Mean Abdominal Aortic Aneurysm Diameter Research Articles

Use of the GORE Conformable Excluder Device in Highly Angulated Aortic Neck Anatomy: Mid-term Outcomes.

Patients with complex aortic anatomy require meticulous surgical planning to optimize intraoperative and postoperative outcomes. The GORE Excluder Conformable Abdominal Aortic Aneurysm Endoprosthesis (CEXC Device, WL Gore and Associates, Flagstaff, AZ) allows for endovascular treatment of highly angulated and short proximal neck abdominal aortic aneurysms (AAA). Owing to its recent approval, short-term clinical outcomes of this device remain scarce. In this report, we present a case series of 3 patients who underwent endovascular aortic repair using the GORE Excluder Conformable device with highly angulated (>70°) aortic neck anatomy. Endografts were deployed in a radiology suite using standard 2D angiography in conjunction with a CYDAR Medical (Wilmington, Delaware) reconstructed 3D overlay. The patients' ages were 85, 67, and 85 years. The mean abdominal aortic aneurysm diameter in these cases was 6.9cm. The mean proximal neck length was 2.1cm, proximal mean neck angulation was 83°. The mean operative time, total fluoroscopy time, and contrast used were 208 minutes, 28.3°minutes, and 94.5milliliters, respectively. No adjunctive procedures, such as proximal cuff or endo-anchors, were performed at the time of index procedure. Type Ia endoleak was observed in 1 patient post-operatively but after treatment with an aortic cuff there was no evidence of enlarging aneurysm sac. The GORE Excluder Conformable Endoprosthesis expands access to endovascular management of AAAs. Our early experience with this device demonstrated excellent patient and clinical outcomes in a highly angulated neck anatomy.

Preoperative risk score for mortality within 3 years of visceral segment fenestrated endovascular aortic repair

ObjectiveThe purpose of this study was to create a risk score for the event of mortality within 3 years of complex fenestrated visceral segment endovascular aortic repair utilizing variables existing at the time of preoperative presentation. MethodsAfter exclusions, 1916 patients were identified in the Vascular Quality Initiative who were included in the analysis. The first step in development of the risk score was univariable analysis for the primary outcome of mortality within 3 years of surgery. χ2 analysis was performed for categorical variables, and comparison of means with independent Student t-test was performed for ordinal variables. Variables that achieved a univariable P value less than 0.1 were then placed into Cox regression multivariable time dependent analysis for the development of mortality within 3 years. Variables that achieved a multivariable significance of less than 0.1 were utilized for the risk score, with point weighting based on the beta-coefficient. Variables with a beta coefficient of 0.25 to 0.49 were assigned 1 point, 0.5 to 0.74 2 points, 0.75 to 0.99 3 points, and 1.0 to 1.25 4 points. A cumulative score for each patient was then summed, the percentage of patients at each score experiencing mortality within 3 weeks was then calculated, and a comparison of score outcomes was conducted with binary logistic regression. Area under the curve analysis was performed. ResultsThe primary outcome of mortality within 3 years of surgery occurred in 12.8% of patients (245/1916). The mean age for the study population was 73.35 years (standard deviation [SD], 8.26 years). The mean maximal abdominal aortic aneurysm (AAA) diameter was 60.43 mm (SD, 10.52 mm). The mean number of visceral vessels stented was 3.3 (SD, 0.76). Variables present at the time of surgery that were included in the risk score were: hemodialysis (3 points); age >87, chronic obstructive pulmonary disease, hypertension, AAA diameter >77 mm (all 2 points); and body mass index <20 kg/m2, female sex, congestive heart failure, active smoking, chronic renal insufficiency, age 80 to 87 years, and AAA diameter 67 to 77 mm (all 1 point). BMI >30 kg/m2 (mean, 34.46 kg/m2) and age <67 years were protective (−1 point). Testing the model resulted in an area under the curve of 0.706. Hosmer and Lemeshow goodness of fit test for logistic regression utilizing the 15 different risk score total groups revealed a model predictive accuracy of 87.3%. Significant escalations in 3-year mortality were noted to occur at scores of 6 and greater. Mean AAA diameter was significantly larger for patients who had higher risk scores (P < .001). ConclusionsA novel risk score for mortality within 3 years of fenestrated visceral segment aortic endograft has been developed that has excellent accuracy in predicting which patients will survive and derive the strongest benefit from intervention. This facilitates risk-benefit analysis and counseling of patients and families with realistic long-term expectations. This potentially enhances patient-centered decision-making.

Acute kidney injury after surgical treatment of failed endovascular aneurysm repair.

