Ruptured Abdominal Aortic Aneurysm Repair Research Articles

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

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

The open-first strategy is acceptable for ruptured abdominal aortic aneurysm even in the endovascular era.

To examine the surgical findings of ruptured abdominal aortic aneurysm (RAAA) based on the open-first strategy in the last decade, and to analyze the predictors of in-hospital mortality for RAAA in the endovascular era. The subjects of this retrospective study were 116 patients who underwent RAAA repair, for whom sufficient data were available [25% female, median age 76 (70-85) years]. Sixteen (13.8%) patients were managed with endovascular aneurysm repair (EVAR) and 100 patients (86.2%) were managed with open surgical repair (OSR). Univariate analysis identified base excess (BE) (odds ratio [OR] 0.88; 95% confidence interval [CI] 0.79-0.96; p = 0.006), and preoperative cardiopulmonary arrest (CPA) [OR] 15.4; 95% [CI] 1.30-181; p = 0.030), BE (OR 0.88; 95% CI 0.79-0.96; p = 0.006), shock index (OR 2.44; 95% CI 1.01-5.94; p = 0.050), lactic acid (Lac) (OR 1.18; 95% CI 1.02-1.36; p = 0.026), and blood sugar (BS) > 215 (OR 3.46; 95% CI 1.10-10.9; p = 0.034) as positive predictors of hospital mortality. The findings of this study suggest that a first-line strategy of OSR for ruptured AAAs is acceptable. Poor preoperative conditions, including a high shock index, CPA, low BE, high Lac, and a BS level > 215mg/dl, were identified as predictors of hospital mortality, rather than the procedures themselves.

Incidence and Outcomes of Abdominal Aortic Aneurysm Repair in New Zealand from 2001 to 2021.

The burden of abdominal aortic aneurysms (AAA) has changed in the last 20 years but is still considered to be a major cause of cardiovascular mortality. The introduction of endovascular aortic repair (EVAR) and improved peri-operative care has resulted in a steady improvement in both outcomes and long-term survival. The objective of this study was to identify the burden of AAA disease by analysing AAA-related hospitalisations and deaths. All AAA-related hospitalisations in NZ from January 2001 to December 2021 were identified from the National Minimum Dataset, and mortality data were obtained from the NZ Mortality Collection dataset from January 2001 to December 2018. Data was analysed for patient characteristics including deprivation index, repair methods and 30-day outcomes. From 2001 to 2021, 14,436 patients with an intact AAA were identified with a mean age of 75.1 years (SD 9.7 years), and 4100 (28%) were females. From 2001 to 2018, there were 5000 ruptured AAA with a mean age of 77.8 (SD 9.4), and 1676 (33%) were females. The rate of hospitalisations related to AAA has decreased from 43.7 per 100,000 in 2001 to 15.4 per 100,000 in 2018. There was a higher proportion of rupture AAA in patients living in more deprived areas. The use of EVAR for intact AAA repair has increased from 18.1% in 2001 to 64.3% in 2021. The proportion of octogenarians undergoing intact AAA repair has increased from 16.2% in 2001 to 28.4% in 2021. The 30-day mortality for intact AAA repair has declined from 5.8% in 2001 to 1.7% in 2021; however, it has remained unchanged for ruptured AAA repair at 31.6% across the same period. This study highlights that the incidence of AAA has declined in the last two decades. The mortality has improved for patients who had a planned repair. Understanding the contemporary burden of AAA is paramount to improve access to health, reduce variation in outcomes and promote surgical quality improvement.

Individual Patient Data Meta-Analysis of 10-Year Follow-Up after Endovascular and Open Repair for Ruptured Abdominal AorticAneurysms

Endovascular aortic repair (EVAR) has conferred an early survival advantage compared to an open surgical repair (OSR) in patients with ruptured abdominal aortic aneurysms (rAAA). However, the long-term survival benefit after EVAR was not displayed among randomized controlled trials (RCTs), whereas many non-RCTs have provided conflicting results. We conducted a time-to-event individual patient data (IPD) meta-analysis on long-term rAAA data. All studies comparing mortality after EVAR versus OSR for rAAA were included. We used restricted mean survival times (RMSTs) as a measure of life expectancy for EVAR and OSR. A total of 21 studies, including 12,187 patients (4952 EVAR and 7235 OSR) were finally deemed eligible. A secondary IPD analysis included 725 (372 EVAR and 353 OSR) patients only from the 3 RCTs (Immediate Management of the Patient With Rupture : Open Versus Endovascular Repair, Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus and Amsterdam Acute Aneurysm Trial trials). Among all studies, the median survival was 4.20 (95% confidence interval [CI]: 3.70-4.58) years for EVAR and 1.91 (95% CI: 1.57-2.39) years for OSR. Although EVAR presented with increased hazard risk from 4 to 7years, which peaked at 6years after the operation, the RMST difference was 0.54 (95% CI: 0.35-0.73; P<0.001) years gained with EVAR at the end of the 10-year follow-up. IPD meta-analysis of RCTs did not demonstrate significant differences. At 10-years follow-up, EVAR was associated with a 6.5month increase in life expectancy when compared to OSR after analyzing all eligible studies. Evidence from our study suggests that a strict follow-up program would be desirable, especially for patients with long-life expectancy.

