Open Abdominal Aortic Aneurysm Research Articles

Efficacy of contrast-enhanced ultrasound in detection of type II endoleak after abdominal aortic aneurysm surgery: A prospective cohort study.

This study aimed to evaluate the efficacy of conventional contrast-enhanced ultrasound (CEUS) in detection of type II endoleak after endovascular abdominal aortic aneurysm repair (EVAR). From January 2015 to April 2018, 205 patients underwent EVAR were included. CEUS and computed tomography angiography (CTA) were performed at 1-month follow-up postoperatively to detect type II endoleak. CEUS was performed at 3- and 6-month follow-up to evaluate the development of type II endoleak. The diameter extension of type II endoleak increased greater than 5 mm was defined as enlarge group, and that increased less than 5 mm was defined as stable group. The difference of arrival time (AT) of contrast agent, maximum cross-sectional area (MCSA) of contrast agent and the blood flow velocity (BFV) of the abnormal blood around the stent graft were compared. At 1-month after EVAR, 65 cases of endoleak were detected by CEUS, including 25 cases of type I, 30 cases of type II endoleak and 10 cases of type III endoleak. Among them, 50 cases were also detected by CTA. The diameter extension of 12 cases of type II endoleak increased greater than 5 mm, and that of eight cases increased less than 5 mm. The average AT of the enlarge group was significantly shorter than that of the stable group, while the MCSA of contrast agent and the BFV were significantly higher than that of the stable group (p < 0.05). CEUS has predictive value for the natural outcome of type II endoleak.

Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study

The Dutch Surgical Aneurysm Audit (DSAA) initiative was established in 2013 to monitor and improve nationwide outcomes of aortic aneurysm surgery. The objective of this study was to examine whether outcomes of surgery for intact abdominal aortic aneurysms (iAAA) have improved over time.

Surgeon volume and established hospital perioperative mortality rate together predict for superior outcomes after open abdominal aortic aneurysm repair

Background: In 2018, the Society for Vascular Surgery (SVS) published hospital volume guidelines for elective open abdominal aortic aneurysm (AAA) repair, recommending that elective open surgical repair of AAAs should be performed at centers with an annual volume of ≥10 open aortic operations of any type and a documented perioperative mortality of ≤5%. Recent work has suggested a yearly surgeon volume of at least seven open aortic cases for improved outcomes. The objective of the present study was to assess the importance of hospital volume and surgeon volume at these cut points for predicting 1-year mortality after open surgical repair of AAAs.

Risk Factors of Long‐Term Incisional Hernia after Open Surgery for Abdominal Aortic Aneurysm: A Bicentric Study

Conventional open surgery is still important beside endovascular surgery in the management of abdominal aortic aneurysms, with less reinterventions in the long-term follow-up. Incisional hernias are the major complication open surgery in the mid- and long term. The occurrence of this late complication could be due to the choice of the incision, median or transverse. The objectives of our retrospective and bicentric study were to characterize the long-term risk factors for incisional hernias after open surgery for abdominal aortic aneurysms, in particular by comparing the 2 types of laparotomy, and to determine the prevalence of the operated and not operated incisional hernias. Between January 2009 and December 2011, all the patients having elective open surgery for abdominal aortic aneurysm (AAA) by midline laparotomy at the University hospital of Besancon or by transversal laparotomy at the University Hospital of Strasbourg were included retrospectively. The demographic data, the time of diagnosis of the incisional hernia and the parietal reinterventions were collected during a 5-year postoperative follow-up. A univariate and multivariate Cox model was used for the statistical analysis to determine the long-term risk factors for the appearance of an incisional hernia. During the study period, 223 patients presenting with AAA were included, 112 of them were operated by a midline laparotomy and 111 by a transverse laparotomy. The mean age of the patients was 69 ± 8,4years and 208 (93.3%) were men. The 5-year prevalence of incisional hernias was 14.3% (32), and 20 of these hernias (9%) had to be operated. Eighteen hernias (16.1%) occurred after a midline laparotomy and 14 (12.6%) after a transverse incision (P=0.30). In univariate analysis, obstructive chronic pulmonary disease was the only significant risk factor for incisional hernia (P=0.01) and an age over 65 years appeared to protect against this risk (P=0.049). These results were confirmed by multivariate analysis, which showed that obstructive chronic pulmonary disease was an independent risk factor for incisional hernia (HR=2.35, 95% CI 1.16-4.75), and that an age over 65 years was a protective factor (HR=0.49 95% IC 0.00-0.99). The type of laparotomy did not modify the rate of incisional hernias. We showed that only 9% of the patients had to be operated to treat an incisional hernia during the first 5 years after surgery for AAA in our bicentric study. Chronic obstructive pulmonary disease was the only independent risk factor for the occurrence of an incisional hernia.