This study aims to report the incidence of acute kidney injury following surgical reconstruction after a failed endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysms. This retrospective study included 44 patients (39 males, 5 females; mean age: 70±11.3 years; range, 35 to 84 years) who underwent emergency or elective surgical reconstruction after failed EVAR between February 2015 and January 2019. Patients were divided into two groups: acute kidney injury group and no acute kidney injury group. The primary end-point of the study was to evaluate the development of acute kidney injury following surgery. The secondary end-points included the 30-day and one-year mortality rates. Surgical reconstruction of the abdominal aorta was performed electively in 29 (65.9%) patients and urgently in 15 (34.1%) patients. Acute kidney injury occurred in 12 (27.3%) patients. The interval from endovascular aneurysm repair to surgical reconstruction was statistically significantly higher in the no acute kidney injury group than in the acute kidney injury group (24.6±11.5 and 18.1±13.3 months, respectively; p=0.145). The mean abdominal aortic aneurysm diameter, neck angulation, and neck diameter were statistically significantly higher in the acute kidney injury group than in the no acute kidney injury group (p=0.001, p=0.009, and p<0.001, respectively). No statistically significant difference was observed between the acute kidney injury and no acute kidney injury groups for the overall 30-day mortality (p=0.185) and oneyear mortality (p=0.999). Acute kidney injury is not uncommon after the surgical reconstruction of a failed EVAR. Aneurysm-related anatomical factors may have an impact on the development of postoperative acute kidney injury. Comprehensive surgical planning should be performed for open abdominal aortic surgery after a failed EVAR.

Long-term clinical outcomes of EVAR within IFU compared to outside IFU

Abstract Background Endovascular aneurysm repair (EVAR) has been used worldwide to treat abdominal aortic aneurysm (AAA). Outcomes after EVAR between within instruction for use (IFU) and outside IFU are still controversial. We analyzed long term outcomes of EVAR within IFU compared to EVAR outside IFU and baseline clinical/anatomical characteristics that influence outcomes of EVAR. Methods We collected data from 766 patients (mean age 71.0 ± 12.5 years, male 90.2%) who underwent EVAR for infrarenal AAA between August 1997 and July 2021 at two centers in Korea. The primary endpoint was aneurysm related mortality (ARM) during follow up. The secondary outcomes were endoleak, reintervention and aneurysm sac enlargement. Results The mean AAA diameter is 59.0 ± 12.2 mm. The proportion of patients underwent EVAR outside IFU was 62.7% (n=466). Neck angle &amp;gt; 60 degree was the most common outside IFU criterion (n=210, 27.4%). The median clinical and imaging follow-up duration was 36.5 and 51.0 months, respectively. Total 110 patients (14.8%) had complications during follow up. The outside IFU group had more complications compare to the within IFU group (p=0.033). Overall mortality rate was 8.8% (n=60). ARM occurred in 0% of patients with EVAR within IFU and in 7 (1.5%) of patients with EVAR outside IFU (p=0.041), respectively. There was no significant difference in incidence of endoleak (28.5 vs. 23.1%, p=0.173), reintervention rate (8.4 vs. 9.3%, p=0.688) and aneurysm sac enlargement (23.6 vs. 23.4%, p=0.957) between patients underwent EVAR within IFU and outside IFU group. In multivariate analysis, proximal neck diameter &amp;gt; 28 mm was independent risk factor for ARM (HR, 9.132; 95% CI, 1.684 – 49.516, P=0.010). In addition, proximal neck angle &amp;gt; 60 degree was independent risk factor for endoleak (HR, 1.553; 95% CI, 1.042 – 2.314, P=0.031) and reintervention (HR, 2.297; 95% CI, 1.333 – 3.955, P=0.003). Neck length &amp;lt; 10 mm and neck diameter &amp;gt;28 mm were risk factors for aneurysm sac enlargement (HR, 4.363; 95% CI, 1.252 – 15.211, P=0.021 and HR, 3.148; 95% CI, 1.261 – 7.859, P=0.014). Age over 75 was also a risk factor for endoleak (HR, 2.491; 95% CI, 1.666 – 3.726, P=0.000) and aneurysm sac enlargement (HR, 3.150; 95% CI, 1.536 – 6.458, P=0.002). Conclusions Our study showed EVAR outside IFU is associated higher ARM compared to EVAR within IFU. In addition, neck angulation was risk factor for endoleak and reintervention. Clinicians should be caution when they perform EVAR outside IFU and select optimal patient for successful EVAR.

Delays in Treatment Are Associated With Increased Mortality in Patients Undergoing Endovascular Repair of Abdominal Aortic Aneurysms

