Open Abdominal Aortic Aneurysm Surgery Research Articles

Activated clotting time-guided heparinization during open AAA surgery: a pilot study

BackgroundArterial thrombo-embolic complications (TEC) are still common during and after non-cardiac arterial procedures (NCAP). While unfractionated heparin has been used during NCAP for more than 70 years to prevent TEC, there is no consensus regarding the optimal dosing strategy. The aim of this pilot study was to test the effectiveness and feasibility of an activated clotting time (ACT)-guided heparinization protocol during open abdominal aortic aneurysm (AAA) surgery, in anticipation of a randomized controlled trial (RCT) investigating if ACT-guided heparinization leads to better clinical outcomes compared to a single bolus of 5000 IU of heparin.MethodsA prospective multicentre pilot study was performed. All patients undergoing elective open repair for an AAA (distal of the superior mesenteric artery) between March 2017 and January 2020 were included. Two heparin dosage protocols were compared: ACT-guided heparinization with an initial dose of 100 IU/kg versus a bolus of 5000 IU. The primary outcome was the effectiveness and feasibility of an ACT-guided heparinization protocol with an initial heparin dose of 100 IU/kg during open AAA surgery. Bleeding complications, TEC, and mortality were investigated for safety purposes.ResultsA total of 50 patients were included in the current study. Eighteen patients received a single dose of 5000 IU of heparin and 32 patients received 100 IU/kg of heparin with additional doses based on the ACT. All patients who received the 100 IU/kg dosing protocol reached the target ACT of > 200 s. In the 5000 IU group, TEC occurred in three patients (17%), versus three patients (9.4%) in the 100 IU/kg group. Bleeding complications were found in six patients (33%) in the 5000 IU group and in 9 patients (28%) in the 100 IU/kg group. No mortality occurred in either group.ConclusionsThis pilot study demonstrated that ACT-guided heparinization with an initial dose of 100 IU/kg appears to be feasible and leads to adequate anticoagulation levels. Further randomized studies seem feasible and warranted to determine whether ACT-guided heparinization results in better outcomes after open AAA repair.

Protocol for an independent patient data meta-analysis of prophylactic mesh placement for incisional hernia prevention after abdominal aortic aneurysm surgery: a collaborative European Hernia Society project (I-PREVENT-AAA)

IntroductionIncisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention...

The role of Tranexamic acid in the Reduction of Bleeding in Abdominal Aortic Aneurysm Surgery

Objective: To determine the effects of Tranexamic acid on intraoperative blood loss. Study Design: Quasi-experimental study. Place and Duration of Study: Combined Military Hospital, Rawalpindi Pakistan, from Jun to Oct 2021. Methodology: A total of 96 patients from both genders undergoing elective open abdominal aortic aneurysm surgery under general anaesthesia enrolled in the study after random distribution to Drug and Control Groups. The primary determinant was intraoperative blood loss. Additionally, determining variables were intraoperative and postoperative blood transfusions, thromboembolic episodes, and postoperative mortality rate. Results: A total of 96 patients enrolled in the study, out of which 90(93%) were males, whereas 6(7%) were females, with a mean age of 65.37±7.01 (55–75 years). Of 96 participants, 52(54%) patients were from ASA Class II and 44(46%) were from ASA Class III. There was no significant correlation between surgical time (p-value 0.45), clamping time (p-value 0.34), and intraoperative and postoperative transfusions (p-value 0.56 and 0.28, respectively). However, a statistically significant reduction in intraoperative and postoperative blood loss was recorded (p-value <0.001). Conclusion: Tranexamic acid significantly impacts the reduction of intraoperative and postoperative bleeding in elective open abdominal aortic aneurysm surgeries under general anaesthesia.

