Open Aortic Aneurysm Repair Research Articles

Target Artery Outcomes Following Endovascular versus Open Surgical Repair of Thoracoabdominal Aortic Aneurysms - A Single Center Comparative Study.

To compare target artery (TA) outcomes after fenestrated or branched endovascular aortic repair (FB-EVAR) versus open surgical repair (OSR) of thoracoabdominal aortic aneurysms (TAAAs). Few studies have compared TA outcomes after endovascular incorporation and open reconstruction. Among consecutive patients who underwent elective OSR or FB-EVAR of TAAAs (2008-2020), we reviewed those who had postoperative imaging studies evaluating TA. Data of FB-EVAR patients were obtained from a prospectively maintained institutional database. TAs included celiac, superior mesenteric, right and left renal arteries treated during TAAA repairs. Primary endpoint was TA patency (primary and secondary). There were 131 patients (487 TAs) treated by OSR and 350 (1,300 TAs) by FB-EVAR. In the OSR group, 440 TAs (90.3%) were reconstructed by bypasses, and 47 (9.7%) by reimplantation. In the FB-EVAR group, 841 TAs (64.7%) were incorporated by fenestrations, and 459 (35.3%) by DBs. Thirty-day TA primary patency rates were not significantly different between FB-EVAR and OSR (99.4%% vs. 99.0%, P=0.36), but secondary patency rate was higher after FB-EVAR (99.8% vs. 99.0%, P=0.02). Three-year primary patency rates were 95.9% (95% confidence interval [CI], 94.7-97.2%) and 94.7% (95% CI, 92.2-97.2%), respectively; secondary patency rates were 98.5% (95% CI, 97.7-99.2%) and 94.7% (95% CI, 95.7-99.2%), respectively. There were no significant differences in late primary patency and secondary patency between groups (each P<0.05). Target artery primary and secondary patency rates following elective OSR or FB-EVAR were high. Endovascular repair was not associated with loss of primary patency and late secondary patency.

Adequacy of Anesthesia Guidance for Combined General/Epidural Anesthesia in Patients Undergoing Open Abdominal Infrarenal Aortic Aneurysm Repair; Preliminary Report on Hemodynamic Stability and Pain Perception.

Background/Objectives: Hemodynamic instability and inappropriate postoperative pain perception (IPPP) with their consequences constitute an anesthesiological challenge in patients undergoing primary elective open lumbar infrarenal aortic aneurysm repair (OLIAAR) under general anesthesia (GA), as suboptimal administration of intravenous rescue opioid analgesics (IROAs), whose titration is optimized by Adequacy of Anaesthesia (AoA) guidance, constitutes a risk of adverse events. Intravenous or thoracic epidural anesthesia (TEA) techniques of preventive analgesia have been added to GA to minimize these adverse events. Methods: Seventy-five patients undergoing OLIAAR were randomly assigned to receive TEA with 0.2% ropivacaine (RPV) with fentanyl (FNT) 2.5 μg/mL (RPV group) or 0.2% bupivacaine (BPV) with FNT 2.5 μg/mL (BPV group) or intravenous metamizole/tramadol (MT group). IROA using FNT during GA was administered under AoA guidance. Systemic morphine was administered as a rescue agent in all groups postoperatively in the case of IPPP, assessed using the Numeric Pain Rating Score > 3. The maximum score at admission and the minimum at discharge from the postoperative care unit to the Department of Vascular Surgery, perioperative hemodynamic stability, and demand for rescue opioid analgesia were analyzed. Results: Ultimately, 57 patients were analyzed. In 49% of patients undergoing OLIAAR, preventive analgesia did not prevent the incidence of IPPP, which was not statistically significant between groups. No case of acute postoperative pain perception was noted in the RPV group, but at the cost of statistically significant minimum mean arterial pressure values, reflecting hemodynamic instability, with clinical significance < 65mmHg. Demand for postoperative morphine was not statistically significantly different between groups, contrary to significantly lower doses of IROA using FNT in patients receiving TEA. Conclusions: AoA guidance for IROA administration with FNT blunted the preventive analgesia effect of TEA compared with intravenous MT that ensured proper perioperative hemodynamic stability along with adequate postoperative pain control with acceptable demand for postoperative morphine.

Characterization of cerebrospinal fluid markers as indicators of spinal cord ischemia following an endovascular aortic aneurysm repair procedure.