This study aims to evaluate the association between delays in treatment and outcomes after endovascular aneurysm repair (EVAR). A retrospective analysis of consecutive patients undergoing EVAR for abdominal aortic aneurysm (AAA) between January 1998 and December 2019 was performed. Patients undergoing early EVAR (within less than 8 weeks after meeting size threshold for repair) were compared with delayed EVAR (8 weeks or more). The primary outcome was freedom from all-cause mortality. Secondary outcomes were sac regression (defined as a reduction in AAA diameter by 5 mm or more), freedom from reinterventions, 30-day mortality, and complications. Variables were compared using the χ2 test or the Student t test as appropriate. Kaplan-Meier survival curves and Cox regression proportional hazards models were used. A P value of <.05 was considered significant. The study consisted of 513 patients (83% male) with 33% (n = 170) and 67% (n = 343) undergoing early and delayed EVAR, respectively. Early EVAR patients had a larger mean AAA diameter (60 ± 13 mm vs 54 ± 7 mm in delayed EVAR; P < .001). There were no major differences in medical comorbidities between the groups (Table). Operative timing was longer in the early group (119 ± 42 minutes vs 108 ± 45 minutes in delayed; P = .019). Kaplan-Meier survival estimates show that freedom from all-cause mortality was 90% in early EVAR vs 82% in delayed EVAR (P = .023; Fig) at a mean of 25.8 months. Sac regression was similar between the two groups at 54% and 45% for early and delayed EVAR, respectively (P = .304). In addition, freedom from reinterventions was 78% in early EVAR and 83% in delayed EVAR (P = .364). Perioperative mortality was 0% in both groups. Perioperative complication rates were similar at 11% and 9% in early and delayed EVAR, respectively. The Cox regression proportional hazards model showed that delayed EVAR predicted increased mortality (hazard ratio: 1.886, 95% confidence interval [CI]: 1.083-3.285; P = .025). The effect persisted after adjusting for age, AAA diameter, and comorbidities (hazard ratio: 2.597, 95% CI: 1.350-4.998; P = .004). Patient undergoing EVAR within less than 8 weeks after meeting indications for repair tend to have larger aneurysms. Delaying EVAR beyond 8 weeks was associated with increased all-cause mortality after adjusting for preoperative AAA diameter, age, and comorbidities. These findings suggest the need to adopt a pathway that permits expedited treatment within 8 weeks of meeting indications for repair.TableBaseline characteristics of early and delayed EVAR patientsCharacteristicEarlyDelayedP valueAge, mean (SD), years77 (8)77 (8).873Male sex, % (No.)87 (147)80 (275).090Mean AAA diameter, mean (SD), mm60 (13)54 (7)<.001Comorbidities, % (No.) Cardiac37 (63)37 (127).994 Respiratory21 (36)25 (87).296 Hemodialysis01 (4).157 HTN48 (82)55 (189).143 DM12 (20)15 (50).382 Dyslipidemia47 (79)56 (191).049 PAD11 (18)10 (34).811 Active or previous cancer14 (23)11 (36).316 Active smoking15 (24)20 (66).137Medications, % (No.) β-Blockers31 (52)34 (116).437 ACEI/ARB24 (41)34 (116).022 CCB18 (30)21 (73).326 Statin41 (70)53 (182).010 Antiplatelets38 (65)51 (175).006 Anticoagulation11 (19)11 (36).815AAA, Abdominal aortic aneurysm; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blockers; DM, diabetes mellitus; EVAR, endovascular aortic repair; HTN, hypertension; PAD, peripheral arterial disease. Open table in a new tab

Association Between Obesity and Outcomes Following Endovascular Aneurysm Repair

Obesity is prevalent in patients with abdominal aortic aneurysms (AAA). There is an association between increasing body mass index (BMI) and increased overall cardiovascular mortality and morbidity. This study aims to assess the difference in mortality and complication rates between normal weight (NW), overweight (OW), and obese patients undergoing endovascular aneurysm repair (EVAR) for infrarenal AAA. This is a retrospective analysis of consecutive patients undergoing EVAR for AAA between January 1998 and December 2019. Weight classes were defined as: BMI<18.5kg/m2, underweight; BMI 18.5-24.9kg/m2, NW; BMI 25.0-29.9kg/m2, OW; BMI 30.0-39.9kg/m2, obese; BMI>39.9kg/m2 morbidly obese. Primary outcomes were long-term all-cause mortality and freedom from reintervention. Secondary outcome was aneurysm sac regression (defined as a reduction in sac diameter of 5mm or more). Kaplan-Meier survival estimates and mixed model analysis of variance were used. The study included 515 patients (83% males, mean age 77±8years) with a mean follow-up of 3.8±2.8years. In terms of weight class, 2.1% (n=11) were underweight, 32.4% (167) were NW, 41.6% (n=214) were OW, 21.2% (n=109) were obese, and 2.7% (n=14) were morbidly obese. Obese patients were younger (mean difference -5.0years) but had a higher prevalence of diabetes mellitus (33.3% vs. 10.6% for NW) and dyslipidemia (82.4% vs. 60.9% for NW). Obese patients had similar freedom from all-cause mortality (88%) compared to OW (78%) and NW (81%) patients. The same findings were evident for freedom from reintervention where obese (79%) was similar to OW (76%) and NW (79%). At a mean follow-up of 5.1±0.4years, sac regression was observed similarly across weight classes at 49.6%, 50.6%, and 51.8% for NW, OW, and obese, respectively (P=0.501). There was a significant difference in mean AAA diameter pre- and post-EVAR [F(2,318)=24.37, P<0.001] across weight classes. NW [mean reduction 4.8mm (2.0-7.6mm, P<0.001)], OW [mean reduction 3.9mm (1.5-6.3mm, P<0.001)], and obese [mean reduction 5.7mm (2.3-9.1mm, P<0.001)] achieved similar reductions. Obesity was not associated with increased mortality or reintervention in patients undergoing EVAR. Obese patients achieved similar rates of sac regression on imaging follow-up.

