Patients Undergoing Abdominal Aortic Aneurysm Repair Research Articles

The Potential Value of Prehabilitation for Preventing Delirium in Elective Surgery for Aneurysms of the Abdominal Aorta.

Delirium is a common and serious postoperative complication in elderly patients undergoing abdominal aortic aneurysm (AAA) repair and is associated with a variety of adverse outcomes. Multimodal prehabilitation aims to identify and minimize potential risk factors for delirium and improve overall health. The aim of this study is to investigate the effect of multimodal prehabilitation on delirium incidence in elderly patients undergoing elective repair for AAA. A single-centre cohort analysis was performed in the Netherlands for patients aged ≥70 years, undergoing elective repair for AAA (open surgery and endovascular aortic repair). Prehabilitation was gradually introduced between 2016 and 2019 and offered as standard care from 2019. The program was constructed to optimize overall health and included delirium risk assessment, home-based tailor-made exercises by a physical therapist, nutritional optimization by a dietician, iron infusion in case of anaemia and a comprehensive geriatric assessment by a geriatrician in case of frailty. The primary outcome was incidence of delirium within 30 days after surgery. A total of 81 control and 123 prehabilitation patients were included. A reduction in incidence of delirium was found (11.1% in the control group to 4.9% in the prehabilitation group), with too small numbers to reach statistical significance (p=0.09). Also, patients in the prehabilitation group had a small, non-significant decreased length of hospital stay (4 days) compared to the control group (5 days) (p=0.07). Although no significant differences were found, we carefully conclude that this study provides some support for implementing multimodal prehabilitation for delirium prevention in elderly patients undergoing AAA repair. Further research with larger cohorts is necessary to identify and select patients that would most benefit from prehabilitation.

467-P: Reinterventions after Abdominal Aortic Aneurysm Repair in People with Diabetes Mellitus—A Systematic Review and Meta-analysis

Background: There is a known negative association between diabetes (DM) and abdominal aortic aneurysm (AAA). Patients with DM have a higher long-term mortality following AAA repair. However, whether that is related to their AAA is unclear. Aims: To determine the rates of reinterventions in patients with DM post-AAA repair. Outcomes included; AAA sac enlargement, reinterventions, endoleaks, AAA rupture, and conversion. Methods: Pubmed, Embase and Cochrane databases were searched for primary research studies between 2005 and 2022 according to PRISMA guidelines. Patients undergoing AAA repair either via endovascular aneurysm repair or open surgical repair were included. Meta-analysis was conducted using Review Manager. Results: Eight studies were identified totalling 75678 patients in the control group, and 22284 in the DM group. Patients with DM had a lower rate of reintervention compared to the control group, (6.63% v 9.15%; OR 0.80, 95%CI[0.67, 0.94], P=0.007). There was no significant difference in rate of all endoleaks (8.54% v 12.38%; OR 0.91, 95%CI[0.53-1.58], P=0.74), which remained non-significantly in favour of DM when comparing type 1 and 2 separately, with similar results with sac expansion. There was a significant reduction in rates of conversion to open surgery in those with DM (3.07% v 4.21%; OR 0.75, 95%CI[0.55-0.99], P=0.04), and a reduction in post op AAA rupture (3.35% v 5.69%; OR 0.53, 95%CI[0.49-0.58], P<0.001). Conclusion: Postoperative AAA ruptures, reinterventions, and conversion to open surgery were lower in patients with DM. However, the rates of endoleaks were not significantly different, so the reason for higher complication rates remains unknown. Disclosure K.Dhatariya: Other Relationship; Novo Nordisk, AstraZeneca, Boehringer-Ingelheim, Eli Lilly and Company. E.A.A.Otify: None. M.A.E.Mekki: None. P.W.Stather: None.

A Preoperative Supervised Exercise Program Provides a 5-year Mortality Benefit for Patients Undergoing Abdominal Aortic Aneurysm Repair

Supervised exercise prior to abdominal aortic aneurysm (AAA) repair reduces complications. The aim of this follow-up study was to identify if there was a survival benefit 5 years after surgery. We report on the long-term follow-up of a randomized controlled trial in which 124 patients undergoing AAA repair were randomized to a preoperative exercise program or control. All 124 patients were followed up, up to 5 years after surgery. Survival analysis was performed on an intention-to-treat and per-protocol basis using Kaplan-Meier curves and the log-rank test. Additional analysis was performed using compliance average causal effect analysis with compliance measured on an all or nothing scale. One hundred patients were still alive at 5 years after surgery. On intention-to-treat analysis, there were 16 deaths in the control group and 8 in the exercise group (P = .08). For per-protocol analysis, there were 16 deaths in the control group and 4 in the exercise group (P = .01). The compliance average causal effect analysis showed a significant intervention effect for compliers (hazard ratio, 0.36; P = .02). There is a long-term survival benefit for patients undergoing AAA repair who attend preoperative supervised exercise. We will reevaluate these patients via interview, cardiopulmonary exercise test and quality of life questionnaires, to establish what drives this benefit.

