Comparison of outcomes after endovascular and open repair of abdominal aortic aneurysms in low-risk patients

Analysis of textbook outcomes for ampullary carcinoma patients following pancreaticoduodenectomy

BACKGROUND

Textbook outcomes (TOs) have been used to assess the quality of surgical treatment for many digestive tumours but not ampullary carcinoma (AC).

AIM

To discuss the factors associated with achieving a TO and further explore the prognostic value of a TO for AC patients undergoing curative pancreaticoduodenectomy (PD).

METHODS

Patients who underwent PD at the China National Cancer Center between 1998 and 2020 were identified. A TO was defined by R0 resection, examination of ≥ 12 Lymph nodes, no prolonged hospitalization, no intensive care unit treatment, no postoperative complications, and no 30-day readmission or mortality. Cox regression analysis was used to identify the prognostic value of a TO for overall survival (OS) and recurrence-free survival (RFS). Logistic regression was used to identify predictors of a TO. The rate of a TO and of each indicator were compared in patients who underwent surgery before and after 2010.

RESULTS

Ultimately, only 24.3% of 272 AC patients achieved a TO. A TO was independently associated with improved OS [hazard ratio (HR): 0.443, 95% confidence interval (95%CI): 0.276-0.711, P = 0.001] and RFS (HR: 0.379, 95%CI: 0.228-0.629, P < 0.001) in the Cox regression analysis. Factors independently associated with a TO included a year of surgery between 2010 and 2020 (OR: 4.549, 95%CI: 2.064-10.028, P < 0.001) and N1 stage disease (OR: 2.251, 95%CI: 1.023-4.954, P = 0.044). In addition, the TO rate was significantly higher in patients who underwent surgery after 2010 (P < 0.001) than in those who underwent surgery before 2010.

CONCLUSION

Only approximately a quarter (24.3%) of AC patients achieved a TO following PD. A TO was independently related to favourable oncological outcomes in AC and should be considered as an outcome measure for the quality of surgery. Further multicentre research is warranted to better elucidate its impact.

Characteristics Associated With Failure to Rescue After Open Abdominal Aortic Aneurysm Repair

INTRODUCTION

Failure to Rescue (FTR), defined as mortality following a complication of care, is an important indicator of hospital care quality. Understanding risk factors associated with FTR in the elective Abdominal Aortic Aneurysm (AAA) population may help surgeons prevent operative mortality.

METHODS

Elective open AAA repairs (2008-2018) were identified from Cerner's HealthFacts database using ICD-9 and ICD-10 diagnosis and procedure codes. Patient, hospital, and encounter characteristics were analyzed. Multivariate logistic regression models determined the relative contribution of patient and encounter characteristics leading to FTR.

RESULTS

For 1761 patients who underwent open repair for nonruptured AAA, overall mortality was 6.1%. Of patients with one or more complications (40%), mortality was 9.6%, increasing to 21.5% for patients with ≥4 major complications. Complications of care most associated with death were myocardial infarction (MI), gastrointestinal (GI) bleeding, and pulmonary failure. After multivariable adjustment, FTR was associated with advanced age (odds ratio [OR] 1.19 for 5 y, 95% confidence interval [CI] 1.06-1.34); female sex (OR 1.74, 95% CI 1.12-2.70); congestive heart failure (OR 1.65, 95% CI 1.00-2.73); peptic ulcer disease (OR 3.99, 95% CI 1.18-13.5); diabetes (OR 4.90, 95% CI 1.90-12.6), and the number of complications of care.

CONCLUSIONS

Complications of care were common following open elective AAA repair. The complications with the highest mortality included MI, GI bleeding, and respiratory failure. FTR was associated with female sex, comorbidities, and increasing numbers of complications of care. Often, the lowest occurring complications had the highest FTR. Adopting gender-specific assessment tools, a protocol-driven approach for perioperative GI prophylaxis, and preoperative MI risk mitigation may lead to reduced FTR.

MIDTERM RESULTS OF ENDOVASCULAR VERSUS OPEN SURGICAL REPAIR FOR INFRARENAL ABDOMINAL AORTIC ANEURYSMS IN LOW SURGICAL RISK PATIENTS

OBJECTIVE

To analyse midterm outcomes of endovascular repair (EVAR) versus open surgery (OR) for treatment of infrarenal abdominal aortic aneurysms (AAA) in low surgical-risk patients.

