Late Rupture Research Articles

Sex differences in outcomes among adults undergoing abdominal aortic aneurysm repair

ObjectiveAlthough the differences in short-term outcomes between male and female patients in abdominal aortic aneurysm (AAA) repair have been well studied, it remains unclear if these sex disparities extend to other long-term adverse outcomes after AAA repair, such as reintervention and late rupture. MethodsWe performed a retrospective cohort study of 13,007 patients who underwent either endovascular (EVAR) or open AAA repair (OAR) between 2003 and 2015 using data from the Vascular Quality Initiative registries. Eligible patients were linked to fee-for-service Medicare claims to identify late outcomes of rupture and aneurysm-specific reintervention. ResultsThe mean age of our cohort was 76 ± 6.7 years, 22% were female, 94% were White, and 77% underwent EVAR. The 10-year rupture incidence was slightly higher for women at 4.8 per 1000 person-years, vs 3.9 for men, but this difference was not statistically significant after risk adjustment (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 0.74-1.73). Likewise, we found no sex difference in reintervention rates (5.1 vs 4.8 in women per 1000 person-years) even after risk adjustment (HR = 0.95, 95% CI: 0.83-1.09). Regression models suggest effect modification by repair type for reintervention, where women who underwent index EVAR had a higher risk of reintervention than men (HR = 1.08, 95% CI: 0.93-1.26), whereas women who underwent OAR were at a lower risk of reintervention than men (HR = 0.79, 95% CI: 0.58-1.08); however, neither effect reached statistical significance within each subgroup. In addition, we found that the risk of reintervention for women vs men varied by clinical presentation, where women were less likely to undergo reintervention after an elective or symptomatic AAA repair but were more likely to undergo reintervention after a repair for AAA rupture (HR = 1.70, 95% CI: 1.05-2.75). ConclusionsMale and female patients who underwent AAA repair had similar rates of reintervention and late aneurysm rupture in the 10 years after their procedure. However, our findings suggest that repair type and clinical presentation may affect the role of sex in clinical outcomes and warrant further exploration in these subgroups.

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

Postoperative Renal Complications Adversely Impact Late Survival Following Open Juxtarenal Aortic Aneurysm Repair

Preoperative renal function is a predictor of morbidity and mortality after the repair of juxtarenal aortic aneurysms. However, the impact of postoperative renal failure on late outcomes after repair are poorly understood. Therefore, our objective was to assess the impact of postoperative renal dysfunction on long-term outcomes after juxtarenal aortic aneurysm repair. We identified all open repairs of juxtarenal aortic aneurysms in the Vascular Quality Initiative from 2011 to 2018 with linkage to Medicare claims data. Juxtarenal aortic aneurysm repair was defined as the placement of proximal clamp above at least one renal artery during open repair. Postoperative renal function was categorized as stable renal function, acute kidney injury (AKI; ≥0.5 mg/dL serum creatinine increase) or new renal replacement therapy (RRT). Kaplan-Meier estimates and Cox regression were used to identify the effect of AKI or RRT on 5-year mortality, rupture, and reintervention. Of 1643 open repairs, 29% experienced postoperative AKI, and 6.5% required RRT. Renal visceral ischemia time >25 minutes was higher in the AKI and RRT cohorts (stable: 52% vs AKI 65% vs RRT 67%; P < .001). Postoperative mortality was higher with increasing severity of postoperative renal dysfunction (2.5% vs 9.5% vs 31%; P < .001). Increasing renal dysfunction severity was also associated with higher risk of 5-year mortality (14% vs 25% vs 57%; AKI: adjusted hazard ratio [aHR], 1.7 [1.3-2.4]; P < .001/RRT: aHR, 4.6 [3.1-7.0]; P < .001) (Fig). In addition, RRT was associated with higher risk of late rupture (3.1% vs 6.8% vs 10%; AKI: aHR, 1.1 [0.3-3.7]; P < .788/RRT: aHR, 5.5 [1.2-25]; P < .026) and late reintervention (15% vs 20% vs 55%; AKI: aHR, 1.4 [0.9-2.2]; P = .114/RRT: aHR, 3.4 [1.7-7.0]; P = .001). Postoperative renal dysfunction adversely impacts late mortality, rupture, and reintervention. In addition increasing severity of postoperative renal dysfunction has a dose-dependent effect on perioperative and late outcomes after repair. Preoperative and intraoperative care should be taken to prevent renal complications after repair. Furthermore, these patients may benefit from closer follow-up after repair.