Relationship between intraoperative dopamine infusion and postoperative acute kidney injury in patients undergoing open abdominal aorta aneurysm repair

BackgroundAcute kidney injury (AKI) is one of the most common complications in patients undergoing open abdominal aortic aneurysm (AAA) repair. Dopamine has been frequently used in these patients to prevent AKI. We aimed to clarify the relationship between intraoperative dopamine infusion and postoperative AKI in patients undergoing open AAA repair.MethodsWe analyzed 294 patients who underwent open AAA repair at a single tertiary center from 2009 to 2018, retrospectively. The primary outcome was the incidence of postoperative AKI, determined by the Kidney Disease Improving Global Outcomes definition, after open AAA repair. Secondary outcomes included survival outcome, hospital and intensive care unit length of stay, and postoperative renal replacement therapy (RRT).ResultsPostoperative AKI occurred in 21.8% (64 out of 294 patients) The risk of postoperative AKI by intraoperative dopamine infusion was greater after adjusting for risk factors (odds ratio [OR] 2.56; 95% confidence interval [CI], 1.09–5.89; P = 0.028) and after propensity score matching (OR 3.22; 95% CI 1.12–9.24; P = 0.030). On the contrary, intraoperative norepinephrine use was not associated with postoperative AKI (use vs. no use; 19.3 vs. 22.4%; P = 0.615). Patients who used dopamine showed higher requirement for postoperative RRT (6.8 vs. 1.2%; P = 0.045) and longer hospital length of stay (18 vs. 16 days, P = 0.024).ConclusionsIntraoperative dopamine infusion was associated with more frequent postoperative AKI, postoperative RRT, and longer hospital length of stay in patients undergoing AAA repair, when compared to norepinephrine. Further prospective randomized clinical trial may be necessary for this topic.

Potency of miR-144-3p in promoting abdominal aortic aneurysm progression in mice correlates with apoptosis of smooth muscle cells

Abdominal aortic aneurysm (AAA), a life-threatening disease, is commonly diagnosed among people with risk factors, including increasing age, male gender, and smoking. The apoptosis of smooth muscle cells (SMCs) has been reported to disrupt the vascular structural integrity, which causes AAA. Thus, we sought to characterize the potential role of microRNA (miR)-144-3p in SMC apoptosis, and to outline the molecular mechanisms involved in this pathway. We collected pathological abdominal aortic tissues and adjacent normal aortic biopsy specimens from 18 patients undergoing AAA repair surgery. The relationship between miR-144-3p expression and SMC proliferation was assessed by transfecting mimic/inhibitor of miR-144-3p in human aortic smooth muscle cells (HASMCs). Anti-growth effect of miR-144-3p and related genes was evaluated in a murine AAA model. Dual luciferase reporter gene assay was adopted to validate the targeting relationship between miR-144-3p and enhancer of zeste homolog 2 (EZH2), and the enrichment of EZH2 in the p21 promoter region was determined by chromatin immunoprecipitation assay. MiR-144-3p was highly expressed in AAA tissues. Enhanced miR-144-3p diminished SMC proliferation by binding to the EZH2 3′-untranslated region and thereby inhibiting EZH2 expression. In addition, EZH2 was highly enriched in the promoter region of p21, and knockdown of p21 expression could rescue the effect of miR-144-3p on SMC proliferation and apoptosis. miR-144-3p serves as a promoter for the apoptosis of SMCs, which contributes to the occurrence and progression of AAA. This observation will serve as the basis for further investigations into potential p21-based therapies for AAA treatment.

The Content of Pre-habilitative Interventions for Patients Undergoing Repair of Abdominal Aortic Aneurysms and Their Effect on Post-Operative Outcomes: A Systematic Review

Patients requiring abdominal aortic aneurysm (AAA) repair are at risk of post-operative complications due to poor pre-operative state. Pre-habilitation describes the enhancement of functional capacity and tolerance to an upcoming physiological stressor, intended to reduce those complications. The ability to provide such an intervention (physical, pharmacological, nutritional, or psychosocial) between diagnosis and surgery is a growing interest, but its role in AAA repair is unclear. This paper aimed to systematically review existing literature to better describe the effect of pre-habilitative interventions on post-operative outcomes of patients undergoing AAA repair. EMBASE and Medline were searched from inception to October 2020. Retrieved papers, systematic reviews, and trial registries were citation tracked. Randomised controlled trials (RCTs) comparing post-operative outcomes for adult patients undergoing a period of pre-habilitation prior to AAA repair (open or endovascular) were eligible for inclusion. Two authors screened titles for inclusion, assessed risk of bias, and extracted data. Primary outcomes were post-operative 30 day mortality, composite endpoint of 30 day post-operative complications, hospital length of stay (LOS), and health related quality of life (HRQL) outcomes. The content of interventions was extracted and a narrative analysis of results undertaken. Seven RCTs with 901 patients were included (three exercise based, two pharmacological based, and two nutritional based). Risk of bias was mostly unclear or high and the clinical heterogeneity between the trials precluded data pooling for meta-analyses. The quality of intervention descriptions was highly variable. One exercise based RCT reported significantly reduced hospital LOS and another improved HRQL outcomes. Neither pharmacological nor nutritional based RCTs reported significant differences in primary outcomes. There is limited evidence to draw clinically robust conclusions about the effect of pre-habilitation on post-operative outcomes following AAA repair. Well designed RCTs, adhering to reporting standards for intervention content and trial methods, are urgently needed to establish the clinical and cost effectiveness of pre-habilitation interventions.

