1
|
Rastogi V, Summers SP, Yadavalli SD, Perrier J, Allievi S, Jabbour G, Stangenberg L, de Bruin JL, Jones D, Ferran CJ, Verhagen HJM, Schermerhorn ML. Association between Diabetes Status and Long-term Outcomes Following Open and Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms. J Vasc Surg 2024:S0741-5214(24)01782-8. [PMID: 39181338 DOI: 10.1016/j.jvs.2024.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 08/09/2024] [Accepted: 08/14/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVE Current literature reports conflicting findings regarding the effect of diabetes mellitus (DM) on outcomes of AAA repair. In this study we examined the effect of DM and its management on outcomes following open (OAR) and endovascular (EVAR) AAA repair. METHODS We identified all patients undergoing OAR or EVAR for infrarenal AAA between 2003-2018 in the Vascular Quality Initiative (VQI) registry data linked with Medicare claims. We excluded patients with missing DM status. Patients were stratified by their preoperative DM status, and then further stratified by DM management: dietary, non-insulin anti-diabetic medications (NIM), or insulin. Outcomes of interest included one-year aneurysm sac dynamics, 8-year aneurysm rupture, reintervention, and all-cause mortality. These outcomes were analyzed with chi-square, Kaplan-Meier methods, and multivariable cox regression analyses. RESULTS We identified 34,021 EVAR patients and 4,127 OAR patients of which 20% and 16% had DM, respectively. Of all DM patients, 22% were managed by dietary management, 59% by NIM, and 19% by insulin. Following EVAR, DM patients were more likely to have stable sacs while non-DM patients were more likely to have sac regression at 1 year. Compared with non-DM, DM was associated with a significantly lower risk for 8-year rupture in EVAR (EVAR HR: 0.68 [0.51-0.92]). Compared with non-DM, NIM was associated with lower risk of rupture within 8-years for both EVAR and OAR (EVAR HR: 0.64 [0.44-0.94]; OAR HR: 0.29 [0.41-0.80]), while dietary and insulin had similar rupture risk compared with non-DM. However, compared with non-DM, DM was associated with higher risk of 8-year all-cause mortality following EVAR and OAR (DM vs. non-DM: EVAR HR: 1.17 [1.11-1.23]; OAR HR: 1.16 [1.00-1.36]). Following further DM management sub-stratification, compared with non-DM, management with NIM and insulin were associated with higher 8-year mortality in EVAR and OAR (EVAR: NIM HR: 1.12 [1.05-1.20] & insulin HR: 1.40 [1.26-1.55]; OAR: NIM HR: 1.27 [1.06-1.54] & insulin HR: 1.57 [1.15-2.13]). Finally, there was a similar risk of reintervention across the DM and non-DM populations in EVAR and OAR. CONCLUSION DM was associated with lower adjusted risk of rupture following EVAR as well as OAR in patients managed with NIM. Nevertheless, just as in patients without AAA, preoperative DM was associated with a higher adjusted risk of all-cause mortality. Further study is needed to evaluate for differences in aneurysm-related mortality between DM and non-DM, and studies are planned to evaluate the independent effect of NIM on aneurysm-related outcomes.
Collapse
Affiliation(s)
- Vinamr Rastogi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Steven P Summers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan Perrier
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Surgery, Division of Vascular Surgery, Strong Memorial Medical Center, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA
| | - Sara Allievi
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriel Jabbour
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lars Stangenberg
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Douglas Jones
- Department of Vascular Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Christiane J Ferran
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical Center, University of Massachusetts Medical School, Worcester, MA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
2
|
Silva NP, Amin B, Dunne E, Hynes N, O’Halloran M, Elahi A. Implantable Pressure-Sensing Devices for Monitoring Abdominal Aortic Aneurysms in Post-Endovascular Aneurysm Repair. SENSORS (BASEL, SWITZERLAND) 2024; 24:3526. [PMID: 38894317 PMCID: PMC11175030 DOI: 10.3390/s24113526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
Over the past two decades, there has been extensive research into surveillance methods for the post-endovascular repair of abdominal aortic aneurysms, highlighting the importance of these technologies in supplementing or even replacing conventional image-screening modalities. This review aims to provide an overview of the current status of alternative surveillance solutions for endovascular aneurysm repair, while also identifying potential aneurysm features that could be used to develop novel monitoring technologies. It offers a comprehensive review of these recent clinical advances, comparing new and standard clinical practices. After introducing the clinical understanding of abdominal aortic aneurysms and exploring current treatment procedures, the paper discusses the current surveillance methods for endovascular repair, contrasting them with recent pressure-sensing technologies. The literature on three commercial pressure-sensing devices for post-endovascular repair surveillance is analyzed. Various pre-clinical and clinical studies assessing the safety and efficacy of these devices are reviewed, providing a comparative summary of their outcomes. The review of the results from pre-clinical and clinical studies suggests a consistent trend of decreased blood pressure in the excluded aneurysm sac post-repair. However, despite successful pressure readings from the aneurysm sac, no strong link has been established to translate these measurements into the presence or absence of endoleaks. Furthermore, the results do not allow for a conclusive determination of ongoing aneurysm sac growth. Consequently, a strong clinical need persists for monitoring endoleaks and aneurysm growth following endovascular repair.