P-084 INDEPENDENT PATIENT DATA META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS ON PROPHYLACTIC MESH PLACEMENT FOR INCISIONAL HERNIA PREVENTION: STUDY PROTOCOL

Abstract Aim In high risk groups such as patients undergoing open abdominal aortic aneurysm (AAA) surgery, the risk of incisional hernia (IH) formation is up to 69%. IH can be prevented through prophylactic mesh augmentation (PMA). Several randomized controlled trials (RCT) have shown a significant decrease in IH formation after PMA. However, due to study design and sample size issues, implementation of PMA into daily practice is lacking. Methods International collaboration will be initiated under the guidance of the European Hernia Society. RCTs studying PMA after open AAA surgery will be identified through a literature search. Corresponding authors of the selected studies will be approached for participation by e-mail, telephone or other means. Where independent patient data (IPD) are available, a suitable data delivery agreement (DDA) will be drafted and signed upon agreement. Pseudonymised or anonymised data sets will be securely transferred and stored, and relevant study parameters will be harmonized. A 1-stage IPD meta-analysis (IPDMA) will be performed, stratified per centre, assessing PMA effectivity according to the intention-to-treat principle. If a 1-stage IPDMA is not feasible, a 2-step IPDMA will be performed, analysing each RCT separately and pooling outcomes. Results will be published in internationally recognized, peer-reviewed journals. This study protocol was registered under PROSPERO number CRD42022347881. Conclusions Gathering IPD across relevant RCTs and performing an IPDMA on the combined data will help to better establish effectiveness of PMA in preventing IH after open AAA surgery. Secondarily, subgroup analyses will allow identification of patients who will benefit from PMA most.

Impact of General Anaesthesia Versus Combined Epidural and General Anesthesia on Postoperative Complications and Mortality in Elective Abdominal Aortic Aneurysm Surgeries

Objective: To determine the impact of general anaesthesia versus combined epidural and general anaesthesia on postoperative complications in elective abdominal aortic aneurysm surgeries.
 Study Design: Quasi-experimental study.
 Place and Duration of Study: Combined Military Hospital, Rawalpindi Pakistan, from Jun 2018 to Sep 2020.
 Methodology: A total of 100 patients from both genders undergoing elective open abdominal aortic aneurysm surgery under general anaesthesia enrolled in the study after random distribution to drug and control groups in equal proportions. The primary determinants were postoperative complications. Additionally, it determined the impact on postoperative mortality rate. 
 Results: Of 100 participants, 54% of patients were from ASA status II, and 46% were from ASA status III. Among postoperative complications, bowel ischemia was recorded in 16% and 2% among Group-A and Group-B, respectively (pvalue 0.01). Postoperative dialysis was required in 18% of patients in Group-A, whereas among Group-B, only 4%went through it (p-value 0.02). Pulmonary complications variation was not statistically different between the two groups, with 54%  and 46% (p-value 0.42) frequencies in Group-A and Group-B, respectively. However, surgical reintervention within 30 days was notable, 36% in Group-A and 14% in Group-B (p-value 0.01).
 Conclusion: Combined general and epidural anaesthesia, when compared with general anaesthesia alone, significantly impacts the reduction of postoperative complications after elective open abdominal aortic aneurysm surgeries without increasing morbidity and mortality.

Open Surgery for Abdominal Aortic Aneurysm: 980 Consecutive Patient Outcomes from a High-Volume Centre in the United Kingdom.

Controversy persists regarding the optimal treatment for large abdominal aortic aneurysm (AAA), highlighted by the publication of the National Institute for Health and Care Excellence (NICE) guideline (NG156) on March 2020. The pendulum of opinion swings once more from endovascular to open surgical treatment. We report our experience over the last 15years in treating consecutive AAA by open surgery. A retrospective review of a prospectively collected vascular database of all patients undergoing infra-renal open abdominal aortic aneurysm repair (OR) repair from 2004 to 2019 at the largest aneurysm centre in the United Kingdom. OR for elective and emergency (ruptured and symptomatic) outcomes included early morbidity and 30-day mortality, and long-term survival. 1017 patients underwent OR between 2004-2019, on application of our inclusion-criteria 994 patients formed our cohort for analysis (81.2% male) with a mean age 73.6 ± 7.8years treated by OR for AAA. In that group 672 were elective and 308 were emergency (for ruptured or symptomatic). Overall 30day mortality was 11.3%, elective 30day mortality was 2.5%, and emergency 30day mortality was 29.9%. 30day re-intervention rate was 9.5%, (elective 7.0%, emergency 15.9%). Survival at 1000days for elective repair was 72 v 46.7% for emergency and at 2000 days was 43.4% for elective v 25% for emergency. Our data confirm that open surgery for AAA can be performed in large volume centres quite safely. Elective and Emergency surgery does affect early 30day mortality but does not influence long-term outcome.