Association of Medicaid Expansion with In-Hospital Outcomes After Abdominal Aortic Aneurysm Repair

ObjectivesMultiple studies have shown improved outcomes and higher utilization of care with the increase of insurance coverage. This study aims to assess whether Medicaid expansion (ME) has changed the utilization and outcomes of abdominal aortic aneurysm (AAA) repair in the United States. DesignRetrospective observational study. MaterialsData of patients undergoing AAA repair in the Vascular Quality Initiative (2010-2017). MethodsInterrupted time-series (ITS) analysis was utilized to evaluate changes in annual trends of postoperative outcomes after elective AAA repair before and after 2014. We also assessed if these trend changes were significant by comparing the changes in states which adopted ME in 2014 versus nonexpansion states (NME), and conducting a difference-in-difference analysis. Primary outcomes included in-hospital mortality and adverse events (bowel and leg ischemia, cardiac, renal, respiratory, stroke and return to the OR). ResultsA total of 19,143 procedures were included (Endovascular: 85.8% and open: 14.2%), of which 40.9% were performed in ME States. Compared to preexpansion trends (P1), there was a 2% annual increase in elective AAA repair in ME states (P1: -1.8% versus P2: +0.2%, P< 0.01) with no significant change in NME (P1: +0.3% versus P2: +0.2%, P = 0.97). Among elective cases, annual trends in the use of EVAR increased by 2% in ME states (95% confidence interval (CI) = -0.1, 4.1, P = 0.06), compared to a 3% decrease in NME States [95%CI = -5.8, -0.6, P = 0.01) (PMEversusNME < 0.01]. There was no association between ME and in-hospital mortality. Nonetheless, it was associated with a decrease in the annual trends of in-hospital complications (ME: -1.4% (-2.1,-0.8) versus NME: +0.2% (-0.2, +0.8), P < 0.01). ConclusionsWhile no association between ME and increased survival was noted in states which adopted ME, there was a significant increase of elective AAA cases and EVAR utilization and a decrease in in-hospital complications in ME States.

Depression Predicts Non-Home Discharge After Abdominal Aortic Aneurysm Repair

Mental health's impact on vascular surgical patients has long been overlooked. While outside the expertise of most surgeons, understanding the role that depression plays in the postoperative course could provide additional insight into opportunities to improve surgical outcomes and healthcare value. Additionally, non-home discharge (NHD) to a rehabilitation or skilled nursing facility after surgery is associated with impaired quality of life and higher postdischarge complications, readmissions, and mortality. We hypothesized that depression would be associated with an increased risk for NHD following abdominal aortic aneurysm (AAA) repair. Nonruptured AAA repair cases were identified from the National Inpatient Sample (NIS) using ICD-9 codes between 2005 and 2014. Depression, comorbidities, postoperative complications, and discharge destination were evaluated using statistical tests as appropriate to the data. A hierarchical multivariable logistic regression controlling for hospital level variation was used to examine the independent association between depression, and the primary outcome of NHD controlling for median income and confounders meeting P < 0.05 on univariate analysis. There were 99,934 total cases analyzed, of which 4,755 (4.8%) were diagnosed with depression and 10,618 (11.9%) required NHD. Patients with depression were younger, more likely to be women, white, have diabetes, chronic obstructive pulmonary disease, hypertension, tobacco use, and more likely to experience a postoperative complication. On adjusted multivariable analysis, patients with depression were more likely to require NHD (odds ratio [OR] 1.87, 95% confidence interval [CI]: 1.68-2.08, c-statistic = 0.82). On stratified analysis by operative approach, depression had a larger effect estimate in endovascular repair (OR 2.19; 95% CI: 1.90-2.52) versus open repair (OR 1.60; 95% CI: 1.38-1.87). In a nationally representative sample, patients with depression were more likely to require NHD after AAA repair. This study highlights the importance that depression plays in postoperative outcomes after AAA repair. Furthermore, addressing mental health preoperatively has the potential to improve outcomes in patients undergoing AAA repair.

Renal Transplant Patients Undergo Abdominal Aortic Aneurysm Repair at a Younger Age and Experience More Complications: Review of the Healthcare Cost and Utilization Project Database

ObjectiveThe objective of this study was to determine whether history of kidney transplant is a risk factor for increased complications in patients who undergo abdominal aortic aneurysm (AAA) repair. BackgroundThe incidence of renal failure and subsequent kidney transplant is steadily rising. Many risk factors leading to AAA overlap with those of renal disease. Due to these similarities, a rising incidence of kidney transplant patients undergoing AAA repair is expected. We surmised a notable difference in AAA surgical repair outcomes in renal transplant recipients compared to the general population. MethodsA retrospective analysis was performed on 59,836 adult patients with history of AAA repair and kidney transplant from 2008 to 2015. Data were obtained from the Nationwide Inpatient Sample database developed for the Healthcare Cost and Utilization Project. ResultsSignificant differences in age, race, hospital characteristics, and complications were identified. The results suggest that patients with prior transplant generally have AAA repair at a significantly younger age (P < .001). A difference in race (P = .017), with 75% vs 87.4% non-Hispanic whites and 5% vs 1.5% Asian/Pacific Islander in the transplant and nontransplant groups, respectively, was shown. Procedures at transplant centers had significantly longer lengths of stay (P < .001) and higher total charges (P < .001). In addition, transplant recipients exhibited a higher in-hospital mortality index (P < .001) than the nontransplanted population. ConclusionA history of kidney transplant significantly influences multiple aspects of care and complications regarding future AAA repair and is associated with increased in-hospital mortality index. Significant findings include increased total charges, longer lengths of stay, postoperative complications, and differences in age and race.