Long-term Evaluation of Proximal Aortic Neck Dilatation After Endovascular Abdominal Aortic Aneurysm Repair With a Variety of Contemporary Endografts

To measure the long-term proximal aortic neck dilatation (AND) after elective endovascular aortic aneurysm repair (EVAR) with a variety of contemporary, third-generation, endograft devices. This is a noninterventional prospective cohort study of 157 patients that underwent standard EVAR with self-expanding abdominal endografts. Patients' recruitment lasted from 2013 to 2017, and postoperative follow-up was up to 5 years. A computed tomography angiography (CTA) was performed at the first month and then at 1, 2, and 5 years. Proximal aortic neck's (PAN) basic morphological characteristics (diameter, length, angulation) were measured based on the analysis of CTA in a standardized fashion. Neck-related adverse events, such as migration, endoleak or rupture, and reinterventions were recorded. Significant straightening of the PAN was evident even in the first-month CTA with concurrent neck shortening that became significant at 5 years. Both the suprarenal aorta and the PAN significantly dilated overtime, with PAN dilating more progressively. Mean neck dilatation at the juxtarenal level was 0.8±0.4 mm at 1 year, 1.8±0.8 mm at 2 years, and 3.9±1.7 mm at 5 years, with a mean neck dilatation rate of 0.07 mm/month overall. The incidence of AND ≥2.5 mm was 37.2% at 2 years and 58.1% at 5 years after EVAR and was considered important (≥5 mm) in 11.5% of patients at 2 years and 30.6% of patients at 5 years. A multivariate analysis performed showed that the endograft oversizing, the preoperative neck diameter, and the preoperative abdominal aortic aneurysm sac diameter served as independent predictors of AND at 5 years. At the 5-year follow-up, 8 late type Ia endoleaks (6.5%) and 7 caudal migrations (5.6%) were identified, while no late ruptures were reported. In total, 11 late endovascular reinterventions (8.9%) were performed. Overall, proximal neck-related adverse outcomes (5/7 migrations and 5/8 endoleaks) and reinterventions (7/11) were significantly associated with the presence of important late AND. Proximal AND after EVAR is common. It can influence the long-term durability of proximal endograft fixation and is significantly associated with adverse outcomes, often leading to reinterventions. A systemic and extended surveillance protocol is needed for maintenance of good long-term results. This is a thorough and systematic analysis of the long-term geometric remodeling of the proximal aortic neck after EVAR, that highlights the importance of a strict, and extended surveillance protocol for maintenance of good long-term results of EVAR.

Complications of total knee arthroplasty and the development of late deep infection in patients with rheumatoid arthritis

Aim: This study aimed to assess complications and the presence of late deep infection in patients with rheumatoid arthritis (RA) who underwent primary and revision total knee arthroplasty (TKA). &#x0D; Materıial and Method: Between June 1997 and October 2022, cemented TKA that cut the posterior cruciate ligament (PCL) was applied to 50 knees of 34 patients with RA, and posterior-stabilized (PS) revision TKA was applied to 7 knees of 5 patients. All the patients enclosed in this study were adults diagnosed with RA by a rheumatology or physical therapy physician according to the RA diagnostic criteria recommended by the American College of Rheumatology in 1987. The diagnosis of infection was based on the Periprosthetic Infection Diagnostic Criteria of the 2018 International Periprosthetic Joint Infections Consensus Meeting.&#x0D; Results: Complications were found in 9 (18%) of the 50 knees who underwent primary TKA. Postoperative serous discharge was observed in 3 (6%) knees, serous discharge and late partial rupture of the quadriceps tendon in 1 (2%), early deep infection in 1 (2%), late deep infection in 3 (6%), and hematoma in 1 (2%). Revision surgery was performed on 3 (6%) knees due to infection and on 4 (8%) knees due to aseptic loosening. Complications developed in 2 of these knees who underwent revision TKA, 1 (14.3%) knee with periprosthetic fracture in the femur in the first postoperative year, and 1 (14.3%) knee with early deep infection. Deep vein thrombosis (DVT), pulmonary emboli (PE) and heterotopic ossification (HO) were not observed in any patient.&#x0D; Conclusion: In patients with rheumatoid arthritis, total knee arthroplasty increased chronic late deep infection and the associated need for revision surgery, and decreased the rates of DVT, PE, HO.

