Mortality Of Endovascular Aneurysm Repair Research Articles

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

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

Incidence, Prognostic Significance, and Risk Factors of Acute Kidney Injury Following Elective Infrarenal and Complex Endovascular Aneurysm Repair

Acute kidney injury (AKI) is a well known complication following cardiovascular procedures. The objective was to assess the incidence, risk factors, and prognostic significance of AKI after infrarenal endovascular aneurysm repair (EVAR) and complex EVAR (cEVAR; fenestrated or branched EVAR). Consecutive patients undergoing elective infrarenal EVAR or cEVAR between 2000 and 2018 in two large teaching hospitals in the Netherlands were included. AKI was determined by serum creatinine levels increasing > 1.5 times or by an absolute increase of 26.5 mmol/L from baseline value (KDIGO criteria). The primary outcome was incidence of peri-operative AKI development. Secondary outcomes included mid-term renal function (RIFLE criteria), overall survival, and risk factors for AKI development. To determine survival and risk factors for AKI, multivariable Cox regression and logistic regression analyses were performed, accounting for pre-operative renal function and other confounders. In total, 540 patients who underwent infrarenal EVAR with 147 patients who underwent cEVAR also included. The incidence of AKI was 8.7% (n= 47) in infrarenal EVAR patients and 23% (n= 34) in cEVAR patients (fenestrated EVAR 18%; branched EVAR 38%). In contrast to patients without AKI, the renal function of surviving patients with AKI remained significantly reduced at six weeks and did not return to pre-operative values following infrarenal EVAR (three year estimated glomerular filtration rate [eGFR] 59.3 ± 23.1 mL/min/1.73m2vs. pre-operative eGFR 74.0 ± 21.7 mL/min/1.73m2; p= .006) or following cEVAR (three year eGFR 52.0 ± 23.7 mL/min/1.73m2vs. pre-operative eGFR 65.4 ± 18.6 mL/min/1.73m2; p= .082). After risk adjusted analysis, compared with non-AKI, post-operative AKI development was associated with a higher three year mortality rate following both infrarenal and cEVAR (infrarenal EVAR mortality hazard ratio [HR 1.6, 95% confidence interval [CI] 1.01 - 2.7 [p= .046]; cEVAR mortality HR 2.4, 95% CI 1.1 - 5.2 [p= .033]). Following multivariable logistic regression, pre-operative chronic kidney disease (eGFR < 60 mL/min/1.73m2; odds ratio [OR] 2.2, 95% CI 1.03 - 4.8) and neck diameter (OR 1.1, 95% CI 1.01 - 1.2) were significantly associated with AKI following infrarenal EVAR, whereas for cEVAR only contrast volume (OR 1.1, 95% CI 1.0 - 1.2]) was found to be statistically significantly associated with AKI. AKI is a well described complication following infrarenal EVAR and is common after cEVAR. As AKI seems to be associated with permanent renal deterioration and lower survival, efforts to prevent AKI are essential. Future studies are required to assess what factors are associated with a higher risk of developing AKI following cEVAR.

Effects of hospital preference for endovascular repair on postoperative mortality after elective abdominal aortic aneurysm repair: analysis of the Dutch Surgical Aneurysm Audit.

BackgroundIncreased use of endovascular aneurysm repair (EVAR) and reduced open surgical repair (OSR), has decreased postoperative mortality after elective repair of abdominal aortic aneurysms (AAAs). The choice between EVAR or OSR depends on aneurysm anatomy, and the experience and preference of the vascular surgeon, and therefore differs between hospitals. The aim of this study was to investigate the current mortality risk difference (RD) between EVAR and OSR, and the effect of hospital preference for EVAR on overall mortality.MethodsPrimary elective infrarenal or juxtarenal aneurysm repairs registered in the Dutch Surgical Aneurysm Audit (2013–2017) were analysed. First, mortality in hospitals with a higher preference for EVAR (high-EVAR group) was compared with that in hospitals with a lower EVAR preference (low-EVAR group), divided by the median percentage of EVAR. Second, the mortality RD between EVAR and OSR was determined by unadjusted and adjusted linear regression and propensity-score (PS) analysis and then by instrumental-variable (IV) analysis, adjusting for unobserved confounders; percentage EVAR by hospital was used as the IV.ResultsA total of 11 997 patients were included. The median hospital rate of EVAR was 76.6 per cent. The overall mortality RD between high- and low-EVAR hospitals was 0.1 (95 per cent −0.5 to 0.4) per cent. The OSR mortality rate was significantly higher among high-EVAR hospitals than low-EVAR hospitals: 7.3 versus 4.0 per cent (RD 3.3 (1.4 to 5.3) per cent). The EVAR mortality rate was also higher in high-EVAR hospitals: 0.9 versus 0.7 per cent (RD 0.2 (−0.0 to 0.6) per cent). The RD following unadjusted, adjusted, and PS analysis was 4.2 (3.7 to 4.8), 4.4 (3.8 to 5.0), and 4.7 (4.1 to 5.3) per cent in favour of EVAR over OSR. However, the RD after IV analysis was not significant: 1.3 (−0.9 to 3.6) per cent.ConclusionEven though EVAR has a lower mortality rate than OSR, the overall effect is offset by the high mortality rate after OSR in hospitals with a strong focus on EVAR.