Trends in Incidence of Abdominal Aortic Aneurysm Rupture, Repair, and Mortality in Nova Scotia

The purpose of this study was to examine sex-based trends in incidence of elective abdominal aortic aneurysm (AAA), ruptured AAA, ruptured AAA repair, and AAA-related mortality. A retrospective analysis of patients presenting with AAA from 2005 to 2015 was conducted. Rates of elective AAA repair, ruptured AAA, ruptured AAA repair, and mortality were obtained from linking provincial administrative data using medical services insurance billing number. The age-adjusted incidence of elective AAA repair, overall rate of ruptured AAA, ruptured AAA repair, and AAA-related mortality was calculated for each sex based on Canadian census estimates, adjusted to the Canadian standard population. Weighted linear regression was performed to analyze trends in incidence over time. One thousand nine hundred eighty-six elective AAA repairs were identified, of which 1,098 were repaired open and 898 underwent endovascular abdominal aneurysm repair (EVAR). Five hundred and seventy ruptured AAAs were identified, of which 295 (52%) were repaired: 259 open and 36 EVAR. The proportion of ruptured AAA that was repaired did not change over time (P=0.54). The proportion repairs performed using EVAR increased significantly in both elective (P<0.001) and rupture repairs (P<0.001). During the study period, 662 patients died of AAA-associated mortality. The average incidence of elective AAA repair in men was 29.3 (95% confidence interval (CI): 27.8 to 30.8) per 100,000 and decreased over time (P=0.04), whereas the average incidence in women was 9.2 [8.3 to 10.0] and stable (P=0.07). The incidence of open elective AAA repair was 10.5 [9.9-11.1] with a decreasing trend over time (P<0.001) and EVAR was 9.0 (8.5-9.6) with an increasing trend over time (P<0.001). A decreasing trend of overall ruptured AAA (5.4 [5.0-5.9], P<0.001), ruptured AAA repair (2.9 [2.5-3.2], P=0.02), and of AAA-related mortality (6.2 [5.8-6.8], P<0.001) was found, with consistent trends in both sexes. The incidence of open ruptured AAA repair decreased over time (P=0.001) whereas the incidence of ruptured EVAR remained stable (P=0.23). The incidence of elective AAA repair is decreasing in males but not females, whereas the incidence of rupture has decreased in both sexes. This has translated into reduced incidence of AAA-related mortality. Increased adoption of EVAR for ruptured AAA should continue these trends.

Comparison between endovascular aneurysm repair-selected and endovascular aneurysm repair-only strategies for the management of ruptured abdominal aortic aneurysms: An 11-year experience at a Chinese tertiary hospital.

ObjectivesThe aim of this study was to review our management experience of ruptured abdominal aortic aneurysms (RAAAs) using an endovascular aneurysm repair (EVAR)-only strategy, and discuss the feasibility of this strategy.Materials and methodsA retrospective analysis of clinical data was performed in patients with RAAAs from January 2009 to October 2020. Our strategy toward operative treatment for RAAAs evolved from an EVAR-selected (from January 2009 to April 2014) to an EVAR-only (from May 2014 to October 2020) strategy. Baseline characteristics, thirty-day mortality, perioperative complications, and long-term outcomes of patients were compared between the two periods.ResultsA total of 93 patients undergoing emergent RAAA repair were eventually included. The overall operation rate in RAAAs at our centre was 70.5% (93/132). In the EVAR-only period, all 53 patients underwent ruptured endovascular aneurysm repair (rEVAR). However, only 47.5% (19/40) of patients in the EVAR-selected period underwent rEVAR, and the remaining 21 patients underwent emergent open surgery. Thirty-day mortality in the EVAR-only group was 22.6% (12/53) compared with 25.0% (10/40) for the EVAR-selected group (P = 0.79). Systolic blood pressure ≤70 mmHg [adjusted odds ratio (OR) 4.99, 95% confidence interval (CI), 1.13–22.08, P = 0.03] and abdominal compartment syndrome (adjusted OR 3.72, 95% CI, 1.12–12.32, P = 0.03) were identified as independent risk factors responsible for 30-day mortality. After 5 years, 47.5% (95% CI, 32.0–63.0%) of patients in the EVAR-selected group were still alive versus 49.1% (95% CI, 32.3–65.9%) of patients in the EVAR-only group (P = 0.29).ConclusionThe EVAR-only strategy has allowed rEVAR to be used in nearly all the RAAAs with similar mortality comparing with the EVAR-selected strategy. Due to the avoidance of operative modality selection, the EVAR-only strategy was associated with a more simplified algorithm, less influence on haemodynamics, and a shorter operation and recovery time.