METHODS

Elective AAA patients undergoing treatment from 2003 to 2017 in a single, tertiary-care institution were evaluated. All patients with a low preoperative risk of complications and perioperative mortality (Medicare Aneurysm Scoring System <3) were included, and rates of perioperative and long-term mortality, adverse events and reintervention were evaluated for EVAR and OR. A propensity score matched cohort (PMC), levelling age, risk factors, and comorbidities was additionally performed.

RESULTS

A total of 227 patients were included (59.9% EVAR and 40.1% OR), and followed for a mean of 80 ± 48 months. Patients undergoing EVAR were older (66.6 ± 5 vs. 64.1 ± 6 years; p <.001, had a higher body mass index (29.6 ± 4 vs 28.1 ± 3; p = .005), a higher prevalence of COPD (27.3% vs 9.9%; p = .001) and lower prevalence of dyslipidaemia (46.3% vs 65.9%; p= .004). Patients undergoing OR had a higher rate of major adverse events (19.7% vs 2.6%, p = .001) and 30-day reinterventions (8.8% vs. 1.5%, p=.016), with 30-day mortality being 0% in both groups. The propensity-score matched cohort included 76 matched pairs (1:1), with differences in hospital-stay and major complications kept significant, without affecting mortality. At 5-year follow-up, there were no significant differences in the reintervention rate (18.5% EVAR vs 17.6% OAR; p = .67) or survival (85% EVAR vs 91% OR; p = .195).

CONCLUSION

In low surgical risk patients suffering from AAA, EVAR may offer comparable midterm results to open repair, with a lower rate of major adverse events and a shorter in-hospital stay. With the current OR-first paradigm in low-risk patients, several factors should be taken into account for decision making (anatomic suitability, risk of sexual dysfunction, risk of type 2 endoleaks and need of follow-up).

The survival rate among endovascular and open surgical repair of abdominal aortic aneurysms

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients with Infrarenal abdominal aortic aneurysm (AAA), Does endovascular abdominal aortic repair (EVAR), AS compared to open surgical repair (OSR), has higher Survival rates? The outcomes assessed were the overall survival rates in both techniques. The best evidence showed that there is no statistically significant difference between EVAR and OSR in survival rates.

Short-term outcomes of open surgical abdominal aortic aneurysm repair from the Dutch Surgical Aneurysm Audit

Background

The sharp decrease in open surgical repair (OSR) for abdominal aortic aneurysm (AAA) has raised concerns about contemporary postoperative outcomes. The study was designed to analyse the impact of complications on clinical outcomes within 30 days following OSR.

Methods

Patients who underwent OSR for intact AAA registered prospectively between 2016 and 2019 in the Dutch Surgical Aneurysm Audit were included. Complications and outcomes (death, secondary interventions, prolonged hospitalization) were evaluated. The adjusted relative risk (aRr) and 95 per cent confidence intervals were computed using Poisson regression. Subsequently, the population-attributable fraction (PAF) was calculated. The PAF reflects the expected percentage reduction of an outcome if a complication were to be completely prevented.

Results

A total of 1657 patients were analysed. Bowel ischaemia and renal complications had the largest impact on death (aRr 12·44 (95 per cent c.i. 7·95 to 19·84) at PAF 20 (95 per cent c.i. 8·4 to 31·5) per cent and aRr 5·07 (95 per cent c.i. 3·18 to 8.07) at PAF 14 (95 per cent c.i. 0·7 to 27·0) per cent, respectively). Arterial occlusion had the greatest impact on secondary interventions (aRr 11·28 (95 per cent c.i. 8·90 to 14·30) at PAF 21 (95 per cent c.i. 14·7 to 28·1) per cent), and pneumonia (aRr 2·52 (95 per cent c.i. 2·04 to 3·10) at PAF 13 (95 per cent c.i. 8·3 to 17·8) per cent) on prolonged hospitalization. Small effects were observed on outcomes for other complications.

Conclusion

The greatest clinical impact following OSR can be made by focusing on measures to reduce the occurrence of bowel ischaemia, arterial occlusion and pneumonia.

Re-intervention rate in endovascular vs open surgical repair for abdominal aortic aneurysms

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In patients with Infrarenal abdominal aortic aneurysm (AAA), Does endovascular abdominal aortic repair (EVAR), AS compared to open surgical repair (OSR), has lower re-intervention rates? The outcomes assessed were the re-interventional rates in both techniques. The best evidence showed that the OSR has lower statistically significant difference rates in re-intervention rates than the EVAR.

