased hospital mortality after OS (7.5±1.3% to 7.4±1.1% to 8.3±3.7%, p< 0.001) (Figure 1). Low-volume centres (< 15 repairs/year) did not present higher mortality rates. The number of EVARs per year in a center presented a positive association with EVAR mortality (Spearman correlation of 0.696, p=0.004) (Figure 2). Conclusion: In this Mediterranean country, the incidence of repair of iAAA continues to grow, especially in patients ≥ 75 years-old, and did not reach a break-point yet. These figures lag behind those described in other European countries but a catching up effect is noticeable. This is happening along with decreased repair mortality mainly due to the increased use of EVAR. Notwithstanding, centres with a higher number of EVARs per year presented an unexpected positive association with EVAR mortality, possibly due to broader case selection for EVAR. Hospital mortality for iAAA repair is still a matter of concern, warranting further investigation and planning of vascular surgical services.Figure 2Correlation between the rate of EVAR per year in a center and EVAR mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Table 1Percentage of hospital mortality among different types of intact AAA repair of over time. Legend: yo - years-old, SD - standard deviationTime periods / (Cases/year, n)2000-2015 (249)2000-2004 (143)2005-2009 (245)2010-2015 (342)pEVAR, n (%)1462 (36.6)-270 (22.0)1192 (58.1)<0.001≥ 75, n (%)1574217 (30.0)483 (39.4)874 (42.6)<0.001All repairs, rate per 100,000/y, mean (SD)6.63 (2.03)4.19 (0.73)6.69 (0.53)8.60 (1.01)<0.001EVAR, rate per 100,000/y, mean (SD)2.33 (2.39)-1.45 (1.41)5.00 (0.89)<0.001OS, rate per 100,000/y, mean (SD)4.30 (1.04)4.19 (0.73)5.24 (0.96)3.61 (0.77)<0.001Men, rate per 100,000/y, mean (SD)13.86 (4.26)8.83 (1.52)13.88 (1.07)18.05 (2.29)<0.001Women, rate per 100,000/y, mean (SD)0.81 (0.31)0.45 (0.19)0.91 (0.21)1.02 (0.17)0.024< 75 yo, rate per 100,000/y, mean (SD)5.24 (1.40)3.69 (0.57)5.25 (0.38)6.53 (1.03)<0.001≥ 75 yo, rate per 100,000/y, mean (SD)11.13 (4.01)6.02 (1.29)11.61 (1.24)15.00 (1.14)<0.001 Open table in a new tab Table 2Mortality rate referring to patients discharged as death after repair of intact AAA (iAAA) across three time periodsTime periods / (Deaths/year, n)2000-2015 (14)2000-2004 (11)2005-2009 (16)2010-2015 (17)pAll repairs, rate per 100,000/y, mean (SD)0.39 (0.10)0.31 (0.05)0.44 (0.09)0.42 (0.11)<0.001EVAR, rate per 100,000/y, mean (SD)0.07 (0.07)-0.05 (0.04)0.13 (0.03)<0.001OS, rate per 100,000/y, mean (SD)0.33 (0.10)0.31 (0.05)0.39 (0.12)0.29 (0.10)<0.001Men, rate per 100,000/y, mean (SD)0.79 (0.21)0.63 (0.07)0.87 (0.17)0.85 (0.27)<0.001Women, rate per 100,000/y, mean (SD)0.07 (0.04)0.05 (0.04)0.09 (0.04)0.08 (0.04)0.218< 75 yo, rate per 100,000/y, mean (SD)0.26 (0.06)0.25 (0.06)0.29 (0.09)0.26 (0.03)0.019≥ 75 yo, rate per 100,000/y, mean (SD)0.82 (0.41)0.55 (0.26)0.95 (0.40)0.94 (0.48)0.001 Open table in a new tab Disclosure: Nothing to disclose

Effect of Endovascular Treatment Rate on Outcomes and Survival after Intact Abdominal Aortic Aneurysm Repair

