Open Aortic Aneurysm Repair Research Articles

Preoperative Functional Status Predicts 2-year Mortality in Patients Undergoing Fenestrated/branched Endovascular Aneurysm Repair

Fenestrated/branched endovascular aneurysm repair (F/BEVAR) is a minimally invasive alternative for patients at high risk for open repair of complex aortic aneurysms. Nearly all investigative study protocols evaluating F/BEVAR require a predicted life expectancy >2 years for study inclusion. However, accurate risk models for predicting 2-year survival in this patient population are lacking. We sought to identify preoperative predictors of 2-year survival in patients undergoing F/BEVAR. Prospectively collected data on all consecutive F/BEVAR procedures, performed in an institutional review board-approved registry and/or physician-sponsored investigational device exemption trial (IDE# G130210), were reviewed (November 2010 to February 2019). Forty-four preoperative patient characteristics, including comorbidities, preoperative functional status, and aneurysm/repair characteristics, were assessed. Preoperative functional status was defined as totally dependent (any impairment in activities of daily living (ADLs) or residence in a skilled nursing facility), partially dependent (any impairment in instrumental ADLs), or independent (no impairment of ADLs/instrumental ADLs). Based on a univariate screen (P < .2), a Cox proportional hazards model was constructed to identify independent predictors of 2-year all-cause mortality. Among 256 consecutive F/BEVARs (six [2.3%] common iliac, 94 [41%] juxtarenal, 35 [14%] pararenal, 119 [47%] thoracoabdominal, and 2 [0.8%] arch aneurysms), the 2-year mortality was 18%. On Cox modeling, the only independent preoperative predictor of 2-year mortality was functional status (totally dependent, hazard ratio [HR], 5.4 [95% CI, 1.8-16; P < .01]; partially dependent, HR, 4.7 [95% CI, 2.5-8.7; P < .01]). A history of coronary revascularization was protective (HR, 0.5, 95% CI, 0.2-0.9; P = .03). Factors such as age, congestive heart failure, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, aneurysm extent, and prior aortic surgery were not significant. The 2-year mortality for the independent (n = 176 [69%]), partially dependent (n = 69 [27%]), and totally dependent groups (n = 10 [3.9%]), was 11%, 33%, and 40%, respectively (Fig). In patients undergoing F/BEVAR, decreased preoperative functional status is the strongest predictor of 2-year mortality, with totally dependent patients experiencing poor survival. Traditional risk factors were not independently significant, perhaps reflecting a high prevalence of severe chronic illness in these high-risk patients participating in an investigational device exemption trial. Given that 2-year survival in the independent group of this high-risk cohort is 89%, which mirrors that of infrarenal EVAR, expanding the indication for F/BEVAR to patients who are independent is reasonable for low-risk patients as well.

A Sensitive Matter: Performance of Contemporary Outcomes Measures in Detecting Complications in Complex Endovascular Aortic Repair

Agency for Healthcare Research and Quality Patient Safety Indicators are quality improvement indicators used to determine hospital performance and, increasingly, to rank surgical programs. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) databases are also frequently used to compare outcomes, but definitions of complications vary between the systems, and the optimal system for tracking complications in complex endovascular repair remains unclear. Herein we assess the three outcomes tracking systems and their ability to capture complications in fenestrated endovascular (FEVAR) and open aortic aneurysm (OAR) repair at a large complex aortic program. Demographic and operative data for patients undergoing repair of juxta- or pararenal aortic aneurysms between 2004 and 2018 via both open and fenestrated endovascular (FEVAR) approaches at the Johns Hopkins Medical Institutions were compiled in a prospectively maintained retrospective database. Postoperative complications were defined according to the SVS-VQI, ACS-NSQIP and data dictionaries and were compared between surgical approaches as well as eras before and after the introduction of FEVAR. Complication rates between the classification systems were compared using proportion testing and strength of correlation between the systems was evaluated with Spearman’s rank test. Statistical analysis was performed with Stata version 15.1 (StataCorp, Cary, NC). Introduction of fenestrated technology was associated with a decrease in the overall number of complications (37.2% to 20.6%; P = .036). By classification systems, VQI identified the most complications (39.9% of the entire cohort and 25% of FEVAR cases), followed by NSQIP (29.0% and 33.3%, respectively) and PSI (4.1% and 5%, respectively). The two clinically focused databases were found to correlate well with a surgeon-designed classification system as well as each other (Spearman ρ ≥ 0.735) but not with PSI (ρ < 0.23). Proportion testing demonstrated the rate of complications identified by PSI to be significantly less than either VQI or NSQIP (P < .001). Specifically, PSI did not effectively identify renal complications (1.4% vs 9% by NSQIP and 27.3% by VQI definitions; P < .001). The introduction of FEVAR is associated with an overall reduction in complications in this study, mostly owing to a reduction in respiratory complications. The clinically relevant VQI and NSQIP databases show good concordance in capturing complications; however, PSI did not correlate with either and captured significantly fewer complications. This highlights the value of high scrutiny classification systems to track endovascular complications and suggests that PSI are insufficient to rank complex aortic programs with high levels of FEVAR use.