Center volume is associated with diminished failure to rescue and improved outcomes following elective open abdominal aortic aneurysm repair

ObjectiveConflicting annual procedure volumes have been endorsed among different watchdog groups and professional societies, obscuring credentialing paradigms. There has been ample focus on surgeon volume to date but less attention on the effect of center volume. Specifically, whether center volume might be a better proxy for high-quality care. In the present study, we aimed to measure the association of center volume on open abdominal aortic aneurysm (AAA) repair (OAR) outcomes and failure to rescue (FTR). MethodsAll elective OARs (2003-2020) in the Society for Vascular Surgery Vascular Quality Initiative were reviewed (n = 9791). FTR was defined as in-hospital death after the occurrence of a complication (ie, cardiac, stroke, pulmonary, renal, colonic ischemia, return to the operating room for bleeding). The annual center volume for 218 hospitals was calculated, and the volume quartiles (quartile 1 [Q1], ≤3 procedures/y; quartile 2 [Q2], 4-6 procedures/y; quartile 3 [Q3], 7-10 procedures/y; quartile 4 [Q4], >10 procedures/y) were derived for comparison. Logistic regression was used to estimate the effect of center volume and determine the predictors of FTR. ResultsThe center volume quartiles and incidence of FTR varied significantly (Q4, 2.5% vs Q1 and Q2, 4.9%; P < .0001; overall FTR, 3.1% [n = 302]). The patients were demographically similar among the quartiles. High-volume centers had used epidural anesthesia more often (Q4, 53%; vs Q1, 31%; P < .0001) but were less likely to use thrombectomy (Q4, 5%; vs Q1, 10%; P < .0001) or any concomitant procedure (Q4, 19%; vs Q1, 22%; P = .05). High-volume centers had had lower rates of pulmonary, renal, and overall complications (pulmonary: Q4, 7%; vs Q1-Q2, 8%-11%; renal: Q4, 16%; vs Q1-2, 19%-21%; P < .0001; overall mean number of complications: Q4, 0.46; vs Q1, 0.52; P = .0008). The crude 30-day and 1-year mortality rates were reduced at the higher volume centers (30 days: Q4, 3%; vs Q1-Q2, 6%; P < .0001; 1 year: Q4, 7%; vs Q1-Q2, 10%-11%; P < .0001). A strong inverse relationship between center volume and FTR was identified (P < .0001). In the adjusted analysis, OARs performed in high-volume centers (Q4 vs Q1) had a 50% risk reduction in FTR (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.3-0.8; P = .004). Among the complications, a return to the operating room for bleeding was most likely to result in FTR (OR, 11.8; 95% CI, 4.3-33; P < .0001). A 24-fold increased risk of FTR was found for patients experiencing three or more complications vs one complication (OR, 24; 95% CI, 17-35; P < .0001). ConclusionsA greater center volume was strongly associated with significantly diminished FTR, reduced complications, and need for surgical adjuncts during OAR. These findings highlight the utility of center volume as an effective proxy to ensure high-quality aneurysm care.

Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study

<h3>Objective</h3> The Dutch Surgical Aneurysm Audit (DSAA) initiative was established in 2013 to monitor and improve nationwide outcomes of aortic aneurysm surgery. The objective of this study was to examine whether outcomes of surgery for intact abdominal aortic aneurysms (iAAA) have improved over time. <h3>Methods</h3> Patients who underwent primary repair of an iAAA by standard endovascular (EVAR) or open surgical repair (OSR) between 2014 and 2019 were selected from the DSAA for inclusion. The primary outcome was peri-operative mortality trend per year, stratified by OSR and EVAR. Secondary outcomes were trends per year in major complications, textbook outcome (TbO), and characteristics of treated patients. The trends per year were evaluated and reported in odds ratios per year. <h3>Results</h3> In this study, 11 624 patients (74.8%) underwent EVAR and 3 908 patients (25.2%) underwent OSR. For EVAR, after adjustment for confounding factors, there was no improvement in peri-operative mortality (aOR [adjusted odds ratio] 1.06, 95% CI 0.94 – 1.20), while major complications decreased (2014: 10.1%, 2019: 7.0%; aOR 0.91, 95% CI 0.88 – 0.95) and the TbO rate increased (2014: 68.1%, 2019: 80.9%; aOR 1.13, 95% CI 1.10 – 1.16). For OSR, the peri-operative mortality decreased (2014: 6.1%, 2019: 4.6%; aOR 0.89, 95% CI 0.82 – 0.98), as well as major complications (2014: 28.6%, 2019: 23.3%; aOR 0.95, 95% CI 0.91 – 0.99). Furthermore, the proportion of TbO increased (2014: 49.1%, 2019: 58.3%; aOR 1.05, 95% CI 1.01 – 1.10). In both the EVAR and OSR group, the proportion of patients with cardiac comorbidity increased. <h3>Conclusion</h3> Since the establishment of this nationwide quality improvement initiative (DSAA), all outcomes of iAAA repair following EVAR and OSR have improved, except for peri-operative mortality following EVAR which remained unchanged.

Nationwide Experience with EVAS Relining of Previous Open or Endovascular AAA Treatment in The Netherlands

Relining of a previously placed surgical graft or endograft for an abdominal aortic aneurysm (AAA) is a reintervention to treat progression of disease or failure of the primary (endo)graft. Endovascular Aneurysm Sealing (EVAS) relining is a technique with potential advantages due to the absence of a bifurcation, the possibility for a unilateral approach, and sealing concept of the endobags. The purpose of this study was to describe the nationwide experience with EVAS relining of previous AAA repair in the Netherlands. A retrospective analysis of all patients who underwent EVAS relining in 7 high volume vascular centres in the Netherlands between 2014 and 2019 was performed. Primary outcomes were technical and clinical success. Secondary outcomes were perioperative outcomes, complications and survival. Thirty-three patients underwent EVAS relining of open (n=10) or endovascular (n=23) repair. 26 were elective cases, 5 were urgent and 2 were acute (ruptured). Mean time between primary treatment and EVAS relining was 99 ± 74 months. Indications after open repair were proximal progression of disease (n=7) and graft defect (n=3). Indications after EVAR were type IA (n=10), type IB (n=3), type IIIA (n=4), type IIIB (n=3) endoleak, and endotension (n=3). 18 patients underwent regular EVAS, 4 unilateral EVAS and 11 chimney-EVAS. In-hospital mortality was 6% (both patients with rAAA). Technical success was achieved in 97%. Median follow-up after EVAS relining was 20 months (range 0-43). Freedom from reintervention at 1-year and 2-year were 83% and 61% and the estimated survival 79% and 71%, respectively. EVAS relining after open repair had a clinical success of 90% at 1-year and of 70% at latest follow-up, while after EVAR clinical success rates were 70% and 52%, respectively. EVAS relining of previous AAA repair is associated with high technical success, however with limited clinical success at median follow-up of 20 months. Clinical success was higher in patients with EVAS relining after open repair than after EVAR. In patients with failed AAA repair, EVAS relining should only be considered, when established techniques such as fenestrated repair or open conversion are not available or indicated.

Changes in functional health status following open abdominal aortic aneurysm repair and the role of exercise-based rehabilitation: protocol for a systematic review and meta-analysis

Background and objectives: The aim of this systematic review is to explore the current evidence surrounding the changes in functional status following open or endovascular abdominal aortic aneurysm (AAA) repair and the role of postoperative exercise-based rehabilitation programmes. Methods: The proposed study will incorporate two separate systematic reviews within it, one to assess changes in functional status (component 1) and another to consider the role of exercise-based rehabilitation for improving functional status (component 2), both following AAA repair. The Medline, EMBASE and Cochrane CENTRAL databases will be searched using two separate search strategies including the terms “aortic aneurysm”, “functional capacity”, “functional decline” and” exercise therapy”. We plan to include all prospective randomised and non-randomised trials that have considered the impact of AAA repair on functional status and/or the effect of exercise-based rehabilitation following AAA repair. For component 1, the primary outcome will be changes in objective measures of functional capacity or physical function following AAA repair and, for component 2, it will be changes in physical function or functional capacity following exercise-based rehabilitation after AAA repair. The extracted data will include study characteristics – ie, sample size, a description of the intervention and control conditions (where applicable), outcome measures, length of follow-up and main findings related to outcome measures. For both components a narrative synthesis will be produced, supported by a summary table. We intend to conduct quantitative meta-analyses for both components. For each selected outcome we plan to evaluate the certainty of evidence based on the GRADE approach and risk of bias of included studies will be assessed using the Cochrane tool. Conclusions: Based on a lack of current evidence, we present a protocol for a systematic review to investigate the functional changes associated with open and endovascular AAA repair and the potential value of postoperative exercise rehabilitation.