Introduction - The endovascular aortic repair (EVAR) rate in patients with abdominal aortic aneurysms (AAAs) varies country-to-country between 28–79% (1). Although EVAR has many advantages over conventional open aortic repair (OAR), such as lower in-hospital mortality (2), no long-term survival benefit has been shown for AAA patients who have undergone EVAR compared with OAR (3). However, the patient populations vary between clinical trials and even within registries. To overcome this potential bias, we investigated the EVAR rates and outcomes after AAA repair in four geographically adjacent populations with identical demographics in terms of age, sex, ethnicity and burden of cardiovascular risk factors (4). Methods - This retrospective multicenter study was based on prospectively collected registry data from an area of 815 000 inhabitants. The catchment area was divided into four health care districts (population A, B, C and D) with one central hospital in each district. Each hospital was responsible for the treatment of AAA patients of their respective population. OARs were performed in all four hospitals, while all EVARs were performed in one center. Each hospital decided independently which patients they would treat with OAR and whom to refer for EVAR. The study involved 532 consecutive patients with intact (non-ruptured) infrarenal or juxtarenal AAA treated with EVAR (n=329) or OAR (n=203) between 2010 and 2016. Total intact AAA repair rates and EVAR rates were calculated for each population. Major complications were registered (in-hospital mortality, rebleeding, surgical wound infection, major cardiac event, stroke, acute kidney failure, gastrointestinal complications and limb ischemia), and patients were monitored for mortality until March 2017. The population demographics were retrieved from a national statistic database. Results - The sex and the age distributions were the same between the populations. The populations ranged between 147 000–252 000 inhabitants. The intact AAA repair rates were 9.8, 8.9, 9.9 and 8.7 per 100 000 inhabitants/year for populations A, B, C and D, respectively. There were no significant differences in the mean age (73.6 ± 8.0 years) or the mean aortic diameter (62 ± 13 mm) between the study populations. Populations A and B had high EVAR rates (74% and 72%, respectively) whereas the EVAR rate was lower in populations C and D (50% and 38%, respectively) (P<0.001). The 30-day mortality rates were 2.4%, 2.6%, 3.9% and 1.0%, and complication rates were 17.7%, 12,7%, 15.1% and 11.5% for populations A, B, C and D, respectively. There were no statistically significant differences in 30-day mortality and complication rates, and neither in the long-term survival between the groups (Figure). The mean follow-up time was 3.3 ± 2.0 years. Conclusion - High EVAR rate had no measurable effect on the survival and outcomes in patients with intact AAA. In population D with the highest OAR rate, immediate outcomes were favourable, however, the differences did not reach statistical significance.

Long-term Survival After Endovascular Repair for Intact Infrarenal Abdominal Aortic Aneurysms is Improving Over Time

Introduction: There is a growing body of literature raising concerns over the long-term durability of endovascular repair (EVAR) for abdominal aortic aneurysms (AAA) and suggesting that long-term outcomes may be better after open AAA repair. However, the data investigating these long-term outcomes largely originate from early in the endovascular era and therefore do not account for increasing clinical experience and technological improvements. Therefore, we investigated whether long-term outcomes after EVAR and open repair have improved over time. Methods: We identified all EVARs and open repairs for intact infrarenal AAA within an international vascular clinical database (2003-2018). We then stratified patients by procedure year into treatment cohorts of four years: 2003-2006, 2007-2010, 2011-2014, and 2015-2018. We used Kaplan-Meier analysis and Cox proportional hazards models to assess whether there was an improvement in EVAR or open repair over time. Additionally, we matched EVAR and open repairs for each time cohort, to investigate whether the relative survival benefit of EVAR over open repair changed over time. Results: We included 40,811 EVARs (increasing from 549 performed between 2003-2006 to 24,059 between 2015-2018) and 9,241 open AAA repairs (increasing from 739 performed between 2003-2006 to 4,273 between 2015-2018). For both EVAR and open repair, median age decreased over time (EVAR: 75 vs. 74 vs. 74 vs. 73, P< .001; open repair: 72 vs. 70 vs. 70 vs. 70, P< .001). Four-year survival increased for the periods 2003-2006, 2007-2010, 2011-2014, and 2015-2018 as 76% vs. 80% vs. 84% vs. 88% for EVAR (P< .001) and 81% vs. 85% vs. 86% vs. 88% for open repair (P=.003; Figure 1). After risk-adjustment, compared to 2003-2006, the hazard ratio (HR) for long-term mortality after EVARs performed between 2011-2014 was 0.64 (95%CI: 0.47-0.88; P=.017) and 0.46 for those performed between 2015-2018 (95%CI: 0.34-0.64; P< .001). In contrast, the risk-adjusted mortality did not decrease for open repair cohorts over time (2007-2010: HR: 1.23 [95%CI: 0.85-1.77; P=.28]; 2011-2014: HR: 0.98 [95%CI: 0.64-1.51; P=.94]; 2015-2018: HR: 0.91 [95%CI: 0.58-1.43; P=.69]). From the early to the latest follow-up cohort, we matched 365, 431, 1,339, and 1,211 EVAR to open repair patients. Survival curves for these cohorts are displayed in Figure 2: whereas EVAR and open repair showed similar survival in the first two cohorts, EVAR patients treated between 2011-2014 showed only a survival benefit up to two years, with no difference in four-year survival (P=.15). However, EVAR patients in the latest cohort experienced a higher survival over the full time period (P=.02).Figure 2Four-year Survival for Matched EVAR and Open Repair Procedures per Treatment Cohort.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Conclusion: Long-term outcomes following EVAR are still improving over time, but not following open repair. Consequently, we found a trend towards higher relative survival rates after EVAR compared to open repair over time. These finding suggests that long-term durability following EVAR may be improving with new generations of endografts and increased experience, information that should be considered by surgeons and policymakers when evaluating the long-term value of contemporary EVAR to open AAA repair. Disclosure: HV is a consultant for Medtronic, WL Gore, Endologix, Abbott, Arsenal AAA MS is a consultant for Abbott Vascular, Cook Medical, Endologix, Medtronic, and Silk Road