Collapse
Affiliation(s)
- Nuno P. Silva
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
| | - Bilal Amin
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Eoghan Dunne
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Niamh Hynes
- Western Vascular Institute, Galway Clinic, Doughiska Road, H91 HHT0 Galway, Ireland;
| | - Martin O’Halloran
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Adnan Elahi
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (B.A.); (E.D.); (M.O.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
| |
Collapse
|
3
|
Silva NP, Elahi A, Dunne E, O’Halloran M, Amin B. Design and Characterisation of a Read-Out System for Wireless Monitoring of a Novel Implantable Sensor for Abdominal Aortic Aneurysm Monitoring. SENSORS (BASEL, SWITZERLAND) 2024; 24:3195. [PMID: 38794049 PMCID: PMC11126120 DOI: 10.3390/s24103195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/14/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024]
Abstract
Abdominal aortic aneurysm (AAA) is a dilation of the aorta artery larger than its normal diameter (>3 cm). Endovascular aneurysm repair (EVAR) is a minimally invasive treatment option that involves the placement of a graft in the aneurysmal portion of the aorta artery. This treatment requires multiple follow-ups with medical imaging, which is expensive, time-consuming, and resource-demanding for healthcare systems. An alternative solution is the use of wireless implantable sensors (WIMSs) to monitor the growth of the aneurysm. A WIMS capable of monitoring aneurysm size longitudinally could serve as an alternative monitoring approach for post-EVAR patients. This study has developed and characterised a three-coil inductive read-out system to detect variations in the resonance frequency of the novel Z-shaped WIMS implanted within the AAA sac. Specifically, the spacing between the transmitter and the repeater inductors was optimised to maximise the detection of the sensor by the transmitter inductor. Moreover, an experimental evaluation was also performed for different orientations of the transmitter coil with reference to the WIMS. Finally, the FDA-approved material nitinol was used to develop the WIMS, the transmitter, and repeater inductors as a proof of concept for further studies. The findings of the characterisation from the air medium suggest that the read-out system can detect the WIMS up to 5 cm, regardless of the orientation of the Z-shape WIMS, with the detection range increasing as the orientation approaches 0°. This study provides sufficient evidence that the proposed WIMS and the read-out system can be used for AAA expansion over time.
Collapse
Affiliation(s)
- Nuno P. Silva
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (A.E.); (E.D.); (M.O.); (B.A.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
| | - Adnan Elahi
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (A.E.); (E.D.); (M.O.); (B.A.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
| | - Eoghan Dunne
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (A.E.); (E.D.); (M.O.); (B.A.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Martin O’Halloran
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (A.E.); (E.D.); (M.O.); (B.A.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Bilal Amin
- Translational Medical Device Lab, University of Galway, H91 TK33 Galway, Ireland; (A.E.); (E.D.); (M.O.); (B.A.)
- Electrical and Electronic Engineering, University of Galway, H91 TK33 Galway, Ireland
- School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| |
Collapse
|
4
|
Moulakakis KG, Lazaris AM, Georgiadis GS, Kakkos S, Papavasileiou VG, Antonopoulos CN, Papapetrou A, Katsikas V, Klonaris C, Geroulakos G. A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:756-764. [PMID: 38154499 DOI: 10.1016/j.ejvs.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/02/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. METHODS A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital death. RESULTS A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p = .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 - 32.40; p = .010) and in hospital death (OR 9.53, 95% CI 2.79 - 32.58; p < .001). CONCLUSION These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.
Collapse
Affiliation(s)
- Konstantinos G Moulakakis
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece.