Effects of Suprarenal Aortic Cross-Clamping and Adjunctive Renal Reconstruction on Outcomes of Open Abdominal Aortic Aneurysm Repair.

Purpose: To analyze our contemporary experience in open abdominal aortic aneurysm (AAA) repair. We focused on the effects of suprarenal (SR) aortic cross-clamping and adjunctive renal reconstruction (RR) on postoperative outcomes.Methods: We retrospectively reviewed our institutional data of 141 consecutive patients who received elective open AAA repair between January 2014 and December 2020.Results: Seventy-five procedures were performed with SR aortic cross-clamping, 20 of which required an adjunctive RR. Patients in the SR group had a higher incidence of postoperative acute kidney injury (AKI) (18.7% vs. 7.6%, P = 0.045). There were no significant between-group differences in other major complications. The 30-day mortality rate in the infrarenal (IR) and SR groups was 0% and 1.3%, respectively. After a median follow-up of 33 months, the rates of chronic renal decline in the IR (18.2%) and SR (21.3%) groups were similar. All reconstructed renal arteries were patent without reintervention. The 5-year overall survival rate in the IR and SR groups was 88.8% and 83.2%, respectively.Conclusions: SR aortic cross-clamping was associated with postoperative AKI but neither SR aortic cross-clamping nor RR affected the long-term renal function or mortality. Open repair remains an essential option for patients with AAA, especially those with complex anatomy.

Continuous Epidural Block and Balanced General Anesthesia in Abdominal Aortic Aneurysm Surgery in a General Hospital. Case Report

Introduction: Abdominal Aortic Aneurysms (AAA) are becoming more frequent in our population; the surgical management of this pathology represents a highly complex surgery which must be performed in a well-equipped medical unit, with implements and suitable personnel, since morbidity and mortality depends a lot on the preoperative evaluation of these patients with high coronary risk. Peripheral locoregional anesthesia techniques occupy an important place in anesthetic treatment and postoperative resuscitation due to the frequent possibility of cardiovascular, respiratory, renal complications or mesenteric ischemia, which justifies a treatment adapted to the high surgical risk, therefore, postoperative management should generally be in an Intensive Care Unit. Objective: Present the case of a patient with Abdominal Aortic Aneurysm (AAA) with acute abdomen urgently operated in a second-level hospital using mixed anesthesia. Case: Octogenarian patient with a diagnosis of infrarenal AAA, undergoing emergency surgery for abdominal pain, which was under balanced general anesthesia plus epidural block a bifurcated Dacron synthetic graft was interposed, with postoperative management in general surgery hospitalization area because there was no availability in the Intensive Care Unit (ICU), evolving properly. Conclusion: Evolution depends a lot on the anesthetic technique, which must be directed towards a multimodal strategy, where hemodynamic stability is a priority.

Cloud-based Fusion Imaging Improves Operative Metrics During Fenestrated Endovascular Aneurysm Repair