Spinal cord ischemia (SCI) remains one of the most devastating complications in both open and endovascular stent graft repair of thoracoabdominal aortic aneurysms. The endovascular aortic aneurysm repair (EVAR) can be either thoracic (TEVAR) when it targets the thoracic aortic aneurysm or fenestrated branched when repair involves the visceral and/or renal arteries. Even though EVAR interventions are less invasive than open repair, they are still associated with a significant risk of SCI. The current primary strategy to prevent SCI after TEVAR is to increase and/or maintain spinal cord perfusion pressure (blood flow) by increasing the mean arterial pressure while simultaneously draining CSF. Although the benefit of CSF drainage in EVAR procedures remains uncertain, it provides an opportunity to study the changes in cytokine and oxidative stress markers that may signal the pathophysiology of SCI following EVAR. The aim of this study was to evaluate the temporal relationship between stent deployment and CSF cytokine and oxidative stress marker levels as predictors of delayed SCI in patients undergoing an EVAR procedure. There were 16 EVAR cases across 15 patients enrolled in this study, with 1 patient undergoing the procedure twice 1 year apart. The levels of oxidative stress (8-hydroxy-2'-deoxyguanosine [8-OHdG], glial fibrillary acidic [GFAP], and lactic acid) and proinflammatory (tumor necrosis factor-alpha [TNF-α], interleukin (IL)-6, and IL-1β) and antiinflammatory (IL-4) markers were quantified at different time points between 0 and 48 hours after EVAR by enzyme-linked immunosorbent assay. The changes in protein levels of both oxidative stress and inflammatory markers were expressed as fold change from the time of the lumbar drain insertion prior to surgery. Following the EVAR procedure, 8-OHdG resulted in the highest upregulation at later time points postoperatively (48 hours) and this increase was positively correlated with TNF-α level. The data also revealed that IL-6 peaked during the stent deployment intervention and this pattern of expression was positively correlated with the expression of lactic acid. No significant changes were noted in the expression levels of GFAP, lactic acid, and IL-1β. There appears to be a temporal relationship between lumbar CSF drainage and CSF cytokines and oxidative stress markers that may help 1) identify patients at risk for developing delayed SCI and 2) modify patient management to prevent the damage from delayed SCI.

Cerebrospinal fluid drain placement and comprehensive strategies for spinal cord protection in open thoracoabdominal aortic aneurysm repair.

Ischaemic spinal cord injury remains a significant challenge in thoracoabdominal aortic repairs. Modern techniques have reduced spinal cord injury rates yet managing patients during and after thoracoabdominal aortic repairs remains complex. This article outlines our comprehensive approach to the prevention of spinal cord injuries in open thoracoabdominal aortic repair operations, focusing on the placement of cerebrospinal fluid drain and intraoperative strategies to enhance spinal cord protection. Preoperative planning involves thorough patient assessment, prehabilitation and nutritional support, detailed imaging review, thorough operative planning and patient blood management. Intraoperative measures include the use of neuromonitoring techniques like near-infrared spectroscopy and motor evoked potentials, as well as cerebrospinal fluid drainage together with blood pressure management to optimize spinal cord perfusion. Postoperative management focuses on maintaining haemodynamic stability with high mean arterial pressure, along with close monitoring and management of the cerebrospinal fluid drain to improve spinal cord perfusion. Additionally, thromboelastography-guided strategies are crucial for optimizing coagulation and addressing postoperative bleeding complications. The goal of this multifaceted approach is to minimize the risk of spinal cord injury, thereby improving patient outcomes and reducing the incidence of postoperative paraplegia. Our video tutorial shows some of our preoperative and intraoperative techniques for spinal cord protection in thoracoabdominal aortic repairs.

Routine Use of Indwelling Urinary Catheters During Endovascular Abdominal Aortic Aneurysm Repair is Not Necessary.

