Open Surgical Repair Patients Research Articles

Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms

Although repair of large abdominal aortic aneurysms (AAAs) is well accepted, randomized clinical trials have failed to demonstrate benefit for early surgical repair of small aneurysms compared with surveillance. Endovascular repair has been shown to be safer than open surgical repair in patients with large aneurysms, prompting a randomized trial of early endovascular repair vs surveillance in patients with small aneurysms. We randomly assigned 728 patients (13.3% women; mean age, 71 +/- 8 years) with 4 to 5 cm AAAs to early endovascular repair (366 patients) or ultrasound surveillance (362 patients). Rupture or aneurysm-related death and overall mortality in the two groups were compared during a mean follow-up of 20 +/- 12 months. Among patients randomized to treatment, 89% underwent aneurysm repair. Among patients randomized to surveillance, 31% underwent aneurysm repair during the course of the study. After a mean follow-up of 20 +/- 12 months (range, 0-41 months), 15 deaths had occurred in each group (4.1%). The unadjusted hazard ratio (95% confidence interval) for mortality after early endovascular repair was 1.01 (0.49-2.07, P = .98). Aneurysm rupture or aneurysm-related death occurred in two patients in each group (0.6%). The unadjusted hazard ratio was 0.99 (0.14-7.06, P = .99) for early endovascular repair. Early treatment with endovascular repair and rigorous surveillance with selective aneurysm treatment as indicated both appear to be safe alternatives for patients with small AAAs, protecting the patient from rupture or aneurysm-related death for at least 3 years.

Endovascular Repair for Descending Thoracic Aortic Disease

Endovascular aortic repair with stent grafts is a less invasive alternative to open surgical repair for patients with descending thoracic aneurysms. In this systematic review, investigators compared the two treatment modalities in a meta-analysis …

Endovascular Treatment of Blunt Traumatic Thoracic Aortic Injury

Blunt traumatic thoracic aortic injury (BTTAI) is a lethal injury associated with a prehospital mortality of 80% to 90%. Patients arriving in the emergency room and considered appropriate to undergo emergency open surgical repair still have a mortality rate of 15% to 30% because of severe associated injuries. Conventional open surgical repair requires a left thoracotomy, single lung ventilation, aortic-cross clamping and unclamping, with or without the adjunct use of partial or full cardiopulmonary bypass and systemic heparinization. All this leads to significant physiological stress and surgical trauma resulting in perioperative complications such as major blood loss, coagulopathy, myocardial infarction, stroke, respiratory failure, renal failure, bowel infarction, and paraplegia. Despite advances in anesthesia, critical care medicine, and surgical techniques, a recent meta-analysis showed no definite improvement in operative mortality over the past decade, following open surgical repair in patients with BTTAI. Endovascular repair of BTTAI does not require a thoracotomy, single lung ventilation, aorticcross clamping and unclamping, or systemic heparinization. As a result, endovascular repair of BTTAI has emerged as an effective, minimally invasive treatment alternative, especially in patients with severe concomitant injuries, which may be prohibitive to open surgical repair. Recent published studies have shown that endovascular repair of BTTAI is associated with lower morbidity, mortality, stroke, and paraplegia/paraparesis rates, when compared with open surgical repair of BTTAI.

Cost-effectiveness analysis of elective endovascular repair compared with open surgical repair of abdominal aortic aneurysms for patients at a high surgical risk: A 1-year patient-level analysis conducted in Ontario, Canada

Abdominal aortic aneurysm (AAA) is a prevalent health condition affecting up to 14% of men and 6% of women. The objective of this study was to estimate the cost-effectiveness and cost-utility of elective endovascular aneurysm repair (EVAR) compared with open surgical repair (OSR) in patients at a high risk of surgical complications. Patient-level cost and outcome data from a 1-year prospective observational study conducted at London Health Sciences Centre, London, Ontario, Canada, was used to determine the incremental cost per life-year gained and the incremental cost per quality-adjusted life year (QALY) gained of EVAR compared with OSR in patients with an AAA >5.5 cm and a high risk of surgical complications. The analysis was taken from a societal perspective and the time horizon was 1 year. To measure sampling uncertainty on costs and effects, nonparametric bootstrap techniques were applied. Uncertainty results were expressed using cost-effectiveness acceptability curves. Extrapolations of the 1-year results to a 5-year time horizon were conducted in sensitivity analyses. Between August 11, 2003, and April 3, 2005, 192 patients at a high risk of surgical complications were enrolled: 140 received EVAR and 52 OSR. Point estimates during a 1-year period showed that EVAR dominated OSR for high-risk patients in terms of incremental cost per life-year gained and incremental cost per QALYs. However, bootstrap estimates for the two cost-effectiveness measures indicated there was a great deal of uncertainty regarding the costs and the QALYs and less uncertainty regarding life-years gained. If society was willing to pay $50,000 per life-year gained or per QALY gained, the probability of EVAR being cost-effective was found to be 0.76 and 0.55, respectively. Five-year extrapolations indicated that EVAR was cost-effective compared with OSR. According to this 1-year observational study, EVAR may be a cost-effective strategy compared with OSR for high-risk patients. Longer-term data are needed to decrease the uncertainty associated with the results.