Not All Databases Are Created Equal, a Comparison of Administrative Data and Quality Improvement Registries for Abdominal Aortic Aneurysm Repair

Databases are essential in evaluating surgical outcomes. However, there are important differences in how data from administrative databases and surgical quality improvement (QI) registries are collected and interpreted. Therefore, we aim to compare trends, demographics, and outcomes of open and endovascular aortic abdominal aneurysm (AAA) repair in an administrative database and two QI registries.

Neurologic Outcomes in Open Thoracoabdominal Aortic Aneurysm Repair Performed Under Deep Hypothermic Circulatory Arrest With and Without Spinal Drainage

Spinal drainage is a well-accepted adjunct employed to reduce the incidence of spinal cord morbidity after open thoracoabdominal aortic aneurysm (TAAA) repair. However, major complications associated with spinal drains, such as epidural hematoma, can be devastating. Our practice has evolved to routine performance of extensive TAAA repair under cardiopulmonary bypass and deep hypothermic circulatory arrest (DHCA); the intraoperative hypothermia provides spinal cord and other organ protection. The aim of this study was to evaluate the utility of additional spinal cord drainage in preventing paraplegia under these circumstances.

Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms: A Meta-Analysis

Contemporary outcomes of open repair of thoracoabdominal aortic aneurysms (TAAAs) and descending thoracic aortic aneurysms (DTAs) have not been analyzed in an inclusive meta-analysis. After a systematic literature search, studies from 2008 to 2018 reporting outcomes of open repair of DTAs or TAAAs were pooled in a single-arm meta-analysis performed using the generic inverse variance method. Primary outcome was operative mortality. Secondary outcomes were late mortality, postoperative stroke, permanent and temporary spinal cord injury, renal failure, respiratory failure, and myocardial infarction. Fifty-four studies with 12,245 patients were included. Pooled operative mortality for open repair was 10.4% (95% confidence interval [CI], 8.3-12.8): 6.6% (95% CI, 3.7-11.6) for DTA and 10.5% (95% CI, 7.5-14.5) for TAAA. Pooled incidence rate of late mortality was 0.6% (95% CI, 0.5-0.8) per person-year. Pooled rates for postoperative outcomes were 4.9% (95% CI, 3.9-6.1) for stroke; 5.7% (95% CI, 4.3-7.5) and 3.0% (95% CI, 2.1-4.2) for permanent and temporary spinal cord injury, respectively; 13.2% (95% CI, 9.9-17.3) for renal failure; 23.3% (95% CI, 17.5-30.4) for respiratory failure; and 2.7% (95% CI, 1.8-4.1) for myocardial infarction. At metaregression, year of publication, use of the clamp-and-sew technique, and use of the cerebrospinal fluid drain were associated with lower operative mortality. Ruptured aneurysms were associated with higher operative mortality. Despite improvement, open repair of DTAs and TAAAs continues to be associated with a considerable risk for operative death and perioperative complications. Use of the cerebrospinal fluid drain is associated with better outcomes.