Successful Treatment of Late Rupture of Kidney Biopsy Associated Pseudoaneurysm

Successful Treatment of Late Rupture of Kidney Biopsy Associated Pseudoaneurysm

Childhood outcomes after induction of labor or expectant management for preterm prelabor rupture of membranes: a 10-year follow-up of the PPROMEXIL trials

Management of late preterm prelabor rupture of membranes between 34+0 and 36+6 weeks' gestation balances the risks of preterm birth with the risks of infection for both the mother and the neonate. Expectant management to prolong pregnancy showed similar risks of neonatal sepsis, but children at 2 years of age showed more neurodevelopmental delay when compared with induction of labor. Long-term outcomes on child development after 2 years of age are unknown. This study aimed to assess the long-term outcomes of children born after singleton pregnancies complicated by late preterm prelabor rupture of membranes managed by induction of labor in comparison with expectant management. This was a follow-up study of the Preterm Prelabor Rupture of Membranes Expectant Management Versus Induction of Labor (PPROMEXIL) trials (randomized controlled trials between 2007 to 2011) evaluating children at 10 to 12 years of age (Netherlands Trial Register 6953). The primary outcomes were cognition, motor function, and behavior as assessed by the Wechsler Intelligence Scale for Children-V-NL, Movement Assessment Battery for Children-2, and Child Behavior Checklist, respectively. The secondary outcomes were sensory processing, respiratory problems, educational attainment, and general health. Mild delay was defined as -1 standard deviation or corresponding percentile. The relative risk and confidence intervals were calculated using standard methods. This follow-up study invited 711 surviving children of the 714 singleton pregnancies randomized in the original trials. In total, 248 (35%) children participated (127 induction of labor, 121 expectant management). Children born after induction of labor had no significant differences in the primary outcomes when compared with those born after expectant management. Mild cognitive delay was observed in 7 of 122 (5.7%) children born after induction of labor in comparison with in 12 of 120 (10.0%) children born after expectant management (relative risk, 0.57; 95% confidence interval, 0.23-1.41). A mild delay in motor function was observed in 42 of 122 (34.4%) children born after induction of labor vs in 55 of 120 (45.8%) children born after expectant management (relative risk, 0.75; 95% confidence interval, 0.55-1.03). Mild abnormal behavior was observed in 37 of 125 (29.6%) children born after induction of labor compared with in 33 of 118 (28.0%) children born after expectant management (relative risk, 1.05; 95% confidence interval, 0.71-1.57). Secondary outcomes were also comparable between the induction of labor and the expectant management groups except that more children born after expectant management had a hospital admission (relative risk, 0.68; 95% confidence interval, 0.52-0.89) or a surgery (relative risk, 0.58; 95% confidence interval, 0.41-0.82). In children born after pregnancies with late preterm prelabor rupture of membranes, expectant management did not improve long-term outcomes at 10 to 12 years when compared with induction of labor.

Multi-constituent simulation of thrombosis in aortic dissection

Aortic dissection is a major aortic catastrophe with a high morbidity and mortality risk, and thoracic endovascular repair (TEVAR) has recently been established as the preferred treatment option for promoting false lumen (FL) remodeling and improving hemodynamics in the true lumen. Complete thrombosis of the FL has been thought to be a prerequisite for healing of the aorta postdissection, whereas flow and pressurization of the FL caused by partial thrombosis are thought to contribute to late dilation and rupture. Therefore, it is important to anticipate FL remodeling outcomes of different TEVAR procedures to determine which one will favor complete FL thrombosis. In this paper, a spatio-temporal mathematical model is proposed to simulate thrombosis in dissection. Blood is treated as a multi-constituent mixture consisting of a linear fluid phase and a thrombus (solid) phase. The transport and reactions of chemical and biological species are incorporated using a system of coupled convection-reaction-diffusion equations to represent two interacting sub-processes in thrombosis: coagulation cascade and platelet activity. Computational fluid dynamic simulations of two in vivo problems were performed using the libraries of OpenFOAM: thrombus growth in an injured straight blood vessel and TEVAR induced thrombosis in a patient-specific acute type B aortic dissection for which multiple follow-up scans are available. For both problems, the simulated thrombus formation was consistent with experimental or clinical observations, indicating the potential applicability of this modeling approach to predict the progression of dissection in patient-specific phantoms and its further use to help surgeons personalize treatment strategy for dissection patients in the future.