Incidence and risk factors for incisional hernia after open abdominal aortic aneurysm repair

IntroductionIncisional hernia (IH) is common after open abdominal aortic aneurysm (AAA) repair. Recent studies reported incidence rates higher than previously stated. The aim of this study was to quantify the IH incidence after open AAA surgery. The secondary outcome was to identify the risk factors associated with the development of an IH. MethodsRetrospective observational study of all consecutive patients who underwent an open repair of AAA, from January 2010 to June 2018, at our institution. Patients were free of abdominal wall hernias at the moment of inclusion in the study. Data were extracted from electronic records: baseline characteristics, surgical factors, and postoperative events. Computed tomography (CT) scans performed during follow-up were analyzed. ResultsA total of 157 patients were analysed. The IH incidence after open repair of AAA was 46.5% (73 patients). The median time for IH development was 24.43 months (IQR: 10.40–45.27), while the median follow-up time was 37.20 months (IQR: 20.53–64.12). The risk factors linked to IH were: active (HR: 4.535; 95% CI: 1.369–15.022) or previous smoking habit (HR: 4.652; 95% CI: 1.430–15.131), chronic kidney disease (HR: 2.007; 95% CI: 1.162–3.467) and previous abdominal surgery (HR: 1.653; 95% CI: 1.014–2.695). ConclusionThe incisional hernia after open abdominal aortic aneurysm repair affected a high proportion of the intervened patients. Previous abdominal surgery, chronic kidney disease, and smoking habit were independent factors for the development of an incisional hernia.

Intraoperative cell salvage using swab wash and serial thromboelastography in elective abdominal aortic aneurysm surgery involving massive blood loss.

The loss of 50% blood volume is one accepted definition of massive haemorrhage, which ordinarily would trigger the massive transfusion protocol, involving the administration of high ratios of fresh frozen plasma and platelets to allogeneic red cells. We investigated 53 patients who experienced >50% blood loss during open elective abdominal aortic aneurysm surgery to assess allogeneic blood component usage and coagulopathy. Specialist patient blood management practitioners used a tailored cell salvage technique including swab wash to maximise blood return. We assessed the proportion of patients who did not require allogeneic blood components and develop evidence of coagulopathy by thromboelastography (TEG) parameters. Blood loss was 50%-174% (mean [SD] 68% [27%]) of blood volume. The mean (SD) intraoperative decrease in haemoglobin concentration, assessed by arterial blood gas analysis, was 5(13)g/l. No patient received allogeneic red cells intraoperatively. Four of the 53 (8%) patients received blood components in the first 24 h postoperatively at the anaesthetists' discretion. No patient had intraoperative TEG changes indicative of fibrinolysis or coagulopathy. The 30-day mortality was 2% (one of 53). Reduction of allogeneic transfusion is one aim of patient blood management techniques. We have demonstrated virtual avoidance of allogeneic blood product transfusion despite massive blood loss. These data show possible alternatives to the current massive transfusion protocols to the management of elective vascular surgical patients.

Endografts for the treatment of abdominal aortic aneurysms with a hostile neck anatomy: A systematic review.