•

Endovascular abdominal aortic aneurysm repair is inferior to the open surgical repair regarding the re-intervention rates.

•

Long term outcomes of the open surgical repair are better than the Endovascular repair.

•

Secondary procedures are more in endovascular repair than the open surgical repair of abdominal aortic aneurysm.

Comparison of the Short and Long-Term Outcomes of Endovascular Repair and Open Surgical Repair in the Treatment of Unruptured Abdominal Aortic Aneurysms: Meta-Analysis and Systematic Review

Background

Although the initial results of endovascular repair (EVAR) were promising, a comparison of its long-term efficacy against open surgical repair (OSR) remains largely elusive, and late-onset adverse events have not been systematically evaluated. Since OSR and EVAR are currently the only treatment options available in the management of abdominal aortic aneurysms (AAAs), the main question arising in clinical practice is whether EVAR or OSR confers more favourable short and long-term outcomes for patients presenting with unruptured AAAs.

Aims

The present meta-analysis aims to draw a head-to-head comparison between EVAR and OSR and facilitate the formulation of an evidence-based approach to the clinical management of unruptured AAAs.

Methods

A systematic review was conducted using three databases to identify all relevant studies with comparative data on EVAR vs. OSR. All-cause mortality was the primary outcome. Procedural outcomes, such as stroke, myocardial infarction, renal complications, rupture, and reintervention rates, were determined as secondary outcomes.

Results

Sixteen studies were included for comparative analysis, including four randomised-controlled trials and six non-randomised comparative clinical trials. EVAR conferred a clear perioperative survival advantage as compared to OSR (P < 0.00001). However, this survival advantage did not persist beyond two years post-procedure; all-cause mortality rates were comparable between the two treatment groups at two years (P = 0.09), four years (P = 0.58), and six years (P = 0.88) post-procedure. Although no statistically significant differences in aneurysm-related mortality, postoperative stroke, or myocardial infarction were identified, the OSR group had a statistically significant higher rate of postoperative renal complications. On the other hand, there was a statistically significant higher rate of rupture and reintervention following EVAR.

Conclusion

Whether the initial survival advantage afforded by EVAR is sufficient to justify the long-term risk of rupture, reintervention, and long-term mortality should be determined on a case-by-case basis by the multidisciplinary team overseeing the clinical care of the patient. Currently, it is reasonable to conclude that EVAR is as efficacious as OSR, but it would be invalid to claim it as superior. Ultimately, longer follow-up data must be presented before any definitive conclusions can be established for this potentially revolutionary technique. Presently, one can neither advocate nor refute EVAR over OSR.

Impact of Gradual Adoption of EVAR in Elective Repair of Abdominal Aortic Aneurysm: A Retrospective Cohort Study from 2009 to 2015

INTRODUCTION

The recommendations about the preferred type of elective repair of abdominal aortic aneurysm (AAA) still divides guidelines committees, even nowadays. The aim is to assess outcomes after AAA repair focusing on differences between endovascular aneurysm repair (EVAR) and open surgical repair (OSR).

METHODS

The observational retrospective cohort study of consecutive patients submitted to elective AAA repair at a tertiary center, 2009-2015. Exclusion criteria were as follows: nonelective cases or complex aortic aneurysms. Primary outcomes were postoperative complications, length of hospital stay, survival, freedom from aortic-related mortality, and vascular reintervention. Time trends were assessed along the period under analysis.

RESULTS

From a total of 211 included patients, those submitted to EVAR were older (74 ± 7 vs. 67 ± 9 years; P < 0.001), presented a higher prevalence of hypertension (83.5% vs. 68.5%, P = 0.004), obesity (28.7% vs. 14.3%, P = 0.029), previous cardiac revascularization (30.5% vs. 14.7%, P = 0.005), heart failure (17.2% vs. 5.2%, P = 0.013), and chronic obstructive pulmonary disease (32.8% vs. 13.3%, P = 0.002). Patients were followed during a median of 49 months. EVAR resulted in a significantly shorter length of hospital stay (median 4 and interquartile range 3 vs. 8 (9); P < 0.001), lower 30-day complications (10.6% vs. 22.8%, P = 0.017), lower aortic-related mortality, and similar reintervention after adjustment with a propensity score. Along the time under analysis, EVAR became the predominate type of repair (P = 0.024), the proportion of complications decreased (P = 0.014), and the 30-day mortality (P = 0.035).