Evolving Utility of Endovascular Treatment of Juxtarenal, Pararenal, and Suprarenal Abdominal Aortic Aneurysms Associated With Increased Risk of Mortality Over Time

Continued advances in endovascular technologies are resulting in fewer open abdominal aortic aneurysm (AAA) repairs. In addition, more complex juxtarenal, pararenal, and suprarenal (JPS) AAAs are being managed with various endovascular techniques. This study sought to evaluate the evolving trends in endovascular aneurysm repair (EVAR) of AAAs, hypothesizing increased rate of JPS AAA repair by EVAR. We also sought to evaluate the risk for morbidity and mortality for EVAR and open aneurysm repair (OAR) of JPS AAAs over time. The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for patients undergoing OAR or EVAR for AAAs. A multivariable logistic regression analysis was performed for both infrarenal and JPS AAA repairs. Of 18,661 patients who underwent AAA repair, 3,941 (21.1%) were OAR and 14,720 (78.9%) were EVAR. The rate of OAR decreased from 29.5% in 2011 to 21.3% in 2017 (P<0.001) with a geometric-mean-annual decrease of 27.8%. The rate of EVAR increased from 70.5% to 78.7% during the same time period (P<0.001) with a geometric-mean-annual increase of 11.6%. These trends remained true for both infrarenal and JPS AAAs. After adjusting for covariates, there was no difference in associated risk of 30-day mortality, renal complications, or ischemic colitis for either OAR or EVAR over each incremental year for infrarenal AAAs (P>0.05). However, in patients undergoing EVAR for JPS AAAs, the associated risk of mortality increased with each incremental year (odds ratio [OR]: 1.30, confidence interval [CI]: 1.01-1.69, P=0.039), whereas there was no difference in the risk of mortality for OAR of JPS AAAs with each incremental year (OR: 1.11, CI: 0.99-1.23, P=0.067). The rate of OAR for AAA has decreased over the past seven years with an increase in EVAR, particularly for more complex JPS AAAs. The associated risk for morbidity and mortality for treatment of infrarenal AAAs was not significantly affected by this increased utility of EVAR. The associated risk of mortality for JPS AAAs treated by EVAR increased over time, whereas this trend for associated risk of mortality was not seen for OAR of JPS AAAs. These findings, especially the increased associated risk of mortality over time with EVAR for JPS AAAs, warrant careful prospective analysis.

Different Preoperative Factors Affect Early Versus Late Mortality After Repair of Ruptured Abdominal Aortic Aneurysm

Outcomes after endovascular aneurysm repair (EVAR) or open repair of ruptured abdominal aortic aneurysms (RAAA) are dependent on both intraoperative and postoperative care of this patient population. We sought to characterize perioperative RAAA care and determine the effect of patient characteristics and interventions, including the role of perioperative blood product administration, on survival. We reviewed demographic, comorbidity, perioperative, and transfusion data for patients who underwent treatment of RAAA at a single institution between 2003 and 2018. The primary outcomes were 30-day and early (48-hour) mortality. Use of EVAR and perioperative blood product administration over time were measured as secondary outcomes. We identified 466 patients (age 74.5 ± 0.44, 74.3% male). EVAR was utilized in 29.6% of patients overall, increasing to 50% over the last 5 years as we shifted to an EVAR-first approach over time (Fig 1). Median time from arrival to the operating room was 63 minutes (interquartile range [IQR], 41-124 minutes). The proportion of crystalloid to total fluid (65.1 ± 28.4%) and blood to total fluid (23.7 ± 21%) did not change over time. The proportion of plasma to blood was 51% (IQR, 0%-91%) and increased over time. Mortality at 30 days was 34.1% (39.3% open, 21.7% EVAR) and did not change over time despite low EVAR mortality, due to increasing open surgical mortality after the introduction of EVAR (Fig 2). Blood product resuscitation ratios did not affect 30-day, early, or late mortality on adjusted analysis. Multivariable logistic regression showed that age >76 years (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.70-4.26; P < .001), creatinine >2 mg/dL (OR, 3.09; 95% CI, 1.77-5.39; P < .001), systolic blood pressure 2 mg/dL (OR, 4.82; 95% CI, 2.53-9.20 P < .001) with nonsignificant impact from systolic blood pressure and cardiopulmonary resuscitation. Mortality rates for RAAA have not improved despite increasing use and low perioperative mortality of EVAR over time as mortality for open surgery has increased. Increasing perioperative plasma to blood ratios have not demonstrated any mortality benefit in our study. Early mortality is strongly associated with the shock-based factors of hypotension and need for cardiopulmonary resuscitation, while late mortality is more strongly associated with elevated creatinine suggesting multiple organ failure despite hemodynamic stability.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

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.