BackgroundEndovascular aortic repair (EVAR) of abdominal aortic aneurysms (AAAs) has emerged as a better alternative to conventional open surgery for AAAs. The purpose of the review is to define the improvement in the clinical management of the patient with hostile neck AAAs due to the introduction of new endografts while giving a thorough description of their instructions for use (IFUs), main characteristics and part sizing, reporting their outcomes from clinical studies and categorizing their usability.MethodsA MEDLINE search was conducted using keyword-specific combinations. Clinical studies were searched via the clinicaltrials.gov website. Relevant articles' references were also hand-searched.ResultsWe retrieved 640 records describing Alto, Ovation iX, Treovance, Aorfix, Anaconda, Conformable, and Endurant II/IIs endografts. Aortic necks >60° can be managed with Anaconda, Aorfix, and Conformable, which can treat up to 90° necks requiring ≥15 mm (Anaconda ≥20 mm), and Treovance, which is eligible for necks ≤75° with ≥15 mm length. Ovation's innovation of combining polymer-filled O-rings with integral anchors can treat conical necked AAAs giving Ovation iX and Alto an advantage. Short-necked AAAs can be treated with Alto, eligible for necks as short as 7 mm, and Endurant II, which can treat ≥10 mm necks or 4 mm if used in conjunction with the EndoAnchors system, respectively. Alto and Conformable report a 100% technical success rate, absence of AAA-related death, migration, ruptures, and limb occlusion during follow-up. Endurant II and Ovation iX report >99% technical success rate and are almost free from the AAA mortality rate, ruptures, migration, and limb occlusion, while Ovation iX has a high rate of sac dilation (15.5%) in a 5-year follow-up. Anaconda is slightly better than Aorfix and Treovance, which are related to the lowest technical success rates, 98.3%, 96.3%, and 96%, respectively. Aorfix has the highest AAA mortality rate, 4% in a 60 month follow-up.ConclusionMost new generation endografts described have comparable results. They broaden the eligibility of patients for EVAR due to their unique technical characteristics described. There is a lack of comparative studies for newer endografts and postmarket clinical studies with long-term results concerning the most recently approved devices described, Alto and Conformable.

Risk factors of long-term incisional hernia after open surgery for abdominal aortic aneurism: A bicentric study

Conventional surgery still retains a dominating place beside endovascular surgery in the care of abdominal aortic aneurysms (AAA), with a lower rate of reinterventions in the long-term. Incisional hernias are the major complication of open surgery in the long-term. The occurrence of this late complication could be due to the choice of the incision, median or transverse. The principal aim of this work was to characterize the long-term risk factors of hernia after open surgery for AAA, in particular by comparing the two types of laparotomy.

A Systematic Review and Meta-Analysis of Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery.

Introduction: Open abdominal aortic aneurysm (AAA) surgery is associated with significant morbidity, mortality and high length of stay (LOS). Enhanced recovery is now commonplace and has been shown to decrease these in other non-vascular surgery settings. This systematic review and meta-analysis aimed to assess the benefits of enhanced recovery (ERAS) in aortic surgery. Method: Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to undertake a systematic review via Ovid MEDLINE and Embase on 10.07.2021. The search terms were "aortic aneurysm" and "fast track" or "enhanced recovery". Data was obtained on major complications, 30-day mortality and LOS. Results: 107 papers were identified and 10 papers included for meta-analysis. Complication rates were significantly reduced with ERAS compared to non-ERAS protocols (ERAS n = 709, non-ERAS n = 930) (odds ratio .38, .22 to .65: P = .0005). LOS was also significantly reduced with an ERAS protocol (ERAS n = 708, non-ERAS n = 956) with a mean reduction of 3 .18 days (-5.01 to -1.35days) (P = .0007: I2 = 97%). There was no significant difference however in 30-day mortality (P = .92). Conclusion: This meta-analysis demonstrates significant benefits to an enhanced recovery programme in open AAA surgery. There is a need for a multi-centre randomized controlled trial to assess this further.

AB038. SOH22ABS133. Swings and roundabouts—is open abdominal aortic aneurysm surgery back in fashion?

AB038. SOH22ABS133. Swings and roundabouts—is open abdominal aortic aneurysm surgery back in fashion?

Patients' body image after open abdominal surgery of abdominal aortic aneurysm - Perceptions and experiences.

AimsTo explore and gain an understanding of patients’ perceptions and experiences of their body and bodily function in connection with open surgery of abdominal aortic aneurysm.BackgroundAfter the operation of an abdominal aortic aneurysm (AAA) it may be difficult for the patients to understand what the procedure means.DesignThe design was descriptive and based on an analysis of 13 audio‐taped consultations with patients undergoing open surgery for AAA at a Swedish university hospital. The patients’ age varied from 57–79 and the mean age was 71 (70.5 female).MethodsA hermeneutic approach was used whereby patients were interviewed and draw a picture of their thoughts and experiences of the surgery and what had been done in their bodies. Once patients had finished their drawings, the interviewer asked what thoughts and experiences they had of the AAA.ResultsPatients described experiences as a process of “going from broken to whole again.”