Identification of Risk Factors and Development of Predictive Risk Score Model for Mortality after Open Ruptured Abdominal Aortic Aneurysm Repair.

Background and Objectives: Despite the relatively large number of publications concerning the validation of these models, there is currently no solid evidence that they can be used with absolute precision to predict survival. The goal of this study is to identify preoperative factors that influenced 30-day mortality and to create a predictive model after open ruptured abdominal aortic aneurysm (RAAA) repair. Materials and Methods: This was a retrospective single-center cohort study derived from a prospective collected database, between 1 January 2009 and 2016. Multivariate logistic regression analysis was used to identify all significant predictive factors. Variables that were identified in the multivariate analysis were dichotomized at standard levels, and logistic regression was used for the analysis. To ensure that dichotomized variables were not overly simplistic, the C statistic was evaluated for both dichotomized and continuous models. Results: There were 500 patients with complete medical data included in the analysis during the study period. Of them, 37.6% were older than 74 years, and 83.8% were males. Multivariable logistic regression showed five variables that were predictive of mortality: age > 74 years (OR = 4.01, 95%CI 2.43–6.26), loss of consciousness (OR = 2.21, 95%CI 1.11–4.40), previous myocardial infarction (OR = 2.35, 95%CI 1.19–4.63), development of ventricular arrhythmia (OR = 4.54, 95%CI 1.75–11.78), and DAP < 60 mmHg (OR = 2.32, 95%CI 1.17–4.62). Assigning 1 point for each variable, patients were stratified according to the preoperative RAAA mortality risk score (range 0–5). Patients with 1 point suffered 15.3% mortality and 3 points 68.2% mortality, while all patients with 5 points died. Conclusions: This preoperative RAAA score identified risk factors readily assessed at the bedside and provides an accurate prediction of 30-day mortality after open repair of RAAA.

Overview of screening eligibility in patients undergoing ruptured AAA repair from 2003 to 2019 in the Vascular Quality Initiative

ObjectiveAlthough efforts such as the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act have improved access to abdominal aortic aneurysm (AAA) screening, certain high-risk populations are currently excluded from the guidelines yet may benefit from screening. We therefore examined all patients who underwent repair of ruptured AAA (rAAA) to characterize those who are ineligible for screening under current guidelines and evaluate the potential impact of these restrictions on their disease. MethodsWe identified patients undergoing rAAA repair in the Vascular Quality Initiative (VQI) database between 2003 and 2019. These patients were stratified by AAA screening eligibility according to the Centers for Medicare and Medicaid reimbursement guidelines. We then described baseline characteristics to identify high-risk features of these cohorts. Groups with disproportionate representation in the screening-ineligible cohort were identified as potential targets of screening expansion. Trends over time in screening eligibility and the proportion of AAA repairs performed for rAAA were also analyzed. ResultsA total of 5340 patients underwent rAAA repair. The majority (66%) were screening-ineligible. When characterizing the screening-ineligible group by sex and risk factors (smoking history or family history of AAA), the largest contributors to screening ineligibility were males less than 65 years of age with a smoking history or family history of AAA (25%), males greater than 75 years of age with a smoking history (25%), and females older than 65 years of age with a smoking history (19%). In comparison with rAAAs prior to implementation of the SAAAVE act, the proportion of AAA repair performed for rupture among males undergoing AAA repair in the VQI decreased from 12% to 8% (P < .001), whereas in females, there was no change (P = .990). There was no statically significant difference in screening eligibility for either males (P = .762) or females (P = .335). ConclusionsMost patients who underwent rAAA repair were ineligible for initial AAA screening or aged out of the screening window. Furthermore, rAAA rates and screening ineligibility have not improved as much as expected since the passage of the SAAAVE Act. Our data suggest that three high-risk populations may benefit from expansion of AAA screening guidelines: males with a smoking history or family history of AAA between ages 55 and 64 years, female smokers older than 65 years, and male smokers older than 75 years who are otherwise in good health. Increased efforts to screen these high-risk populations may increase elective AAA repair and minimize the morbidity and mortality associated with rAAAs.