Meta-Analysis and Meta-Regression Analysis of Outcomes of Endovascular and Open Repair for Ruptured Abdominal Aortic Aneurysm

The aim was to assess peri-operative mortality of endovascular aneurysm repair (EVAR) vs. open repair for ruptured abdominal aortic aneurysm (AAA) and to investigate whether outcomes have improved over the years and whether there is an association between institutional caseload and peri-operative mortality. Electronic information sources (MEDLINE, EMBASE, CINAHL and CENTRAL) were searched up to August 2019. A systematic review was carried out according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using a registered protocol (CRD42018106084). Studies were selected that reported peri-operative mortality of EVAR for ruptured AAA. A proportion meta-analysis was conducted, and summary estimates of odds ratios (ORs) and 95% confidence intervals (CIs) for EVAR vs. open surgical repair were obtained using random effects models. Mixed effects regression models were developed to investigate outcome changes over time and with institutional caseload. One hundred and thirty-six studies were included in quantitative synthesis reporting a total of 267 259 patients (EVAR 58 273; open surgery 208 986). The pooled peri-operative mortality of EVAR and open surgical repair was 0.245 (95% CI 0.234–0.257) and 0.378 (95% CI 0.364–0.392), respectively. EVAR was associated with reduced peri-operative mortality (OR 0.54, 95% CI 0.51–0.57, p < .001). Meta-regression analysis found decreasing peri-operative mortality over the years following EVAR (p < .001) and open repair (p < .001), and a decreasing OR of peri-operative mortality in favour of EVAR (p = .053). Meta-regression found a significant positive association between peri-operative mortality and institutional case load for open repair (p = .004). If EVAR can be done, it is a better treatment for ruptured AAA in view of the reduced peri-operative mortality compared with open surgery. The outcomes of both EVAR and open surgical repair have improved over the years, and the difference in peri-operative mortality in favour of EVAR has become more pronounced. There is a significant association between peri-operative mortality and institutional case load for open repair of ruptured AAA.

High Postoperative Mortality After Elective Open Surgical Abdominal Aortic Aneurysm Repair in Hospitals with EVAR Preference and Lessons From an Instrumental Variable Analysis of the Dutch Surgical Abdominal Aneurysm Audit

Introduction: It is possible that the postoperative mortality following AAA surgery has changed due to the increased application of endovascular aneurysm repair (EVAR) at the expense of open surgical repair (OSR), along with the preference of a hospital. The aim of this study was to investigate the effect of the relative hospital preference for EVAR on mortality after EVAR and OSR and current risk difference (RD) of postoperative mortality between EVAR and OSR in a large consecutive cohort by using an instrumental variable (IV) analysis. Methods: Patients with a primary elective infra-or juxtarenal aneurysm (EAAA) repair registered in the Dutch Surgical Aneurysm Audit (DSAA) between 2013 and 2017 were analysed. Mortality rates in hospitals with a higher preference for EVAR were compared with hospitals with a lower preference: high%EVAR versus low%EVAR hospitals, divided by the median percentage of EVAR performed. The RD between patients undergoing EVAR and OSR was determined in 4 ways: unadjusted linear regression analysis, adjusted linear regression analysis with observed confounders, propensity score (PS) analysis adjusting for observed confounders and IV analysis (Two-Stage-Least-Square Regression), adjusting for unobserved confounders, using the variation in percentage of EVAR per hospital performed as the IV instrument. Results: 11 997 EAAA patients were analysed. The overall RD on mortality between high% and low%EVAR hospitals was 0.1% (95% CI -0.5-0.4). Mortality after OSR was significantly higher in high%EVAR hospitals compared to low%EVAR hospitals: 7.3% versus 4.0% (RD 3.3%; 95%CI1.4-5.3). After EVAR mortality was resp. 0.9% versus 0.7% (RD 0.2%; 95%CI -0.02-0.6). The unadjusted RD between EVAR and OSR was 4.2% (95%CI 3.7-4.8) in favour of EVAR. The adjusted RD for observed confounders was 4.4% (95%CI 3.8-5.0). The RD following PS analysis was 4.7% (95%CI 4.1-5.3). IV analysis showed a non-significant RD between EVAR and OSR of 1.3 (95%CI -0.9-3.6). Conclusion: Overall, in high% and low%EVAR hospitals mortality was not significantly different. When adjusted for observed confounders by multivariate analysis patients with EVAR had a significantly lower postoperative mortality compared to patients with OSR. However, the RD was low and non-significant following IV analysis. High% versus low% EVAR hospitals had a significantly higher postoperative mortality following OSR. Disclosure: Nothing to disclose

Meta-analysis and Meta-regression Analysis of Outcomes of Endovascular Repair for Ruptured Abdominal Aortic Aneurysm

Introduction: The role and potential advantages of endovascular aneurysm repair (EVAR) in the management of ruptured abdominal aortic aneurysm (AAA) is controversial. We aimed to assess the perioperative mortality of EVAR versus open surgical repair for ruptured AAA and investigate whether outcomes have improved over the years and whether there is an association between institutional caseload and perioperative mortality.