Abdominal Aortic Aneurysm Morphology in the Chinese Population and Endovascular Aortic Aneurysm Repair Eligibility

Introduction: The current commercial endovascular abdominal aortic stent grafts are designed based on the anatomical data from the Western population. Objective: To investigate the morphological features of abdominal aortic aneurysm (AAA) in a Chinese cohort and its clinical implications. Methods: It was a retrospective, observational study. The preoperative computed tomography angiogram (CTAs) of patients who underwent endovascular aortic aneurysm repair (EVAR) from January 01, 2015 to December 31, 2020, were analyzed. A predefined set of AAA morphological measurements was taken. The eligibility of EVAR with current commercially available stent grafts on the market was examined. Results: A total of 210 cases were studied. The mean AAA diameter was 64.3 mm. The mean proximal and distal neck diameters were 22.9 mm and 24.4 mm, respectively, whereas the mean neck length was 23.8 mm and the mean infra-renal angle was 51.6°. The right and left mean common iliac arteries (CIAs) diameters were 21.2 mm and 18.3 mm. The right and left mean CIA lengths were 35.7 mm and 37.3 mm. The mean external iliac artery (EIA) diameter was 8.3 mm bilaterally. Female gender was associated with significantly smaller neck diameters, smaller EIA diameters, and larger infra-renal angle. EVAR eligibility ranged from 16%–37% and was significantly lower in females. Conclusions: The majority of Chinese patients with AAA did not meet the anatomical eligibility for EVAR, with neck angulation being the major deterrent. Female patients posed an additional anatomical challenge due to larger infra-renal angle and smaller iliac access diameter. The development of low-profile angulated neck-compatible EVAR devices may expand EVAR applicability in future.

A Systematic Review and Meta-Analysis of Laparoscopic Ligation of the Inferior Mesenteric Artery for the Treatment of Type II Endoleaks

Objectives: Type II endoleak (T2E), often generated by persistent retrograde flow through the inferior mesenteric artery (IMA) is the most frequent complication following endovascular aortic aneurysm repair (EVAR). T2E treatment revolves around transarterial and translumbar embolization of the feeding artery and/or sac, with mediocre results. The aim of this study is to assess the safety feasibility and efficacy of laparoscopic IMA ligation for the treatment of T2E. Methods: We conducted a systematic electronic research on Medline, Scopus, EMBASE, and Cochrane Library according to Preferred Reporting Items for Systematic Review and Meta-Analysis protocol (PRISMA) for articles published up to February 2022, describing laparoscopic IMA ligation for the treatment of T2E. Publications describing hand assisted or prophylactic IMA ligation were excluded. A metanalysis was performed utilizing both the random and common effects model and the DerSimonian and Laird method. Additionally, we carried out a post hoc power analysis. Results: Fifteen studies, including one prospective case series (CS), five retrospective CS and nine case reports, including 33 patients (91% male) met the inclusion criteria. The mean abdominal aortic aneurysm diameter at the time of diagnosis was 58.8 mm. The mean operational duration was 117.5 minutes. The mean follow-up for the included studies was 17 months. The mean reported time of T2E identification was 9.1 months post-intervention, while the mean reported aneurysmal sac diameter increase at the time of diagnosis was 11.5 mm. T2E type a (T2aE) and type b (T2bE) patterns were 57.6% and 42.4% respectively. Six CS incorporating 24 patients were included in the meta-analysis. The pooled technical success and postoperative mortality rates are 100% (95% CI: 93.13–100), (I2 = 0.0%, p = 0.99) (power = 99%) and 0.00% (95% CI: 0.00–6.87) (I2 = 0.0%, p = 0.99). The pooled reintervention and conversion to open surgical repair rates are 15.08% (95% CI: 0.79–37.28), (I2 = 0.0%, p = 0.66) (power = 13.6%), and 0.69% (95% CI: 0.00–14.80) (I2 = 0.0%, p = 0.99) (power = 7.05%) respectively. Conclusions: We demonstrated the safety and feasibility of IMA ligation for the treatment of T2E. Definitive conclusions about its efficacy cannot be drawn due to underpowered results warrantying further research. Identification and proper classification of T2E remain an obstacle affecting treatment outcomes and reintervention rates throughout the entire spectrum of available treatments.

Extent of mural thrombus is not associated with increased 5-year mortality following elective AAA repair.