| | - Andreas M Lazaris
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Stavros Kakkos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | | | - Constantine N Antonopoulos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios Papapetrou
- Hellenic Vascular Registry (HEVAR); Vascular Surgery Clinic, K.A.T. General Hospital, Athens, Greece
| | - Vasilios Katsikas
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Gennimatas General Hospital of Athens, Athens, Greece
| | - Chris Klonaris
- Hellenic Vascular Registry (HEVAR); 2nd Department of Vascular Surgery, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - George Geroulakos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
5
|
Rakemaa L, Aho PS, Tulamo R, Laine MT, Laukontaus SJ, Hakovirta H, Venermo M. Ultrasound Surveillance is Feasible After Endovascular Aneurysm Repair. Ann Vasc Surg 2024; 100:223-232. [PMID: 37926137 DOI: 10.1016/j.avsg.2023.09.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/05/2023] [Accepted: 09/09/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Surveillance after endovascular aneurysm repair (EVAR) is traditionally done with computed tomography angiography (CTA) scans that exposes patient to radiation, nephrotoxic contrast media, and potentially increased risk for cancer. Ultrasound (US) is less labor intensive and expensive and might thus provide a good alternative for CTA surveillance. The aim of this study was to evaluate in real-life patient cohorts whether US is able to detect post-EVAR aneurysm-related complications similarly to CTA. METHODS This retrospective study compared the outcome of consecutive patients who underwent EVAR for intact abdominal aortic aneurysm and were surveilled solely by CTA (CTA-only cohort, n = 168) in 2000-2010 or by combined CTA and US (CTA/US cohort, n = 300) in 2011-2016, as a standard surveillance protocol in the department of vascular surgery, Helsinki University Hospital. The CTA-only patients were imaged at 1, 3, and 12 months and annually thereafter. The CTA/US patients were imaged with CTA at 3 and 12 months, US at 6 months and annually thereafter. If there were suspicion of >5 mm aneurysm growth, CTA scan was performed. The patients were reviewed for imaging data, reinterventions, aneurysm ruptures, and death until December 2018. The 2 groups were compared for secondary rupture, aneurysm-related and cancer-related death, reintervention related to abdominal aortic aneurysm, and maximum aneurysm diameter increase ≥5 mm. The mean follow-up in the CTA-only cohort was 67 months and in CTA/US cohort 43 months. RESULTS The 2 cohorts were alike for basic characteristics and for the mean aneurysm diameter. The total number of CT scans for detecting aneurysm was 84.1/100 patient years in the CTA-only cohort compared to 74.5/100 patient years for US/CTA cohort. Forty percent of patients under combined CTA/US surveillance received 1 or more additional CTA scans. The 2 cohorts did not differ for 1-year, 5-year and 8-year freedom from aneurysm related death, secondary sac rupture, nor the incidence of rupture preventing interventions. CONCLUSIONS Based on the follow-up data of this real-life cohort of 468 patients, combined surveillance with US and additional CTA either per protocol or due to suspicion of aneurysm-related complications had comparable outcome with sole CTA-surveillance. Thus, US can be considered a reasonable alternative for the CTA. However, our study showed also that the need of additional CTAs due to suspicion of endoleak or aneurysm nonrelated reasons is substantial.
Collapse
Affiliation(s)
- Lotta Rakemaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Pekka S Aho
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Riikka Tulamo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Matti T Laine
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Sani J Laukontaus
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Harri Hakovirta
- Department of Vascular Surgery, University of Turku and Turku University Hospital, Turku, Varsinais-Suomi, Finland; Department of Surgery, Satasairaala Hospital, Pori, Satakunta, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland.
| |
Collapse
|
6
|
Moulakakis KG, Tsimpoukis A, Katsanos K, Sintou E, Papadoulas S. Re-Rupture 2 Years after Endovascular Aortic Aneurysm Repair Rupture. Vasc Endovascular Surg 2023; 57:760-763. [PMID: 36960838 DOI: 10.1177/15385744231166797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
Re-rupture 2 years after endovascular aortic aneurysm repair (EVAR) rupture is an extremely rare event and limited data exist in the literature. We present an interesting case of a patient with an abdominal aortic rupture that had undergone 2 years before an endovascular repair for rupture after EVAR due to a type IA endoleak. The patient underwent a successful embolization of the type IA endoleak. Onyx was used to seal the gutter between the aortic wall and the endograft and the 1-month post-embolization CT showed complete sealing with no contrast in the sac. Two years after the rupture, he was presented again with clinical signs of hemodynamic shock and instability. An urgent CT Angiograph showed again rupture due to a type IA endoleak. The patient underwent an emergency open laparotomy. We analyze the re-rupture after EVAR while taking data from the literature into account.
Collapse
Affiliation(s)
| | | | | | - Eleni Sintou
- Department of Anesthesia, Patras University Hospital, Patras, Greece
| | - Spyros Papadoulas
- Vascular Surgery Department, Patras University Hospital, Patras, Greece
| |
Collapse
|
7
|
Individual Patient Data Meta-Analysis of 10-Year Follow-Up after Endovascular and Open Repair for Ruptured Abdominal AorticAneurysms. Ann Vasc Surg 2023:S0890-5096(23)00032-8. [PMID: 36690248 DOI: 10.1016/j.avsg.2023.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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 7 years, which peaked at 6 years 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. CONCLUSIONS At 10-years follow-up, EVAR was associated with a 6.5 month 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.