CONCLUSIONS

Although EVAR was offered to patients with more comorbidities, better and durable outcomes were achieved after EVAR, favoring its adoption for elective AAA repair.

Meta-analysis of phase-specific survival after elective endovascular versus surgical repair of abdominal aortic aneurysm from randomized controlled trials and propensity score-matched studies

OBJECTIVE

Although endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) significantly decreases perioperative mortality compared with open surgical repair (OSR), we have not concluded superiority between EVAR and OSR beyond the perioperative period. The aim of this study was to compare phase-specific survival after EVAR vs OSR.

METHODS

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Embase and MEDLINE were searched up to November 2019 to identify randomized controlled trials and propensity score-matched studies that investigated ≥2-year all-cause mortality (primary outcome) after EVAR vs OSR for intact infrarenal AAA. For each study, the hazard ratio (HR) with 95% confidence interval (CI) of mortality for EVAR vs OSR was calculated using survival curves for the following specific phases: early term (0-2 years after repair), midterm (2-6 years after repair), long term (6-10 years after repair), and very long term (≥10 years after repair). The risk ratio (RR) in the perioperative (in-hospital or 30-day) period was also extracted. Phase-specific HRs or RRs were separately pooled using the random effects model. Sensitivity analyses were performed by removing one study at a time to confirm that our findings were not derived from any single study. Funnel plot asymmetry was also examined using the linear regression test.

RESULTS

Our search identified four randomized controlled trials and seven propensity score-matched studies enrolling a total of 106,243 AAA patients assigned to EVAR (n = 53,123) or OSR (n = 53,120). The mortality after EVAR compared with OSR was significantly lower in the perioperative period (RR, 0.39; 95% CI, 0.29-0.51; P < .00001) and similar in the early-term period (HR, 0.93; 95% CI, 0.84-1.03; P = .16). Notably, significantly higher mortality was observed in the EVAR group compared with the OSR group in the midterm period (HR, 1.15; 95% CI, 1.03-1.29; P = .01). However, similar mortality was observed between the EVAR group and the OSR group in the long-term (HR, 1.06; 95% CI, 0.96-1.17; P = .27) and very-long-term (HR, 1.17; 95% CI, 0.93-1.47; P = .19) periods. In sensitivity analyses, the significant benefit of EVAR in the perioperative period and that of OSR in the midterm period were not changed. No funnel plot asymmetry was identified in all analyses.

CONCLUSIONS

Compared with OSR, EVAR was associated with lower perioperative mortality and higher mortality in the midterm period for intact infrarenal AAA. The superiority of EVAR was absent in the early-term period, and the inferiority of EVAR in the midterm period disappeared in the long-term and very-long-term periods.

Endovascular Abdominal Aortic Aneurysm Repair: Does Anesthesia Type Matter?

BACKGROUND

Given the various types of anesthesia used for endovascular abdominal aortic aneurysm repair (EVAR), we sought to determine the effect of anesthesia type in the outcomes of elective EVAR in a large multiinstitutional healthcare maintenance organization.

METHODS

A retrospective chart review was conducted on all elective EVAR conducted from August 2010 to August 2017 in 14 regional hospitals of Kaiser Permanente Southern California. Patients undergoing emergent, nonelective abdominal aortic aneurysm repairs, thoracoabdominal aneurysm repair, requiring conversion to open surgery or general anesthesia were excluded from the study. Basic demographic information, medical risk factors, anesthesia type, operative data, and postoperative morbidity and mortality data were obtained for univariate and multivariate statistical analysis.

RESULTS

A total of 1,536 patients underwent EVAR, of which 1,206 met inclusion criteria. A total of 788 patients underwent general anesthesia, 164 patients underwent spinal anesthesia, 82 patients underwent epidural anesthesia, and 172 patients underwent local and monitored anesthesia care (AC). There was a significant difference in length of stay and operative time when comparing local/monitored AC to general anesthesia. No significant difference was noted in 30-day morbidity or mortality among the anesthesia groups.

CONCLUSIONS

Local and regional anesthesia is a safe and effective approach for elective EVAR.