Neonatal outcomes in an expectantly managed prospective cohort of late preterm prelabor rupture of membranes

Neonatal outcomes in an expectantly managed prospective cohort of late preterm prelabor rupture of membranes

Perioperative and long-term outcomes after open conversion of endovascular aneurysm repair versus primary open aortic repair.

The use of endovascular abdominal aortic aneurysm repair (EVAR) has superseded that of open aneurysm repair (OAR) as the procedure of choice for abdominal aortic aneurysm repair. However, significant rates of late reintervention and aneurysm rupture have been reported after EVAR, resulting in the need for conversion to OAR (C-OAR). To assess the relative effects of C-OAR on patients, we compared the outcomes of these patients to those of patients who had undergone P-OAR. The data from all patients who had undergone C-OAR and P-OAR in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database from 2003 to 2018 were queried. Multivariable logistic regression and Kaplan-Meier survival and Cox proportional hazard regression analyses were used to assess the perioperative long-term outcomes. A total of 4763 patients were included (91.4%, P-OAR; 8.6%, C-OAR). C-OAR was associated with a significant increase in the odds of perioperative mortality (odds ratio, 1.7; 95% confidence interval [CI], 1.1-2.7; P= .027) and renal complications (odds ratio, 1.5; 95% CI, 1.1-2; P= .004) vs P-OAR. At 5years, conversion was associated with a higher risk of mortality (hazard ratio [HR], 1.5; 95% CI, 1.3-1.9; P< .001), aneurysmal rupture (HR, 1.9; 95% CI, 1.2-3.1; P= .007), and reintervention (HR, 1.4; 95% CI, 1.05-1.97; P= .022) compared with P-OAR. These results also persisted at 10years, with conversion associated with a higher risk of mortality (HR, 1.5; 95% CI, 1.2-1.8; P< .001), rupture (HR, 1.8; 95% CI, 1.1-2.8; P= .018), and reintervention (HR, 1.5; 95% CI, 1.1-2.1; P= .010). The results from the present study have demonstrated that C-OAR is associated with a significantly higher risk of perioperative morbidity and mortality compared with P-OAR. We found a significant increase in mortality, aneurysm rupture, and reintervention at 5 and 10years of follow-up.

Use of linked registry claims data for long term surveillance of devices after endovascular abdominal aortic aneurysm repair: observational surveillance study

ObjectiveTo evaluate long term outcomes (reintervention and late rupture of abdominal aortic aneurysm) of aortic endografts in real world practice using linked registry claims data.DesignObservational surveillance study.Setting282 centers in the...

Clinical presentation, operative management, and long-term outcomes of rupture after previous abdominal aortic aneurysm repair

ObjectiveThe aim of the present study was to evaluate the presentation trends, intervention, and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or endovascular aortic aneurysm repair (EVAR). MethodsWe reviewed the clinical data from a single-center, retrospective database for patients treated for LAR from 2000 to 2020. The end points were the 30-day mortality, major postoperative complication, and survival. The outcomes between LAR managed with EVAR (group I) vs OR were compared (group II). ResultsOf 390 patients with infrarenal aortic rupture, 40 (10%) had experienced aortic rupture after prior aortic repair and comprised the LAR cohort (34 men; age 78 ± 8 years). LAR had occurred before EVAR in 30 and before OR in 10 patients. LAR was more common in the second half of the study with 32 patients after 2010. LAR after prior OR was secondary to ruptured para-anastomotic pseudoaneurysms. After initial EVAR, LAR had occurred despite reintervention in 17 patients (42%). The time to LAR was shorter after prior EVAR than after OR (6 ± 4 vs 12 ± 4 years, respectively; P = .003). Treatment for LAR was EVAR for 25 patients (63%; group I) and OR for 15 (37%, group II). LAR after initial OR was managed with endovascular salvage for 8 of 10 patients. Endovascular management was more frequent in the latter half of the study period. In group I, fenestrated repair had been used for seven patients (28%). Salvage for the remaining cases was feasible with EVAR, aortic cuffs, or limb extensions. The incidence of free rupture, time to treatment, 30-day mortality (8% vs 13%; P = .3), complications (32% vs 60%; P = .1), and disposition were similar between the two groups. Those in group I had had less blood loss (660 vs 3000 mL; P < .001) and less need for dialysis (0% vs 33%; P < .001) than those in group II. The median follow-up was 21 months (interquartile range, 6-45 months). The overall 1-, 3-, and 5-year survival was 76%, 52%, and 41%, respectively, and was similar between groups (28 vs 22 months; P = .48). Late mortality was not related to the aorta. ConclusionsLAR after abdominal aortic aneurysm repair has been encountered more frequently in clinical practice, likely driven by the frequency of EVAR. However, most LARs, including those after previous OR, can now be salvaged with endovascular techniques with lower morbidity and mortality.