Endovascular treatment of complex aortic pathology is associated with increases in procedural-related metrics including operative time and radiation exposure. Three-dimensional fusion imaging technology has decreased radiation dose and iodinated contrast use in endovascular aneurysm repair. The aim of this study is to report our institutional experience with use of a cloud-based fusion imaging platform in fenestrated endovascular aneurysm repair (FEVAR). A retrospective review of a prospectively maintained aortic database was performed to identify all patients who underwent commercially-available FEVAR (Zenith Fenestrated, Cook Medical, Bloomington, Ind) between 2013 and 2020, as well as all endovascular aneurysm repairs performed using Cydar EV Intelligent Maps (Cydar Medical, Cambridge, UK). The Cydar EV cohort was reviewed further to select all FEVAR performed with intelligent map guidance. Patient demographics, clinical, and procedural-related metrics were analyzed, with comparative analysis of FEVAR performed without and with the Cydar EV imaging platform. Patients were excluded from the comparative analysis if incomplete in the data set, or if documented history of prior open or endovascular abdominal aortic aneurysm repair. Over the 7-year study period 191 FEVAR were performed. The Cydar EV imaging platform was implemented in 2018 and used in 124 complex endovascular aneurysm repairs, including 69 consecutive FEVAR. A complete dataset was available on 137 FEVAR. With exclusions to select for de novo FEVAR, comparative analysis was performed on 53 FEVAR without and 63 with Cydar EV. Cohorts were similar with respect to patient demographics, medical comorbidities, and aortic aneurysm characteristics. No significant difference was noted between groups on major adverse postoperative events, length of stay, or length of intensive care unit stay. Use of the Cydar EV resulted in nonsignificant decreases in mean fluoroscopy time (69.3 minutes vs 66.2 minutes; P = .598), and a positive trend toward shorter operative times (204.4 minutes vs 186 minutes; P = .278). Notably, a statistically significant decrease in both iodinated contrast volume (104.7 mL vs 83.8 mL; P = .005), and patient radiation exposure via dose-area product (1,049,841 mGy/cm2 vs 630,990; P < .001) was observed in patients undergoing FEVAR with Cydar EV Intelligent Maps. Our aortic center has observed a trend toward shorter operative times, and significant decreased in both iodinated contrast use and radiation exposure during FEVAR with the use of Cydar EV Intelligent Maps. Intelligent map guidance improves the efficiency of complex endovascular aneurysm repair, providing a safer intervention for both patient and practitioner.

Impact of a regional smoking cessation intervention for vascular surgery patients

Tobacco use is common among vascular surgery patients and negatively impacts outcomes and longevity. In the second quarter of 2018, a statewide vascular quality collaborative launched an initiative across its 35 participating hospitals to promote smoking cessation at the time of surgery. This intervention was based on the Vascular Physician Offer and Report (VAPOR) trial and consisted of 3 components: brief physician-delivered advice, referral to telephone-based counseling, and nicotine replacement therapy. The goal of this study is to evaluate the results of this intervention. We performed a retrospective analysis of patients undergoing vascular surgery between 2018 and 2020. Procedures included open abdominal aortic aneurysm repair, endovascular aneurysm repair, open vascular bypass, open thrombectomy, carotid endarterectomy, and carotid stenting. The primary explanatory variables were receipt of tobacco cessation interventions as documented in the medical record. The primary outcome was tobacco cessation, captured during 30-day and 1-year chart review and/or patient follow-up. A multivariable logistic regression model was calculated to estimate the association of covariates with smoking cessation while adjusting for patient and clinical characteristics. A total of 13,890 patients underwent surgery during the study period. The mean age was 69.4± 10years; 4687 patients (34%) were female, and 5158 patients (37%) were current smokers. At least one smoking cessation component was delivered to 2245 patients (44% of smokers). The quit rate was 35% among 4671 patients with 30-day follow-up and 43% among 2936 patients with 1-year follow up. On multivariable regression, at 30days, receiving two intervention components was associated with 1.29 (95% confidence interval [CI], 1.07-1.55) higher odds of quitting. At both time points,smoking cessation was also associated with undergoing an emergent procedure (30-day odds ratio [OR], 1.52; 95% CI, 1.16-1.99; 1-year OR, 1.41; 95% CI, 1.01-1.97) and undergoing open abdominal aortic aneurysm repair (30-day OR, 1.71; 95% CI, 1.20-2.43; 1-year OR, 1.75; 95% CI, 1.11-2.78). In a cohort of vascular surgical patients where tobacco use was common, nearly one-half of patients quit smoking 1year after surgery. Receiving two smoking cessation intervention components was associated with quitting at 30days. Overall, these results demonstrate encouraging quit rates and identify an opportunity for longer-term intervention to maintain even greater 1-year tobacco cessation.

Endovascular aneurysm repair conversion is an increasingly common indication for open abdominal aortic aneurysm repair.