Reporting of Complications and Mortality in Relation to Risk Communication in Patients with an Abdominal Aortic Aneurysm: A Systematic Review

OBJECTIVES

High-quality reporting of surgical risks is necessary for evidence-based risk communication in clinical practice. Risk communication is defined as the process of discussing benefits and harms of treatment options with patients. This review addressed the current quality of reporting of complications and mortality in publications on abdominal aortic aneurysm treatment, with a focus on items relevant to risk communication.

DESIGN

A systematic review.

MATERIALS

Randomised clinical trials, comparative observational studies and registries from 2010 onwards were eligible if they reported complications and/or mortality in patients with an asymptomatic abdominal aortic aneurysms who received primary treatment.

METHODS

Quality of reporting was assessed by scoring items relevant to risk communication from the reporting standards of the Society for Vascular Surgery (SVS) and the Consolidated Standards of Reporting Trials (CONSORT) statement. Screening, quality assessment and data extraction were independently undertaken by two authors.

RESULTS

Forty-seven publications were included. Nine of 47 publications (19%) provided no definition of complications. In 14 of 47 publications (30%), it was unclear whether the number of adverse events or the number of patients with adverse events were presented. Absolute risk differences were provided in 1 of 32 publications (3.1%) that compared complications between two treatment options. Forty-six of 47 publications reported mortality, of which 42 reported overall mortality rates (91%). Absolute risk differences were given in 2 of the 31 publications (6.5%) that compared mortality between two treatment options.

CONCLUSIONS

The quality of reporting of complications and mortality following primary abdominal aortic aneurysm treatment varied considerably. Better adherence to the SVS reporting standards and the CONSORT statement, as well as stating absolute risk differences may improve the quality of reporting and facilitate evidence-based risk communication.

Meta-analysis of long-term survival after elective endovascular or open repair of abdominal aortic aneurysm

BACKGROUND

Endovascular aneurysm repair (EVAR) has become the preferred strategy for elective repair of abdominal aortic aneurysm (AAA) for many patients. However, the superiority of the endovascular procedure has recently been challenged by reports of impaired long-term survival in patients who underwent EVAR. A systematic review of long-term survival following AAA repair was therefore undertaken.

METHODS

A systematic review was performed according to PRISMA guidelines. Articles reporting short- and/or long-term mortality of EVAR and open surgical repair (OSR) of AAA were identified. Pooled overall survival estimates (hazard ratios (HRs) with corresponding 95 per cent c.i. for EVAR versus OSR) were calculated using a random-effects model. Possible confounding owing to age differences between patients receiving EVAR or OSR was addressed by estimating relative survival.

RESULTS

Some 53 studies were identified. The 30-day mortality rate was lower for EVAR compared with OSR: 1·16 (95 per cent c.i. 0·92 to 1·39) versus 3·27 (2·71 to 3·83) per cent. Long-term survival rates were similar for EVAR versus OSR (HRs 1·01, 1·00 and 0·98 for 3, 5 and 10 years respectively; P = 0·721, P = 0·912 and P = 0·777). Correction of age inequality by means of relative survival analysis showed equal long-term survival: 0·94, 0·91 and 0·76 at 3, 5 and 10 years for EVAR, and 0·96, 0·91 and 0·76 respectively for OSR.

CONCLUSION

Long-term overall survival rates were similar for EVAR and OSR. Available data do not allow extension beyond the 10-year survival window or analysis of specific subgroups.

Patients with end-stage renal disease have poor outcomes after endovascular abdominal aortic aneurysm repair

OBJECTIVE

Although endovascular repair of abdominal aortic aneurysms (AAAs) has been demonstrated to have favorable outcomes, not all cohorts of patients with AAA fare equally well. Our goal was to investigate perioperative and 1-year outcomes in patients with end-stage renal disease (ESRD) on dialysis, who have traditionally fared worse after vascular interventions, to assess how ESRD affects outcomes in a large modern cohort of endovascular aneurysm repair (EVAR) patients.

METHODS

The Vascular Quality Initiative database was queried for all patients undergoing EVAR from 2010 to 2017. ESRD patients were compared with patients not on dialysis. Propensity-matched scoring and multivariable analysis were used to isolate the effects of ESRD.