Mural thrombus in abdominal aortic aneurysm (AAA) has been associated with increased rates of aneurysm growth as well as adverse cardiovascular events. The extent of mural thrombus in thoracoabdominal aortic aneurysms has recently been linked to 1-year mortality following endovascular repair and has been hypothesized as a marker for reduced cardiac reserve. This study investigates whether the extent of mural thrombus in infra-renal AAA is associated with 5-year mortality following elective repair. Retrospective review of all patients undergoing elective infra-renal AAA repair at a single academic medical center between 2007 and 2016 was performed. The following variables at the time of surgery were investigated for association with 5-year mortality: age, sex, ethnicity, insurance status and co-morbidities, repair type, renal insufficiency, end-stage renal disease on dialysis, history of smoking, coronary artery disease, congestive heart failure, diabetes mellitus, hypertension, stroke, chronic obstructive pulmonary disease, body mass index category, AAA diameter, and ratio of aortic thrombus to total aneurysm diameter. Amongst 427 patients undergoing infra-renal AAA repair during the study period, 232 met extensive inclusion criteria. Univariate analysis found mean age (76 vs 72, p < 0.01), age cohort over 72 years (OR = 1.9, p = 0.04), renal insufficiency (OR = 3.1, p < 0.01), ESRD (OR = 6.5, p < 0.01), AAA diameter 6cm or greater (OR = 2.3, p < 0.01), and mean AAA diameter (61.36vs 56.99mm, p < 0.01) all predictive of 5-year mortality. Multivariate analysis revealed renal insufficiency (p < 0.01) and AAA diameter 6cm or greater (p = 0.03) to be significantly associated with 5-year mortality. The extent of mural thrombus was identical between 5-year survivors and non-survivors. The mean inner to outer AAA diameter was 0.65 in the survivor cohort and 0.64 in the mortality cohort. Inner to outer ratio of < 0.5 was identified in 23% of 5-year survivors and 27% of the mortality group. In our experience, the extent of mural thrombus in AAA does not influence long-term survival after elective repair. AAA repair may provide protection against circulating components of mural thrombus which have the potential to promote atherosclerotic-related adverse events. Patients with renal insufficiency and larger AAA have increased risk of mortality 5 years after elective repair.

Can endovascular repair be the first-line treatment option in abdominal aortic aneurysms during COVID-19 pandemic?

Objectives: This study aims to investigate the effectiveness of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) during the novel coronavirus-2019 (COVID-19) pandemic. Patients and methods: A total of 22 patients (17 males, 5 females; mean age: 76.7±7.1 years; range, 66 to 90 years) who underwent EVAR for AAAs in our center between March 2020 and December 2020 were retrospectively analyzed. All patients underwent reverse transcriptase- polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection. All EVAR procedures were performed under spinal anesthesia in the elective setting in the angiography laboratory. Results: The RT-PCR test result was positive in six patients with asymptomatic infection. The mean AAA diameter was 74.7±5.5 (range, 68.50 to 85.60) mm. Stent-graft implantation was successfully performed in all patients. There was no significant relationship between the mean age and examined variables (p&gt;0.050). The mean AAA diameter was 83.95 mm in the COVID-19-positive patients and 71.50 mm in the COVID-19-negative patients, indicating a significant difference (p=0.001). No mortality, stent migration or thrombotic events were observed during the first 30 days of follow-up. Conclusion: The operation can be delayed in patients requiring open surgical repair or in those with small AAAs. Based on our findings, the EVAR can be used as the first-line treatment option during the pandemic, as it does not require intubation and requires a low number of staff and is cost-effective with minimum necessity for intensive care unit stay and less use of healthcare resources.

Ten-year single center experience in elective standard endovascular abdominal aortic aneurysm repair.

Endovascular aneurysm repair (EVAR) has become the treatment of choice for abdominal aortic aneurysm (AAA), demonstrating excellent early outcomes. However, EVAR durability has been questioned in the long-term period. The aim of this study was to assess EVAR outcomes in terms of survival and freedom from re-intervention during a long-term period. All consecutive patients being treated, with elective standard EVAR, in a single tertiary center, were included between 2008 and 2018. Outcomes were defined as survival and freedom from re-intervention and were reported using Kaplan-Meyer lifetables. In subgroup analyses, sex, age (threshold at 65 and 80 years), neck diameter>28mm and type of fixation were also analyzed. Type of re-intervention and endoleak type I (ETIa) were also reported. Five hundred and eight patients (94% males, mean age 72±7.3, mean AAA diameter 59±9mm) were included. The median follow-up was 3 years (range 0-10 years). The survival rate was 92.8% (SE 1.5%), 76.5% (SE 3.1%) and 41.6% (SE 6%), at 2, 5 and 10 years of follow-up, respectively. In total, 78 patients died; 8 deaths (8/75, 10%) were aneurysm related. In multivariate regression analysis, age (CI. 1.02-1.14; p=0.006) and ever tobacco use (CI. 1.02-6.12, P=0.045) were associated with the long-term mortality. Freedom from re-intervention was 96% (SE 1.1%), 93% (SE 1.8%), 85.5% (SE 5%) at 2, 5 and 9 years of follow-up. Limb occlusion was a common complication (n/n; 30% of re-intervention), particularly within the first 2 postoperative years. Six patients presented with rupture and were treated with open conversion. EVAR cases with supra-renal fixation graft presented lower rates of ETIa (CI. 76-87.27, P<0.001). Elective standard EVAR is associated with good long-term survival showing low aneurysm-related mortality. Common risk factors such as advanced age and smoking are associated to higher mortality. The procedure presents low re-intervention rates, while limb occlusion is a complication presented within the first 2 postoperative years.