Novel Predictors of Peri-Operative Mortality in a Series Of 931 Consecutive Patients with Intact Aortoiliac Aneurysms Managed at a Single Centre

Introduction - The aim of our study was to identify preoperative and intraoperative factors associated with in-hospital mortality after repair of intact abdominal aortic or iliac aneurysms. Methods - This was a retrospective analysis of prospectively collected information on patients undergoing repair of intact aortoiliac aneurysms during a 28-year period. Recorded information included preoperative demographics, risk factors and co-morbidities, aneurysm characteristics, investigations and operative variables including special aneurysm presentation (inflammatory, mycotic/infected, aortocaval fistula) and procedure type (open vs. endovascular repair). Univariate and multivariate logistic regression analyses (with odds ratios, OR) were performed, the latter performed to develop a predictive model using the generated output. The area under the curve of the receiver operating characteristics (ROC) curve of our score, the Glasgow aneurysm score (GAS),1 and the Vascular Study Group of New England (VSGNE) score,2 was calculated. Results - During the study period we operated on 931 patients with intact aortoiliac aneurysms, on an elective (n=882) or urgent (n=49) basis, and an in-hospital mortality of 1.7% and 8.2%, respectively (p=0.015). Endovascular aneurysm repair (EVAR, n=414) was a predictor of lower mortality (0.5% vs. 3.3% for open repair, n=517, p=0.003). Other significant predictors included the presence of abdominal or back pain (7.5% vs 1.3% for no pain, p<0.001), preoperative angiography (6.9% vs 1.6% for no angiography, p=0.01), special aneurysm presentation (10.7% vs 1.5% for 875 ordinary atherosclerotic aneurysms, p<0.001), concomitant major procedures (19% vs 1.6% for the rest, p<0.001), serious intraoperative complications (9.1% vs 1.5% for no such complications, p<0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, p<0.001) and duration of the procedure (300min and 150min for cases with and without mortality, respectively, p<0.001). On multivariate analysis, EVAR was an independent predictor of lower mortality (OR=0.22, p=0.05) and special aneurysm presentation (OR=6.45, p=0.001) and concomitant major procedures (OR=14.3, p<0.001) were independent predictors of higher mortality. The area under the ROC curve, and p values for the GAS, VSGNE score and our score was 0.46, 0.62 and 0.81, and 0.59, 0.084 and 0.00003, respectively (Figure). The difference between the VSGNE and our score was significant (p=0.029). Repeat analysis for electively operated cases demonstrated an area under the ROC curve of 0.66 (p=0.029) and 0.80 (p=0.000069), respectively, for the VSGNE and our score, with the difference becoming non-significant. Conclusion - Our study in patients undergoing aortoiliac aneurysm repair has demonstrated novel risk factors for mortality and externally validated VSGNE in different healthcare settings.