Survival After Elective Endovascular or Open AAA Repair: A Systematic Review and Meta-analysis

Introduction - Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective AAA repair. However, superiority of EVAR has recently been challenged by reports of impaired longevity in patients who underwent elective endovascular repair. (1, 2) In this context we considered a systematic review and meta-analysis of the available survival data relevant. Possible confounding by age differences between patients receiving EVAR or open surgical repair (OSR) was addressed by estimating relative survival. Methods - A search using PubMed, Embase, Web of Science and Cochrane for the 1993-2018 interval identified 53 eligible papers that reported short-term and/or long-term mortality of EVAR and OSR. Identified studies included 4 randomized controlled trials (RCTs), 20 reports based on administrative registries, and 29 cohort studies. Pooled overall survival estimates (Hazard ratios with corresponding 95% CIs for EVAR versus OSR) were calculated using a random-effects model. For each study expected survival was calculated based on the matched (age, sex, year of operation and country) general population. Relative survival was consequently calculated as the ratio between observed and expected survival, according to EVAR or OSR. (3, 4) Results - The analysis includes data of 189.022 patients: 102.053 EVARs and 86.969 OSRs. Pooled 30-day mortality for EVAR was 1.16% (95% CIs 0.92 – 1.39) and 3.27% (95% CIs: 2.71 – 3.83) for OSR. Combined (overall) 3, 5, and 10-year survival rates were similar for EVAR and OSR. However, data from cohort studies indicated superior survival after OSR at 3 years and a trend towards superior survival at 5 and 10 years. Yet, EVAR patients included in these cohort studies were older (73.7 years) compared to OSR patients (71.4 years). Correction of age inequality through relative survival analysis showed comparable 3, 5, and 10 years survival for EVAR and OSR among all types of studies. Conclusion - Pooled data confirm superior 30-day survival of EVAR over OSR, but long-term survival up to 10 years is equivalent, when corrected for age inequality. Asymmetrical medical decision making with regard to EVAR and OSR may result in confounding by indication in the cohort and registry studies. Although relative survival estimates reduce the impact of age differences, it is plausible that fitter patients or patients with more complex AAA morphologies are more likely to receive OSR. Published data do not allow for extension beyond the 10-year survival window or for analysis of specific subgroups (women, young patients).

Interaction between frailty and sex on mortality after elective abdominal aortic aneurysm repair

BackgroundControversy exists surrounding gender outcome disparity and abdominal aortic aneurysm (AAA) repair. Previous reports have demonstrated worse outcomes for women undergoing open aneurysm repair (OAR); however, these differences are less evident with endovascular aneurysm repair (EVAR). Epidemiologic studies have documented that women score higher on most frailty assessment scales but paradoxically have longer life expectancy compared to men. The interaction of gender/frailty and the influence on outcomes and practice patterns surrounding EVAR and OAR is poorly described. This analysis characterizes the association of frailty/sex interactions on mortality as well as patient selection surrounding elective AAA repair in the Society for Vascular Surgery Vascular Quality Initiative. MethodsAll elective infrarenal AAA (EVAR + OAR; 2003-2017) cases were queried from the Vascular Quality Initiative database. Each patient was assigned a previously published modified frailty index (mFI) score derived from comorbidity and preoperative functional status data. Cox proportional hazard models, adjusted for statistically significant covariates, including procedural complexity, determined associations within full models and sex-stratified models. ResultsA total of 20,750 elective AAA cases were analyzed (EVAR 15,893 [77%]; OAR 4857 [23%]). Thirty-day mortality for EVAR and OAR was 0.7% (n = 115) and 3.5% (n = 169), respectively. Patients who died were significantly more likely to be older (EVAR, 78 vs 73 years; OAR, 74 vs 69 years; P < .0001), have larger AAA diameters (EVAR, 59 vs 56 mm; P = .005; OAR, 62 vs 59 mm; P = .001), higher mFI scores (EVAR, 3.2 vs 2.4; OAR, 3.1 vs 2.2; P < .0001), and be of female sex (EVAR hazard ratio = 1.66 [95% confidence interval, 1.10-2.52]; P = .007; OAR-1.43 [1.02-1.99]; P = .003). Significant differences in the gender distribution of frailty scores among EVAR patients were evident (mean mFI: male 2.42 vs female 2.34; P = .02), but no difference was detected for OAR (male 2.17 vs female 2.22; P = .38). The mFI was a strong independent predictor of mortality (30 days: EVAR hazard ratio = 1.36 [1.22-1.53] and OAR 1.46 [1.32-1.60]; 1 year: EVAR 1.32 [1.25-1.39] and OAR-1.38 [1.28-1.48]). There was no interaction between mFI and gender on the association with mortality. Across frailty strata, male patients were nearly twofold more likely to undergo either elective EVAR or OAR for an AAA below recommended minimum diameter thresholds (male, <5.5 cm; female, <5.0 cm). Greater mFI score did not alter OAR selection but was associated with less frequent EVAR of small AAA. ConclusionsGiven the strong association between frailty and postoperative mortality, mFI can be used as a predictive tool to aid in surgical planning of patients undergoing elective AAA repair. While mFI can predict postoperative mortality for both men and women, it does not account for the survival disparity between sexes, and further research is warranted to explain this difference. There appear to be significant gender differences in patient selection based on current Society for Vascular Surgery–endorsed treatment thresholds that may have important implications on the appropriateness of AAA care delivery nationally.

Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm.

Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective repair of abdominal aortic aneurysm (AAA) for many patients. However, the superiority of the endovascular procedure has recently been challenged by reports of impaired long-term survival in patients who underwent EVAR. A systematic review of long-term survival following AAA repair was therefore undertaken. A systematic review was performed according to PRISMA guidelines. Articles reporting short- and/or long-term mortality of EVAR and open surgical repair (OSR) of AAA were identified. Pooled overall survival estimates (hazard ratios (HRs) with corresponding 95 per cent c.i. for EVAR versus OSR) were calculated using a random-effects model. Possible confounding owing to age differences between patients receiving EVAR or OSR was addressed by estimating relative survival. Some 53 studies were identified. The 30-day mortality rate was lower for EVAR compared with OSR: 1·16 (95 per cent c.i. 0·92 to 1·39) versus 3·27 (2·71 to 3·83) per cent. Long-term survival rates were similar for EVAR versus OSR (HRs 1·01, 1·00 and 0·98 for 3, 5 and 10 years respectively; P =0·721, P =0·912 and P =0·777). Correction of age inequality by means of relative survival analysis showed equal long-term survival: 0·94, 0·91 and 0·76 at 3, 5 and 10 years for EVAR, and 0·96, 0·91 and 0·76 respectively for OSR. Long-term overall survival rates were similar for EVAR and OSR. Available data do not allow extension beyond the 10-year survival window or analysis of specific subgroups.

Invited commentary

Whereas the early mortality benefit of endovascular aneurysm repair (EVAR) over open repair for intact abdominal aortic aneurysms (AAAs) has been confirmed in numerous randomized trials and observational studies, the data regarding outcomes after repair of ruptured AAAs (rAAAs) are conflicting. As summarized in a recent Cochrane review, four randomized controlled trials failed to demonstrate improved short-term mortality after EVAR for rAAA.1Badger S. Forster R. Blair P.H. Ellis P. Kee F. Harkin D.W. Endovascular treatment for ruptured abdominal aortic aneurysm.Cochrane Database Syst Rev. 2017; 5: CD005261PubMed Google Scholar However, these trials were limited by small sample size, inclusion criteria leading to the exclusion of many patients, and frequent treatment variation from randomization. In this issue of the Journal of Vascular Surgery, Gupta et al add to the growing body of literature supporting EVAR for rAAA. Their analysis of a retrospective cohort from a national administrative database demonstrates lower in-hospital mortality after EVAR compared with open repair. EVAR was also associated with a lower frequency of major complications. These results are consistent with previously published observational studies that suggest an advantage to EVAR. In a retrospective cohort of Medicare beneficiaries, we identified a decrease in overall perioperative mortality for rAAA repair from 1995 to 2008, largely driven by increasing use of EVAR and its association with lower perioperative mortality.2Schermerhorn M.L. Bensley R.P. Giles K.A. Hurks R. O'Malley A.J. Cotterill P. et al.Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995-2008: a retrospective observational study.Ann Surg. 2012; 256: 651-658Crossref PubMed Scopus (161) Google Scholar In addition, as the authors illustrate in their discussion, their results closely resemble the 30-day mortality from the as-treated analysis of the Immediate Management of Patients with Rupture: Open Versus Endovascular Repair (IMPROVE) trial, suggesting that the conclusions of this trial may be limited by the intention-to-treat approach. Furthermore, newly published 3-year data from IMPROVE do demonstrate a survival advantage with EVAR. In patients in whom repair was started, the odds ratio for death after EVAR at 3 years was 0.62 (95% confidence interval, 0.43-0.88). EVAR also led to decreased cost and better quality of life compared with open repair.3IMPROVE Trial InvestigatorsComparative effectiveness of an endovascular strategy versus open repair for ruptured abdominal aortic aneurysm: 3-year results of the IMPROVE randomised trial.Br Med J. 2017; 359: j4859Crossref PubMed Scopus (113) Google Scholar With their paper in this issue of JVS, Gupta et al further the argument that EVAR is superior to open repair for the treatment of rAAA. The selection of treatment modality for rAAA remains complex and will continue to depend on demographics of the patient, anatomic factors, hospital facilities, and experience of the surgeon.4Meltzer A.J. Connolly P.H. Schneider D.B. Sedrakyan A. Impact of surgeon and hospital experience on outcomes of abdominal aortic aneurysm repair in New York State.J Vasc Surg. 2017; 66: 728-734.e2Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar However, based on the results of both randomized trials and observation studies, we advocate for an endovascular-first approach. All patients with rAAAs should be treated in a hybrid operating room when one is available under local anesthesia, at least initially, with an aortic occlusion balloon available as needed for both EVAR and open repair. If the anatomy is suitable and appropriate endografts are available, percutaneous EVAR is our preferred treatment modality. However, open repair will continue to be necessary in certain circumstances, and surgeons must be prepared. In addition, decompressive laparotomy may be indicated despite successful EVAR, particularly when an aortic occlusion balloon is needed. We believe that the current literature composed of both randomized trials and observational studies supports this approach. Furthermore, as aortic stent grafts continue to improve and experience with EVAR expands, the advantage of EVAR in the treatment of rAAA is likely to continue to grow. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Real-world evidence of superiority of endovascular repair in treating ruptured abdominal aortic aneurysmJournal of Vascular SurgeryVol. 68Issue 1PreviewThe majority of previous studies, including randomized controlled trials, have failed to provide sufficient evidence of superiority of endovascular aneurysm repair (EVAR) over open aortic repair (OAR) of ruptured abdominal aortic aneurysm (rAAA) while comparing mortality and complications. This is in part due to small study size, patient selection bias, scarce adjustment for essential variables, single insurance type, or selection of only older patients. This study aimed to provide real-world, contemporary, comprehensive, and robust evidence on mortality of EVAR vs OAR of rAAA. Full-Text PDF Open Archive