Safety of transition from a routine to a selective intensive care admission pathway after elective open aneurysm repair

BackgroundThere is a growing trend to implement intermediate care units to avoid unnecessary costs associated with intensive care unit (ICU) admission and associated resources. We sought to evaluate the safety of transitioning from a routine to a selective policy of postoperative transfer to the ICU for elective open abdominal aortic aneurysm (AAA) repair.MethodsThis retrospective study included consecutive open elective AAA repair procedures performed at a single centre from Aug. 8, 2010, to Dec. 1, 2014. Patients were identified through a prospectively maintained database, and electronic charts were reviewed. Patients with interventions before Mar. 13, 2012, were routinely sent to the ICU after operation (group A). Patients treated after this date were sent directly to an intermediate care unit (group B) unless preoperative or intraoperative factors deemed them suitable for ICU admission. The primary outcome was in-hospital death; secondary outcomes were perioperative complications and length of stay. We used logistic and linear regression to determine the association between the use of an intermediate care unit and the primary and secondary outcomes after adjusting for confounders and clinically relevant covariates.ResultsThe cohort comprised 310 patients (266 men, 44 women) with a mean age of 69.7 (standard deviation 10.1) years and a mean AAA diameter of 61.2 mm (SD 9.6 mm). Groups A and B included 118 and 192 patients, respectively. Admission to the ICU was spared in 149 patients (77.6%) in group B. Only 2 patients (1.3%) in group B were subsequently admitted to the ICU. There was no statistically significant difference in in-hospital mortality or perioperative complications between the 2 groups on multivariable logistic regression. There was a nonsignificant trend toward slightly shorter length of stay in group B.ConclusionIn this single-centre experience with the majority of patients sent directly to an intermediate care unit, there was no statistically significant difference in mortality or morbidity between routine and selective ICU admission. Our results confirm the safety of a selective ICU admission pathway.

Assessment of Correlation Between Mean Size of Infrarenal Abdominal Aortic Aneurysm at Time of Intact Repair Against Repair and Rupture Rate in Nine Countries

This study aimed to analyse the mean abdominal aortic aneurysm (AAA) diameter for repair in nine countries, and to determine variation in mean AAA diameter for elective AAA repair and its relationship to rupture AAA repair rates and aneurysm related mortality in corresponding populations.

Editor's Choice – Assessment of Correlation Between Mean Size of Infrarenal Abdominal Aortic Aneurysm at Time of Intact Repair Against Repair and Rupture Rate in Nine Countries

This study aimed to analyse the mean abdominal aortic aneurysm (AAA) diameter for repair in nine countries, and to determine variation in mean AAA diameter for elective AAA repair and its relationship to rupture AAA repair rates and aneurysm related mortality in corresponding populations. Data on intact (iAAA) and ruptured infrarenal AAA (rAAA) repair for the years 2010-2012 were collected from Denmark, England, Finland, Germany, Hungary, New Zealand, Norway, Sweden, and the USA. The rate of iAAA repair and rAAA per 100000 inhabitants above 59 years old, mean AAA diameter for iAAA repair and rAAA repair, and the national rates of rAAA were assessed. National cause of death statistics were used to estimate aneurysm related mortality. Direct standardisation methods were applied to the national mortality data. Logistic regression and analysis of variance model adjustments were made for age groups, sex, and year. There was a variation in the mean diameter of iAAA repair (n=34566; range Germany=57mm, Denmark=68mm). The standardised iAAA repair rate per 100000 inhabitants varied from 10.4 (Hungary) to 66.5 (Norway), p<.01, and the standardised rAAA repair rate per 100000 from 5.8 (USA) to 16.9 (England), p<.01. Overall, there was no significant correlation between mean diameter of iAAA repair and standardised iAAA rate (r2 = 0.04, p = .3). There was no significant correlation between rAAA repair rate (n=12628) with mean diameter of iAAA repair (r2 = 0.2, p = .1). Despite recommendations from learned society guidelines, data indicate variations in mean diameter for AAA repair. There was no significant correlation between mean diameter of AAA repair and rates of iAAA repair and rAAA repair. These analyses are subject to differences in disease prevalence, uncertainties in rupture rates, validations of vascular registries, causes of death and registrations.