Surveillance of patients post-endovascular aneurysm repair

Endovascular aneurysm repair (EVAR) is increasingly being employed as an alternative to open surgical repair for patients with abdominal aortic aneurysms. The surveillance of patients post-EVAR has traditionally been carried...

Will Stent-Graft Repair Emerge as Treatment of Choice for Acute Type B Dissection?

Endovascular stent grafts are now accepted globally and approved by the US Food and Drug Administration as an alternative to open surgical repair for patients with descending thoracic aortic aneurysm. However, as opposed to the abdominal aorta, application of this technology to manage thoracic aortic disease is not limited to degenerative aneurysms. In fact, international registries and surveys estimate that only 60% of the thoracic cases managed currently with stent-graft placement are aneurysms. The remainder of this experience includes acute dissection, chronic dissection, traumatic aortic injury, penetrating ulcer, intramural hematoma, aortic fistula, anastomotic pseudoaneurysm, and an embolizing lesion. In this regard, it is important to keep in mind that the present devices used in these nonaneurysmal applications are not designed to address the unique anatomical and pathological features that these lesions present. Consequently, in the future, it is possible that we will see stent-graft designs that focus specifically on the challenges of some of the nonaneurysmal thoracic aortic pathologies.

Transfemoral endoluminal aortic management versus open surgical repair inpatients with infra-renal abdominal aortic aneurysms who are suitable for both techniques. Technical and clinical outcome

Transfemoral endoluminal aortic management versus open surgical repair inpatients with infra-renal abdominal aortic aneurysms who are suitable for both techniques. Technical and clinical outcome

Will endovascular repair replace open surgery for abdominal aortic aneurysm repair?

To evaluate of the impact of endovascular aneurysm repair on the rate of open surgical repair and on the overall treatment of abdominal aortic aneurysms (AAAs). All patients with AAA who were treated during two consecutive 40-month periods were reviewed. During the first period, only open surgical repair was performed; during the subsequent 40 months, endovascular repair and open surgical repair were treatment options. A total of 727 patients with AAA were treated during the entire period. During the initial 40 months, 268 patients were treated with open surgical repair, including 216 infrarenal (81%), 43 complex (16%), and 9 ruptured (3%) aortic aneurysms. During the subsequent 40 months, 459 patients with AAA were treated (71% increase). There was no significant change in the number of patients undergoing open surgical repair and no significant difference in the rate of infrarenal (238 [77%]) and complex (51 [16%]) repairs. A total of 353 patients were referred for endovascular repair. Of these, 190 (54%) were considered candidates for endovascular repair based on computed tomography or arteriographic morphologic criteria. Analyzing a subgroup of 123 patients, the most common primary reasons for ineligibility for endovascular repair were related to morphology of the neck in 80 patients (65%) and of the iliac arteries in 35 patients (28%). A total of 149 patients underwent endovascular repair. Of these, the procedure was successful in 147 (99%), and 2 (1%) patients underwent surgical conversion. The hospital death rate was 0%, and the 30-day death rate was 1%. During a follow-up period of 1 to 39 months (mean 12 +/- 9), 21 secondary procedures to treat endoleak (20) or to maintain graft limb patency (1) were performed in 17 patients (11%). There were no aneurysm ruptures or aneurysm-related deaths. Endovascular repair appears to have augmented treatment options rather than replaced open surgical repair for patients with AAA. Patients who previously were not candidates for repair because of medical comorbidity may now be safely treated with endovascular repair.