Endovascular infra-renal abdominal aortic aneurysm repair (EVAR) has proven to be an effective, less invasive alternative to open aortic aneurysm repair with decreased 30-day mortality. Historically, urinary drainage catheters were routinely placed preoperatively before EVAR in our institution. A shift to reduced catheter placement has occurred in conjunction with percutaneous EVARs becoming more routine. Urethral catheterization carries risk of infection (UTI), urinary retention and prostatic trauma inducing hematuria. The purpose of this study was to evaluate whether avoidance of urinary catheter placement during EVAR is an effective practice to reduce cost and morbidity. This was a single-institution, retrospective review of 177 consecutive patients who underwent elective infrarenal EVAR. Ruptured aneurysms and emergent EVAR were excluded. The study end points were postoperative UTI, urinary retention, length of stay, and readmission within 30 days. Univariable analysis was performed for these four outcomes in patients with (N = 92 and without (N = 65) preoperative urinary catheter placement. A more expansive multivariable investigation for risk of urinary retention following EVAR was conducted with binary logistic regression with co-variates including age, sex, femoral cutdown, estimated blood loss (EBL), urinary catheter, congestive heart failure, diabetes, and postoperative urinary retention as co-variates. Patients who had a Urinary catheter placed had an over two fold higher event rate of urinary retention (10.9% vs 4.6%) This urinary retention trend lacked power to reach significance (OR 2.52 (.665-9.55). Placement of urinary catheter also had a strong trend towards increased rate of UTI but lacking power for significance (7.6% vs 3.10%, OR 1.96 (.556-6.57). There was no difference with or without urinary catheter placement regarding 30-day readmission (yes catheter 7.6% vs no catheter 6.2%, P = .725), or length of stay (yes catheter 2.13 days vs no catheter 1.74 days, P = .723). Urinary retention was significantly associated with the development of a UTI with 23% of patients who had retention developing UTI compared with 4.2% of patients without retention developing UTI (adjusted odds ratio = 17.98, P = .019). Increased blood loss (P = .027) was also associated with increased rate of UTI on multivariable analysis. Avoidance of preoperative urinary catheter placement displays a trend towards avoiding urinary retention and UTI. Patients who develop post EVAR urinary retention experience a significantly increased rate of UTI. Selective urinary catheter placement should be used to help reduce urinary-related complications following elective EVAR.

Comparison of Open and Endovascular Repair of Complex Abdominal Aortic Aneurysms

To compare perioperative and 5-year outcomes following endovascular (FEVAR) and open repair (OAR) of complex abdominal aortic aneurysms (cAAA) in males and females separately, given the known sex related differences in perioperative outcomes. We studied all elective cAAA repairs between 2014-2019 in the Vascular Implant Surveillance and Interventional Outcomes Network (VISION) registry. We stratified patients based on sex. We calculated propensity scores for assignment to either OAR or FEVAR. Covariates including age, race, diameter, baseline comorbidities, proximal extent of repair, annual center volumes, and annual surgeon volumes were introduced into the model for estimating propensity scores. Within matched cohorts, perioperative outcomes and 5-year outcomes (mortality, reinterventions, and ruptures) were evaluated using multivariable logistic and Cox regression models. We identified 2,825 patients of whom 29% were female. Within both the sexes, OAR was more commonly performed (OAR vs FEVAR: males: 53% vs 47%; females: 63% vs 37%). After matching, among males (n=1326), FEVAR was associated with lower perioperative mortality (FEVAR vs OAR: 2.3% vs 5.1%; p<.001). However, FEVAR was associated with comparable 5-year mortality (38% vs 28%; hazard ratio (HR) 1.2 [0.92-1.4]; p=.22) and a higher hazard of 5-year reintervention (19% vs 3.7%; aHR: 4.5 [2.6-7.6], p<.001). Among females (n=456), FEVAR and OAR showed similar perioperative mortality (8.3% vs 7.0%; p=.73). At 5 years, FEVAR was associated with higher hazards of mortality (43% vs 32%; aHR: 1.5 [1.03-2.2], p=.034) and reintervention (20% vs 3.0%; aHR: 4.8 [2.1-11], p<.001) compared with OAR. Among males, FEVAR was associated with favorable perioperative outcomes compared with OAR, though these advantages attenuate over time. However, among females, FEVAR was associated with similar perioperative outcomes, eventually leading to higher reinterventions and possibly higher mortality within 5 years. Future efforts should focus on determining the factors associated with these sex disparities to improve outcomes following FEVAR in females. Based on current evidence, females undergoing elective cAAA repair should be selected with due caution, especially for endovascular repair.

Moderate hypothermic circulatory arrest with antegrade cerebral perfusion for the open repair of juxtarenal abdominal aortic aneurysm repair with shaggy aorta

Shaggy aorta is severe luminal surface degeneration of the aorta leading to an increased risk of plaque destabilization and embolization to the peripheral or visceral vessel beds. It represents a challenging clinical entity for both endovascular and open repair owing to potential atheroembolization, increased early morbidity and mortality, and poor long-term survival. Patients may be denied repair owing to its high risks. Herein, we present a novel approach to open repair of a juxtarenal abdominal aortic aneurysm with shaggy aorta using moderate hypothermic circulatory arrest with antegrade cerebral perfusion and concurrent flow modification to mitigate the risk of atheroma embolism.

Tabular review of contemporary open surgical repair experiences for treatment of thoracoabdominal aortic aneurysms.

Open surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is one of the most challenging operations due to extensive surgical dissection and exposure, risk of complications and need for reconstruction of the aorta and its branches. In the last two decades, endovascular techniques have evolved and now are considered a viable alternative to open surgical repair in patients with suitable anatomy. Regardless of which technique is selected, open or endovascular, reduction of postoperative morbidity and mortality requires large clinical volume, optimal patient selection and a multidisciplinary team that can take care of the surgical, anesthetic, critical care and postoperative issues that occur after these operations. The aim of this article is to summarize the clinical data on open surgical repair of thoracoabdominal aortic aneurysms in a schematic tabular format.