Elective late open conversion after endovascular aneurysm repair is associated with comparable outcomes to primary open repair of abdominal aortic aneurysms

ObjectiveThree of four patients with infrarenal abdominal aortic aneurysm are now treated with endovascular aneurysm repair (EVAR). The incidence of secondary procedures and surgical conversions is increasing for a population theoretically unfit for open surgery. The indications and outcomes of late open surgical conversions after EVAR in a high-volume tertiary vascular unit are reported. MethodsThis retrospective single-center study includes all patients who underwent a late open conversion between January 1996 and July 2018. Data were collected from records on patient demographics, operative indications, surgical strategy, perioperative outcomes, and medium-term survival. ResultsSixty-two consecutive patients (88.7% male) with a mean age of 77.5 years are included. The median duration since index EVAR was 38.5 months; 65% of stent grafts requiring late open conversion had suprarenal fixation. Indications included 22.6% type IA, 16.1% type IB, and 45.2% type II endoleaks; 12.9% graft thrombosis; and 14.5% endoprosthesis infection. Complete endograft explantation was performed in 37.1% of patients and a partial explantation in 54.8%, whereas 8.1% of stent grafts were wholly preserved in situ. Overall 30-day mortality was 12.9% (n = 8) in the cohort and 2.7% for elective patients. The all-cause morbidity rate was 40.1%, and the median length of hospital stay was 9 days. After follow-up of 28.4 months (range, 1.8-187.3 months), all-cause survival was 58.8%. Avoidance of aortic clamping (P = .006) and elective procedures (P = .019) were associated with a significant reduction in the length of hospital stay. Moreover, the 30-day mortality (P = .002), occurrence of postoperative renal dysfunction (P = .004), and intestinal ischemia (P = .017) were increased in the emergency setting. Excluding cases with rupture or infection, survival estimates were 97%, 97%, and 71% at 1 year, 2 years, and 5 years, respectively. ConclusionsTechnically more complex than primary open surgery, late open conversion is a procedure that generates an acceptable perioperative risk when it is performed in a high-volume aortic surgical center. Elective open conversion is associated with excellent early and late outcomes. Endograft preservation strategies decrease perioperative morbidity.

Increased hospital volume is associated with reduced mortality after thoracoabdominal aortic aneurysm repair

ObjectiveContemporary data on outcomes in open thoracoabdominal aortic aneurysm (TAAA) repair are limited to reports from major aortic referral centers showing excellent outcomes. This study aimed to characterize the national experience of open TAAA repair using national outcomes data, with a primary focus on the association of hospital volume with mortality and morbidity. MethodsThe Nationwide Inpatient Sample was queried from 1998 to 2011, and all patients with a diagnosis of TAAA who underwent open operative repair were included. These patients were further stratified into tertiles based on the operative volume of the institution that performed the operation: low volume (LV), <3 cases/y; medium volume (MV), 3 to 11 cases/y; and high volume (HV), ≥12 cases/y. Baseline demographics as well as perioperative outcomes were compared between these groups. Multivariable logistic regression was performed to determine predictors of operative mortality and morbidity. Subgroup analyses were performed for patients presenting for elective surgery and for those presenting for urgent and emergent surgery. ResultsOverall operative mortality was 21% for the entire cohort. Operative mortality was higher at LV (26%) and MV (21%) centers compared with HV centers (15%; P < .001). This difference was similar in both elective surgery (LV, 18%; MV, 14%; HV, 12%; P < .001) and urgent and emergent surgery (LV, 34%; MV, 30%; HV, 19%; P < .001). Furthermore, rates of blood transfusion and acute renal failure were significantly lower in the HV group. Multivariable analysis revealed that compared with the HV group, patients operated on at LV centers (odds ratio [OR], 1.9, 95% confidence interval [CI], 1.7-2.1; P < .001) and MV centers (OR, 1.5; 95% CI, 1.4-1.7; P < .001) had at least 1.5 times the odds of in-hospital mortality. The HV group also had significantly lower odds of dying in the subgroup analyses of both elective surgery and urgent and emergent surgery. Increasing TAAA volume was associated with increased use of distal aortic perfusion (OR, 1.03; 95% CI, 1.02-1.03; P < .001). ConclusionsPatients with TAAA in the United States operated on at HV centers have significantly lower mortality and morbidity compared with patients operated on at lower volume centers. Consideration of referral to HV centers may be warranted, but further research is required to justify this conclusion.