RAPID IDENTIFICATION OF RUPTURED ABDOMINAL AORTIC ANEURYSM USING POINT-OF-CARE ULTRASOUND IN THE EMERGENCY DEPARTMENT: A CASE REPORT

A ruptured abdominal aortic aneurysm (AAA) is a catastrophic cardiovascular emergency which carries high risk of morbidity and mortality. Clinical manifestation includes severe abdominal pain, back or flank pain, syncope, hypotension, gastrointestinal bleeding and cardiovascular collapse. Misdiagnosis is often due to atypical presentation and results in fatal consequences. Rapid diagnosis of ruptured AAA is essential because it influences the patient’s prognosis. Timely and accurate diagnosis can be made in the Emergency Department using point-of-care ultrasound (POCUS) which has high sensitivity and specificity. We report a case of an elderly male who came with non-specific abdominal pain to the Emergency Department. Timely diagnosis of ruptured AAA was made with POCUS. The diagnosis was made by a non-radiologist using POCUS, however, the decision for ruptured AAA repair was only made by surgical team following computed tomography scan of the abdomen.

Association Between Body Mass Index and Perioperative Mortality After Repair of Ruptured Abdominal Aortic Aneurysms.

The attempt to repair a ruptured abdominal aortic aneurysm carries a significant risk of perioperative mortality. The relationship between body mass index (BMI) and outcomes after repair of ruptured abdominal aortic aneurysms (AAAs) has not been well defined. We report the association of BMI with outcomes after ruptured AAA repair. Patients undergoing ruptured AAA repairs between 2008 and 2017 at 2 tertiary academic centers were included in this retrospective study. Demographics (including BMI), type of repair, length of stay, and admission mortality risk scores were gathered and analyzed using bivariate and multivariate logistic regressions. Adjusted odds ratio (AOR) was reported with 95% CIs and P values from the multivariate analysis. The primary outcome was 30-day mortality. Akaike information criterion (AIC) and c-statistics were used to assess the predictive power of models including physiologic score with or without BMI. A total of 202 patients underwent repair of ruptured AAA. In bivariate relationship, increased BMI was significantly associated with 30-day mortality. With multivariate analysis, adjusting for demographics, type of procedure, and physiologic score, for each kg/m2 increase in BMI, an 8% increase in the likelihood of perioperative mortality (AOR = 1.08, 95% CI: 1.01-1.17; P = .04) was observed. When adjusted for admission risk score, type of procedure, and demographics, obesity was associated with increased 30-day mortality. With BMI as an additional data point, the c-statistics and AIC comparisons indicated that we would have a greater ability to preoperatively estimate mortality after ruptured AAA repair. Consideration could be made to include BMI in future mortality risk scoring systems for ruptured AAA.

Re-Interventions after Repair of Ruptured Abdominal Aortic Aneurysm: Mid-Term Results of the Improve Trial

Introduction - After elective abdominal aortic aneurysm (AAA) repair, re-interventions are more common after endovascular repair (EVAR) than open repair. There is some evidence that re-interventions also may be more common after successful repair of ruptured AAA. The aim of this study describe the severity of re-interventions, as perceived by both patients and clinicians, in the mid-term following ruptured AAA repair in patients randomised in the IMPROVE trial and to assess how whether these were associated with baseline aortic morphology. Methods - The IMPROVE trial randomised 613 patients to either an endovascular strategy (n=316) or open repair (n=297) at 30 hospitals, September 2009 to July 2013. Randomization in a 1:1 ratio, using variable block sizes, was computer generated by an independent contractor. 502 patients, had repair of ruptured AAA started and were followed up for 3 years for aneurysm-related re-interventions. The severity of re-interventions (arterial, laparotomy-related or other) was scored by trial investigators and separately by a patient focus group. The admission CT scans were measured in a core laboratory for maximum diameter, aneurysm neck and common iliac morphology. Results - There were 230 aneurysm-related re-interventions recorded within 3 years of randomisation; 121 and 109 in the endovascular strategy (n=259) and open repair (n=243) groups respectively, HR 1.02 [95%CI 0.79,1.32], p=0.88. Overall 28% of each group required at least one re-interventions, with about half of these being graded as severe by clinicians. The time to first severe re-intervention also was similar between the randomised groups. The time to the first arterial re-interventions was associated with increased common iliac artery diameter, the hazard ratio per 9mm increase in diameter was 1.48 (1.13,1.93), p=0.004, otherwise there were no significant associations with baseline morphology, including aortic diameter. The patient focus group had a different ranking of re-intervention severity from clinicians, rating amputation as the most severe re-intervention. But again, from the patient perspective the rates were similar after EVAR and open repair, but amputation (n=7) and unclosed stomas (n=5) were more common after open repair whereas secondary rupture (n=3) was more common after EVAR. Conclusion - The mid-term re-intervention rates and severity were similar in the endovascular strategy and open repair groups. Increasing baseline iliac diameter increased the rate of arterial re-interventions. Reporting metrics should change to accommodate patient ratings of re-interventions.