Real-world evidence of superiority of endovascular repair in treating ruptured abdominal aortic aneurysm

ObjectiveThe majority of previous studies, including randomized controlled trials, have failed to provide sufficient evidence of superiority of endovascular aneurysm repair (EVAR) over open aortic repair (OAR) of ruptured abdominal aortic aneurysm (rAAA) while comparing mortality and complications. This is in part due to small study size, patient selection bias, scarce adjustment for essential variables, single insurance type, or selection of only older patients. This study aimed to provide real-world, contemporary, comprehensive, and robust evidence on mortality of EVAR vs OAR of rAAA. MethodsA retrospective observational cohort study was performed of rAAA patients registered in the Premier Healthcare Database between July 2009 and March 2015. A multivariate logistic regression model was operated to estimate the association between procedure types (OAR vs EVAR) and in-hospital mortality. The final model was adjusted for demographics (age, sex, race, marital status, and geographic region), hospital characteristics (urban or rural, teaching or not), and potential confounders (hypertension, diabetes, hypercholesterolemia, obesity, ischemic heart disease, chronic kidney disease, symptoms of critical limb ischemia, chronic obstructive pulmonary disease, smoking, and alcoholism). Furthermore, coarsened exact matching was applied to substantiate the result in the matched cohort. ResultsThere were a total of 3164 patients with rAAA (1550 [49.0%] OAR and 1614 [51.0%] EVAR). Mortality was 23.79% in the EVAR group compared with 36.26% in the OAR group (P < .001). The adjusted odds ratios of mortality (1.91; 95% confidence interval [CI], 1.62-2.25; P < .001), cardiac complication (1.54; 95% CI, 1.22-1.96; P < .001), pulmonary failure (1.90; 95% CI, 1.60-2.24; P < .001), renal failure (1.90; 95% CI, 1.61-2.23; P < .001), and bowel ischemia (2.40; 95% CI, 1.70-3.35; P < .001) were significantly higher after OAR compared with EVAR. We further applied coarsened exact matching, which followed the same pattern of mortality (odds ratio, 1.68; 95% CI 1.41-1.99; P < .001) and all major complications. ConclusionsAlthough the choice of repair of rAAA is highly dependent on the experience of the operating team and the anatomic suitability of the patient, this contemporary analysis of a large cohort of rAAA showed significantly higher adjusted risk of mortality in OAR compared with EVAR and substantially higher complications.

Endovascular aneurysm repair in the elderly: First do no harm.

Endovascular aneurysm repair (EVAR) has become the intervention of choice for supra-threshold aortic aneurysms due to the lower 30-day mortality of EVAR as compared with open surgery, despite no long-term longevity gains. Trials such as EVAR-1 that established the current status of endovascular aortic intervention often excluded participants over the age of 80, and specific studies of EVAR in the elderly reveal higher mortality than accepted averages. Analyses of the cost-effectiveness of EVAR have not demonstrated superiority of endovascular intervention over open repair, in particular when considering complications such as endoleak. Post-intervention surveillance and the frequent need for re-intervention following EVAR has a detrimental impact on quality of life. Taking these factors into consideration, combined with an ageing population and the likely increase in octogenarian endovascular intervention, there is a clear clinical need for appropriate risk-stratification of elderly patients with supra-threshold aneurysms to determine who will benefit from endovascular repair.