Underutilization of Nonopioid Pain Medication in Patients Undergoing Abdominal Aortic Aneurysm Repair

With increased focus on the opioid crisis, it was our goal to describe rates and risk factors for postoperative use of opioids in patients undergoing abdominal aortic aneurysm (AAA) repair as well as identify pain modalities that are underutilized. We retrospectively analyzed perioperative analgesic prescriptions for endovascular (EVAR) and open AAA repair between January 1, 2010 and January 1, 2018. Patients' baseline opioid use, demographics, and medical comorbidities were obtained. The EVAR group was further subdivided into percutaneous (pEVAR) and cutdown (cEVAR) groups. Primary outcomes were postoperative and discharge pain medication prescriptions. Relative rates of opioid prescribing were obtained through the electronic medical record and normalized into morphine milligram equivalents (MMEs). Of the 128 patients analyzed in the entire cohort, 21.8% (n=28) underwent open repair and 78.12% (n=100) underwent EVAR (46 pEVAR, 54 cEVAR). As expected, open repair had increased postoperative pain reported compared to EVAR (2.67±0.75 vs. 0.96±0.19, P<0.01). Adjunctive epidural reduced postoperative pain for open repair (0.77±0.48 vs. 3.50±0.96, P<0.01). EVAR had less postoperative opioid prescriptions compared to open repair (35.0% vs. 77.3%, P<0.01). In the endovascular group, there was no difference between postoperative opioid prescription based on access, pEVAR versus cEVAR (65.8% vs. 80.1%, P=0.11). When stratifying patients by number of cutdowns, patients with bilateral cutdown as opposed to a single cutdown received more opioid prescriptions than pEVAR patients (84.44% vs. 65.8%, P=0.036). Of those receiving opioids, the average MME for open repair was 320.94mg compared to 28.82mg for EVAR (P<0.01). Those undergoing percutaneous repair had significantly less MME use during hospitalization compared to femoral cutdown (17±3.52 vs. 31.90±5.43mg, P<0.01). Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and ketorolac, were rarely used in the postoperative period for open or EVAR (8.3% vs 1.1%). Percutaneous EVAR patients reported less pain at discharge compared to cEVAR patients (0.18±0.12 vs. 0.88±0.29, P=0.036). Open and EVAR had comparable low rates of NSAID and acetaminophen prescriptions at discharge. Open patients had longer postoperative length of stay compared to EVAR patients (9.82±1.27 vs. 3.86±0.47, P<0.01). pEVAR had a shorter length of postoperative course compared to cEVAR (3.2±0.26 vs. 4.12±0.30, P<0.01). Patients undergoing EVAR with use of pain medications amounting to <20 MME had a significantly shorter length of stay. This single institutional retrospective study evaluated pain prescription patterns for patients undergoing AAA repair. AAA patients are predominantly treated with opioid pain medications with few adjunctive therapies. Intraoperative epidural and pEVAR may aid in decreasing the total MME used; however, the total number of opioids prescribed is similar for pEVAR and cEVAR despite the difference in approach. Clinicians must consider alternative nonopioid based pain management strategies.

Extended screening guidelines for the diagnosis of abdominal aortic aneurysm

BackgroundThe U.S. Preventive Services Task Force (USPSTF) guidelines are the most widely used criteria for screening for abdominal aortic aneurysms (AAA). However, when the USPSTF criteria are applied retrospectively to a group of patients who have undergone treatment for AAA, there are many patients who satisfy none of the AAA screening criteria. The more sensitive Society for Vascular Surgery (SVS) guidelines have expanded the criteria for screening for AAA with the hope of capturing a greater fraction of those individuals who can undergo treatment for their AAA before presenting with AAA rupture. We sought to identify the number of patients who would have been identified as having criteria for screening for AAA by both the USPSTF and SVS criteria, in a cohort of patients who have undergone treatment for AAA. MethodsWe assessed demographic, comorbidity, and perioperative complication data for all patients undergoing endovascular and open AAA repair in the Vascular Quality Initiative. Patients meeting each of the screening criteria were identified. Clinical factors and demographic variables were collected. ResultsWe identified 55,197 patients undergoing AAA repair in the Vascular Quality Initiative, including 44,602 patients who underwent endovascular aneurysm repair (EVAR) and 10,595 patients undergoing open repair. Of these, the USPTF guidelines would have identified fewer than one-third of patients (32% EVAR and 33% open repair). Applying the SVS guidelines increased the number meeting criteria for screening by 6% and 12% for the EVAR and open repair cohorts, respectively. Finally, adoption of the expanded SVS guidelines (including the “weak recommendations”) would have identified an additional 34% of EVAR patients and 21% of open AAA repair patients. Use of the expanded criteria would have resulted in 27% of patients undergoing EVAR and 33% of patients undergoing open AAA repair who would not have met any screening criteria. In EVAR patients not meeting the criteria, 52% were younger than 65 years had a history of heavy smoking. Of all those who did not meet screening criteria, ruptured AAA was twice as prevalent as those who met screening criteria (8.5% vs 4.4%; P ≤ .0001). ConclusionsExpanding established USPSTF screening guidelines to include the expanded SVS criteria may potentially double the number of patients identified with AAA. Smokers under the age of 65, and elderly patients 70 and older with no smoking history, represent two groups with AAA and potentially twice the risk of presenting with rupture.