The Impact of Body Composition on Mortality and Hospital Length of Stay after Endovascular and Open Aortic Aneurysm Repair: A Retrospective Cohort Study.

Background: Sarcopenia is an indicator of preoperative frailty and a patient-specific risk factor for poor prognosis in elderly surgical patients. Some studies have explored the prognostic significance of body composition parameters in relation to perioperative mortality after aortic repair and to mid- and long-term survival following endovascular aneurysm repair (EVAR). This study aimed to comprehensively investigate the effects of various body composition parameters, including but not limited to sarcopenia, on short- and long-term mortality as well as the length of hospital stay in two large cohorts of patients undergoing open surgical aortic repair (OSR) or EVAR. Methods: A single-institution retrospective cohort study included patients who underwent EVAR or OSR from January 2010 to December 2017. Several parameters of body composition on axial CT angiography images were analyzed, such as skeletal muscle area (SMA) with derived skeletal muscle index (SMI), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). Results: 477 patients were included: 250 treated by OSR and 227 by EVAR; the mean age was 70.8 years (OSR) and 76.3 years (EVAR), with a mean follow-up of 54 months. Sarcopenia was associated with a prolonged length of hospital stay in EVAR patients but not in OSR patients (β coefficient 3.22; p-value 0.022 vs. β coefficient 0.391; p-value 0.696). Sarcopenia was an elevated one-year mortality risk post-EVAR compared to those without sarcopenia (p-value for the log-rank test 0.05). SMA and SMI were associated with long-term mortality in EVAR patients even after adjusting for multiple confounders (HR 0.98, p-value 0.003; HR 0.97, p-value 0.032). The analysis of the OSR cohort did not show a significant correlation between short- and long-term mortality and sarcopenia indicators. Conclusions: The results suggest that body composition could predict increased mortality and longer hospital stays in patients undergoing EVAR procedures. These findings were not confirmed in the cohort of patients who underwent OSR. Patients with sarcopenia and pre-operative malnutrition should be critically assessed to define the indication for treatment in this predominantly elderly and morbid cohort, despite EVAR procedures being less invasive. Body composition evaluation is an inexpensive and reproducible tool that can contribute to an improved decision-making process by identifying patients who will benefit most from EVAR, ensuring a more personalized and cost-effective treatment strategy. Further studies are planned to explore the added value of integrating body composition into a comprehensive risk stratification before aortic surgery.

Determinants of Neurological Outcome Following Elective and Emergency Open Thoracoabdominal Aortic Aneurysm Repair-A Retrospective Multi-Center Study.

Background/Objectives: This study aimed to evaluate and establish the incidence of all types of neurological complications at our high-volume reference center for open TAAA repair in the Netherlands and Germany. Additionally, we sought to identify predictors for various neurological complications. Methods: This retrospective study was conducted in accordance with the STROBE guidelines, with the aim of reporting neurological outcomes for all patients who underwent open thoracoabdominal aortic aneurysm repair at two centers (Maastricht-Aachen) from 2000 to 2023, and to examine the association between these outcomes and pre- and perioperative parameters. The primary endpoints of the study were all-cause mortality, spinal cord ischemia (SCI), stroke, intracerebral bleeding (ICB), critical illness polyneuropathy/myopathy (CIP/CIM), and recurrent laryngeal nerve paralysis. Results: A total of 577 patients were operated on for open TAAA repair in two centers. The total in-hospital mortality rate was 20.6%, while the elective cases in-hospital mortality rate was 14.6%. In all, 28.2% of patients experienced neurological complications. The spinal cord ischemia rate was 7.5%, intracerebral bleeding 3.6%, stroke 5.9%, critical illness polyneuropathy 3.5%, and laryngeal nerve paresis 5.7%. Crawford extent II was significantly associated with increased neurological complications (OR 2.05, 95% CI 1.39-3.03, p = 0.003), while Crawford extent III and IV were significantly associated with fewer postoperative neurological complications (OR 0.61 (0.38-0.98) p = 0.04) (OR 0.52 (0.30-0.92) p = 0.02). Preoperative ASA score > 3 (OR 1.76, 95% CI 1.16-2.67, p = 0.007), COPD (OR 1.82, 95% CI 1.19-2.78, p = 0.006), massive intraoperative transfusion (OR 1.48, 95% CI 1.01-2.17, p = 0.04), and reinterventions during hospital stay (OR 1.98, 95% CI 1.36-2.89, p < 0.001) and surgery time (p =< 0.001) were significantly associated with neurological complications. Patients with neurological complications had higher rates of other postoperative morbidities. Conclusions: Neurological complications after open TAAA repair remain a significant concern, with identified risk factors associated with increased morbidity, mortality, and resource utilization. Identifying at-risk patients could potentially lead to a reduction in neurological complications.