Collapse
|
8
|
Identifying high risk for proximal endograft failure after EVAR in patients suitable for both open and endovascular elective aneurysm repair. J Vasc Surg 2022; 76:1261-1269. [PMID: 35709862 DOI: 10.1016/j.jvs.2022.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/21/2022] [Accepted: 06/03/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Proximal endograft failure (type Ia endoleak or migration) after endovascular aneurysm repair (EVAR) is associated with hostile aneurysm neck morphology. Neck scoring systems were developed to predict proximal endograft failure but were studied in retrospective studies, which due to selection bias may have led to an overestimation of bad outcomes after EVAR. To predict patients who benefit from open repair, preoperative neck morphology and occurrence of long-term proximal endograft failure were investigated in patients enrolled in the endovascular arm of the DREAM-trial who were suitable for open repair by definition and have long-term follow-up. METHODS A post-hoc on-treatment analysis of patients after EVAR was performed in 171 patients. Aneurysm neck morphology was quantified using the aneurysm severity grading (ASG)-neck score calculated on pre-operative CT-angiography images. The ASG-neck score was used to predict proximal endograft failure. ROC analysis was performed to calculate a threshold to divide favorable and unfavorable aneurysm necks (low and high-risk), positive and negative likelihood-ratios were calculated accordingly. Freedom from proximal endograft failure was compared between groups using Kaplan Meier analysis. RESULTS During a median follow-up of 7.6 years, 20 patients suffered proximal endograft failure. ROC analysis showed an AUC 0.77 (95% CI 0.65-0.90; p<0.001) indicating acceptable prediction. The threshold was determined at ASG-neck score ≥5, 30 patients had unfavorable neck morphology of whom 11 developed proximal endograft failure. The positive likelihood-ratio was 4.4 (95% CI 2.5-7.8) and the negative likelihood-ratio was 0.51 (95% CI 0.3-0.8). Twelve years postoperatively, freedom from proximal endograft failure was 91.7% in favorable and 53.2% in unfavorable groups, difference 38.5% (95% CI 13.9-63.1; p<0.001). CONCLUSION In this study, the ASG-neck score predicted proximal endograft failure during the entire follow-up. This exhibits the persistent risk for proximal endograft failure long after EVAR and calls for ongoing surveillance especially in patients with unfavorable aneurysm necks.
Collapse
|
9
|
Avril S, Gee MW, Hemmler A, Rugonyi S. Patient-specific computational modeling of endovascular aneurysm repair: State of the art and future directions. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2021; 37:e3529. [PMID: 34490740 DOI: 10.1002/cnm.3529] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 06/13/2023]
Abstract
Endovascular aortic repair (EVAR) has become the preferred intervention option for aortic aneurysms and dissections. This is because EVAR is much less invasive than the alternative open surgery repair. While in-hospital mortality rates are smaller for EVAR than open repair (1%-2% vs. 3%-5%), the early benefits of EVAR are lost after 3 years due to larger rates of complications in the EVAR group. Clinicians follow instructions for use (IFU) when possible, but are left with personal experience on how to best proceed and what choices to make with respect to stent-graft (SG) model choice, sizing, procedural options, and their implications on long-term outcomes. Computational modeling of SG deployment in EVAR and tissue remodeling after intervention offers an alternative way of testing SG designs in silico, in a personalized way before intervention, to ultimately select the strategies leading to better outcomes. Further, computational modeling can be used in the optimal design of SGs in cases of complex geometries. In this review, we address some of the difficulties and successes associated with computational modeling of EVAR procedures. There is still work to be done in all areas of EVAR in silico modeling, including model validation, before models can be applied in the clinic, but much progress has already been made. Critical to clinical implementation are current efforts focusing on developing fast algorithms that can achieve (near) real-time solutions, as well as ways of dealing with inherent uncertainties related to patient aortic wall degradation on an individualized basis. We are optimistic that EVAR modeling in the clinic will soon become a reality to help clinicians optimize EVAR interventions and ultimately reduce EVAR-associated complications.