Sexual dysfunction after elective laparoscopic or endovascular abdominal aortic aneurysm repair in men

Infrarenal abdominal aortic aneurysm (AAA) repair can lead to ejaculation and erection troubles in men. There are few studies on sexual dysfunction after endovascular repair (EVAR) but they suggest less retrograde ejaculation than after open repair. We assessed the sexual dysfunction and ejaculation troubles after elective laparoscopic repair or EVAR. We conducted a monocentric prospective study on 124 patients undergoing AAA repair between 2013 and 2015. Sexual function was evaluated using the IIEF-15 questionnaire and questions on ejaculation. Only 45 patients (36.3%) accepted to complete the IIEF preoperatively with 20-37.8% having preoperative sexual dysfunction. Among them, 21 (46.7%) accepted to complete the questionnaire at 3, 6 and 12 months. Mean age at inclusion was 65±5.6 years in the laparoscopic group and 77±10.5 years in the EVAR group (P=0.003). Erectile and sexual function were slightly improved at 12 months in the laparoscopic group (+1.4 for erectile score and +4.6 for IIEF score) with no significant difference (P=0.83 and 0.74) whereas 8 patients (61.5%) had persistent ejaculation troubles at 3 months. In the EVAR group, patients had moderate sexual dysfunction at baseline without improvement at 12 months, but only one patient reported ejaculation troubles. Most patients eligible for AAA repair present with baseline erectile and sexual dysfunction. Laparoscopic AAA repair provides no onset of erectile or sexual dysfunction but a global improvement after surgery. Ejaculation troubles are frequent and persistent at 1 year. However, EVAR treatment, doesn't allow recovering of sexual function at 1 year. 4.

The Role of Low Core Muscle Mass in Survival of Patients with Abdominal Aortic Aneurysm: A Prognostic Factor Review and Meta-analysis of Time-to-event Data

Introduction: Patients with abdominal aortic aneurysm (AAA) often present with a significant burden of comorbidities and are likely to be frail. Low psoas muscle mass, a surrogate marker of sarcopenia and indicator of frailty, is associated with increased perioperative mortality and morbidity. Recent evidence has linked low psoas muscle mass with medium-term outcomes after AAA repair. We conducted a review of the literature to investigate the prognostic role of low skeletal muscle mass in survival of patients with AAA undergoing open or endovascular aneurysm repair (EVAR). Methods: We conducted a review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (registration number: CRD42018107793). The prognostic factor of interest was degenerative loss of core skeletal muscle. We performed a time-to-event data meta-analysis for all-cause mortality using the inverse-variance method and reported the results as summary hazard ratio (HR) and 95% confidence interval (CI). We calculated pooled estimates of peri-operative outcome data using the odds ratio (OR) or risk difference (RD) and 95% CI. We applied random-effects models of meta-analysis. Results: Seven observational cohort studies reporting a total of 1440 patients (264 with low skeletal muscle mass) were eligible for quantitative synthesis. Patients with low skeletal muscle mass had a significantly higher hazard of mortality than those without low skeletal muscle mass (HR 1.66, 95% CI 1.15 - 2.40, P=0.007). Subgroup analysis including only patients who underwent EVAR showed a marginal survival benefit for patients without low skeletal muscle mass (HR 1.86, 95% CI 1.00 - 3.43, P< =0.05). Meta-analysis of two studies found no significant difference inperi-operative mortality (RD 0.04, 95% CI -0.13 - 0.21) and morbidity (OR 1.58, 95% CI 0.90 - 2.76, P=0.11) between patients with and without low skeletal muscle mass. Conclusion: There is a significant and clinically relevant link between low core skeletal muscle mass and mortality in patients undergoing AAA repair. Prospective studies validating the use of body composition for risk prediction after aortic surgery are required before this tool can be used to support decision making and patient selection. Disclosure: Nothing to disclose