Predicting operative mortality in patients who undergo elective open thoracoabdominal aortic aneurysm repair

BackgroundWe have developed a model aimed at identifying preoperative predictors of operative mortality in patients who undergo elective, open thoracoabdominal aortic aneurysm (TAAA) repair. We converted this model into an intuitive nomogram to aid preoperative counseling. MethodsWe retrospectively analyzed data from 2884 elective, open TAAA repairs performed between 1986 and 2023 in a single practice. Using clinical and selected operative variables, we built 4 predictive models: multivariable logistic regression (MLR), random forest, support vector machine, and gradient boosting machine. Each model’s predictive effectiveness was evaluated with the C-statistic. Test C-statistics were computed using an 80:20 cross-validation scheme with 1000 iterations. ResultsOperative death occurred in 200 patients (6.9%). Test set C-statistics showed that the MLR model (median, 0.68; interquartile range [IQR], 0.65-0.71) outperformed the machine learning models (0.61 [IQR, 0.59-0.64] for random forest; 0.61 [IQR, 0.58-0.64] for support vector machine; 0.65 [IQR, 0.62-0.67] for gradient boosting machine). The final MLR model was based on 7 characteristics: increasing age (odds ratio [OR], 1.04/y; P < .001), cerebrovascular disease (OR, 1.54; P = .01), chronic kidney disease (OR, 1.53; P = .008), symptomatic aneurysm (OR, 1.42; P = .02), and Crawford extent I (OR, 0.66; P = .08), extent II (OR, 1.61; P = .01), and extent IV (OR, 0.41; P = .002). We converted this model into a nomogram. ConclusionsUsing institutional data, we evaluated several models to predict operative mortality in elective TAAA repair, using information available to surgeons preoperatively. We then converted the best predictive model, the MLR model, into an intuitive nomogram to aid patient counseling.

Endovascular (stent-graft)-assisted open vascular anastomosis.

Endovascular and open surgical approaches are an integral part of treating patients with complex vascular disease and are often considered separately. In some situations, traditional open surgical techniques can be used to facilitate an endovascular approach, as example: iliac conduit use for EVAR/TEVAR, subclavian or axillary conduits for complex endovascular aortic repairs (chimney, B-FEVAR), and bypass to great vessels or visceral artery (celiac, superior mesenteric and renal arteries) debranching. As devices and techniques evolve, the open and endovascular approaches can be utilized in more complimentary fashion. This paper describes the use of endovascular procedures to assist difficult open surgical situations such as iliofemoral bypass, aortic arch debranching involving the left subclavian artery, and distal right iliac artery management during open thoracoabdominal aortic aneurysm (TAAA) repair.

Commentator Discussion: Predicting operative mortality in patients who undergo elective, open thoracoabdominal aortic aneurysm repair

Commentator Discussion: Predicting operative mortality in patients who undergo elective, open thoracoabdominal aortic aneurysm repair

Outcome analysis of the surgical team in open surgical repair of intact abdominal aortic aneurysm surgery.

To analyze how the experience of the surgical team went to impact the outcomes after open surgical repair (OSR) of intact abdominal aortic aneurysms (AAAs). This is a single-center, observational cohort study with retrospective analysis of all OR for intact AAA performed between 1 January 2010 and 31 December 2022. The primary outcome was survival at 30 days and in follow-up, and a composite outcome of mortality and major complication. The secondary outcome was freedom from aorta-related reintervention. All outcomes were stratified according to the experience of the operating team (surgeons and anesthesiology). We analyzed 103 (7.2%) patients: 97 (94.2%) males and 6 (5.8%) females. The mean age was 76 ± 8 years (range, 55-93). The best possible team composition was present in 52 (50.5%) interventions. The follow-up index was 0.82 ± 0.18 (range, 0.6-1.0). Mean follow-up duration was 59 ± 43 months (range, 0-158). We observed no differences between teams in major complications (best, 17.3% vs mixed, 21.6%; OR: 0.4, P = 0.622), 30 days mortality (best, 0% vs mixed, 5.9%; OR: 7.6, P = 0.118) and composite outcome (best, 11.5% vs mixed, 17.6%; OR: 0.8, P = 0.416). Cox regression analysis identified the best possible team as a protective factor against the need for reintervention (hazard ratio: 0.2; 95% confidence interval: 0.06-0.88, P = 0.032). In our experience, OR of AAA yielded satisfactory results in terms of safety and efficacy independently of the team's experience. A more experienced team may protect against aorta-related reintervention.