Open Surgery for Ruptured Abdominal Aortic Aneurysm – 38 Years Experience at an Academic Center in Chile

Few series of ruptured abdominal aortic aneurysm (RAAA) from Latin America have been published. To report the outcomes of RAAA treated with open surgical repair (OSR) in a University Hospital in Chile. Secondary objectives are the identification of prognostic factors and survival rates. Retrospective review of consecutive RAAA patients treated with OSR between September 1979 and December 2017. Medical records, diagnostic images, and follow-up details were obtained. Statistical methods include multiple logistic regression analysis. One hundred and sixteen patients underwent OSR for RAAA. The average age was 72.3years (54-95), 62.9%≥70years, and 81.9% male. Preoperative systolic pressure <90mm Hg was present in 74 patients (63.8%), and 10 (8.6%) experienced cardiac arrest before surgery. Only 30.2% were known to have an AAA before rupture. The mean aortic diameter was 7.9cm. Sixteen patients had juxtarenal aneurysms (13.8%). The rupture was intra or retroperitoneal in 111 cases (95.7%), there were 4 fistulas to neighboring veins and one into the duodenum. Reconstruction included tubular graft in 39.7% and bifurcated in 58.6%. The estimated mean blood loss was 3,456±2,768mL (median 3,000). Mean mechanical ventilation was 7.4±12.0days and hemodialysis requirement in 21.8%. Six patients died during surgery and other 24 during the first postoperative month or in hospital, for an overall mortality rate of 25.9%. Age ≥70years (P<0.01), blood pressure less than 90mm Hg (P=0.03) and dialysis (P<0.01) were associated with higher 30-day mortality rates. The survival rate was 68.0, 65.3, 44.3, and 25.2% at 1, 2, 5, and 10years, respectively. EVAR for RAAA is not affordable in every country. Outcomes of open RAAA repair at our institution are similar to results reported recently for OSR by the USA and European Medical centers.

The Value of Sigmoidoscopy to Detect Colonic Ischaemia After Ruptured Abdominal Aortic Aneurysm Repair

Diagnosing colonic ischaemia (CI) after ruptured abdominal aortic aneurysm (RAAA) repair is challenging. This study determined the diagnostic value of sigmoidoscopy in patients suspected of CI after RAAA repair. This was a retrospective multicentre cohort study. Patients who underwent RAAA repair in three hospitals in Amsterdam, the Netherlands, between 2004 and 2011 (AJAX cohort) were included. Sigmoidoscopies were carried out based on clinical judgment. Endoscopy results were classified as “no ischaemia,” “mild CI,” or “moderate to severe CI.” The surgical diagnosis was classified as “transmural” or “no transmural” CI. The value of sigmoidoscopy was assessed with calculation of positive and negative predictive values (PPV, NPV) with 95% CI for transmural CI. Logistic regression analysis was used to express the association of risk factors with CI as adjusted OR. Transmural CI was diagnosed in 23 of 351 patients (6.6%). Thirteen of sixteen patients (81%) who underwent direct laparotomy for high suspicion of CI indeed had transmural CI. Forty-six patients (13%) underwent sigmoidoscopy. The prevalence of transmural CI was 22% (10/46; 95% CI 12–36%) in these patients. The PPV for transmural CI of “moderate to severe CI” on sigmoidoscopy was 73% (8/11; 95% CI 43–90%). The PPV of “mild CI” on sigmoidoscopy was 11% (2/19; 95% CI 2.9–31%). The NPV of “no ischaemia” on sigmoidoscopy was 100% (95% CI 78–100%). Cardiac comorbidity (OR 3.1, 95% CI 1.19–7.97), low first haemoglobin (OR 0.6, 95% CI 0.47–0.87), and high vasopressor administration (OR 9.4, 95% CI 1.99–44.46) were independently associated with CI. Sigmoidoscopy increases the likelihood of correctly identifying the presence or absence of transmural CI, especially in patients with a moderate clinical suspicion for CI after RAAA repair.

Trajectory Modelling to Assess Trends in Long-Term Readmission Rate among Abdominal Aortic Aneurysm Patients.