Although endovascular aneurysm repair (EVAR) reintervention is common, conversion to open repair (EVAR-c) occurs less frequently but can be associated with significant technical complexity and perioperative risk. There is a paucity of data highlighting the evolution of periprocedural results surrounding EVAR-c and change in practice patterns, especially for referral centers that increasingly manage EVAR failures. The purpose of this analysis was to perform a temporal analysis of our EVAR-c experience and describe changes in patient selection, operative details, and outcomes. A retrospective single-center review of all open abdominal aortic aneurysm repairs was performed (2002-2019), and EVAR-c procedures were subsequently analyzed. EVAR-c patients (n= 184) were categorized into two different eras (2002-2009, n= 21; 2010-2019, n= 163) for comparison. Logistic regression and Cox proportional hazards modeling were used for risk-adjusted comparisons. A significant increase in EVAR-c as an indication for any type of open aneurysm repair was detected (9% to 27%; P< .001). Among EVAR-c patients, no change in age or individual comorbidities was evident (mean age, 71± 9years); however, the proportion of female patients (P= .01) and American Society of Anesthesiologists classification >3 declined (P= .05). There was no difference in prevalence (50% vs 43%; P= .6) or number (median, 1.5 [interquartile range (IQR), 0-5]) of preadmission EVAR reinterventions; however, time to reintervention decreased (median, 23 [IQR, 6-34] months vs 0 [IQR, 0-22] months; P= .005). In contrast, time to EVAR-c significantly increased (median, 16 [IQR, 9-39] months vs 48 [IQR, 20-83] months; P= .008). No difference in frequency of nonelective presentation (mean, 52%; P= .9] or indication was identified, but a trend toward increasing mycotic EVAR-c was observed (5% vs 15%; P= .09). Use of retroperitoneal exposure (14% vs 77%; P< .0001), suprarenal cross-clamp application (6286%; P= .04), and visceral-ischemia time(median, 0 [IQR, 0-11] minutes vs 5 [IQR, 0-20] minutes; P= .05) all increased. In contrast, estimated blood loss (P trend= .03) and procedure time (P= .008) decreased. The unadjusted elective 30-day mortality rate improved but didnot reach statistical significance (elective, 10% vs 5%; P= .5) with no change for non-elective operations (18% vs 16%; P= .9). However, a significantly decreased risk of complications was evident (odds ratio, 0.88; 95% confidence interval, .8-.9; P= .01). One- and 3-year survival was similar over time. EVAR-c is now a common indication for open abdominal aortic aneurysm repair. Patients frequently present nonelectively and at increasingly later intervals after their index EVAR. Despite increasing technical complexity, decreased complication risk and comparable survival can be anticipated when patients are managed at a high-volume aortic referral center.

Identifying Women at High Risk of 90 Day Death after Elective Open Abdominal Aortic Aneurysm Repair: A Multicentre Case Control Study

The aim of this study was to identify risk factors for 90 day death after elective open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) in women. This was a multicentre case control study. The nationwide Dutch Surgical Aneurysm Audit registry (2013-2019) was solely used to identify women who underwent elective OSR as eligible patients. Data for this study were subsequently collected from the patients' medical files. Women with AAA were included and those who died (cases) were compared with those who survived (controls) 90 days after surgery. Inflammatory, mycotic, or symptomatic or ruptured AAA were excluded. The association between pre- and peri-operative risk factors and death was assessed by logistic regression analysis in the whole sample and after matching cases to controls of the same age at the time of repair. Mesenteric artery patency was also assessed on pre-operative computed tomography and used in the analysis. In total, 266 patients (30 cases and 236 controls) from 21 hospitals were included. Cases were older (median [interquartile range; IQR] 75 years [71, 78.3] vs. 71 years [66, 77]; p= .002) and more often had symptomatic peripheral arterial disease (PAD) (14/29 [48%] vs. 49/227 [22%]; p= .002). Intra-operative blood loss (median [IQR] 1.6 L [1.1, 3.0] vs. 1.2 L [0.7, 1.8]), acute myocardial infarction (AMI) (10/30 [33%] vs. 8/236 [3%]), renal failure (17/30 [57%] vs. 33/236 [14%]), and bowel ischaemia (BI) (17/29 [59%] vs. 12/236 [5%]) were more prevalent among cases. Older age (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.03-1.19) and PAD (OR 3.91, 95% CI 1.57-9.74) were associated with death. Multivariable analysis demonstrated that, after adjustment for age, AMI (OR 9.34, 95% CI 1.66-52.4) and BI (OR 35.6, 95% CI 3.41-370) were associated with death. Superior mesenteric artery stenosis of >70% had a clinically relevant association with BI (OR 5.23, 95% CI 1.43-19.13; p= .012). Age, symptomatic PAD, AMI, and BI were risk factors for death after elective OSR in women. The association between a >70% SMA stenosis and BI may call for action in selected cases.