Contemporary mortality after emergent open repair of complex abdominal aortic aneurysms

ObjectiveMortality after open repair for emergent complex abdominal aortic aneurysm (AAA) is poorly defined. This study evaluated the 30-day mortality of open complex AAA repair performed for rupture or other emergent indication using a national surgical registry. We subsequently identified factors associated with mortality. MethodsThe targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing open repair for juxtarenal and suprarenal AAAs or type IV thoracoabdominal aneurysms (TAAAs) for rupture or other emergent indication from 2011 to 2017. Univariate analyses were performed using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Multivariable logistic regression was performed to identify factors independently associated with mortality. ResultsWe included 374 patients who underwent an emergent complex open AAA repair during the study period. There were 142 (38%) cases performed for rupture with hypotension, 141 (38%) for rupture without hypotension, 40 (11%) for symptomatic AAA, and 51 (14%) for another indication. The distribution by aneurysm type was 224 juxtarenal AAAs, 122 suprarenal AAAs, and 28 type IV TAAAs. Overall, there was a 30-day mortality of 32% (118 deaths). For those with juxtarenal AAA repair, 67 (30%) patients died within 30 days; there were 38 (31%) deaths within 30 days in those with suprarenal AAA, and 13 (46%) deaths within 30 days in those with type IV TAAA. On univariate analysis, preoperative variables associated with death were increasing age, use of a transperitoneal surgical approach, lower preoperative estimated glomerular filtration rate, low baseline albumin concentration (<3.5 g/dL), need for preoperative transfusion, low body mass index (<18.5 kg/m2), and hypotension at presentation. Intraoperative variables associated with mortality were supraceliac clamp location and concurrent renal revascularization. On multivariable analysis, factors independently associated with death included rupture with associated hypotension (reference: other emergent indication; adjusted odds ratio [AOR], 3.28; confidence interval [CI], 1.75-5.41; P < .001), age >60 years (reference: <60 years; AOR, 1.59; CI, 1.18-2.13; P = .002), longitudinal laparotomy incision (reference: retroperitoneal; AOR, 3.28; CI, 1.75-6.16; P < .001), and supraceliac cross-clamp (reference: clamp above one renal artery; AOR, 2.14; CI, 1.31-3.50; P = .003). ConclusionsNearly one-third of patients die within 30 days of emergent open complex AAA repair. Mortality is particularly high for patients with type IV TAAAs, approaching 50%. Predictors of 30-day mortality include rupture with associated hypotension, increasing age, supraceliac clamp location, and longitudinal transperitoneal repair approach. These results will help inform surgical decisions preoperatively and intraoperatively.

A novel physician-assembled endograft for the repair of pararenal, paravisceral, Crawford type IV thoracoabdominal aortic aneurysms, and aneurysms requiring treatment after prior repair

ObjectiveIn the present study, we reviewed the 30-day and 1-year clinical results of the use of the investigational unitary manifold (UM) stent graft system (Sanford Health, Sioux Falls SDak) for the repair of Crawford type IV, pararenal, paravisceral, juxtarenal, and short-neck infrarenal aneurysms (<10 mm). MethodsThe present study was a single-center, multiarm, prospective review of the first 44 patients who had undergone repair of Crawford type IV, pararenal, juxtarenal, and short-neck infrarenal aneurysms (<10 mm) using the physician-modified UM under a physician-sponsored investigational device exemption. The primary end point was freedom from major adverse events at 30 days, including all-cause mortality, myocardial infarction, stroke, paraplegia, bowel ischemia, respiratory failure, and renal failure. ResultsTechnical success was achieved in all 44 patients (100%), with a large number of these patients having undergone previous aortic repair (20 of 44; 45.5%). All the intended 170 visceral vessels (100%) had been successfully cannulated and stent grafted. No episodes of paraplegia or in-hospital deaths were recorded. One patient had died of aneurysm-related ischemic stroke (2.3%). The rate of transient nonclinically significant spinal cord ischemia was 4.5%. At the last follow-up, one reintervention had been required owing to branch patency from a thrombotic event. Of the 170 bridging stent grafts, 169 have remained patent through a mean follow-up of 8.8 months (range, 0-36 months). No type I or III endoleaks, migration, or component separation in the investigational device has occurred. ConclusionsThe early and midterm results with the use of the UM suggest it could be a viable option for the repair of Crawford type IV, pararenal, paravisceral, juxtarenal, and short-neck infrarenal aneurysms (<10 mm) without exposing patients to the increased risk of permanent spinal cord ischemia, renal failure, visceral vessel ischemia, or aneurysm-related mortality that results from open thoracoabdominal aortic aneurysm repair. The high technical success rate, in native and previous repairs, supports the utility of this device as a bail-out technique for failed endovascular aneurysm repair or proximal extension of disease after previous aortic repair. However, experience is limited, and this approach requires further study before widespread adoption.