Introduction The aim of the study was to use trajectory analysis to categorise high-impact users based on their long-term readmission rate and identify their predictors following AAA (abdominal aortic aneurysm) repair. Methods. In this retrospective cohort study, group-based trajectory modelling (GBTM) was performed on the patient cohort (2006-2009) identified through national administrative data from all NHS English hospitals. Proc Traj software was used in SAS program to conduct GBTM, which classified patient population into groups based on their annual readmission rates during a 5-year period following primary AAA repair. Based on the trends of readmission rates, patients were classified into low- and high-impact users. The high-impact group had a higher annual readmission rate throughout 5-year follow-up. Short-term high-impact users had initial high readmission rate followed by rapid decline, whereas chronic high-impact users continued to have high readmission rate. Results Based on the trends in readmission rates, GBTM classified elective AAA repair (n=16,973) patients into 2 groups: low impact (82.0%) and high impact (18.0%). High-impact users were significantly associated with female sex (P=0.001) undergoing other vascular procedures (P=0.003), poor socioeconomic status index (P < 0.001), older age (P < 0.001), and higher comorbidity score (P < 0.001). The AUC for c-statistics was 0.84. Patients with ruptured AAA repair (n=4144) had 3 groups: low impact (82.7%), short-term high impact (7.2%), and chronic high impact (10.1%). Chronic high impact users were significantly associated with renal failure (P < 0.001), heart failure (P = 0.01), peripheral vascular disease (P < 0.001), female sex (P = 0.02), open repair (P < 0.001), and undergoing other related procedures (P=0.05). The AUC for c-statistics was 0.71. Conclusion Patients with persistent high readmission rates exist among AAA population; however, their readmissions and mortality are not related to AAA repair. They may benefit from optimization of their medical management of comorbidities perioperatively and during their follow-up.

The Value of Sigmoidoscopy to Detect Colonic Ischaemia After Ruptured Abdominal Aortic Aneurysm Repair

Diagnosing colonic ischaemia (CI) after ruptured abdominal aortic aneurysm (RAAA) repair is challenging. This study determined the diagnostic value of sigmoidoscopy in patients suspected of CI after RAAA repair. This was a retrospective multicentre cohort study. Patients who underwent RAAA repair in three hospitals in Amsterdam, the Netherlands, between 2004 and 2011 (AJAX cohort) were included. Sigmoidoscopies were carried out based on clinical judgment. Endoscopy results were classified as "no ischaemia," "mild CI," or "moderate to severe CI." The surgical diagnosis was classified as "transmural" or "no transmural" CI. The value of sigmoidoscopy was assessed with calculation of positive and negative predictive values (PPV, NPV) with 95% CI for transmural CI. Logistic regression analysis was used to express the association of risk factors with CI as adjusted OR. Transmural CI was diagnosed in 23 of 351 patients (6.6%). Thirteen of sixteen patients (81%) who underwent direct laparotomy for high suspicion of CI indeed had transmural CI. Forty-six patients (13%) underwent sigmoidoscopy. The prevalence of transmural CI was 22% (10/46; 95% CI 12-36%) in these patients. The PPV for transmural CI of "moderate to severe CI" on sigmoidoscopy was 73% (8/11; 95% CI 43-90%). The PPV of "mild CI" on sigmoidoscopy was 11% (2/19; 95% CI 2.9-31%). The NPV of "no ischaemia" on sigmoidoscopy was 100% (95% CI 78-100%). Cardiac comorbidity (OR 3.1, 95% CI 1.19-7.97), low first haemoglobin (OR 0.6, 95% CI 0.47-0.87), and high vasopressor administration (OR 9.4, 95% CI 1.99-44.46) were independently associated with CI. Sigmoidoscopy increases the likelihood of correctly identifying the presence or absence of transmural CI, especially in patients with a moderate clinical suspicion for CI after RAAA repair.

Open repair of ruptured abdominal aortic aneurysm with associated horseshoe kidney.

Ruptured abdominal aortic aneurysms (RAAA) with concomitant horseshoe kidney (HK) present a unique challenge at the time of repair. The aim of this article was to propose the most rationale strategy during open repair (OR) of RAAA in the presence of HK. We identified and analyzed all patients treated at the clinic due to RAAA and HK. An extensive search was performed on all articles published up to August of 2017 describing open and endovascular repair of RAAA with concomitant horseshoe kidney. The following data were extracted and analyzed: patient number, number of renal arteries, Crawford classification of horseshoe kidney vascularization, type of aortic reconstruction, management with renal arteries, 30-day kidney failure and outcome. Transperitoneal approach followed by supraceliac aortic cross clamping without the division of the renal isthmus occurred in all our six cases. Four of them required additional procedures with accessory renal arteries after aortic replacement. Three of patients (50%) died during the first 30 postoperative days, while one developed transitory renal insufficiency. The renal isthmus was preserved in 43.90% and divided in 46.34% of cases. Crawford type I of HK vascularization was presented in 21.95% of cases, type II also in 39.02%, while the type III in 19.51% of cases. In 46.33% of cases a procedure with renal arteries was necessary. In 26.82% accessory renal arteries were ligated, while in 19.51% preserved (reattachment or aorto-renal bypass). Thirty-day mortality was 21.95%, while the incidence of postoperative renal failure was also 21.95%. There was not significant correlation between the renal artery ligation and the postoperative renal failure (r=-0.81, P=0.59). Transperitoneal approach should be preferred during urgent OR of RAAA with concomitant HK. A supraceliac aortic cross clamping and the placement of occlusive Fogarty catheters into both iliac arteries are recommended for proximal and distal bleeding control. Preservation of accessory renal arteries that are larger than 3 mm in diameter or supply more than 30% of renal parenchima is recommended. The division of the renal isthmus should be avoided if vascularized. It seems that renal arteries could be covered in emergency EVAR without any implications on postoperative kidney function, allowing broader aplication of endovascular treatment for thesse patients.