Collapse
Affiliation(s)
- Stéphane Avril
- Mines Saint-Étienne, Univ Lyon, Univ Jean Monnet, INSERM, Saint-Étienne, France
| | - Michael W Gee
- Mechanics & High Performance Computing Group, Department of Mechanical Engineering, Technical University of Munich, Garching, Germany
| | - André Hemmler
- Mechanics & High Performance Computing Group, Department of Mechanical Engineering, Technical University of Munich, Garching, Germany
| | - Sandra Rugonyi
- Biomedical Engineering Department, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
10
|
Soares Ferreira R, Oliveira-Pinto J, Ultee K, Voûte MT, Oliveira NFG, Hoeks S, Verhagen HJM, Bastos Gonçalves F. Long Term Outcomes of Post-Implantation Syndrome After Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2021; 62:561-568. [PMID: 34456118 DOI: 10.1016/j.ejvs.2021.06.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 06/12/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the association between post-implantation syndrome (PIS) and long term outcomes, with emphasis on cardiovascular prognosis. METHODS One hundred and forty-nine consecutive patients undergoing EVAR in a tertiary institution were previously included in a study investigating the risk factors and short term consequences of PIS (defined as tympanic temperature ≥ 38°C and CRP > 10 mg/L, after excluding complications with an effect on inflammatory markers). This study was based on a prospectively maintained database. Survival status was derived from inquiry of civil registry database information and causes of death from the Dutch Central Bureau of Statistics. The primary endpoint was cardiovascular events. Secondary endpoints were overall and specific cause mortality (cardiovascular, ischaemic heart disease, AAA, and cancer related mortality). Aneurysm sac dynamics and occurrence of endoleaks were also analysed. Survival estimates were obtained using Kaplan-Meier plots and a multivariable model was constructed to correct for confounders. RESULTS The PIS incidence was 39% (58/149). At the time of surgery, patients had a mean age of 73 ± 7 years and were predominantly male. There were no baseline differences between the PIS and non-PIS groups. The median follow up was 6.4 years (3.2 - 8.3), similar in both groups (p = .81). There was no difference in cardiovascular events for PIS and non-PIS patients (p = .63). However, Kaplan-Meier plots suggest a trend towards a higher rate of cardiovascular events in PIS patients during the first years: freedom from cardiovascular events at one year was 94% vs. 89% and at three years 90% vs. 82%. No differences were found in overall and specific cause mortality. There was a higher rate of type II endoleaks for non-PIS patients (28% vs. 9%, p = .005). Sac dynamics were similar in both groups. CONCLUSION The results suggest that PIS is not associated with a statistically significantly higher risk of cardiovascular events. PIS had no impact on mortality. Lastly, PIS patients had fewer type II endoleaks, but sac dynamics were analogous.
Collapse
Affiliation(s)
- Rita Soares Ferreira
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School, Universidade NOVA de Lisboa, Portugal
| | - José Oliveira-Pinto
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Centro Hospitalar São João, Porto, Portugal; Department of Surgery and Physiology, Faculdade de Medicina da Univesidade do Porto, Porto, Portugal
| | - Klaas Ultee
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Michiel T Voûte
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Nelson F G Oliveira
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Hospital do Divino Espírito Santo, Ponta Delgada, Azores, Portugal
| | - Sanne Hoeks
- Department of Anaesthetics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Frederico Bastos Gonçalves
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal; NOVA Medical School, Universidade NOVA de Lisboa, Portugal.
| |
Collapse
|
11
|
Columbo JA, Martinez-Camblor P, O’Malley AJ, Suckow BD, Hoel AW, Stone DH, Schanzer A, Schermerhorn ML, Sedrakyan A, Goodney PP. Long-term Reintervention After Endovascular Abdominal Aortic Aneurysm Repair. Ann Surg 2021; 274:179-185. [PMID: 31290764 PMCID: PMC10683776 DOI: 10.1097/sla.0000000000003446] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the long-term reintervention rate after endovascular abdominal aortic aneurysm repair (EVR), and identify factors predicting reintervention. SUMMARY OF BACKGROUND DATA EVR is the most common method of aneurysm repair in America, and reintervention after EVR is common. Clinical factors predicting reintervention have not been described in large datasets with long-term follow-up. METHODS We studied patients who underwent EVR using the Vascular Quality Initiative registry linked to Medicare claims. Our primary outcome was reintervention, defined as any procedure related to the EVR after discharge from the index hospitalization. We used classification and regression tree modeling to inform a multivariable Cox-regression model predicting reintervention after EVR. RESULTS We studied 12,911 patients treated from 2003 to 2015. Mean age was 75.5 ± 7.3 years, 79.9% were male, and 89.1% of operations were elective. The 3-year reintervention rate was 15%, and the 10-year rate was 33%. Five factors predicted reintervention: operative time ≥3.0 hours, aneurysm diameter ≥6.0 cm, an iliac artery aneurysm ≥2.0 cm, emergency surgery, and a history of prior aortic surgery. Patients with no risk factors had a 3-year reintervention rate of 12%, and 10-year rate of 26% (n = 7310). Patients with multiple risk factors, such as prior aortic surgery and emergent surgery, had a 3-year reintervention rate 72%, (n = 32). Modifiable factors including EVR graft manufacturer or supra-renal fixation were not associated with reintervention (P = 0.76 and 0.79 respectively). CONCLUSIONS All patients retain a high likelihood of reintervention after EVR, but clinical factors at the time of repair can predict those at highest risk.