One Year on: Test Your Knowledge from April 2019

1. According to the EVAR-SCREEN study carried out in the UK, which one of the following statements is correct?A.Compliance to EVAR surveillance varied widely across individual centres.B.Compliance to EVAR surveillance is very good (>80%) across the UK.C.Compliance to EVAR surveillance is very poor (<10%) across the UK.D.There is no need for surveillance after EVAR.E.There should be no difference in surveillance after EVAR compared with open aortic aneurysm repair.

Vascular Surgeons’ Views on Ejaculation Disorders After Abdominal Aortic Surgery: Results of a Dutch Survey

The aim of this study is to evaluate vascular surgeons' knowledge and appreciation of ejaculatory dysfunction after open aortic aneurysm repair and the knowledge of possible nerve-preserving techniques. A Dutch national survey was conducted on sexual counseling in the case of open aortic surgery. For this purpose, a designed questionnaire based on a review of the literature in the field and on other surveys aiming to analyze care for sexual health by medical specialists was used. The response rate was almost 60%. All responders were familiar with the occurrence of postoperative neurogenic complications. Sixty percent preoperatively informs their patients, but only one-third inquires whether such complications have occurred postoperatively. Most respondents estimated the incidence of postoperative neurogenic complications due to dissection of the periaortic tissues between 5% and 25%. Almost 75% take nerve anatomy into consideration when exposing the abdominal aorta, but only 29% mention the correct structures, and only 37% mention possible correct nerve-sparing techniques. Dutch vascular surgeons are well aware of the occurrence of postoperative sexual disorders after infrarenal aortic reconstruction. A gap in knowledge of pathophysiology and anatomy exists. Furthermore, a significant part of vascular surgeons seems to lack skills in sexual counseling. Therefore, more education should be offered during vascular surgical training. This article addresses iatrogenic neurogenic complications affecting sexual health following open aortic surgery. It opens the discussion on possible gaps in modern training of vascular surgeons and on sexual health in relation to postoperative quality of life and shared decision-making.

Elective Endovascular Versus Open Repair of Abdominal Aortic Aneurysm - Current Long-Term Data

Four randomized clinical trials prospectively compared endovascular (EVAR) and open repair (OR) of abdominal aortic aneurysm (AAA): Chronologically these are EVAR 1 (UK), DREAM (Netherlands), OVER (USA) and ACE (France). All of them investigated whether the superior early postoperative outcome of endovascular repair is maintained in the long-term. The longest follow-up data of EVAR 1, with a mean person-years observation (either until death or end of study) of 8 years, clearly question the superiority of EVAR. In this context, open repair of AAA takes on a new significance and the indication for endovascular repair should be critically assessed with regard to the long-term course. Indication for invasive treatment has not changed and should - apart from exceptions - only be given for men with a diameter of 5,5 cm or more. Furthermore, current studies on prophylactic mesh reinforcement after open repair of AAA show that incisional hernias can be safely avoided.

Detrimental effects of cerebrospinal fluid pressure elevation on spinal cord perfusion: first-time direct detection in a large animal model.

Cerebrospinal fluid (CSF) drainage is routinely utilized to mitigate perioperative and postoperative spinal cord ischaemia in open and endovascular thoraco-abdominal aortic aneurysm repair to prevent permanent paraplegia. Clinical decision-making in the vulnerable perioperative period, however, is still based on limited clinical and experimental data. Our aim was to investigate the isolated effect of CSF pressure elevation on spinal cord perfusion in an established large animal model. Ten juvenile pigs with normal (native) arterial inflow (patent segmental arteries and collaterals) underwent iatrogenic CSF pressure elevation (×2, ×3, ×4 from their individual baseline pressure). Each pressure level was maintained for 30 min to mimic clinical response time. After the quadrupling of CSF pressure, the dural sac was slowly depressurized against gravity allowing CSF pressure to passively return to baseline values. Measurements were taken 30 and 60 min after normalization, and microspheres for regional blood flow analysis were injected at each time point. Spinal cord perfusion decreased significantly at all mid-thoracic to lumbar cord segments at the doubling of CSF pressure and declined to values <53% compared to baseline when pressure was quadrupled. Normalizing CSF pressure led to an intense hyperperfusion of up to 186% at the cervical level and 151% within the lumbar region. CSF pressure elevation results in a relevant impairment of spinal cord blood supply. Close perioperative and postoperative monitoring of CSF pressure is crucial for maintaining sufficient spinal cord perfusion. Radical and rapid withdrawal of CSF is followed by significant hyperperfusion in all spinal cord segments and may lead to 'drainage-related' iatrogenic reperfusion injury-aggravating the risk of delayed spinal cord injury-and should therefore be avoided.