RESULTS

Of 28,683 EVARs identified, there were 321 (1.12%) patients with ESRD on dialysis. Patients with ESRD had no difference in presenting AAA size (57.5 ± 12.7 mm vs 56.7 ± 17.2 mm; P = .44); however, they had more urgent/emergent repairs (20.6% vs 13.6%; P = .002) than those without ESRD. ESRD patients were more often younger, nonwhite, and nonobese and less likely to have commercial insurance (P < .05). ESRD patients more often had hypertension, coronary artery disease, congestive heart failure, previous lower extremity bypass, aneurysm repair, and carotid interventions (P < .05). There was no difference in the rate of concomitant procedures. Matching based on demographics, comorbidities, and operative details showed that ESRD patients had longer hospital length of stay (4.8 ± 9.4 days vs 4.1 ± 12.6 days; P = .026) and higher 30-day mortality (7% vs 2.4%; P < .001). There was no difference in cardiac, pulmonary, lower extremity, bowel, and stroke complications or return to the operating room. On multivariable analysis, ESRD was associated with 30-day mortality (odds ratio, 4.1; 95% confidence interval, 2.6-6.7; P < .001). Of the 24,750 elective EVARs, 1.04% had ESRD on dialysis. Matched data for elective EVAR show increased postoperative length of stay, hospital mortality, and 30-day mortality for ESRD patients on dialysis compared with those who are not. There was no association with postoperative myocardial infarction or pulmonary complications. At 1 year, patients with ESRD on dialysis had worse survival (78% vs 94%; P < .001), and ESRD was associated with higher mortality (hazard ratio, 3.3; 95% confidence interval, 2.5-4.2; P < .001).

CONCLUSIONS

Among patients undergoing EVAR, ESRD is independently associated with higher perioperative and 1-year mortality despite not being associated with higher postoperative complications. This should be taken into account during informed consent for EVAR and risk-benefit considerations in this high-risk population, particularly for elective repair.

Preexisting Conditions Determine the Occurrence of Unplanned Readmissions after Procedures for Treatment of Peripheral Arterial Disease

BACKGROUND

Readmissions after surgical procedures are increasingly considered a metric to indicate the quality of care received during the index hospitalization. Patients with peripheral arterial disease (PAD) requiring peripheral vascular interventions (PVIs) or lower extremity bypasses (LEBs) often have several serious medical comorbidities. Risk factors associated with readmission after PVI and LEB have previously been identified. The purpose of this study is to compare the readmissions among patients receiving PVI and LEB procedures to identify risk factors associated with high risk of readmission.

METHODS

The 2013 Procedure-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database and generalized 2013 general and vascular surgery ACS-NSQIP Program User Files were used for this study. Patient, diagnosis, and procedure characteristics of patients undergoing PVI and LEB were assessed. Odds ratios (ORs) with confidence intervals (CIs) for PVI versus LEB groups within the subgroups of these characteristics were then obtained where significant associations existed between the study groups.

RESULTS

A total of 3,742 patients (males: 2,384 [63.7%] and females: 1,358 [36.3%]) underwent surgical procedures for lower extremity PAD during the year 2013. Among these patients, 1,096 (29.3%) were treated with endovascular interventions and 2,646 (70.7%) were treated with surgical bypasses. Patients were divided into 2 groups: PVI (n = 1,096) and LEB (n = 2,646) groups. Each group was further subdivided into 2 groups: readmission and no readmission. The incidence of readmission was as follows: PVI group (n = 147, 13.4%) and LEB (n = 425, 16.1%). The PVI and LEB groups showed a significant association with readmission within the following factors: dialysis dependency (PVI 32.6% vs. LEB 19.1%, OR: 2.06, CI: 1.13-3.75, P < 0.001), emergency operation (PVI 40.4% vs. LEB 18.7%, OR: 2.96, CI: 1.45-6.03, P < 0.001), chronic obstructive pulmonary disease (COPD; PVI 23.7% vs. LEB 14.6%, OR: 1.82, CI: 1.08-3.07, P = 0.001), cardiac arrest (PVI 45.5% vs. LEB 9.5%, OR: 7.92, CI: 1.21-51.9, P = 0.017), and body mass index > 30 (PVI 9.9% vs. LEB 18.4%, OR: 0.49, CI: 0.33-0.73, P = 0.009).

CONCLUSIONS

Readmissions after lower extremity endovascular or surgical interventions can be used as a quality metric. Patients with dialysis dependency, COPD, in need of emergent operation, or having cardiac arrest are highly likely to be readmitted if treated with endovascular interventions. Similarly, patients with high body mass index are highly likely to be readmitted if treated with open surgical bypasses.