Editor's Foreword

Welcome to the fifth issue of the Journal of Vascular Societies Great Britain and Ireland (JVSGBI). We are really delighted with the success of the journal, and this issue marks the first anniversary of the launch at the Vascular Societies GB&amp;I Annual Scientific meeting last year. The increasing interest in the JVSGBI has been demonstrated by the growing number of submitted articles and the impressive website stats (over 3,000 views). This issue includes three editorials. The first by Andrew Garnham (VSGBI President Elect) and Rachael Forsythe (Rouleaux President) provides a thoughtful reflection on the problem of bullying, undermining and harassment in (vascular) surgical training highlighted as a persistent problem by a Rouleaux Club paper in this edition. The second editorial from Dr Una Adderley, National Wound Care Strategy Programme (NWCSP) Director, outlines past achievements and future plans for the programme. Finally, Duygu Yenidogan-Schmidt, Chair of the Executive Committee of AAA UK, a newly formed patient representative group giving national representation to AAA patients and relatives, highlights the origins, purpose and aims of this group. I am sure these editorials will be of great interest to readers. There are four original research articles, the first from the Rouleaux Club, the UK Vascular Surgery Trainees’ Association, reports the findings from their recent bullying, undermining and harassment survey. The second from the Vascular and Endovascular Research Network (VERN) reports the findings from the Tier 3 COVID-19 Vascular Service (COVER) study. The final two original articles present the findings from the James Lind Alliance Priority Setting Partnership from the Vascular Services and Venous Conditions Groups. It is fantastic to see vascular trainees continuing to undertake meaningful and impactful research and choose the JVSGBI to disseminate their work. This edition also contains a research protocol from Ravindhran et al for a systematic review which aims to study changes in functional health status following open abdominal aortic aneurysm repair. Finally, in this issue there is a short educational report entitled ‘Intraoperative management of REBOA’ and a case report entitled ‘Carotid web: an important cause of stroke in young people’. The National Wound Care Strategy Programme Guidelines for lower limb wounds are published as a supplement to this issue and can be located on the journal website. This is our fifth issue, and we would like to take the opportunity to thank all the authors who have submitted articles during the last year, which is building on the success of the journal – your contribution has been really appreciated and I hope you are delighted with your publication. We would also like to thank all the reviewers for their timely and thorough contributions. Finally, please do continue to share your work by submitting articles for publication.

Pen aortic surgical training with trainees as primary operator: a retrospective single-centre analysis

Objective: To review safety outcomes of open aortic surgeries with vascular surgical trainees as the primary operator. Methods: A retrospective analysis of prospectively accrued data was performed using our departmental database, electronic patient records and the National Vascular Registry for all elective open abdominal aortic aneurysms (AAA) (juxtarenal and infrarenal) repairs over 2 years between 1 January 2017 and 31 December 2018. Data on primary operator, training level, number of surgeons, assistant training level, operation time, duration of ITU and hospital stay, 30-day mortality, 1-year mortality and complications were obtained. Results: During the study period 83 elective open AAA repairs were carried out. The primary operator was a trainee in 46% (n=38) and a consultant in 54% (n=45). For trainees and consultants, median operation time was 178 min vs 215 min (p=0.036), duration of ITU stay was 1.5 days vs 2 days (p=0.270), duration of hospital stay was 5.6 days vs 6.8 days (p=0.037), 30-day mortality was 0.0% vs 2.2% (p=0.932) and 1-year mortality was 0.0% vs 2.2% (p=0.932), respectively. Conclusions: Safe surgical outcomes for open AAA repair can be achieved with vascular surgical trainees as primary operators.

Endovascular Aortic Aneurysm Repair: A Narrative Review

AbstractEndovascular aortic aneurysm repair (EVAR) has evolved as minimally invasive method of treating infrarenal abdominal aortic aneurysms (AAA) with perioperatively mortality of less than 1% compared with 5% with open AAA repair as suggested by many randomized control trials. Computed tomography angiography is the imaging of choice for appropriate selection of a patient with EVAR. For patients with unsuitable anatomy, advanced EVARs techniques, such as fenestrated, branch, and chimney EVARs, are also increasingly being offered to patients with equal success. Patients with ruptured AAA are treated with this minimally invasive procedure. Percutaneous EVAR emerged with less of wound-related complications. Endoleaks are the most common complications peculiar to this procedure, and most are preventable by preoperative planning. They are detected on completion angiogram or on the surveillance imaging. This review discusses indications of EVAR, its selection criteria, procedural steps, and common complications associated with this procedure and advanced EVARs.