Direct Reinfusion of Unwashed Shed Autologous Blood During Thoracoabdominal Aortic Aneurysm Repair: A Retrospective Analysis.

This study's purpose was to assess whether larger volumes of reinfused unwashed shed autologous blood (SAB) were associated with adverse events within 30 days for patients undergoing open thoracoabdominal aortic aneurysm (TAAA) repair. During TAAA repair, our institution uses a system wherein SAB is filtered, but not washed or centrifuged, and then returned to the patient via a rapid-infusion device. By reinfusing SAB, the system preserves the patient's autologous whole blood and may reduce the number of allogenic transfusions required during TAAA repair, but the end-organ effects of reinfusing unwashed SAB have not been extensively evaluated. Using a prospectively maintained database, we retrospectively analyzed data from 972 consecutive patients who underwent open TAAA repair at our institution from 2007 to 2021 and who received SAB. Multivariable logistic regressions were performed to assess whether SAB reinfusion volume was associated with a composite outcome of adverse events, as well as operative mortality, a composite of cardiac complications, a composite of pulmonary complications, or persistent paraplegia, stroke, or postoperative renal failure. Among the cohort of 972 patients, the median volume of reinfused SAB was 4159 mL (quartile1-quartile3 [Q1-Q3]: 2524-6790 mL). Greater reinfusion volumes of unwashed SAB were not associated with greater odds of composite adverse events (odds ratio [OR], 1.02 per 1000 mL increase, 97.5% confidence interval [CI], 0.94-1.09, P = .624), nor with any individual outcome-operative mortality (OR, 1.02 per 1000 mL increase, 97.5% CI, 0.93-1.12, P = .617), a composite of cardiac complications (OR, 0.98 per 1000 mL increase, 97.5% CI, 0.93-1.04, P = .447), a composite of pulmonary complications (OR, 1.00 per 1000 mL increase, 97.5% CI, 0.94-1.06, P = .963), renal failure necessitating hemodialysis (OR, 1.01 per 1000 mL increase, 97.5% CI, 0.92-1.11, P = .821), persistent paraplegia (OR, 0.97 per 1000 mL increase, 97.5% CI, 0.84-1.13, P = .676), persistent stroke (OR, 0.85 per 1000 mL increase, 97.5% CI, 0.70-1.04, P = .070), or reoperation to control bleeding (OR, 0.99, 97.5% CI, 0.87-1.13, P = .900)-when adjusted for confounders. For patients undergoing open TAAA repair, larger reinfusion volumes of unwashed SAB were not associated with greater odds of major early postoperative complications.

Preoperative anemia is a risk factor for worse 30-day outcomes in both open and endovascular repair of non-ruptured infrarenal abdominal aortic aneurysm.

Anemia is a highly prevalent condition potentially linked to chronic inflammation. Preoperative anemia is an independent risk factor across many surgical fields. However, the relationship between anemia and abdominal aortic aneurysm (AAA) repair outcomes remains unclear. This study aimed to examine the effects of preoperative anemia on 30-day outcomes of non-ruptured infrarenal AAA repair. Patients who underwent open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infrarenal AAA were identified in National Surgical Quality Improvement Program (NSQIP) targeted databases from 2012 to 2021. Anemia was defined as preoperative hematocrit less than 39% in males and 36% in females. Multivariable logistic regression was used to compare 30-day perioperative outcomes between anemic and non-anemic patients, adjusting for demographics, comorbidities, indications, aneurysm extents, operation time, and surgical approaches. There were 408 (22.13%) anemic and 1436 (77.88%) non-anemic patients who underwent OSR for non-ruptured AAA, while 3586 (25.20%) patients with and 10,644 (74.80%) without anemia underwent EVAR. In both OSR and EVAR, anemic patients had higher risks of bleeding requiring transfusion (OSR, aOR = 2.446, p < .01; EVAR, aOR = 3.691, p < .01), discharge not to home (OSR, aOR = 1.385, p = .04; EVAR, aOR = 1.27, p < .01), and 30-day readmission (OSR, aOR = 1.99, p < .01; EVAR, aOR = 1.367, p < .01). Also, anemic patients undergoing OSR had higher pulmonary events (aOR = 2.192, p < .01), sepsis (aOR = 2.352, p < .01), and venous thromboembolism (aOR = 2.913, p = .01), while in EVAR, anemic patients had higher mortality (aOR = 1.646, p = .01), cardiac complications (aOR = 1.39, p = .04), renal dysfunction (aOR = 1.658, p = .02), and unplanned reoperation (aOR = 1.322, p = .01). Moreover, in both OSR and EVAR, anemic patients had longer hospital length of stay (p < .01). In OSR and EVAR, preoperative anemia was independently associated with worse 30-day outcomes. Preoperative anemia could be a useful marker for risk stratification for patients undergoing infrarenal AAA repair.