Infrarenal Abdominal Aortic Aneurysm Endovascular Treatment: Long-term Results From a Single-Center Experience in an Unselected Patient Population

The aim of the present study was to evaluate early-, mid-, and long-term outcomes in an unselected population of patients treated for abdominal aortic aneurysms (AAAs) by endovascular aneurysm repair (EVAR) with different commercially available off-the-shelf devices. A retrospective study was conducted on a prospectively compiled computerized database on patients presenting an infrarenal AAA treated between January 2008 and December 2015 in a high-volume Italian tertiary referral Center. Demographic, clinical, and specific morphological features were considered as potentially influencing the outcomes and the type of the implanted device. Outcome measures were procedure-related reintervention, AAA-related, and all-cause mortality rates at 30-day, 12-month, and long-term follow-up. Reinterventions considered for the analysis were AAA rupture, graft infection, type I or III endoleaks, type II endoleaks with sac enlargement > 5mm, graft stenosis or occlusions, procedures related to renal or visceral ischemia, and reintervention for access vessel injury. Of 498 EVAR procedures performed for elective infrarenal AAA treatment during the entire study period, 479 patients were enrolled, the mean age was 73.5±7.34years (range 51-91), and 416 (86.84%) were men. The mean maximum AAA diameter was 52.02±8.04mm (range 39-90.2), a maximum AAA diameter ≥59mm was recorded in 107 patients (22.33%), and an aortic neck length was <10mm in 137 (28.60%). Technical success was achieved in all patients. At a mean follow-up of 52.97±26.16months (range 1-120), overall reintervention and death rates were 8.14% and 20.04%, respectively, without AAA-related deaths. At univariate analysis, hypertension was the only demographical variable found to be associated with higher risk of reintervention, P=0.04 (OR: 2.34; CI 95%: 1.00-5.42). Furthermore, male sex (P=0.02; OR: 2.62; CI 95%: 1.09-6.27) and chronic renal insufficiency (P=0.003; OR: 2.08; CI 95%: 1.27-3.42) were associated with higher mortality rates. AAA diameter ≥59mm was statistically associated with a higher rate of both reintervention and mortality: P<0.001 (OR: 9.05; CI 95%: 4.52-18.11) and <0.001 (4.00; 2.46-6.49), respectively. Our experience seems to suggest that EVAR could be safely and effectively performed in an unselected patients' population, with encouraging results up to a ten-year follow-up.

Long-term Results of 180 Consecutive Patients with Abdominal Aortic Aneurysm Treated with the Endurant Stent Graft System

Registry studies have shown that the Endurant stent graft is associated with low rates of all-cause and aneurysm-related mortality when used for the endovascular treatment of abdominal aortic aneurysm (AAA). However, many were limited by length of follow-up and all had a proportion of patients lost to follow-up. The aim of this study is to report results from a large, real-world experience using Endurant, utilizing methods to ensure complete ascertainment of mortality. This study describes a large, single vascular unit experience using the Endurant stent graft in consecutive patients treated between August 2008 and March2019. One-hundred eighty patients (mean age 76.0±8.6years; 90% male) with mean AAA diameter of 57.5±10.5mm underwent endovascular aneurysm repair (EVAR). Technical success was achieved in all cases. At median follow-up of 55.0months (interquartile range 29.8-79.0), 51 (28.3%) patients had died. Kaplan-Meier estimate of 5-year overall survival and freedom from aneurysm-related death was 71.6% and 99.4%, respectively. Lower survival rates were observed in patients who underwent EVAR at age ≥80years (59.2% vs. 78.3%, P<0.01) and with aneurysm diameter ≥70mm (55.6% vs. 73.8%, P=0.03). Thirteen endoleaks (7.2%; 4 type 1A, 2 type 1B, 7 type 2) were observed during follow-up (mean time from implantation 8.7±4.2, range 1-52 months). Eleven patients (6.1%) required secondary intervention for limb occlusion (n=7), endoleak (n=3), and restenosis (n=1). Patients treated within (n = 104; 57.8%) and outside (n = 76; 42.2%) the manufacturer's instructions for use (IFU) had similar rates of endoleak (7 [6.7%] vs. 6 [7.9%]; P = 0.76), secondary re-intervention (7 [6.7%] vs. 4 [5.3%]; P = 0.74) and overall-survival (72 [69.2%] vs. 55 [72.3%]; P = 0.46). Results from this real-world study of consecutive patients treated for AAA using the Endurant stent graft demonstrate that it is safe and effective, with excellent long-term outcomes for anatomy that falls both inside and outside IFU recommendations.

Prevalence of Previously Undiagnosed Abdominal Aortic Aneurysms in Patients With Intracranial Aneurysms: From the Brain and Aortic Aneurysms Study (BAAS)

Single institution prospective observational inception cohort study from the Mayo Clinic Florida in Jacksonville, Florida, between August 14, 2011, and February 10, 2014. Of 81 consecutive patients, 10 (12%) with aneurysmal subarachnoid hemorrhage were found to have abdominal aortic aneurysms (AAAs) on ultrasound screening. The mean AAA diameter was 3.4 cm. The prevalence of AAA in patients with ruptured intracranial aneurysms may be high enough in surviving patients to justify AAA screening.