Late Holocene rupture history of the Ash Hill fault, Eastern California Shear Zone, and the potential for seismogenic strain transfer between nearby faults

AbstractUnderstanding how fault systems interact and transfer strain over seismogenic timescales (seconds to ka) requires temporal records of past ruptures along adjacent and intersecting fault networks. Here we document the record of Late Holocene ruptures as recorded in the geomorphology of alluvial deposits along the Ash Hill fault, in the Eastern California Shear Zone (ECSZ). We leverage a multi‐faceted approach to evaluate the relative timing of Ash Hill fault ruptures to those of nearby faults in the ECSZ. We determine the number and timing of Late Holocene earthquakes on the Ash Hill fault using high‐resolution tectono‐geomorphic mapping, a locally calibrated alluvial fan stratigraphy, feldspar luminescence dating, and fault offset analysis from field observations, LiDAR, and drone‐based digital surface elevation models. We find evidence for three surface‐rupturing earthquakes that have occurred since ~4 ka, each with ~1.0 ± 0.2 m of oblique slip per event (Mw ~ 6.9–7.0), and we constrain the timing of these earthquakes by dating deposits that bracket each event. The timing of these three ruptures is similar to the paleoseismic record along the adjacent range‐bounding fault in southern Panamint Valley. Specifically, the two adjacent faults exhibit similar numbers of earthquakes during the Late Holocene, with similar recurrence intervals and rupture timing. These data suggest that it is possible that these two faults have ruptured in the same or closely temporally related events throughout the Late Holocene. Similar spatio‐temporal clustered earthquakes have been recognized in both historic and paleoseismic records in the region, and such behaviour may be common in complexly interlinked fault networks, like those that exist in the ECSZ.

Endovascular and Hybrid Repair in Patients with Heritable Thoracic Aortic Disease

In individuals with heritable thoracic aortic disease (HTAD), endovascular repair for treatment of aortic aneurysm and dissection may be lifesaving, but is associated with increased risk of failure of endovascular repair and adverse outcomes. This study reports our experience with early and late outcomes of endovascular aortic and branch vessel repair in patients with HTAD. A retrospective case series was performed by chart review of individuals with HTAD followed at Washington University School of Medicine/Barnes-Jewish Hospital who underwent endovascular aortic and/or branch vessel repair. Clinical features, imaging characteristics, and short- and long-term outcomes were collected. Twenty-nine patients with HTAD (20 male; mean age 45±13years) underwent 37 endovascular procedures between 2006 and 2020 with mean follow up of 54±41months. Seven patients underwent two or more separate endovascular procedures. Each procedure was considered separate for data collection and analysis. Underlying conditions included Marfan syndrome (n=16 procedures), Loeys-Dietz syndrome (n=14 procedures), vascular Ehlers-Danlos syndrome (n=3 procedures), and nonsyndromic HTAD (n=4 procedures). Twenty patients (69%) had prior open surgical aortic repair. Indications for endovascular aortic repair (n=31) included urgent repairs of acute complications of aortic dissection (n=10) or aneurysm rupture (n=3), and elective aortic repair (n=18; 10 chronic dissections and eight chronic aneurysms). Six patients underwent elective endovascular repair of six branch vessel aneurysms or dissections. Six patients underwent hybrid open surgical and endovascular repair. Of the 37 procedures, 25 (68%) proximal landing zones were in the native aorta or branch vessel, 11 (30%) were in a surgical graft or elephant trunk and one was in a previously placed endograft. Thirty-six (97%) procedures were technically successful, and none required emergency surgical conversion. Two patients died: one from sepsis and one from presumed late pseudoaneurysm rupture, for a 5% per-procedure mortality rate. Two procedures were complicated by stroke and one patient developed paraparesis. Of the 31 aortic procedures, seven aortic endografts (23%) developed a stent-induced new entry (SINE) discovered with imaging at 20±15days post-procedure. Seven endografts (23%) developed a Type I endoleak and eight (26%) developed a Type II endoleak. No Type III endoleaks were seen. Within 30days, two endografts (of 37, 5%) required reintervention. After 30days, fifteen additional endografts (of 37, 41%) required reintervention. Two patients (of 6, 33%) who underwent hybrid repair required reintervention. This study is the largest single-center case series examining outcomes of HTAD patients following endovascular repair. Urgent and elective endovascular repairs in patients with HTAD can manage acute and chronic complications of aortic aneurysm and dissection with relatively low risk. However, risk of early and late endoleaks and SINE is high. Close post-procedural surveillance is required, and many individuals will require additional interventions. Hybrid repair shows promise and requires further investigation.