Chitosan-doxycycline hydrogel: An MMP inhibitor/sclerosing embolizing agent as a new approach to endoleak prevention and treatment after endovascular aneurysm repair

The success of endovascular repair of abdominal aortic aneurysms remains limited due to the development of endoleaks. Sac embolization has been proposed to manage endoleaks, but current embolizing materials are associated with frequent recurrence. An injectable agent that combines vascular occlusion and sclerosing properties has demonstrated promise for the treatment of endoleaks. Moreover, the inhibition of aneurysmal wall degradation via matrix metalloproteinases (MMPs) may further prevent aneurysm progression. Thus, an embolization agent that promotes occlusion, MMP inhibition and endothelial ablation was hypothesized to provide a multi-faceted approach for endoleak treatment. In this study, an injectable, occlusive chitosan (CH) hydrogel containing doxycycline (DOX)-a sclerosant and MMP inhibitor-was developed. Several CH-DOX hydrogel formulations were characterized for their mechanical and sclerosing properties, injectability, DOX release rate, and MMP inhibition. An optimized formulation was assessed for its short-term ability to occlude blood vessels in vivo. All formulations were injectable and gelled rapidly at body temperature. Only hydrogels prepared with 0.075M sodium bicarbonate and 0.08M phosphate buffer as the gelling agent presented sufficient mechanical properties to immediately impede physiological flow. DOX release from this gel was in a two-stage pattern: a burst release followed by a slow continuous release. Released DOX was bioactive and able to inhibit MMP-2 activity in human glioblastoma cells. Preliminary in vivo testing in pig renal arteries showed immediate and delayed embolization success of 96% and 86%, respectively. Altogether, CH-DOX hydrogels appear to be promising new multifunctional embolic agents for the treatment of endoleaks.

STATEMENT OF SIGNIFICANCE

An injectable embolizing chitosan hydrogel releasing doxycycline (DOX) was developed as the first multi-faceted approach for the occlusion of blood vessels. It combines occlusive properties with DOX sclerosing and MMP inhibition properties, respectively known to prevent recanalization process and to counteract the underlying pathophysiology of vessel wall degradation and aneurysm progression. After drug release, the biocompatible scaffold can be invaded by cells and slowly degrade. Local DOX delivery requires lower drug amount and decreases risks of side effects compared to systemic administration. This new gel could be used for the prevention or treatment of endoleaks after endovascular aneurysm repair, but also for the embolization of other blood vessels such as venous or vascular malformations.

Textbook Outcome: A Composite Measure for Quality of Elective Aneurysm Surgery

OBJECTIVE

To investigate a new composite quality measurement, which comprises a desirable outcome for elective aneurysm surgery, called "Textbook Outcome" (TO).

BACKGROUND

Single-quality indicators in vascular surgery are often not distinctive and insufficiently reflect the quality of care.

METHODS

All patients undergoing elective abdominal aortic aneurysm repair, registered in the Dutch Surgical Aneurysm Audit between 2014 and 2015 were included. TO was defined as the percentage of patients who had abdominal aortic aneurysm-repair without intraoperative complications, postoperative surgical complications, reinterventions, prolonged hospital stay [endovascular aneurysm repair (EVAR) ≤4 d, open surgical repair (OSR) ≤10 d], readmissions, and postoperative mortality (≤30 d after surgery/at discharge). Case-mix adjusted TO rates were used to compare hospitals and to compare individual hospital results for different procedures.

RESULTS

Five thousand one hundred seventy patients were included, of whom 4039 were treated with EVAR and 1131 with OSR. TO was achieved in 71% of EVAR and 53% of OSR. Important obstacles for achieving TO were a prolonged hospital stay, postoperative complications, and readmissions. Adjusted TO rates varied from 38% to 89% (EVAR) and from 0% to 97% (OSR) between individual hospitals. Hospitals with a high TO for OSR also had a high TO for EVAR; however, a high TO for EVAR did not implicate a high TO for OSR.

CONCLUSIONS

TO generates additional information to evaluate the overall quality of the care of elective aneurysm surgery, which subsequently can be used by hospitals to improve the quality of their care.