A Novel Endosurgical Prosthesis to Treat Thoracoabdominal Aortic Aneurysm in Complex Anatomy or Emergency Settings.

Background Despite improvements in operative techniques, open thoracoabdominal aortic aneurysm (TAAA) repair is complex and characterized by high mortality and morbidity rate. Less invasive techniques have been developed since 2005 for the treatment of TAAA. Unfortunately, many of these devices require custom fabrication, resulting in delay of many weeks until treatment can be delivered but crucial in critical emergency cases. We present a novel hybrid endovascular and surgical prosthesis, which was tested on five pigs, with the aim of reducing the barrier issues of endovascular therapy in such particular cases. Methods The principal characteristic of the proposed hybrid endovascular prosthesis is to combine a proximal and distal stented zones and, in between, a classical surgical blood tied Dacron prosthesis. The device was tested in five pigs where feasibility of implantation and acute postoperative outcomes were evaluated, including bleeding, bowel ischemia, renal function, and peripheral blood perfusion. Results In all cases, following laparotomy, the endoprosthesis was successfully implanted under fluoroscopy and the surgical prosthesis zone could be easily detected by the radio-opaque markers. No major bleeding or cardiac events occurred throughout preparation and implantation. One hour after prosthesis implantation and surgical anastomoses of all vessels were completed, normal urine output was registered, and no acidosis was detected. Conclusions This novel graft has shown ease of endoprosthesis and visceral vessels implantation without the need of thoracotomy or extracorporeal circulation and may be useful in an emergency setting or high risk and complex anatomy TAAA unsuitable for traditional endovascular aneurysm repair, or to avoid an excess waiting time for a “custom made” prosthesis. The great adaptability of this “hybrid” prosthesis in complex anatomy for the majority of TAAA could be important in high-risk patients and in some difficult situations, such as a high risk of imminent rupture.

Failure to rescue is not the entire answer to improving open aortic aneurysm repair results but it is an important start

The rapid adoption of endovascular abdominal aortic aneurysm (AAA) repair, with a 1% to 3% mortality rate has reduced hospital mortality rates to levels rarely achieved in open AAA repair publications. Open repair volumes have declined dramatically in favor of endovascular aortic repair; however, open repair remains a durable option with excellent long-term outcomes but higher early mortality rates. Mortality rates for AAA repair and other major surgical interventions are well known to vary with hospital volumes; however, the factors responsible are not clearly identified.

'Double layer' frozen elephant trunk with balloon endoclamping: a technique to simplify the 2-stage open repair of thoraco-abdominal aortic aneurysms.

Staged replacement of the aortic arch and thoraco-abdominal aorta (TAA) with a frozen elephant trunk followed by TAA repair is a valuable treatment for patients with chronic TAA dissection. However, in patients with an unclampable descending thoracic aorta, the retrieval of the trunk can be problematic and the proximal stent graft-to-graft anastomosis technically challenging. Here we present our 'double layer' frozen elephant trunk technique to treat patients with TAA dissection.

Early and long-term results of open repair of inflammatory abdominal aortic aneurysms: Comparison with a propensity score-matched cohort

ObjectiveThe aim of our study was to compare early and long-term results of open repair of patients with inflammatory abdominal aortic aneurysm (IAAA) with matched cohort of patients with abdominal aortic aneurysm (AAA). MethodsThis retrospective single-center cohort study used prospectively collected data from an institutional registry from 1786 patients between 2009 and 2015. Patients with IAAA and AAA were matched by propensity score analysis controlling for demographics, baseline comorbidities, and AAA parameters in a 1:2 ratio. Patients were followed for 5 years. ResultsThere were 76 patients with IAAA and 152 patients with AAA. Patients with IAAA had more common intraoperative lesion of intraabdominal organs (P = .04), longer in-hospital (P = .035) and intensive care (P = .048) stays and a higher in-hospital mortality rate (P = .012). There were four patients (5.26%) with in-hospital lethal outcome in IAAA there were no deaths in the AAA group. During the follow-up, there was no difference in survival (χ2 = 0.07; DF = 1; P = .80) and overall aortic related complications (χ2 = 1.25; DF = 1; P = .26); however, aortic graft infection was more frequent in IAAA group (P = .04). ConclusionsOpen repair of IAAA is challenging and comparing to AAA carries a higher perioperative risk and long-term infection rate, even in high-volume centers. The main causes of complications are intraoperative injury of adjacent organs, bleeding, and coronary events. Patients with AAA in a matched cohort showed equal long-term survival, which should be assessed in bigger registries.