Increasing Mortality Trends for Open Infrarenal and Thoracoabdominal Aneurysm Repairs in the Endovascular Era

Rapid adoption of endovascular aneurysm repair (EVAR) has been driven by improving trends in perioperative morbidity and mortality compared with open repair. Perioperative outcomes in the current era of anatomically more complex open repairs remain undetermined. The purpose of this study was to investigate trends for elective and ruptured aneurysm repairs and in-hospital mortality for these patients at a high-volume tertiary care, university teaching hospital. This study used an institutional, prospectively maintained database that derives all data from electronic hospital records, billing data, and patient charts to capture patients receiving either EVAR or open repair for abdominal aortic aneurysm (AAAs) and thoracoabdominal aortic aneurysms during an 11-year period between January 2004 and January 2015. There were 2753 aneurysm repairs performed throughout the study period; 1673 (60.1%) were open repairs, whereas 1080 (39.2%) were EVAR. In 2004, 29 EVARs were performed (14.9% of total aneurysm repairs), increasing to 110 repairs in 2014 (46.8%; Fig 1). Linear regression demonstrated an 11-year average increase in EVAR of 10.5 cases per year (R2 = 0.68), whereas open repair decreased by 5.2 cases per year (R2 = 0.73). Percentage of ruptured AAA repairs decreased from 11.3% in 2004 to 6.0% in 2014 with an increasing proportion performed by EVAR (9.1% in 2004 and 35.7% in 2014). Mortality for EVAR decreased from 6.9% in 2004 to 0.9% in 2014, whereas open repair mortality increased from 2.4% in 2004 to 6.4% in 2014 (Fig 2). Respectively, average mortality for elective EVAR and open repair was 3.5% and 2.7% from 2004 to 2007, 0.9% and 1.8% from 2008 to 2011, and 1.6% and 5.6% from 2012 to 2014. There is an ongoing transition favoring EVAR over open repair in the management of AAAs and thoracoabdominal aortic aneurysms, albeit a slower rate of adoption at our center. Notably, there is an evident trend toward increasing mortality among patients receiving open repair. We postulate increasing patient complexity and possibly decreased institutional memory (factors related to surgeon, anesthesia, and intensive care unit experience) in the era of increasing endovascular and diminishing open repairs.Fig 2Mortality rate for intact abdominal aortic aneurysms (AAAs) by procedure type and overall combined mortality.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Endovascular Aneurysm Repair of Abdominal Aortic Aneurysms: Standards, Technical Options and Advanced Indications

Since the introduction of endovascular aneurysm repair (EVAR) in 1991, the endovascular therapy with newest stent grafts has assumed a prominent role in the clinical management of abdominal aortic aneurysms (AAA) with a superior perioperative mortality of EVAR and an equivalent mid-term outcome, compared to open surgery. Newest techniques using chimney or periscope grafts and customized fenestrated and branched stent grafts allow the endovascular treatment of complex pararenal AAA. This article reviews EVAR in the treatment of AAA, evidence based results and advanced indication by newest interventional techniques and technical developments. • EVAR has become standard treatment of abdominal aortic aneurysm with equivalent results to open surgery.• Technical advancements and the introduction of newest stent grafts continually expand the indication of EVAR.• Chimney- and periscope grafts as well as custom-made prothesis systems allow endovascular treatment of complex para- and suprarenal aneurysms.

Invited commentary

It is unquestionable that endovascular aneurysm repair (EVAR) has created a paradigm shift in our ability to manage patients with ruptured abdominal aortic aneurysms (AAAs). At Albany Medical Center, shortly after we performed our first ruptured EVAR a decade ago in 2002, we realized the potential benefits of the endovascular technology and techniques for patients with ruptured AAAs. We also realized the potential limitations that might preclude its widespread utilization, and since then we have established and published the benefits of a standardized multidisciplinary approach to rupture EVAR that has resulted in lowering the overall mortality and morbidity in patients with these life-threatening emergencies. Over the past several decades, the overall mortality of open surgical repair (OSR) for a ruptured AAA has been reported by most centers to range between 30% and 70% depending on the local surgeon expertise as well as regionalization of care that generally has a selection bias against acute hemodynamically unstable ruptures that often do not survive to get treatment. Furthermore, over the past decade, a vast majority of >50 publications (single center, multicenter, National Surgical Quality Improvement Program database, and meta-analysis) in peer reviewed journals have reported on the benefits of rupture EVAR. The only studies not indicating rupture EVAR survival advantage are those in which the rupture EVAR mortality ranged from 35% to 50% and matched that of OSR; a clear indication that surgeons and interventionists should stick to what we do best, albeit rupture EVAR or OSR. I want to congratulate Dr Saqib and colleagues at the University of Pittsburgh Medical Center for reporting on their 10-year experience of ruptured EVAR and OSR. Their experience indicates that, with expertise in both emergent EVAR and OSR, the short-term mortality can be equally reduced in both groups, albeit the morbidity of r-EVAR is significantly lower. It would also appear that all 37 patients (100%) with ruptured EVAR and only 111 of 241 patients (46%) with ruptured OSR were available for follow-up and underwent propensity score-based analysis. Although I applaud the University of Pittsburgh Medical Center vascular surgery group to be technically savvy in performing ruptured OSR and obtain outcomes that are remarkable, I feel obliged to comment on their inability to include the remaining 54% of patients with ruptured OSR has resulted in a cumulative midterm Kaplan-Meier survival analysis that would strongly bias in favor of OSR. It is likely that a significantly higher percentage of patients that might be lost to follow-up and were not included in this analysis had died, many secondary to aneurysm-related complications. Endovascular repair of ruptured abdominal aortic aneurysm does not confer survival benefits over open repairJournal of Vascular SurgeryVol. 56Issue 3PreviewEndovascular repair of ruptured abdominal aortic aneurysm (rAAA) is being increasingly performed despite lack of good evidence for its superiority. Other reported studies suffer from patient selection and publication bias with limited follow-up. This study is a single-center propensity score comparing early and midterm outcomes between open surgical repair (OSR) and endovascular repair of rAAA (REVAR). Full-Text PDF Open Archive