Late Rupture Following Endovascular Aneurysm Repair: Open or Endovascular Repair?

Late rupture following endovascular aneurysm repair (EVAR) carries significant morbidity and mortality. Traditionally treated with open surgery, there has been a growing tendency to perform repair using both simple and advanced endovascular techniques. We aimed to compare the short-term outcomes of patients with late rupture following EVAR treated with open surgery (OS) or endovascular repair (ER). A retrospective cohort study was performed using the Vascular Quality Initiative registry from January 2010 to July 2021. All patients with a prior EVAR who presented with a late rupture were included. A comparison was made of those undergoing OS or ER. Primary outcome was in-hospital mortality. Secondary outcomes included postoperative complications. A total of 264 patients (165 OS, 99 ER) underwent surgery for late rupture after EVAR. Mean age was 77.1 ± 8.0 years, and 212 patients (80.3%) were male. Comorbidities were similar between the groups, however preoperative creatinine was higher in those undergoing ER (1.8 ± 1.6 mg/dL vs 1.4 ± 0.7 mg/dL; P = .026). The preoperative mean maximum aortic diameter was 79.5 ± 23.8 mm. There was no difference in the lowest preoperative blood pressure before OS or ER (95.6 ± 29.7 mm Hg vs 93.0 ± 33.0 mm Hg; P = .526). Total procedure time (256.1 ± 124.4 minutes vs 183.9 ± 102.4 minutes; P < .0001), estimated blood loss (4230.5 ± 3759.9 mL vs 504.2 ± 841.9 mL; P < .0001), and packed red blood cell transfusion (6.6 ± 5.6 units vs 3.1 ± 3.3 units; P < .0001) were all significantly higher for open surgery. The time to extubation was significantly longer for those undergoing OS, with 7.5% being extubated in the OR and 60.6% requiring intubation for more than 24 hours, compared with 39.3% and 34.8%, respectively, of those undergoing ER (P < .0001). There was no difference in intensive care unit length of stay (9.1 ± 9.8 days vs 7.8 ± 11.9 days; P = .360) or total length of stay (15.0 ± 15.9 days vs 11.7 ± 12.5 days; P = .061) for those undergoing OS or ER. No significant difference was found in the in-hospital mortality between OS or ER (29.7% vs 30.3%; P = .917). Return to the OR (32.7% vs 17.4%; P = .007), congestive heart failure (8.0% vs 2.1%; P = .047), temporary dialysis (15.4% vs 1.0%; P = .001), and wound complications (10.5% vs 0.0%; P = .001) occurred more frequently in OS. Those undergoing ER had a higher incidence of postoperative stroke (6.2% vs 1.2%; P = .026), with those strokes being more likely to be major (P = .029). OS and ER for late rupture following EVAR have similar mortality. Those undergoing ER had lower morbidity; however, this approach was associated with a higher incidence of stroke.