Outcomes after open repair of aortic aneurysms and dissections in cannabis consumers

ObjectiveTo investigate the influence of cannabis consumption on the mid- and long-term surgical outcomes of patients with aortic aneurysms or dissections. MethodsAll individuals aged 18 years and older with more than 6 months of cannabis use at the time of surgical repair for cardiovascular disease (aortic aneurysms or aortic dissection) between 2007 and 2023 were eligible. Patients were stratified into 2 groups based on their preoperative history of cannabis use: cannabis users and noncannabis users. The primary end point was complications or death within 30 days of intervention. Secondary outcomes included late complications and reinterventions. Data were combined from our institution and inpatient hospital records. ResultsWe identified 134 patients who met the inclusion criteria out of 1543 treated patients (9%). Compared with the nonusing cannabis group, individuals in the cannabis group were significantly younger (cannabis: 48.3 ± 11.8 years vs noncannabis: 58.5 ± 14.9 years; P < .001). The cannabis group included significantly higher patients with Marfan syndrome (cannabis: 11.2% vs noncannabis: 4.4%; P < .001). Furthermore, the cannabis group showed significantly higher history of recreational drug use, including cocaine (25.4% vs 1.6%; P < .001), amphetamines (3.7% vs 0.6%; P < .001), opioids (8.2% vs 0.5%; P < .001), and intravenous drugs (6.7% vs 0.6%; P < .001). Emergency surgeries were significantly more frequent in the cannabis group (cannabis: 56.7% vs noncannabis: 36.2%; P < .001). Surgical mortality was comparable between both groups (cannabis: 9.7% vs noncannabis: 8.6%; P = .662). Postoperative stroke was significantly higher in the cannabis group (cannabis: 14.9% vs noncannabis: 8.2%; P = .009), and the rate of postoperative respiratory complications was also significantly higher in the cannabis group (cannabis: 32.1% vs noncannabis: 19.0%; P < .001). ConclusionsThe increased rates of postoperative cerebrovascular accidents and respiratory complications suggest that cannabis use is a significant risk factor in aortic surgery. Our study showed that young, healthy patients with prolonged cannabis use might be at a higher risk of requiring more emergency surgeries due to their background.

Association between diabetes status and long-term outcomes following open and endovascular repair of infrarenal abdominal aortic aneurysms

ObjectiveCurrent literature reports conflicting findings regarding the effect of diabetes mellitus (DM) on outcomes of abdominal aortic aneurysm (AAA) repair. In this study we examined the effect of DM and its management on outcomes after open AAA repair (OAR) and endovascular AAA repair (EVAR). MethodsWe identified all patients undergoing OAR or EVAR for infrarenal AAA between 2003 and 2018 in the Vascular Quality Initiative registry data linked with Medicare claims. We excluded patients with missing DM status. Patients were stratified by their preoperative DM status, and then further stratified by DM management: dietary, noninsulin antidiabetic medications (NIMs), or insulin. Outcomes of interest included 1-year aneurysm sac dynamics, 8-year aneurysm rupture, reintervention, and all-cause mortality. These outcomes were analyzed with the χ2 test, Kaplan-Meier methods, and multivariable Cox regression analyses. ResultsWe identified 34,021 EVAR patients and 4127 OAR patients, of whom 20% and 16% had DM, respectively. Of all DM patients, 22% were managed by dietary management, 59% by NIM, and 19% by insulin. After EVAR, DM patients were more likely to have stable sacs, whereas non-DM patients were more likely to have sac regression at 1 year. Compared with non-DM, DM was associated with a significantly lower risk for 8-year rupture in EVAR (EVAR hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.51-0.92). Compared with non-DM, NIM was associated with lower risk of rupture within 8-years for both EVAR and OAR (EVAR HR, 0.64; 95% CI, 0.44-0.94; OAR HR, 0.29; 95% CI, 0.41-0.80), whereas dietary control and insulin had a similar rupture risk compared with non-DM. However, compared with non-DM, DM was associated with a higher risk of 8-year all-cause mortality after EVAR and OAR (DM vs non-DM: EVAR HR, 1.17; 95% CI, 1.11-1.23; OAR HR, 1.16; 95% CI, 1.00-1.36). After further DM management substratification, compared with non-DM, management with NIM and insulin were associated with a higher 8-year mortality in EVAR and OAR (EVAR: NIM HR, 1.12; 95% CI, 1.05-1.20; insulin: HR, 1.40; 95% CI, 1.26-1.55; OAR: NIM HR, 1.27; 95% CI, 1.06-1.54; and insulin: HR, 1.57; 95% CI, 1.15-2.13). Finally, there was a similar risk of reintervention across the DM and non-DM populations for EVAR and OAR. ConclusionsDM was associated with a lower adjusted risk of rupture after EVAR as well as OAR in patients managed with NIM. Nevertheless, just as in patients without AAA, preoperative DM was associated with a higher adjusted risk of all-cause mortality. Further study is needed to evaluate for differences in aneurysm-related mortality between DM and non-DM patients, and studies are planned to evaluate the independent effect of NIM on aneurysm-related outcomes.