Surgical repair of abdominal aortic aneurysms on the public health system in the largest city in Brazil: a descriptive analysis of in-hospital data on 2693 procedures over 10 years.

BackgroundFrom 1990 to 2015, mortality from aortic aneurysms increased 16.8% in Brazil. São Paulo is the largest city in Brazil and about 5 million people depend on the public health system there.ObjectivesTo conduct an epidemiological analysis of abdominal aortic aneurysm surgeries in the city of São Paulo.MethodsInfra-renal aortic aneurysm procedures performed over a decade (from 2008 to 2017) were studied using publicly-available platforms from the Unified Health System and DATASUS.Results2693 procedures were analyzed; 66.73% were endovascular; 78.7% of patients were male; 70.7% were aged 65 years or more; 64.02% were elective hospital admissions. There were 288 in-hospital deaths (mortality: 10.69%). In-hospital mortality was lower for endovascular surgery than for open surgery; both for elective (4.13% versus 14.42%) and urgent (9.73% versus 27.94%) (p = 0.019) admissions. The highest volume hospital (n = 635) had the lowest in-hospital mortality (3.31%). USD 24,835,604.84 was paid; an average of $ 2,318.63 for elective open, $ 3,420.10 for emergency open, $ 12,157.35 for elective endovascular and $ 12,969.12 for urgent endovascular procedures. Endovascular procedure costs were statistically higher than the values paid for open surgeries (p <0.001).ConclusionsEndovascular surgeries were performed twice as often as open surgeries; they had shorter hospital stays and lower mortality.

Endovascular Aneurysm Repair for Large Abdominal Aortic Aneurysms is Associated With Higher Late Re-Intervention, Rupture, and Mortality Rates: Abdominal Aortic Aneurysms

Introduction: The risk of abdominal aortic aneurysm (AAA) rupture increases with increasing aneurysm diameter. However, the impact of AAA diameter on late outcomes after aneurysm repair is unclear. Therefore, we assessed the association of large AAA diameter with late outcomes in patients undergoing open and endovascular AAA repair.

Protocol for the Metformin Aneurysm Trial (MAT): a placebo-controlled randomised trial testing whether metformin reduces the risk of serious complications of abdominal aortic aneurysm

BackgroundMultiple observational studies have associated metformin prescription with reduced progression of abdominal aortic aneurysm (AAA). The Metformin Aneurysm Trial (MAT) will test whether metformin reduces the risk of AAA rupture-related mortality or requirement for AAA surgery (AAA events) in people with asymptomatic aneurysms.MethodsMAT is an international, multi-centre, prospective, parallel-group, randomised, placebo-controlled trial. Participants must have an asymptomatic AAA measuring at least 35 mm in maximum diameter, no diabetes, no contraindication to metformin and no current plans for surgical repair. The double-blind period is preceded by a 6-week, single-blind, active run-in phase in which all potential participants receive metformin. Only patients tolerating metformin by taking at least 80% of allocated medication will enter the trial and be randomised to 1500 mg of metformin XR or an identical placebo. The primary outcome is the proportion of AAA events defined as rupture-related mortality or need for surgical repair. Secondary outcomes include AAA growth, major adverse cardiovascular events and health-related quality of life. In order to test if metformin reduced the risk of AAA events by at least 25%, 616 primary outcome events will be required (power 90%, alpha 0.05).DiscussionCurrently, there is no drug therapy for AAA. Past trials have found no convincing evidence of the benefit of multiple blood pressure lowering, antibiotics, a mast cell inhibitor, an anti-platelet drug and a lipid-lowering medication on AAA growth. MAT is one of a number of trials now ongoing testing metformin for AAA. MAT, unlike these other trials, is designed to test the effect of metformin on AAA events. The international collaboration needed for MAT will be challenging to achieve given the current COVID-19 pandemic. If this challenge can be overcome, MAT will represent a trial unique within the AAA field in its large size and design.Trial registrationAustralian Clinical Trials ACTRN12618001707257. Registered on 16 October 2018