Anemia and postoperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms

ObjectiveAnemia is associated with increased cardiac adverse events during the early postoperative period because of high physiologic stress and increased cardiac demand. The aim of this study was to assess the surgical outcomes and prognostic implications of anemia in patients undergoing repair of intact abdominal aortic aneurysms (AAAs). MethodsA retrospective analysis of all patients who underwent open aortic repair (OAR) or endovascular aneurysm repair (EVAR) in the Vascular Quality Initiative database (2008-2017) was performed. Patients with preoperative polycythemia, patients with ruptured aneurysms, and patients transfused with >4 units of packed red blood cells were excluded. Hemoglobin levels were categorized into three groups: moderate-severe anemia (<10 g/dL), mild anemia (10-12 g/dL in women and 10-13 g/dL in men), and no anemia (>12 g/dL in women and >13 g/dL in men). Multivariate logistic models and coarsened exact matching were used to analyze the association between anemia and 30-day mortality and between anemia and major in-hospital complications after OAR and EVAR. ResultsA total of 34,397 patients were identified undergoing AAA repair. Of those, 28.5% had mild anemia and 4.3% had moderate-severe anemia. In both OAR (n = 6112) and EVAR (n = 28,285), patients with moderate-severe anemia had significantly higher rates of in-hospital adverse events, such as in-hospital mortality, myocardial infarction, renal and respiratory complications, and reoperation, compared with patients with mild or no anemia. They also had higher rates of 30-day mortality. After multivariate analysis and 1:1 coarsened exact matching, no association was found between anemia and 30-day mortality and other in-hospital outcomes in patients undergoing OAR. On the other hand, in EVAR, moderate-severe anemia was associated with 2.7 times the odds of 30-day mortality (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.69-4.18), 2.5 times the odds of renal complications (OR, 2.47; 95% CI, 1.78-3.43; P < .05), and twice the risk of acute congestive heart failure (OR, 1.96; 95% CI, 1.18-3.25) and respiratory complications (OR, 2.01; 95% CI, 1.26-3.19). Mild anemia was also associated with increased odds of 30-day mortality and renal and respiratory complications in patients undergoing EVAR. Interestingly, preoperative blood transfusion in mildly anemic patients undergoing EVAR was associated with double the odds of in-hospital major adverse cardiac events (stroke, death, and myocardial infarction; OR, 2.1; 95% CI, 1.38-3.11; P < .001). ConclusionsPreoperative anemia is associated with higher odds of 30-day mortality and in-hospital adverse outcomes after EVAR but not after OAR. These findings highlight the need to incorporate anemia into the preoperative risk assessment of patients undergoing EVAR. Future studies are needed to assess the efficacy of medical therapies in improving postoperative outcomes in anemic patients undergoing AAA repair.

Prevalence of Elective and Ruptured Abdominal Aortic Aneurysm Repairs by Age and Sex From 2003 to 2016 in Ontario, Canada

Age and sex are important considerations in assessing and individualizing therapy for abdominal aortic aneurysm (AAA) repair. To determine the prevalence of open and endovascular elective AAA (EAAA) and ruptured AAA (RAAA) repair by age and sex. In this retrospective, population-based, cross-sectional, time-series analysis in Ontario, Canada, from April 1, 2003, to March 31, 2016, all patients undergoing AAA repair who were older than 39 years were included. Elective AAA and RAAA repair with open surgical repair (OSR) or endovascular aortic repair (EVAR). Age- and sex-standardized rates of EAAA and RAAA repair with OSR and EVAR. From 2003 to 2016, 19 489 EAAA repairs (12 232 [63%] OSR and 7257 [37%] EVAR) and 2732 RAAA repairs (2466 [90%] OSR and 266 [10%] EVAR) were identified. The mean (SD) age was 72.7 (8.1) years in the EAAA subgroup and 73.5 (8.9) years in the RAAA subgroup; 15 813 patients (81%) in the EAAA subgroup and 2178 (80%) in the RAAA subgroup were men. The rates of EAAA by age quintile and sex decreased over the study period except among patients older than 79 years (1.3 per 100 000 population in 2003 to 2.2 per 100 000 population in 2016; 70% increase; P < .001). The rates of elective OSR decreased across all age and sex subgroups (range, 38%-74% decrease; P ≤ .009 for all subgroups) except among patients older than 79 years (1.3 per 100 000 population at baseline to 0.56 per 100 000 population in the second quarter of 2016; 53% decrease; P = .05). The rates of elective EVAR significantly increased across all age and sex subgroups (range, 566%-1585% increase; P ≤ .04 for all subgroups). Elective EVAR became the dominant treatment approach for aneurysms in men around 2010, whereas it maintained parity among women in 2016. The RAAA repair rate decreased over the study period in all subgroups (range, 32%-91% decrease; P ≤ .001 for all subgroups), but the decrease was not significant among women (80% decrease; P = .08). Similarly, the rates of ruptured OSR decreased among all subgroups (range, 47%-91% decrease; P < .001), but the decrease was not significant among women (87% decrease; P = .54). Ruptured EVAR showed significant uptake in all subgroups. Among patients with AAA in Ontario, Canada, use of EVAR appeared to increase from 2003 to 2016, whereas OSR use appeared to decrease. These findings were most pronounced among elective procedures for men and older patients. The delayed increase in the use of EVAR among women may reflect continued anatomical constraints for women seeking elective repair.