The Impact of Centralization and Endovascular Aortic Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries

Introduction - Endovascular aortic repair (EVAR) is the predominant treatment modality for treatment of intact abdominal aortic aneurysms (AAA) in many countries, and its use is also increasing in cases of ruptured AAAs (RAAA).1 Variation in AAA treatment between and within countries influences outcomes of intact AAAs, but little is known on the recent trends and outcomes in RAAA treatment.2 The objective of this analysis was to update recent treatment strategies and outcomes from the Vascunet registry, an international collaboration of vascular surgery registries. Methods - An analysis of all RAAAs from vascular surgical registries in eleven countries from 2010-2013 was carried out. Data were analysed overall, per country, per treatment (EVAR vs. open aortic repair (OAR)), for the volume per centre, divided into quintiles (QI-V), and for centres that were either predominantly EVAR (>50% of rAAA repairs performed with EVAR; pEVAR) or predominantly OAR (pOAR). The primary outcome was perioperative mortality, defined depending on which registry, as either in-hospital or death within 30 days after repair. Data are presented as percentages with 95% confidence intervals (CI), and compared with Chi-square test. Results - There were 9273 patients included. These represented 16.0% (15.7-16.3) of the total number of AAAs operated in this period, ranging from 10.3% (9.8-11.8) in Germany to 29.4% (25.9-32.9) in Finland. The mean age was 74.7 (74.5-74.9), and the majority were men (82.7%, CI, 81.9-83.6). The mean AAA size at the time of rupture was 7.6 cm (7.5-7.6). The perioperative mortality was 28.8% (27.9-29.8), 32.3% (29.9-34.9) for women, greater than for men, 27.1% (26.1-28.2), p <0.001. Perioperative mortality was 32.1% (31.0-33.2) for OAR and 17.9% (16.3-19.6) for EVAR, p<0.001. Perioperative mortality was lower in the highest volume centres (QI, > 22 repairs per year), 23.3% (21.2-25.4), p<0.001. The highest volume centers were also performing the greatest percentage of OAR, 85.6% (83.9-87.4), p<0.001, and all high volume centers (n=13) were pOAR. Perioperative mortality was lower in pEVAR centres (23.0%, 95% CI: 20.6-25.4) vs. pOAR centres (29.7%, 95% CI: 28.6-30.8), p<0.001. Perioperative mortality for OAR was significantly lower in the high volume centres, 25.3% (23.0-27.6), p<0.001. Conclusion - OAR still predominates as the treatment of choice for RAAA treatment, even in the highest volume centres, despite opposite time-trends in intact repair. Perioperative mortality is lower in centres either with high volumes or a predominant EVAR approach to treatment, while results are also better for OAR at centres of high volume. It must be emphasized, however, that this investigation only has reported on those operated on for RAAA. Centralization and EVAR availability favour outcome of those operated on, but there is also a need to study those not offered repair.

Impact on Outcome of Abdominal Aortic Aneurysm Repair Centralization: An Early Experience in Public Health System

Introduction: Several studies described that high volume centers have better outcomes than low volume centers in the treatment of abdominal aortic aneurysm (AAA). However, the real benefit of centralization of this pathology has not been well demonstrated yet. The aim of this study is to analyze the impact of centralization on AAA treatment outcomes in Catalonia (Spain). Methods: Data were collected from official national registries related to AAA treated with endovascular aneurysm repair (EVAR) or open repair (OR) in a ten year period. Two time periods were selected for comparison: before centralization (from January 2008 to May 2015) and after complete centralization (from June 2015 to December 2017). Primary endpoint was to determine the influence of centralization in terms of in-hospital mortality and length of stay (LOS) after treatment of intact AAA (iAAA) and ruptured AAA (rAAA), in low and high volume centers. Data are presented as either mean values with standard deviations (SD) within parentheses or percentages, and compared with Pearson Chi Square or T-Test for independent samples. Results: In overall, 4236 AAA treatments were included (89.8% iAAA, 10.2% rAAA). After centralization a significant decrease in overall mortality in both iAAA and rAAA repairs was observed (4.1% vs 1.9%, p = .001; 52.8% vs 37.2%, p = .003, respectively). In spite of an increase in EVAR proportion after centralization (62.8% vs 77.5%, p < .001 for iAAA and 35.4% vs 67.4% for rAAA, p < .001), mortality reduction in iAAA was significant for OR (7.8% vs 3.3% , p = .014), but not for EVAR (1.9% vs 1.5%, p = .412). Overall LOS decreased as well, mainly in iAAA (9.54 ± 10.93 vs 7.4 ± 12.07, p < .001). Also, regarding only high volume centers, a significant reduction in mortality after centralization for both iAAA (3.8% vs 1.9%, p = .004) and rAAA repair (52.3% vs 37.0%, p = .004) was observed. Conclusion: After centralization, in-hospital mortality significantly decreased for iAAA and rAAA repairs, mainly for OR. LOS was also significantly decreased. Furthermore, high volume centers experienced an improvement in their own results after centralization. Thereafter, centralization for AAA repair into high-volume reference centers should be considered in public health systems. Disclosure: none