Endovascular Repair of Abdominal Aortic Aneurysm does not Improve Early Survival versus Open Repair in Patients Younger than 60 Years

ObjectivesMultiple randomised trials have demonstrated lower perioperative mortality after endovascular aneurysm repair (EVAR) compared to open surgical repair for infrarenal abdominal aortic aneurysms (AAAs). However, in these trials the mortality advantage for EVAR is being lost within 2 years of repair and the patients evaluated are relatively older with no study specifically comparing EVAR and open repair for patients younger than 60 years of age. DesignA retrospective analysis of prospectively collected data. Materials and methodsPatients younger than 60 years of age who underwent EVAR and open surgical repair for elective infrarenal AAA were identified from the 2007–09 National Surgical Quality Improvement Program (NSQIP) – a prospective database maintained at 237 centres across the United States. Univariate and multivariate analyses were performed. ResultsOf the 651 patients, 369 (56.7%) underwent EVAR and 282 (43.3%) underwent open repair. Thirty-day mortality for EVAR and open repair were 1.1% and 0.4%, respectively. This was not significantly different on univariate (P = 0.22) as well as multivariate (P = 0.69) analysis after controlling for other co-morbidities. On multivariate analysis, body mass index, history of stroke and bleeding disorder prior to surgery were associated with a higher 30-day mortality after AAA repair (combined open and EVAR). ConclusionsThese contemporary results demonstrate that the 30-day mortality rate after open repair is similar to that after EVAR in patients younger than 60 years with infrarenal AAA.

Improving Results of Elective Abdominal Aortic Aneurysm Repair at a Low-Volume Hospital by Risk-Adjusted Selection of Treatment in the Endovascular Era

Several studies have observed both higher mortality rates and lower utilization of endovascular aneurysm repair (EVAR) at low-volume centers. This article presents the results of elective abdominal aortic aneurysm (AAA) repair at a low-volume center in the endovascular era and investigates whether postprocedural mortality can be improved by extension of EVAR application also in this setting. This is an 11.6-year retrospective cohort study of 132 patients undergoing elective surgical or endovascular AAA repair at a tertiary care academic hospital between 1997 and July 2008, i.e., a median volume of 12 cases per year. The study was divided into two periods of time according to the respective indications and contraindications for EVAR, which substantially changed in 2005. During period 1, only aneurysms with necks > or =20 mm long and not involving the iliac arteries were treated endoluminally. Beginning in 2005, indication for EVAR was expanded to aortoiliac aneurysms with a minimum neck length of 15 mm. Preoperative risk was assessed by the SVS/AAVS comorbidity score. During the first period (1997-2004) 18.4% (16/87) of all patients received EVAR. By extending anatomical confines and indications for EVAR in 2005, the utilization rate of EVAR increased to 40.0% (18/45) during the second period (2005-July 2008; p = 0.007). Prevalence of preoperative risk factors did not change during the two observation periods. In contrast to period 1, high-risk patients were preferentially treated endoluminally during the second period, resulting in a significantly higher median SVS/AAVS score in the EVAR group (p < 0.001). A significant decrease in median length of stay at the intensive/intermediate care unit (5 vs. 2 days; p = 0.006) and length of in-hospital stay (20 vs. 12.5 days; p < 0.001) was observed during period 2. Overall perioperative mortality was reduced from 6.9% during the first period to 2.2% during the second period (p = 0.256). EVAR mortality was 0%, mortality after open repair was reduced from 8.5% to 3.7% (p = 0.414). In conclusion, by risk-adjusted selection of treatment and frequent application of EVAR, it is possible to improve perioperative outcome of elective AAA repair at a low-volume hospital. Mortality figures are similar to those of recent trials at high-volume centers, as reported in the literature.