Open Abdominal Aortic Aneurysm Surgery and Renal Dysfunction; Association of Demographic and Clinical Variables with Proximal Clamp Location

While cross-clamp site is a known risk factor for postoperative acute and chronic renal dysfunction following open abdominal aortic aneurysm surgery (AAA), the additive impact of patient demographic and clinical factors is lacking. In this study, we investigated the impact of body mass index (BMI), surgical duration and aneurysm diameter on the association between proximal cross-clamp location and postoperative renal dysfunction. In this study, we conducted a retrospective analysis of 4,197 patients undergoing open AAA surgery between 2011 and 2018 using data housed in the American College of Surgeons National Safety Quality Improvement Program (ACS-NSQIP) database. The primary outcome was renal dysfunction, which was defined as patients requiring dialysis within 30days or patients with ≥2mg/dL rise in creatinine from baseline. We assessed the incidence of renal dysfunction with regard to clamp location and subsequently used multivariable logistic regression to assess clinical and demographic factors associated with renal dysfunction. We used a regression model to plot the association of BMI, surgical duration, and aneurysm diameter with an adjusted probability of postoperative acute and chronic renal dysfunction for individual cross-clamp locations. Of the 4,197 patients analyzed, 405 patients (9.6%) developed renal dysfunction within 30 days with 287 patients requiring dialysis. Patients with supraceliac clamp location had the highest incidence of renal dysfunction (20.4%). Our data showed a significant association of renal dysfunction with higher BMI patients [OR 1.04 (1.02, 1.07), P=0.001], longer operative times [OR1.01 (1.01, 1.02), P<0.001], clamp location between the superior mesenteric artery (SMA) and renal artery [OR 1.80 (1.17, 2.78), P=0.007] and supraceliac clamp location [OR 2.47 (1.62, 3.76), P<0.001]. The incidence of renal dysfunction increases with suprarenal clamps. Patients with higher BMI, longer operative times, and increasing aneurysm diameter, and a suprarenal clamp have a significantly increased risk of renal dysfunction compared to those who also had a suprarenal clamp but lower BMI, shorter operative times and smaller aneurysm diameter.

ACTION-1: study protocol for a randomised controlled trial on ACT-guided heparinization during open abdominal aortic aneurysm repair