Collapse
Affiliation(s)
- Jesse A. Columbo
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- The Veterans Health Administration Quality Scholars Program, White River Junction, Vermont
- The Veterans Health Administration Outcomes Group, White River Junction, Vermont
| | - Pablo Martinez-Camblor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Bjoern D. Suckow
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Andrew W. Hoel
- Division of Vascular Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David H. Stone
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Andres Schanzer
- Vascular and Endovascular Surgery, Department of Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Marc L. Schermerhorn
- Division of Vascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Art Sedrakyan
- Department of Surgery, Weill-Cornell Medical School, New York, New York
| | - Philip P. Goodney
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- The Veterans Health Administration Outcomes Group, White River Junction, Vermont
| |
Collapse
|
12
|
Kim LG, Sweeting MJ, Armer M, Jacomelli J, Nasim A, Harrison SC. Modelling the impact of changes to abdominal aortic aneurysm screening and treatment services in England during the COVID-19 pandemic. PLoS One 2021; 16:e0253327. [PMID: 34129649 PMCID: PMC8205127 DOI: 10.1371/journal.pone.0253327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/02/2021] [Indexed: 12/01/2022] Open
Abstract
Background The National Health Service (NHS) abdominal aortic aneurysm (AAA) screening programme (NAAASP) in England screens 65-year-old men. The programme monitors those with an aneurysm, and early intervention for large aneurysms reduces ruptures and AAA-related mortality. AAA screening services have been disrupted following COVID-19 but it is not known how this may impact AAA-related mortality, or where efforts should be focussed as services resume. Methods We repurposed a previously validated discrete event simulation model to investigate the impact of COVID-19-related service disruption on key outcomes. This model was used to explore the impact of delayed invitation and reduced attendance in men invited to screening. Additionally, we investigated the impact of temporarily suspending scans, increasing the threshold for elective surgery to 7cm and increasing drop-out in the AAA cohort under surveillance, using data from NAAASP to inform the population. Findings Delaying invitation to primary screening up to two years had little impact on key outcomes whereas a 10% reduction in attendance could lead to a 2% lifetime increase in AAA-related deaths. In surveillance patients, a 1-year suspension of surveillance or increase in the elective threshold resulted in a 0.4% increase in excess AAA-related deaths (8% in those 5–5.4cm at the start). Longer suspensions or a doubling of drop-out from surveillance would have a pronounced impact on outcomes. Interpretation Efforts should be directed towards encouraging men to attend AAA screening service appointments post-COVID-19. Those with AAAs on surveillance should be prioritised as the screening programme resumes, as changes to these services beyond one year are likely to have a larger impact on surgical burden and AAA-related mortality.
Collapse
Affiliation(s)
- Lois G. Kim
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Michael J. Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Health Sciences, University of Leicester, George Davies Centre, Leicester, United Kingdom
| | - Morag Armer
- Public Health England, Wellington House, London, United Kingdom
| | - Jo Jacomelli
- Public Health England, Wellington House, London, United Kingdom
| | - Akhtar Nasim
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
| | - Seamus C. Harrison
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
13
|
van Schaik TG, Meekel JP, Hoksbergen AWJ, de Vries R, Blankensteijn JD, Yeung KK. Systematic review of embolization of type I endoleaks using liquid embolic agents. J Vasc Surg 2021; 74:1024-1032. [PMID: 33940072 DOI: 10.1016/j.jvs.2021.03.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/29/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The long-term success of endovascular aneurysm repair (EVAR) is limited by complications, most importantly endoleaks. In case of (persistent) type I endoleak (T1EL), secondary intervention is indicated to prevent secondary aneurysm rupture. Different treatment options are suggested for T1ELs, such as endo anchors, (fenestrated) cuffs, embolization, or open conversion. Currently, the treatment of T1EL with liquid embolic agents is available; however, results are not yet addressed. This review presents the safety and efficacy of embolization with liquid embolic agents for treatment of T1ELs after EVAR. METHODS A systematic literature search was performed for all studies reporting the use of liquid embolic agents as monotherapy for treatment of T1ELs after EVAR. Patient numbers, technical success (successful delivery of liquid embolics in the T1EL) and clinical success (absence of aneurysm related death, endoleak recurrence or additional interventions during follow-up) were examined. RESULTS Of 1604 articles, 10 studies met the selection criteria, including 194 patients treated with liquid embolics; 73.2% of the patients were male with a median age of 71 years. The overall technical success was 97.9%. Clinical success was 87.6%. Because the median follow-up was only 13.0 months (range, 1-89 months), data on long-term success are almost absent. Four cases (2.1%) of secondary aneurysm rupture after embolization owing to endoleak recurrence were reported. All ruptures occurred in aneurysms exceeding initial treatment diameter of 70 mm. CONCLUSIONS Initial technical success after liquid embolization for T1EL is high, although long-term clinical success rates are lacking. Within this review, the risk of secondary rupture is comparable with untreated T1EL at 2% with a median follow-up of 13 months, regardless of the initial success of embolization. In general, no decrease in secondary aneurysm rupture after embolization of T1EL after EVAR is demonstrated, although the results of late embolization are debated.