Prevalence of Previously Undiagnosed Abdominal Aortic Aneurysms in Patients With Intracranial Aneurysms: From the Brain and Aortic Aneurysms Study (BAAS)

Single-institution prospective observational inception cohort study from the Mayo Clinic Florida in Jacksonville, Florida, between August 14, 2011, and February 10, 2014. On ultrasound screening, 12% (10) of 81 consecutive patients with aneurysmal subarachnoid hemorrhage were found to have abdominal aortic aneurysms (AAAs). The mean AAA diameter was 3.4 cm. The prevalence of AAA in patients with ruptured intracranial aneurysms may be high enough in surviving patients to justify AAA screening.

Long Term Outcomes Following Emergency Endovascular Aneurysm Repair - A Single Centre Series

Introduction - Recent randomised trials have shown equivalence between open and endovascular repair of ruptured abdominal aortic aneurysm (AAA) in the short term. Compared to open repair, re-intervention is more common following elective endovascular aneurysm repair (EVAR) and in the longer-term aneurysm related mortality is higher due to secondary sac rupture. There are, however, relatively few studies in the field describing the durability of emergency EVAR. Methods - We analysed data from all emergency EVARs (eEVAR) for ruptured AAA performed in an East of England tertiary centre (Addenbrooke’s Hospital) between January 1, 2006, and December 31, 2016. Progress after the initial eEVAR was recorded up until the end of March 2017 for all patients (n=126). The primary outcome measures included mortality rates, re-intervention rates, rates of secondary sac rupture, rates of endoleaks, and the time interval to these notable events. Results - 126 eEVARs were performed during the assigned 11-year time period from which patient data was analysed. The mean age of patients at the point of eEVAR was 77.4 years and 87% were males. The mean AAA diameter at the point of rupture was 8.1 cm. Mortality at 30 days, 1 year and 5 years was 15%, 25% & 50% respectively. There were 6 secondary sac ruptures, with an average time to rupture of 5 years post-eEVAR. Incidence of secondary sac rupture in our data was 1.2 per 100 person years. Secondary sac ruptures were due to type 1a endoleak (n=2), type 1b endoleak (n=2) and type 3 endoleak. In total, 13 Type I endoleaks and 3 Type III endoleaks were identified. 39 out of 126 patients underwent at least one vascular re-intervention post-eEVAR comprising 30.7% of the patient cohort with an average time interval to 1st re-intervention of 2.03 years. There were 69 re-interventions recorded in total. Conclusion - Early and late outcomes following eEVAR are acceptable. Re-interventions are relatively common and there is an incidence of secondary sac rupture therefore life-long surveillance is required.

Evolution of the Diagnosis of Abdominal Aortic Aneurysm in the Same Health Care Area Between 1987 and 2015

Introduction - Several European countries perform population screening for abdominal aortic aneurysm (AAA). Some have reported significant decrease in AAA prevalence in the last few years 1-2. We have analyzed the diagnosis of AAA in the same health care area between 1987 and 2015 to assess possible epidemiological changes. Methods - We have registered, in a prospective database, all AAA diagnosed in our health care area since 1987, including demographical, clinical, anatomical, management and follow-up data. We performed a retrospective analysis of the AAA diagnosed between 1987 and 2015, focusing on the number of cases, age, gender, symptoms, AAA diameter, AAA location and the diagnostic method. We grouped the data in 5-year periods and we used ANOVA to test differences. Results - We analyzed 1847 patients. The number of diagnosed cases has increased progressively, from 6.8/100.000 inhabitants-year in 1987-1990 up to a maximum of 29.3/100.000 inhabitants-year in 2006-2010 (p<0.001). The mean age of the patients at the time of diagnosis was 67.3 years in 1987-1990, with stable mean age of 72-74.6 years between 1991 and 2015 (p=0.027). The AAA were diagnosed in women in 1.9%, 5.1%, 8.1%, 8.3%, 8.3% and 6.7% in 1987-1990, 1991-1995, 1996-2000, 2001-2005, 2006-2010 and 2011-2015 respectively (p=0.055). The mean AAA diameter at the time of diagnosis was 68.7, 53.8, 44.9, 45.3, 43.8 and 44 mm for the same time periods (p<0.0001), The AAA were infrarenal in 96%, 88%, 88.8%, 84.1%, 91.7% and 93.6% of the cases respectively (p=0.021). The proportion of ruptured AAA has remained quite stable, with 9%, 12.2%, 10.2%, 8%, 7.7% and 7.7% for the same time periods (p=0.68). More than 80% of the diagnosis were made by ultrasonography between 1987 and 1995, going down to 56.7% in 2011-2015, in contrast to an increasing number of diagnosis by CT (0% in 1987-1990, 31.4% in 2011-2015) and MRI (0% in 1987-1990, 9.6% in 2011-2015) (p<0.0001). Conclusion - The incidence of AAA has progressively increased in the last 29 years in our health care area, with earlier diagnosis and stable clinical characteristics. The diagnostic imaging methods have changed to increased chance finding by CT and MRI and decreased by ultrasonography.