BackgroundHeparin is used worldwide for 70 years during all non-cardiac arterial procedures (NCAP) to reduce thrombo-embolic complications (TEC). But heparin also increases blood loss causing possible harm for the patient. Heparin has an unpredictable effect in the individual patient. The activated clotting time (ACT) can measure the effect of heparin. Currently, this ACT is not measured during NCAP as the standard of care, contrary to during cardiac interventions, open and endovascular. A RCT will evaluate if ACT-guided heparinization results in less TEC than the current standard: a single bolus of 5000 IU of heparin and no measurements at all. A goal ACT of 200–220 s should be reached during ACT-guided heparinization and this should decrease (mortality caused by) TEC, while not increasing major bleeding complications. This RCT will be executed during open abdominal aortic aneurysm (AAA) surgery, as this is a standardized procedure throughout Europe.MethodsSeven hundred fifty patients, who will undergo open AAA repair of an aneurysm originating below the superior mesenteric artery, will be randomised in 2 treatment arms: 5000 IU of heparin and no ACT measurements and no additional doses of heparin, or a protocol of 100 IU/kg bolus of heparin and ACT measurements after 5 min, and then every 30 min. The goal ACT is 200–220 s. If the ACT after 5 min is < 180 s, 60 IU/kg will be administered; if the ACT is between 180 and 200 s, 30 IU/kg. If the ACT is > 220 s, no extra heparin is given, and the ACT is measured after 30 min and then the same protocol is applied. The expected incidence for the combined endpoint of TEC and mortality is 19% for the 5000 IU group and 11% for the ACT-guided group.DiscussionThe ACTION-1 trial is an international RCT during open AAA surgery, designed to show superiority of ACT-guided heparinization compared to the current standard of a single bolus of 5000 IU of heparin. A significant reduction in TEC and mortality, without more major bleeding complications, must be proven with a relevant economic benefit.Trial registration {2a}NTR NL8421ClinicalTrials.gov NCT04061798. Registered on 20 August 2019EudraCT 2018-003393-27Trial registration: data set {2b}Data categoryInformationPrimary registry and trial identifying numberClinicalTrials.gov: NCT04061798Date of registration in primary registry20-08-2019Secondary identifying numbersNTR: NL8421EudraCT: 2018-003393-27Source(s) of monetary or material supportZonMw: The Netherlands Organisation for Health Research and DevelopmentDijklander ZiekenhuisAmsterdam UMCPrimary sponsorDijklander ZiekenhuisSecondary sponsor(s)N/AContact for public queriesA.M. Wiersema, MD, PhDArno@wiersema.nu0031-229 208 206Contact for scientific queriesA.M. Wiersema, MD, PhDArno@wiersema.nu0031-229 208 206Public titleACT Guided Heparinization During Open Abdominal Aortic Aneurysm Repair (ACTION-1)Scientific titleACTION-1: ACT Guided Heparinization During Open Abdominal Aortic Aneurysm Repair, a Randomised TrialCountries of recruitmentThe Netherlands. Soon the recruitment will start in GermanyHealth condition(s) or problem(s) studiedAbdominal aortic aneurysm, arterial disease, surgeryIntervention(s)ACT-guided heparinization5000 IU of heparinKey inclusion and exclusion criteriaAges eligible for the study: ≥18 yearsSexes eligible for the study: bothAccepts healthy volunteers: noInclusion criteria:Study typeInterventionalAllocation: randomizedIntervention model: parallel assignmentMasking: single blind (patient)Primary purpose: treatmentPhase IVDate of first enrolmentMarch 2020Target sample size750Recruitment statusRecruitingPrimary outcome(s)The primary efficacy endpoint is 30-day mortality and in-hospital mortality during the same admission.The primary safety endpoint is the incidence of bleeding complications according to E-CABG classification, grade 1 and higher.Key secondary outcomesSerious complications as depicted in the Suggested Standards for Reports on Aneurysmal disease: all complications requiring re-operation, longer hospital stay, all complications

Incidence and risk factors for incisional hernia after open abdominal aortic aneurysm repair

IntroductionIncisional hernia (IH) is common after open abdominal aortic aneurysm (AAA) repair. Recent studies reported incidence rates higher than previously stated. The aim of this study was to quantify the IH incidence after open AAA surgery. The secondary outcome was to identify the risk factors associated with the development of an IH. MethodsRetrospective observational study of all consecutive patients who underwent an open repair of AAA, from January 2010 to June 2018, at our institution. Patients were free of abdominal wall hernias at the moment of inclusion in the study. Data were extracted from electronic records: baseline characteristics, surgical factors, and postoperative events. Computed tomography (CT) scans performed during follow-up were analyzed. ResultsA total of 157 patients were analysed. The IH incidence after open repair of AAA was 46.5% (73 patients). The median time for IH development was 24.43 months (IQR: 10.40–45.27), while the median follow-up time was 37.20 months (IQR: 20.53–64.12). The risk factors linked to IH were: active (HR: 4.535; 95% CI: 1.369–15.022) or previous smoking habit (HR: 4.652; 95% CI: 1.430–15.131), chronic kidney disease (HR: 2.007; 95% CI: 1.162–3.467) and previous abdominal surgery (HR: 1.653; 95% CI: 1.014–2.695). ConclusionThe incisional hernia after open abdominal aortic aneurysm repair affected a high proportion of the intervened patients. Previous abdominal surgery, chronic kidney disease, and smoking habit were independent factors for the development of an incisional hernia.

Learning Curve Analysis for Complex Open Abdominal Aortic Aneurysm Repair

Since endovascular repair has revolutionized aneurysm repair, the issue of training vascular surgeons in open complex abdominal aortic aneurysm (cAAA) surgery has received significant attention. Through learning curve analysis, we aimed to determine the number of cases needed for surgeons to achieve satisfactory open surgical skills for cAAA.