Long-term Outcomes Associated With Open vs Endovascular Abdominal Aortic Aneurysm Repair in a Medicare-Matched Database

Endovascular aneurysm repair is associated with a significant reduction in perioperative mortality and morbidity compared with open aneurysm repair in the treatment of abdominal aortic aneurysm. However, this benefit decreases over time owing to increased reinterventions and late aneurysm rupture after endovascular repair. To compare long-term outcomes of endovascular vs open repair of abdominal aortic aneurysm. This multicenter retrospective cohort study used deidentified data with 6-year follow-up from the Medicare-matched Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database. Patients undergoing first-time elective endovascular or open abdominal aortic aneurysm repair from 2003 to 2018 were propensity score matched. Patients with ruptured abdominal aortic aneurysm, concomitant procedures, or prior history of abdominal aortic aneurysm repair, were excluded. Data were analyzed from January 1, 2003, to December 31, 2018. First-time elective endovascular or open repair for abdominal aortic aneurysm. The primary long-term outcome of interest was 6-year all-cause mortality, rupture, and reintervention. Secondary outcomes included 30-day mortality and perioperative complications. Among a total of 32 760 patients (median [IQR] age, 75 [70-80] years; 25 706 [78.5%] men) who underwent surgical abdominal aortic aneurysm repair, 28 281 patients underwent endovascular repair and 4479 patients underwent open repair. After propensity score matching, there were 2852 patients in each group. Open repair was associated with significantly lower 6-year mortality compared with endovascular repair (548 deaths [35.6%] vs 608 deaths [41.2%]; hazard ratio [HR], 0.83; 95% CI, 0.74-0.94; P = .002), with increases in mortality starting from 1 to 2 years (84 deaths [4.3%] vs 126 deaths [6.7%]; HR, 0.63; 95% CI, 0.48-0.83; P = .001) and 2 to 6 years (211 deaths [25.8%] vs 241 deaths [30.6%]; HR, 0.73; 95% CI, 0.61-0.88; P = .001). Open repair, compared with endovascular repair, also was associated with significantly lower rates of 6-year rupture (117 participants [5.8%] vs 149 participants [8.3%]; HR, 0.76; 95% CI, 0.60-0.97; P < .001) and reintervention (190 participants [11.6%] vs 267 participants [16.0%]; HR, 0.67; 95% CI, 0.55-0.80; P < .001). Open repair was associated with significantly higher odds of 30-day mortality (OR, 3.56; 95% CI, 2.41-5.26; P < .001) and complications. These findings suggest that overall mortality after elective abdominal aortic aneurysm repair was higher with endovascular repair than open repair despite reduced 30-day mortality and perioperative morbidity after endovascular repair. Endovascular repair additionally was associated with significantly higher rates of long-term rupture and reintervention. These findings emphasize the importance of careful patient selection and long-term follow-up surveillance for patients who undergo endovascular repair.

Management of Preterm Premature Rupture of Membranes in the Late Preterm Period

For patients who present with prelabor rupture of membrane (PROM) in the late preterm period (34 to 36 6/7 weeks), management remains unclear due to lack of consensus. However, recent guidelines have suggested that shared decision-making may be used and expectant management can be considered up to 37 0/7 weeks. In this article, we review the contemporary studies comparing the risks and benefits of immediate delivery versus expectant management for patients with late preterm prelabor rupture of membranes (PPROM). Original research articles, review articles, and guidelines on management of late PPROM. Three randomized clinical trials and 2 meta-analyses comparing expectant management and immediate delivery outcomes in late PPROM showed no significant difference in neonatal sepsis rates between groups. Expectant management increased the likelihood that pregnancies reached term while decreasing the rate of cesarean delivery. However, data suggest an increased risk of antepartum hemorrhage among patients in the expectant management groups, as well as higher rates of histologic chorioamnionitis. We recommend that clinicians offer expectant management as an alternative to immediate delivery in the setting of late PPROM through a shared decision-making process that clearly outlines the risks and benefits.