Collapse
Affiliation(s)
- Theodorus G van Schaik
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Department of Surgery, Zaans Medisch Centrum, Zaandam The Netherlands
| | - Jorn P Meekel
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Department of Surgery, Zaans Medisch Centrum, Zaandam The Netherlands
| | - Arjan W J Hoksbergen
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands
| | - Ralph de Vries
- Clinical Library, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Jan D Blankensteijn
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands
| | - Kak K Yeung
- Department of Vascular Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands; Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Location VUmc, Amsterdam, Zaandam, The Netherlands.
| |
Collapse
|
14
|
Schmitz-Rixen T, Böckler D, J. Vogl T, T. Grundmann R. Endovascular and Open Repair of Abdominal Aortic Aneurysm. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:813-819. [PMID: 33568258 PMCID: PMC8005839 DOI: 10.3238/arztebl.2020.0813] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 04/28/2020] [Accepted: 07/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND This review presents the surgical indications, surgical procedures, and results in the treatment of asymptomatic and ruptured abdominal aortic aneurysms (AAA). METHODS An updated search of the literature on screening, diagnosis, treatment, and follow-up of AAA, based on the German clinical practice guideline published in 2018. RESULTS Surgery is indicated in men with an asymptomatic AAA ≥ 5.5 cm and in women, ≥ 5.0 cm. The indication in men is based on four randomized trials, while in women the data are not conclusive. The majority of patients with AAA (around 80%) meanwhile receive endovascular treatment (endovascular aortic repair, EVAR). Open surgery (open aneurysm repair, OAR) is reserved for patients with longer life expectancy and lower morbidity. The pooled 30-day mortality is 1.16% (95% confidence interval [0.92; 1.39]) following EVAR, 3.27% [2.7; 3.83] after OAR. Women have higher operative/interventional mortality than men (odds ratio 1.67%). The mortality for ruptured AAA is extremely high: around 80% of women and 70% of men die after AAA rupture. Ruptured AAA should, if possible, be treated via the endovascular approach, ideally with the patient under local anesthesia. Treatment at specialized centers guarantees the required expertise and infrastructure. Long-term periodic monitoring by mean of imaging (duplex sonography, plus computed tomography if needed) is essential, particularly following EVAR, to detect and (if appropriate) treat endoleaks, to document stable diameter of the eliminated aneurysmal sac, and to determine whether reintervention is necessary (long-term reintervention rate circa 18%). CONCLUSION Vascular surgery now offers a high degree of safety in the treatment of patients with asymptomatic AAA. Endovascular intervention is preferred.
Collapse
Affiliation(s)
- Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery and the University Wound Center, Hospital of the Goethe University, Frankfurt/Main, Germany
- Institute of Diagnostic and Interventional Radiology, Hospital of the Goethe University, Frankfurt/Main, Germany
| | - Dittmar Böckler
- Department of Vascular Surgery and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas J. Vogl
- Department of Vascular and Endovascular Surgery and the University Wound Center, Hospital of the Goethe University, Frankfurt/Main, Germany
| | - Reinhart T. Grundmann
- German Institute for Vascular Health Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine (DGG), Berlin, Germany
| |
Collapse
|
15
|
Jean-Baptiste E, Feugier P, Cruzel C, Sarlon-Bartoli G, Reix T, Steinmetz E, Chaufour X, Chavent B, Salomon du Mont L, Ejargue M, Maurel B, Spear R, Midy D, Thaveau F, Desgranges P, Rosset E, Hassen-Khodja R, Bureau P, Ravoux M, Bozzetto C, Sevestre-Pietri MA, Terriat B, Favier C, Degeilh M, Le Hello C, Favre JP, Rinckenbach S, Loppinet A, Goueffic Y, Connault J, Alimi Y, Barthélémy P, Magne JL, Seinturier C, Choukroun ML, Rouyer O, Bitton L, Becquemin JP. Computed Tomography-Aortography Versus Color-Duplex Ultrasound for Surveillance of Endovascular Abdominal Aortic Aneurysm Repair. Circ Cardiovasc Imaging 2020; 13:e009886. [DOI: 10.1161/circimaging.119.009886] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Color-duplex ultrasonography (DUS) could be an alternative to computed tomography-aortography (CTA) in the lifelong surveillance of patients after endovascular aneurysm repair (EVAR), but there is currently no level 1 evidence. The aim of this study was to assess the diagnostic accuracy of DUS as an alternative to CTA for the follow-up of post-EVAR patients.
Methods
Between December 16, 2010, and June 12, 2015, we conducted a prospective, blinded, diagnostic-accuracy study, in 15 French university hospitals where EVAR was commonly performed. Participants were followed up using both DUS and CTA in a mutually blinded setup until the end of the study or until any major aneurysm-related morphological abnormality requiring reintervention or an amendment to the follow-up policy was revealed by CTA. Database was locked on October 2, 2017. Our main outcome measures were sensitivity, specificity, positive predictive value, negative predictive value, positive and negative likelihood ratios of DUS against reference standard CTA. CIs are binomial 95% CI.