The Futility of Surveillance for Old and Small Aneurysms

Inspired by the Canadian Choosing Wisely campaign, we investigated the yield and cost of ultrasound surveillance for small abdominal aortic aneurysms (AAAs) in octogenarians, compared with a younger population, for detecting AAA growth that reaches a sex-specific threshold size for repair. A retrospective cohort review was performed of all patients undergoing AAA surveillance in Ottawa between 2007 and 2017. Patients were dichotomized by enrollment age (<80 years vs ≥80 years) with crossover to prevent lead time bias and stratified by enrollment AAA size. These cohorts were cross-referenced with the Ottawa AAA repair database, leveraging the common Local Health Integration Network to ensure data capture. Survival analysis with Cox proportional hazards models adjusted for significant covariates, and cost-effectiveness analysis was performed referencing Ontario Health Insurance Plan codes. A total of 1378 patients underwent serial ultrasound surveillance. In 355 (25.8%), the AAA size threshold for repair was reached, and 313 (22.1%) underwent AAA repair. Octogenarians were half as likely as their younger counterparts to experience significant AAA growth (hazard ratio, 0.51; 95% confidence interval [CI], 0.37-0.83; Fig 1, A). Similarly, octogenarians were half as likely to experience an aortic event, a composite outcome including threshold-sized AAA, elective aortic repair, or aortic rupture (hazard ratio, 0.54; 95% CI, 0.43-0.68; Fig 1, B). When a threshold-sized AAA was identified, octogenarians were half as likely to undergo elective AAA repair (relative risk, 0.52; 95% CI, 0.45-0.59; Fig 2, A). Both ruptured AAA repair (0.94%) and procedure-related 30-day mortality (0.58%) were rare, and age differences were insignificant (Fig 2, B). AAA surveillance for octogenarians was substantially less cost-effective, incurring $12,080 in surveillance fees to identify one octogenarian with an AAA size of 3 to 3.9 cm who later underwent elective AAA repair (Fig 2, C and D). Octogenarians with small aneurysms are half as likely to experience significant aortic growth. Furthermore, in the unlikely event of AAA growth, octogenarians are half as likely to undergo repair, without a significantly increased risk of requiring repair for AAA rupture. The differences in natural history between the young and elderly patients suggest a difference in aneurysm pathophysiology. In the context of patient-specific factors, surveillance of AAAs <4 cm in octogenarians is costly and unlikely to be beneficial.Fig 2Incidence of abdominal aortic aneurysm (AAA) repair and resulting cost-effectiveness analysis. Groups are stratified by enrollment age and size of AAA at time of enrollment. A, When a threshold-sized AAA was reached, octogenarians were less likely to undergo elective AAA repair than their younger counterparts (overall relative risk, 0.52; 95% confidence interval, 0.45-0.59). B, Repair of ruptured AAA for patients in the surveillance program was rare, and differences were not statistically significant. C, Cost-effectiveness analysis incorporates a base cost of $89.20 for each surveillance ultrasound (Ontario Health Insurance Plan: code H 2, $57.00 technical cost; code P J202, $32.20 professional cost). D, Whereas the cost of surveillance to identify threshold-sized AAA was comparable between age cohorts, there was substantially more discrepancy in the cost of surveillance to prompt elective AAA repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Editor's Choice – The Impact of Centralisation and Endovascular Aneurysm Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries

Current management of ruptured abdominal aortic aneurysms (RAAA) varies among centres and countries, particularly in the degree of implementation of endovascular aneurysm repair (EVAR) and levels of vascular surgery centralisation. This study assesses these variations and the impact they have on outcomes. RAAA repairs from vascular surgical registries in 11 countries, 2010-2013, were investigated. Data were analysed overall, per country, per treatment modality (EVAR or open aortic repair [OAR]), centre volume (quintiles IV), and whether centres were predominantly EVAR (≥50% of RAAA performed with EVAR [EVAR(p)]) or predominantly OAR [OAR(p)]. Primary outcome was peri-operative mortality. Data are presented as either mean values or percentages with 95% CI within parentheses, and compared with chi-square tests, as well as with adjusted OR. There were 9273 patients included. Mean age was 74.7 (74.5-74.9) years, and 82.7% of patients were men (81.9-83.6). Mean AAA diameter at rupture was 7.6cm (7.5-7.6). Of these aneurysms, 10.7% (10.0-11.4) were less than 5.5cm. EVAR was performed in 23.1% (22.3-24.0). There were 6817 procedures performed in OAR(p) centres and 1217 performed in EVAR(p) centres. Overall peri-operative mortality was 28.8% (27.9-29.8). Peri-operative mortality for OAR was 32.1% (31.0-33.2) and for EVAR 17.9% (16.3-19.6), p<.001, and theadjusted OR was 0.38 (0.31-0.47), p<.001. The peri-operative mortality was 23.0% in EVAR(p) centres (20.6-25.4), 29.7% in OAR(p) centres (28.6-30.8), p<.001; adjusted OR=0.60 (0.46-0.78), p<.001. Peri-operative mortality was lower in the highest volume centres (QI>22 repairs per year), 23.3% (21.2-25.4) than in QII-V, 30.0% (28.9-31.1), p<.001. Peri-operative mortality after OAR was lower in high volume centres compared with the other centres, 25.3% (23.0-27.6) and 34.0% (32.7-35.4), respectively, p<.001. There was no significant difference in peri-operative mortality after EVAR between centres based on volume. Peri-operative mortality is lower in centres with a primary EVAR approach or with high case volume. Most repairs, however, are still performed in low volume centres and in centres with a primary OAR strategy. Reorganisation of acute vascular surgical services may improve outcomes of RAAA repair.

Review on management and outcomes of ruptured abdominal aortic aneurysm in women

Vascular procedures in general, and specifically abdominal aortic aneurysm (AAA) repair, are associated with worse outcomes in female patients. However, how female gender influences outcomes in the setting of aneurysm-rupture remains unclear and may be even more pronounced when compared to elective operations. In this report, the authors aim to review the literature regarding ruptured AAA repair in women. Using the traditional threshold for AAA of 30 mm of maximum diameter, the prevalence in women is lesser than in men. However, the true prevalence may be underestimated due to gender discrepancies in normal aortic diameter. For females, aneurysmal disease seems to manifest later, have more associated comorbidities, and rupture occurs at smaller aortic diameters. This has obvious implications for management. There is still no consensus over the optimal treatment for ruptured AAA in women. They are less frequently treated by endovascular aneurysm repair, possibly due to anatomical restrains. When feasible, endovascular repair shows better outcomes, at least in the short-term, and there is new evidence suggesting a lasting benefit as well. For open repair the results are consensually worse when compared to male counterparts. Finally, despite benefitting of apparently similar healthcare, women have a lower relative survival after rAAA repair when compared to men. Further investigation to determine the reasons of these discrepancies is warranted.

A registry-based rationale for discrete intervention thresholds for open and endovascular elective abdominal aortic aneurysm repair in female patients

ObjectiveAn evidence-based consensus for a female-specific intervention threshold for abdominal aortic aneurysms (AAAs) is missing. This study aims to analyze sex-related differences in the epidemiology of ruptured AAA to establish an intervention threshold for women. MethodsThe Dutch Surgical Aneurysm Audit (DSAA) is a compulsory, nation-wide registry of AAA repairs in The Netherlands. All patients with emergency or elective AAA repair between January 1, 2013, and December 31, 2015, were included in the analysis. The main outcomes were age, sex, AAA diameter at time of rupture, and 30-day postoperative mortality. ResultsA total of 1561 ruptured AAA repairs (14.7% women) and 7063 cases of elective AAA repair (13.7% women) were included in the analysis. Women had significantly smaller mean ± standard deviation AAA diameter at time of rupture than men; 70.5 ± 14.4 mm and 78.6 ± 17.5 mm, respectively. In male patients, 8% of ruptures occurred at diameters below the 55 mm intervention threshold. The female equivalent of this eighth percentile is 52 mm. Female patients had significantly higher 30-day mortality after emergency repair, namely, 33% for women versus 24.2% for men, but were also significantly older, mean ± standard deviation age 76.7 ± 7.1 years and 73.9 ± 8.3 years for women and men, respectively. Correcting for age reduced the 30-day mortality risk for women after ruptured AAA repair from 1.53 (95% confidence interval, 1.14-2.04) to 1.27 (95% confidence interval, 0.92-1.73). Outcome after open elective repair was significantly worse for women compared with men, with a 30-day mortality of 7.97% 30 for women and 4.27% for men (P < .01). ConclusionsThe equivalent of the 55-mm intervention threshold for elective endovascular AAA repair in men is 52 mm in women. The almost doubled mortality risk for elective open repair in women implies that the optimal point for open repair is at higher diameters, very possibly at least 55 mm.