Lower Extremity Ischemia after Abdominal Aortic Aneurysm Repair

Introduction - Treatment reality of abdominal aortic aneurysm (AAA) is changing. Up to date, approximately 65% of intact AAA and 30% of ruptured AAA are treated endovascularly. As most comparative studies focus upon mortality and few major complications, some outcomes as lower extremity ischemia (LEI) after invasive AAA repair are often underreported. However, there is evidence for a worse outcome of patients suffering from this kind of complication.

Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over Nine Years

Introduction - Case mix and outcomes of complex surgical procedures vary over time and between regions.1 With noted increasing surgical activity and screening programmes for abdominal aortic aneurysm (AAA) detection and management, the monitoring of surgical outcome measures is increasingly important.2–4 The objective of this study is to describe trends in contemporary AAA practice in an international context, and assess the change in perioperative mortality after repair. Methods - Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analyzed. Data were analyzed overall, per country, per treatment (EVAR vs. open surgery), for high- and low-volume centres, and also between the two time periods (2005-2009 and 2010-2013). The primary outcome was perioperative mortality, defined as either in-hospital death or death within 30 days. Multivariable-adjusted logistic regression analyses were carried out to adjust for variations in case mix. Results - There were 83 253 patients included. Over the two periods, the proportion of patients ≥80 years old increased (18.5% vs. 23.1%; p<0.0001), as well as endovascular repair (EVAR) (44.3% vs. 60.6; p<0.0001). AAAs less than 5.5 cm in the latter period was 25.8%. The mean annual volume of open repairs per center decreased from 12.9 to 10.6 between the two periods, p<0.0001, while it increased for EVAR from 10.0 to 17.1, p<0.0001. Overall, perioperative mortality fell from 3.0% to 2.4% (p<0.0001). Mortality for EVAR decreased from 1.5% to 1.1% (p<0.0001), while the outcome worsened for open repair (3.9% vs. 4.4%, p=0.008). The perioperative risk was greater for octogenarians (Overall, 3.6% vs. 2.1%, p<0.0001; Open, 9.5% vs. 3.6%, p<0.0001; EVAR, 1.8% vs. 0.7%, p<0.0001), and women (Overall, 3.8% vs. 2.2%, p<0.0001; Open, 6.0% vs. 4.0%, p<0.0001; EVAR, 1.9% vs. 0.9%, p<0.0001). Perioperative mortality after repair of AAAs<5.5 cm was 4.4% with open repair and 1.0% with EVAR, p<0.0001. Conclusion - In this large international cohort, total perioperative mortality continues to fall for the treatment of intact AAAs. EVAR procedures now exceed the number of open procedures. Mortality after EVAR has decreased, while mortality for open operations has increased. The perioperative mortality for small AAA treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture. References1Beck AW, Sedrakyan A, Mao J, Venermo M, Faizer R, Debus S, et al. Variations in Abdominal Aortic Aneurysm Care: A Report from the International Consortium of Vascular Registries. Circulation 2016;134(24):1948–58.2Schwarze ML, Shen Y, Hemmerich J, Dale W. Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006. J Vasc Surg 2009;50(4):722-9.e2.3Chun KC, Teng KY, Van Spyk EN, Carson JG, Lee ES. Outcomes of an abdominal aortic aneurysm screening program. J Vasc Surg 2013;57(2):376–81.4Mani K, Lees T, Beiles B, Jensen LP, Venermo M, Simo G, et al. Treatment of abdominal aortic aneurysm in nine countries 2005-2009: A vascunet report. Eur J Vasc Endovasc Surg 2011;42(5):598–607.