A revised paleoseismological record of late Holocene ruptures on the Kekerengu Fault following the 2016 Kaikōura earthquake

ABSTRACT The Mw 7.8 Kaikōura earthquake of November 14th, 2016 provided rare opportunities to evaluate ground deformation during a large strike-slip earthquake. Following the earthquake, both halves of a displaced paleoseismic trench were re-excavated and extended to test, refine, and extend the known late Holocene chronology of surface rupturing earthquakes on the Kekerengu Fault. 28 organic-bearing samples were collected during these excavations. Of these, six samples provided new 14C ages that could be superimposed on the preferred age model of (Little VDR, Kearse J, Norton K, Benson A, Wang N. 2018. Kekerengu fault, New Zealand: Timing and size of Late Holocene surface ruptures. Bulletin of the Seismological Society of America. 108(3B):1556–1572) to derive an expanded, updated age model of earthquake events on the fault that is now based on 16 dated samples. Including the 2016 earthquake, we recognise six surface rupturing earthquakes on the Kekerengu Fault since ∼2000 cal. B.P. Based on the last five events, our analysis yields an updated estimate of the mean recurrence interval for surface rupturing on the fault of 375 ± 32 yrs (1σ) since ∼1650 cal. B.P. An older, sixth event (E5) was not included in the preferred age model due to uncertainties in interpretation; however, incorporating this event into an alternative, six-event age model would adjust the recurrence interval estimate to 433 ± 22 yrs (1σ) since ∼2000 cal. B.P.

Single centre experience with Excluder® stent graft; 17-year outcome.

BackgroundEndovascular abdominal aortic aneurysm repair (EVAR) has become a mainstay of abdominal aorta aneurysm treatment. Long term follow-up on specific stent grafts is needed.Patients and methodsThis study included 123 patients (104 men; mean age 73.0 years, range 51–89) with abdominal aorta aneurysm, treated with Excluder® stent graft between October 2002 and June 2008. Periprocedural and follow-up data were retrieved by reviewing the records of our institution, while time and cause of death were retrieved from the National Institute of Public Health. If an abdominal aortic aneurysm rupture was listed as the cause of death, records were retrieved from the institution that issued the death certificate. Our primary goal was to assess the primary technical success rate, type 1 and type 2 endoleak, reintervention free survival, 30-day mortality, the overall survival and aneurysm rupture-free survival.ResultsThe median follow-up was 9.7 years (interquartile range, 4.6–13.8). The primary technical success was 98.4% and the 30-day mortality accounted for 0.8%. Secondary procedures were performed in 29 (23.6%) patients during the follow-up period. The one-, five-, ten-, fifteen- and seventeen-year overall survival accounted for 94.3%, 74.0%, 47.2%, 35.8% and 35.8%, while the aneurysm-related survival was 98.4%, 96.3%, 92.6%, 92.6%, 92.6%. In seven (5.7%) patients, abdominal aortic rupture was found as the primary cause of death during follow-up.ConclusionsOur data showed that EVAR with Excluder® stent graft offers good long-term results. More than 75% of patients can be treated completely percutaneously. Late ruptures do occur in the first ten years, raising awareness about regular medical controls.

Stress Radiograph Confirmation of Translational Instability After Cruciate-Retaining Total Knee Arthroplasty.

Late rupture of the posterior cruciate ligament (PCL) in cruciate-retaining total knee arthroplasty (TKA) can lead to increased AP instability. This results in increased stress on the medial hamstrings resulting in hamstring-based pain. We looked to identify patients with late PCL failure using a lateral stress radiograph. A prospective cohort analysis was completed at a single institution. Eligible patients were divided into two groups based on the amount of anterior knee pain. Pain was defined as a visual analog scale of greater than or equal to 3. Each group completed a visual analog scale, Knee Injury and Osteoarthritis Outcome Score Junior, Patient-Reported Outcome Measurement Information System score and underwent a lateral posterior stress/nonstress radiograph. Amount of posterior translation and posterior tibial slope was measured. Patients who had painful TKAs at the follow-up had lower Knee Injury and Osteoarthritis Outcome Score Junior (45.86 ± 13.52 versus 78.00 ± 13.26 P < 0.001). Those patients were also found to have significantly higher posterior tibial translation with stress radiograph (6.89 ± 1.874 versus 3.91 ± 2.15 mm P < 0.001) and significantly increased tibial slope (6.51 ± 2.37° versus 3.98 ± 1.79°, P = 0.004). Seven of the 14 patients in the pain group underwent revision surgery, with 6 patients found to have incompetent PCLs. Patients with increased AP translation and increased posterior tibial slope after cruciate-retaining TKA are likely to have worse pain and outcome measures.