Sarcopenia is a Significant Predictor of Mortality After Abdominal Aortic Aneurysm Repair

Repair of abdominal aortic aneurysms (AAA) decreases the incidence of rupture and death. In cancer patients, sarcopenia has been associated with increased surgical complications and mortality. The impact of sarcopenia on survival after AAA repair has yet to be described. Patient demographic, laboratory, body composition measurements and survival data were obtained from patients undergoing AAA repair at the Indiana University medical campus over a 5-year period. Univariate and multivariate analyses were performed to identify factors associated with overall survival. Overall, 58.2% presented with sarcopenia. Sarcopenic patients were older (71.8±8.3 versus 66.8±8.1 years; p<0.001), had lower body mass index (BMI) (26.3±5.2 versus 31.5±5.9 kg/m2; p<0.001), higher rates of myosteatosis (84.4% versus 52.%; p<0.001), greater AAA diameter (60.6±14.0 versus 57.8±11.7 mm; p=0.016), higher Charlson Comorbidity Index (CCI) (32.3% versus 25.1% ≥6; p=0.034), and increased rates of rupture (8.2% versus 3.8%; p=0.047). Sarcopenic and nonsarcopenic patients had no difference in 30-day morbidity (8.5% versus 8.5%; p=0.991) or mortality (3.7% versus 0.9%; p=0.07). Univariate analysis demonstrated age, sarcopenia, myosteatosis, CCI, and BMI to be associated with long-term survival. There was no correlation between BMI and sarcopenia. Both sarcopenia and myosteatosis resulted in decreased one-, three-, and five-year survivals compared to their counterparts. On multivariate analysis sarcopenia is independently associated with survival, conferring a 1.6-fold increase in death (p=0.04). The combination of sarcopenia plus myosteatosis doubled the risk of death compared to sarcopenia alone. This is the first study to demonstrate that over half of all patients undergoing AAA repair are sarcopenic, a condition associated with increased mortality. Sarcopenia with myosteatosis is associated with double the mortality of sarcopenia alone. CT scan, but not BMI, accurately identifies sarcopenia and myosteatosis. Defining the mechanisms through which sarcopenia contributes to late death after AAA repair is critical to developing novel interventions that may improve survival in this high risk population.

Sex differences in mortality after abdominal aortic aneurysm repair in the UK.

BackgroundThe UK abdominal aortic aneurysm (AAA) screening programmes currently invite only men for screening because the benefit in women is uncertain. Perioperative risk is critical in determining the effectiveness of screening, and contemporary estimates of these risks in women are lacking. The aim of this study was to compare mortality following AAA repair between women and men in the UK.MethodsAnonymized data from the UK National Vascular Registry (NVR) for patients undergoing AAA repair (January 2010 to December 2014) were analysed. Co‐variables were extracted for analysis by sex. The primary outcome measure was in‐hospital mortality. Secondary outcome measures included mortality by 5‐year age groups and duration of hospital stay. Logistic regression was performed to adjust for age, calendar time, AAA diameter and smoking status. NVR‐based outcomes were checked against Hospital Episode Statistics (HES) data.ResultsA total of 23 245 patients were included (13·0 per cent women). Proportionally, more women than men underwent open repair. For elective open AAA repair, the in‐hospital mortality rate was 6·9 per cent in women and 4·0 per cent in men (odds ratio (OR) 1·48, 95 per cent c.i. 1·08 to 2·02; P = 0·014), whereas for elective endovascular AAA repair it was 1·8 per cent in women and 0·7 per cent in men (OR 2·86, 1·72 to 4·74; P < 0·001); the results in HES were similar. For ruptured AAA, there was no sex difference in mortality within the NVR; however, in HES, for ruptured open AAA repair, the in‐hospital mortality rate was higher in women (33·6 versus 27·1 per cent; OR 1·36, 1·16 to 1·59; P < 0·001).ConclusionWomen have a higher in‐hospital mortality rate than men after elective AAA repair even after adjustment. This higher mortality may have an impact on the benefit offered by any screening programme offered to women.

Impact of surgeon and hospital experience on outcomes of abdominal aortic aneurysm repair in New York State

ObjectiveThis study aimed to assess the impact of the surgeon's and hospital's experience on the outcomes of open surgical repair (OSR) and endovascular aneurysm repair (EVAR) of intact and ruptured abdominal aortic aneurysms (AAAs) in New York State. MethodsNew York Statewide Planning and Research Cooperative System data were used to identify patients undergoing AAA repair from 2000 to 2011. Characteristics of the provider and hospital were determined by linkage to the New York Office of Professions and National Provider Identification databases. Distinct hierarchical logistic regression models for EVAR and OSR for intact and ruptured AAAs were created to adjust for the patient's comorbidities and to evaluate the impact of the surgeon's and hospital's experience on outcomes. The provider's years since medical school graduation as well as annual volume of the facility and provider are examined in tertiles. Adjusted odds ratios and 95% confidence intervals are presented. ResultsA total of 18,842 patients underwent AAA repair by a vascular surgeon. For intact AAAs (n = 17,118), 26.2% of patients underwent OSR and 73.8% underwent EVAR. For ruptured AAAs (n = 1724), 63.9% underwent OSR and 36.1% underwent EVAR. After intact AAA repair, OSR adjusted outcomes were significantly influenced by the surgeon's annual volume but not by the facility's volume or the surgeon's age. The lowest volume providers (1-4 OSRs) had higher in-hospital mortality rates than high-volume (>11 OSRs) surgeons (adjusted odds ratio, 1.87 [95% confidence interval, 1.1-3.17]). Low-volume providers also had higher odds of major complications (1.23 [1-1.51]). For patients with intact AAA undergoing EVAR, mortality was higher at low-volume facilities (2.6 [1.3-5.3] and 2.7 [1.5-4.8] for <33 EVARs and 34-81 EVARs, respectively). After OSR for ruptured AAA, treatment at a low-volume facility (<9 OSRs for ruptured AAA) was associated with greater mortality than at high-volume (>27 OSRs for ruptured AAA) centers (1.56 [1.02-2.39]), whereas low-volume physicians (<4 OSRs for ruptured AAA) had higher odds of major complications (1.58 [1.04-2.41]). In the case of EVAR for rupture, there were no characteristics of the hospital or surgeon significantly associated with poorer outcomes. ConclusionsFor intact AAA, the surgeon's volume was an important factor for OSR outcomes, whereas low facility volume was associated with worse outcomes after EVAR. For ruptured AAA, low-volume surgeons and low-volume facilities had worse outcomes after OSR but not after EVAR. The interaction between the surgeon's volume and the hospital's volume is complex and varies on the basis of the acuity of presentation and treatment modality.