Contemporary Analysis of Intact Abdominal Aortic Aneurysm Repair by Treatment Method

Introduction: The long-term results of the landmark randomised trials comparing EVAR and open aneurysm repair (OAR) were challenged when recent recommendations of abdominal aortic aneurysm management were being based on them. In the last two decades since those trials were conducted, improvement in perioperative medicine, refined patient selection and advances in graft technology resulted in lower operative mortality. However, the impact of EVAR and OAR on long-term patient survival has been controversial (1, 2). The aim of this study was to compare the outcomes of OAR and EVAR in the recent era. Methods: This was an observational study. Both national administrative and clinical vascular databases were interrogated to capture all patients that underwent a planned AAA repair from the 1st of January 2010 until the 31st of December 2014. The data was matched by using unique patient identifying numbers, and death dates were obtained from national mortality database. Open repair and EVAR using 2nd 3rd generation endografts were included, trial devices and fenestrated/branched configuration were excluded. Logistic regression models were used to determine predictors of 30-day mortality, and Cox proportional hazards model was used to determine predictors of survival. The censoring date for survival analysis was the 31st of January 2018. The national ethics committee approved this study. Results: Overall, 1220 patients underwent aneurysm repair, of which 62 patients were excluded. The mean age was 74 years and 218 (18.2%) patients were females. There were 615 (53.1%) patients on whom an EVAR was performed and the median (interquartile range) AAA diameter was 61 (55-70)mm. The 30-day mortality after OAR and EVAR was 3.5% and 0.7% respectively (adjusted OR: 5.5 [95%CI:1.8-16.4]). The median and maximum follow-up was 4.5 and 8 years respectively. The crude survival curves crossed at 18 months and after adjusting for confounders, EVAR was associated with a HR 1.5 (95%CI:1.2-1.9). Patients who underwent an EVAR had a higher aneurysm-related mortality. Other prognostic factors that were also associated with a lower survival rate were: increased age, being female, and having renal impairment and ischaemic heart disease. Conclusion: In this real world setting using the current endografts devices and technology, patients who underwent EVAR enjoyed a lower short mortality but this benefit disappeared at 2 years follow-up. OAR had a higher survival rate in the long term. Disclosure: Nothing to disclose

Re-interventions After Endovascular Repair for Infrarenal Abdominal Aortic Aneurysms

Introduction: Morbidity and mortality after endovascular abdominal aortic aneurysm repair (EVAR) is significantly lower than open repair. Reintervention rates and late complications after EVAR however have been reported to be higher compared to open repair in the international literature. The aim of this study was to identify and document all re-interventions after EVAR performed for intact abdominal aortic aneurysm at a single center since the introduction of EVAR in this center in 2009 Methods: This is a retrospective single-centre cohort study of re-interventions after standard EVAR. Consecutive patients (n=113) who were treated for non ruptured infrarenal aneurysms between 2009 and 2018 were included in this study. All patients undergoing EVAR were routinely followed up with a duplex scan and a CT angiogram six weeks post EVAR, which were then repeated yearly if the initial results were satisfactory. Results: In total, 22 re-interventions were performed in 19 patients during follow-up. None of the interventions were access related. In all cases, the femoral arteries were exposed via open cutdown. The most common indications for reintervention were thrombosis or stenosis of a graft limb (n=18), type I endoleak (n=3) and type II endoleak (n=1). The most frequent procedures were femoro-femoral crossover graft (n=10), thrombectomy +/- angioplasty of the EVAR graft body or limb (n=5), stenting (n=2) or extension of graft limb (n=2), proximal extension (n=1), embolisation of type II endoleak (n=1). Endovascular technique was used in 27.3% of the re-interventions Conclusion: None of our re-interventions were done for access related complications but non-access-related intervention rates are still considerable after EVAR. In our centre, the commonest indication for intervention was graft limb thrombosis or stenosis. The commonest procedure was femoro-femoral crossover graft, followed by thrombectomy +/- angioplasty of the EVAR graft limb. Re-intervention rates are identical to reintervention rates reported in the literature. No aneurysm ruptures were recorded. Disclosure: Nothing to disclose