Perioperative Infections after Open Abdominal Aortic Aneurysm Repair Lead to Increased Risk of Subsequent Complications

BACKGROUND

Patients undergoing open abdominal aortic aneurysm (AAA) repair are at risk of perioperative infections that can lead to subsequent complications. Our goal was to understand how an initial infectious complication influences the risk of subsequent complications in this cohort of patients.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012), we evaluated the relationship between 3 index infectious complications after open elective AAA repair (pneumonia, deep/organ surgical site infection [SSI], and urinary tract infection [UTI]) and subsequent complications. We used 5:1 propensity matching and calculated propensity score to experience to establish matching cohorts for each index complication. This score was based on preoperative variables and number of event-free days.

RESULTS

There were 3,991 patients who were identified to have undergone elective open AAA repair in the ACS-NSQIP database. Postoperative index pneumonia was associated with increased risk of unplanned intubation (28.6% vs. 3.5%; odds ratio [OR], 10.9; 95% confidence interval [CI]: 6.7-17.5; P < 0.001), prolonged ventilation (38.5% vs. 6.7%; OR, 8.7; 95% CI: 5.9-13.0; P < 0.001), sepsis (14.3% vs. 3.3%; OR, 4.8; 95% CI: 2.8-8.4; P < 0.001), acute renal failure (9.9% vs. 2.1%; OR, 5.1; 95% CI: 2.6-9.9; P < 0.001), deep vein thrombosis (DVT) (3.8% vs. 1.4%; OR, 2.7; 95% CI: 1.1-7.0; P = 0.035), and mortality (7.1% vs. 3.0%; OR, 2.5; 95% CI: 1.3-4.9; P = 0.009). Postoperative index UTI was associated with increased risk of sepsis (21.4% vs. 0%; OR, 49.2; 95% CI: 14.5-166.8; P < 0.001), pneumonia (10.7% vs. 2.9%; OR, 4.0; 95% CI: 1.8-8.6; P = 0.001), DVT (3.6% vs. 0.4%; OR, 10.0; 95% CI: 1.8-55.5; P = 0.008), and mortality (5.4% vs. 1.8%; OR, 3.0; 95% CI: 1.1-8.5; P = 0.02). Finally, postoperative index deep/organ SSI increased the risk of pneumonia (13.0% vs. 0.9%; OR, 16.7; 95% CI: 1.6-168.2; P = 0.017), prolonged ventilation (21.7% vs. 0.9%; OR, 30.8; 95% CI: 3.4-279.4; P = 0.002), and sepsis (13.0% vs. 0.9%; OR, 16.7; 95% CI: 1.6-168.2; P = 0.017).

CONCLUSIONS

A postoperative nosocomial infection after open AAA repair is significantly more likely to lead to serious subsequent complications. Prevention and early identification of infectious index complications and subsequent complications could allow for interventions that could decrease morbidity and mortality.

Pre-operative Simulation of the Appropriate C-arm Position Using Computed Tomography Post-processing Software Reduces Radiation and Contrast Medium Exposure During EVAR Procedures

OBJECTIVE/BACKGROUND

The aim was to evaluate the feasibility and efficacy of a new method for pre-operative calculation of an appropriate C-arm position for iliac bifurcation visualisation during endovascular aortic repair (EVAR) procedures by using three dimensional computed tomography angiography (CTA) post-processing software.

METHODS

Post-processing software was used to simulate C-arm angulations in two dimensions (oblique, cranial/caudal) for appropriate visualisation of distal landing zones at the iliac bifurcation during EVAR. Retrospectively, 27 consecutive EVAR patients (25 men, mean ± SD age 73 ± 7 years) were identified; one group of patients (NEW; n = 12 [23 iliac bifurcations]) was compared after implementation of the new method with a group of patients who received a historic method (OLD; n = 15 [23 iliac bifurcations]), treated with EVAR before the method was applied.

RESULTS

In the OLD group, a median of 2.0 (interquartile range [IQR] 1-3) digital subtraction angiography runs were needed per iliac bifurcation versus 1.0 (IQR 1-1) runs in the NEW group (p = .007). The median dose area products per iliac bifurcation were 11951 mGy*cm² (IQR 7308-16663 mGy*cm²) for the NEW, and 39394 mGy*cm² (IQR 19066-53702 mGy*cm²) for the OLD group, respectively (p = .001). The median volume of contrast per iliac bifurcation was 13.0 mL (IQR: 13-13 mL) in the NEW and 26 mL (IQR 13-39 mL) in the OLD group (p = .007).

CONCLUSION

Pre-operative simulation of the appropriate C-arm angulation in two dimensions using dedicated computed tomography angiography post-processing software is feasible and significantly reduces radiation and contrast medium exposure.