Obesity is Not an Independent Factor for Adverse Outcome after Abdominal Aortic Aneurysm Repair

The prevalence of obesity is increasing, and its impact on the outcome of open and endovascular abdominal aortic aneurysm (AAA) repair remains unclear, particularly in the European population. We herein assessed the impact of obesity on the postoperative course for both techniques. From a database that consecutively collects all patients undergoing AAA repair; we selected all patients undergoing elective surgery for open or endovascular AAA repair, between January 2003 and December 2011. We considered obese patients (body mass index >30kg/m(2)), overweight (25.1-30kg/m(2)), and normal-weight patients (18.7-25kg/m(2)), and compared mortality and/or severe complications at 30days between obese and nonobese patients (overweight and normal weight) separately for each type of surgery by logistic regression analysis. We analyzed wound complications in the 2 groups. We included 748 patients, 174 obese, and 574 nonobese patients. Obese patients were younger (P<0.001) and were less likely to have renal failure (P<0.001) in both techniques. Obese patients in the open repair (OR) group showed a trend toward lower mortality and/or complication rates than in nonobese patients (4.8% vs. 7.5%, P=0.34). In contrast, in the endovascular aortic aneurysm repair (EVAR) group, obese patients showed a trend toward higher mortality and/or complication rates than nonobese patients (7.1% vs. 3.2%, P=0.17). In multivariate analysis, obesity was not an independent predictor of outcomes in OR (P=0.18) or in EVAR (P=0.20). Wound complications were not higher in obese patients in OR and in EVAR. Obesity should not be considered an independent risk factor of death and severe complications at 30days in either open or endovascular AAA repair. Therefore, obesity should not systematically lead to the decision to use EVAR.

Risk factors and outcomes of postoperative ischemic colitis in contemporary open and endovascular abdominal aortic aneurysm repair

Postoperative ischemic colitis (IC) can be a serious complication following infrarenal abdominal aortic aneurysm (AAA) repair. We sought to identify risk factors and outcomes in patients developing IC after open AAA repair and endovascular aneurysm repair (EVAR). The American College of Surgeons National Surgical Quality Improvement Program database was used to examine clinical data of patients undergoing AAA repair from 2011 to 2012 who developed postoperative IC. Multivariate regression analysis was performed to identify risk factors and outcomes. We evaluated a cohort of 3486 patients who underwent AAA repair (11.6% open repair and 88.4% EVAR). The incidence of postoperative IC was 2.2% (5.2% for open repair and 1.8% for EVAR). Surgical treatment was needed in 49.3% of patients who developed IC. The mortality of patients with IC was higher than that of patients without IC (adjusted odds ratio [AOR], 4.23; 95% confidence interval [CI], 2.26-7.92; P< .01). The need for surgical treatment (AOR, 7.77; 95% CI, 2.08-28.98; P< .01) and age (AOR, 1.11; 95% CI, 1.01-1.22; P= .01) were mortality predictors of IC patients. Predictive factors of IC included need for intraoperative or postoperative transfusion (AOR, 6; 95% CI, 3.08-11.72; P< .01), rupture of the aneurysm before surgery (AOR, 4.07; 95% CI, 1.78-9.31; P< .01), renal failure requiring dialysis (AOR, 3.86; 95% CI, 1.18-12.62; P= .02), proximal extension of the aneurysm (AOR, 2.19; 95% CI, 1.04-4.59; P= .03), diabetes (AOR, 1.87; 95% CI, 1.01-3.46; P= .04), and female gender (AOR, 1.75; 95% CI, 1.01-3.02; P=.04). Although open AAA repair had three times higher rate of postoperative IC compared with endovascular repair, in multivariate analysis we did not find any statistically significant difference between open repair and EVAR in the development of IC (5.2% vs 1.8%; AOR, 1.25; 95% CI, 0.70-2.25; P= .43). Postoperative IC has a rate of 2.2% after AAA repair. However, it is associated with 38.7% mortality rate. Rupture of the aneurysm before surgery, need for transfusion, proximal extension of the aneurysm, renal failure requiring dialysis, diabetes, and female gender were significant predictors of postoperative IC. AAA patients who develop IC have four times higher mortality compared with those without IC. Surgical treatment is needed in nearly 50% of IC patients and is a predictor of higher mortality.