The Outcome after Endovascular and Open Repair of Abdominal Aortic Aneurysms-A Binational Study Conducted between 1998 and 2017.

Objective: We aimed to analyse patient outcomes following open (OAR) or endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) in Finland and Sweden from 1998 to 2017. Both intact and ruptured AAAs (rAAAs) were included in the analysis. Methods: Patient-level data from national registries in Finland and Sweden were analysed, pairing operations for intact and ruptured AAA repair with mortality data (date of death). All-cause mortality was the primary endpoint. Anonymized patient data from both countries were pooled, comprising a total of 32,324 operations. Ruptured and intact AAAs were considered separately. In total, EVAR was performed on 9619 intact AAAs and 1470 rAAAs, while OAR was performed on 13,241 intact AAAs and 7994 rAAAs. The patient's age, sex and the date of operation were obtained as demographic information. Cox regression and Kaplan-Meier analyses were used to evaluate long-term (10-year) survival after the treatment of AAA or rAAA with either modality. Kaplan-Meier analysis was performed in three different age groups (<65 years, 65-79 years and ≥80 years). Results: Considering all age groups together, the 1-, 3- and 10-year Kaplan-Meier survival rates after EVAR were 93.4%, 80.5% and 35.3%, respectively, for intact AAA repair and 67.2%, 55.9% and 22.2%, respectively, for rAAA repair. For OAR of intact AAAs, the 1-, 3- and 10-year Kaplan-Meier survival rates were 92.1%, 84.8% and 48.7%, respectively. The respective rates for OAR of rAAAs were 55.4%, 49.3% and 24.6%. In a Cox regression analysis, a more recent year of operation was associated with improved survival, and older age affected survival negatively for both intact and ruptured AAA repair. If patients survived the first 90 days after the operation, the survival after intact AAA repair was 13.5 years for those <65 years (general population: 18.0 years), and 7.3 years for those ≥80 years (general population: 7.9 years). After rAAA repair, the mean survival was 13.1 years for patients <65 years and 5.5 years for patients ≥80 years, respectively. Conclusions: The long-term survival of patients undergoing intact AAA treatment at the age of 80 or older is close to that of the general population, provided they survive the operation. Conversely, for patients younger than 65, the long-term survival is markedly worse. The long-term survival of AAA patients has improved over time. Open surgery is still a safe and effective option for young patients undergoing intact AAA repair. Our results support the ESVS guidelines recommendation of EVAR being the first-line treatment for patients with rAAA.

Wound healing and hernia after abdominal aortic aneurysm repair: Onlay self-gripping polyester mesh reinforcement compared with small bite sutured closure.

Prophylactic mesh implantation following open surgical repair of abdominal aortic aneurysm is a debatable subject. To assess the efficacy of a self-gripping polyester mesh used in on-lay technique to prevent incisional hernia after open abdominal aortic aneurysm repair. We retrospectively reviewed the records of 495 patients who underwent aortic surgery between May 2017 and May 2021. Patients included in the study underwent open surgical repair for infrarenal abdominal aortic aneurysm (AAA) with closure of the abdominal wall with either small bite suture technique or prophylactic mesh reinforcement. Primary endpoint of the study was the occurrence of incisional hernia during a two-year follow-up period. Secondary endpoints were mesh-related complications. Mesh implantation with the on-lay technique was successful in all cases. No patient in the mesh group developed an incisional hernia during the 24-month follow-up period. Two patients in the non-mesh group developed a symptomatic incisional hernia during the follow-up period at 6 months. Three cases of post-operative access site complications were observed in the mesh group. Application of a self-gripping polyester mesh using the on-lay technique demonstrates acceptable early-durability after open surgical repair of abdominal aortic aneurysms. However, it appears to be associated with a number of post-operative access site complications.