The retroperitoneal approach for contemporary open abdominal aortic aneurysm surgery: The anatomical reasoning.

In current practice, the place of open surgery in managing abdominal aortic aneurysm is a contentious issue. The principal reason being greater applications of endovascular techniques treating increasingly complicated aortic disease. Development of branched and fenestrated devices enabled this, with numbers increasing annually. This meant a good risk patient with a long infrarenal aortic neck and normal diameter non-tortuous iliac arteries may be suitable for both endovascular and open techniques. However, indications for open surgery are becoming increasingly unclear nowadays due to short-term gains in morbidity and mortality. Exact aortic anatomical morphologies optimum for open or endovascular techniques remains unclear. As graft technology evolves, possibilities for endovascular options are expanding. Currently, establishing optimum treatment plans for complicated abdominal aortic aneurysm (little or no infrarenal neck) is difficult without considering general fitness of the patient. Hence, two sets of possible postoperative complications and follow-up protocols must be explained to patients before either approach. Complicating matters is the optimum surgical approach used for any open repair. The standard approach for open abdominal aortic aneurysm surgery has been transperitoneal as this provides excellent access to the infrarenal aorta and iliac arteries. However, although less commonly used, the retroperitoneal approach has advantages particularly when location of proximal aortic disease indicates suprarenal clamp might be optimum. This paper scrutinises benefits of the retroperitoneal approach performed purely for anatomical reasons where stent graft may be considered complicated. Also, long-term outcomes are examined in terms of endo-leak and subsequent development of true and false aneurysm following both endovascular and open repair.

Open Abdominal Aortic Aneurysm Surgery Among Vascular Surgery Trainees: On the Verge of Extinction?

Objective: In the past decade, treatment of abdominal aortic aneurysm (AAA) has shifted dramatically from open aneurysm repair (OAR) to an endovascular approach (EVAR). The decreasing number OARs has raised concerns regarding future vascular surgeons’ competence to perform this complex and high risk procedure. The main goal of this study was to evaluate AAA repair trends among vascular surgery residents over the last 15 years on a national level.

Inflammatory Gene Expression of Human Perivascular Adipose Tissue in Abdominal Aortic Aneurysms

Perivascular adipose tissue (PVAT) contributes to vascular homeostasis and is increasingly linked to vascular pathology. PVAT density and volume were associated with abdominal aortic aneurysm (AAA) presence and dimensions on imaging. However, mechanisms underlying the role of PVAT in AAA have not been clarified. This study aimed to explore differences in PVAT from AAA using gene expression and functional tests. Human aortic PVAT and control subcutaneous adipose tissue were collected during open AAA surgery. Gene analyses and functional tests were performed. The control group consisted of healthy aorta from non-living renal transplant donors. Gene expression tests were performed to study genes potentially involved in various inflammatory processes and AAA related genes. Live PVAT and subcutaneous adipose tissue (SAT) from AAA were used for exvivo co-culture with smooth muscle cells (SMCs) retrieved from non-pathological aortas. Adipose tissue was harvested from 27 AAA patients (n [gene expression]= 22, n [functional tests]= 5) and five control patients. An increased inflammatory gene expression of PTPRC (p= .008), CXCL8 (p= .033), LCK (p= .003), CCL5 (p= .004) and an increase in extracellular matrix breakdown marker MMP9 (p= .016) were found in AAA compared with controls. Also, there was a decreased anti-inflammatory gene expression of PPARG in AAA compared with controls (p= .040). SMC co-cultures from non-pathological aortas with PVAT from AAA showed increased MMP9 (p= .033) and SMTN (p= .008) expression and SAT increased SMTN expression in these SMC. The data revealed that PVAT from AAA shows an increased pro-inflammatory and matrix metallopeptidase gene expression and decreased anti-inflammatory gene expression. Furthermore, increased expression of genes involved in aneurysm formation was found in healthy SMC co-culture with PVAT of AAA patients. Therefore, PVAT from AAA might contribute to inflammation of the adjacent aortic wall and thereby plays a possible role in AAA pathophysiology. These proposed pathways of inflammatory induction could reveal new therapeutic targets in AAA treatment.