SLPI - a Biomarker of Acute Kidney Injury after Open and Endovascular Thoracoabdominal Aortic Aneurysm (TAAA) Repair

Acute kidney injury (AKI) is a relevant complication following thoracoabdominal aortic aneurysm repair (TAAA). Biomarkers, such as secretory leucocyte peptidase inhibitor (SLPI), may enable a more accurate diagnosis. In this study, we tested if SLPI measured in serum is an appropriate biomarker of AKI after TAAA repair. In a prospective observational single-center study including 33 patients (51.5% women, mean age 63.0 ± 16.2 years) undergoing open and endovascular aortic aneurysm repair in 2017, SLPI was measured peri-operatively (until 72 h after surgery). After surgery, the postoperative complications AKI, as defined according to the KDIGO diagnostic criteria, sepsis, death, MACE (major cardiovascular events) and, pneumonia were assessed. In a subgroup analysis, patients with preexisting kidney disease were excluded. Of 33 patients, 51.5% (n = 17) of patients developed AKI. Twelve hours after admission to the intensive care unit (ICU), SLPI serum levels were significantly increased in patients who developed AKI. Multivariable logistic regression revealed a significant association between SLPI 12 hours after admission to ICU and AKI (P = 0.0181, OR = 1.055, 95% CI = 1.009–1.103). The sensitivity of SLPI for AKI prediction was 76.47% (95% CI = 50.1–93.2) and the specificity was 87.5% (95% CI = 61.7–98.4) with an AUC = 0.838 (95% CI = 0.7–0.976) for an optimal cut-off 70.03 ng/ml 12 hours after surgery. In patients without pre-existing impaired renal function, an improved diagnostic quality of SLPI for AKI was observed (Sensitivities of 45.45–91.67%, Specificities of 77.7–100%, AUC = 0.716–0.932). There was no association between perioperative SLPI and the incidence of sepsis, death, MACE (major cardiovascular events), pneumonia. This study suggests that SLPI might be a post-operative biomarker of AKI after TAAA repair, with a superior diagnostic accuracy for patients without preexisting impaired renal function.

INVITED COMMENTARY

INVITED COMMENTARY

Ensuring Competency in Open Aortic Aneurysm Repair – Development and Validation of a New Assessment Tool

The aims of this study were to develop a procedure specific assessment tool for open abdominal aortic aneurysm (AAA) repair, gather validity evidence for the tool and establish a pass/fail standard. Validity was studied based on the contemporary framework by Messick. Three vascular surgeons experienced in open AAA repair and an expert in assessment and validation within medical education developed the OPEn aortic aneurysm Repair Assessment of Technical Expertise (OPERATE) tool. Vascular surgeons with varying experiences performed open AAA repair in a standardised simulation based setting. All procedures were video recorded with the faces anonymised and scored independently by three experts in a mutual blinded setup. The Angoff standard setting method was used to establish a credible pass/fail score. Sixteen novices and nine experienced open vascular surgeons were enrolled. The OPERATE tool achieved high internal consistency (Cronbach's alpha .92) and inter-rater reliability (Cronbach's alpha .95) and was able to differentiate novices and experienced surgeons with mean scores (higher score is better) of 13.4±12 and 25.6±6, respectively (p=.01). The pass/fail score was set high (27.7). One novice passed the test while six experienced surgeons failed. Validity evidence was established for the newly developed OPERATE tool and was able to differentiate between novices and experienced surgeons providing a good argument that this tool can be used for both formative and summative assessment in a simulation based environment. The high pass/fail score emphasises the need for novices to train in a simulation based environment up to a certain level of competency before apprenticeship training in the clinical environment under the tutelage of a supervisor. Familiarisation with the simulation equipment must be ensured before performance is assessed as reflected by the low scores in the experienced group's first attempt.