Results
This study recruited prospectively 659 post-EVAR patients of whom 539 (82%) were eligible for further analysis. Following the baseline inclusion visit, 940 additional follow-up visits were performed in the 539 patients. Major aneurysm-related morphological abnormalities were revealed by CTA in 103 patients (17.2/100 person-years [95% CI, 13.9–20.5]). DUS accurately identified 40 patients where a major aneurysm-related morphological abnormality was present (sensitivity, 39% [95% CI, 29–48]) and 403 of 436 patients with negative CTA (specificity, 92% [95% CI, 90–95]). The negative predictive value and positive predictive value of DUS were 92% (95% CI, 90–95) and 39% (95% CI, 27–50), respectively. The positive likelihood ratio was 4.87 (95% CI, 2.9–9.6). DUS sensitivity reached 73% (95% CI, 51–96) in patients requiring an effective reintervention.
Conclusions
DUS had an overall low sensitivity in the follow-up of patients after EVAR, but its performance improved meaningfully when the subset of patients requiring effective reinterventions was considered.
Registration
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01230203.
Collapse
Affiliation(s)
- Elixène Jean-Baptiste
- Service de Chirurgie Vasculaire, INSERM U1065, CHU de Nice, Université Côte D’Azur, Nice, France (E.J.-B., R.H.-K.)
| | - Patrick Feugier
- Service de Chirurgie Vasculaire, CHU Edouard Herriot, Université Claude Bernard Lyon1, Lyon, France (P.F.)
| | - Coralie Cruzel
- Délégation à la Recherche Clinique et à l’innovation, CHU de Nice, Université Côte D’Azur, Nice, France (C.C.)
| | - Gabrielle Sarlon-Bartoli
- C2VN, APHM, CHU Timone, Service de Chirurgie Vasculaire, Aix Marseille Université, Marseille, France (G.S.-B.)
| | - Thierry Reix
- Service de Chirurgie Vasculaire, CHU Amiens-Picardie, Université de Picardie Jules Verne, Amiens, France (T.R.)
| | - Eric Steinmetz
- Service de Chirurgie Vasculaire, CHU Dijon-Bourgogne, Université de Bourgogne, Dijon, France (E.S.)
| | - Xavier Chaufour
- Service de Chirurgie Vasculaire et angiologie, CHU de Toulouse, Université Paul Sabatier, Toulouse, France (X.C.)
| | - Bertrand Chavent
- Service de Chirurgie Cardio-Vasculaire, CHU de Saint-Etienne, Université Jean Monnet, Saint-Etienne, France (B.C.)
| | - Lucie Salomon du Mont
- Service de Chirurgie Vasculaire et Endovasculaire, CHU de Besançon, Université de Franche-Comté, Besançon, France (L.S.d.M.)
| | - Meghann Ejargue
- AP-HM, Department of Vascular Surgery, University Hospital Nord, Aix-Marseille Université, Marseille, France (M.E.)
| | - Blandine Maurel
- CHU Nantes, l’institut du thorax, service de chirurgie vasculaire, Inserm-UN UMR-957, Nantes, France (B.M.)
| | - Rafaelle Spear
- Service de Chirurgie Vasculaire, CHU de Grenoble, Université Grenoble-Alpes, Grenoble, France (R.S.)
| | - Dominique Midy
- Service de Chirurgie Vasculaire, CHU de Bordeaux, Bordeaux, France (D.M.)
| | - Fabien Thaveau
- Service de Chirurgie Vasculaire, CHU de Strasbourg, Strasbourg, France (F.T.)
| | - Pascal Desgranges
- Service de Chirurgie Vasculaire, CHU Henri Mondor, Créteil, France (P.D.)
| | - Eugenio Rosset
- Service de Chirurgie Vasculaire, CHU de Clermont-Ferrand, Université d’Auvergne, Clermont-Ferrand, France (E.R.)
| | - Réda Hassen-Khodja
- Service de Chirurgie Vasculaire, INSERM U1065, CHU de Nice, Université Côte D’Azur, Nice, France (E.J.-B., R.H.-K.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Syn NL, Lee PC, Kovalik JP, Tham KW, Ong HS, Chan WH, Tan CS, Lim CH. Associations of Bariatric Interventions With Micronutrient and Endocrine Disturbances. JAMA Netw Open 2020; 3:e205123. [PMID: 32515795 PMCID: PMC7284307 DOI: 10.1001/jamanetworkopen.2020.5123] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Few studies have described the longitudinal trajectories of serum levels of micronutrients whose deficiencies are associated with serious sequelae following bariatric procedures, such as anemia, osteoporotic fractures, and neuropathies. Furthermore, previous studies comparing laparoscopic sleeve gastrectomy (LSG) vs Roux-en-Y gastric bypass (LRYGB) or one-anastomosis gastric bypass (OAGB) procedures may have been limited by selection and confounding biases. OBJECTIVE To appraise the spectrum and temporal course of micronutrient deficiencies associated with bone metabolism and erythropoiesis after LSG vs OAGB or LRYGB procedures, using the propensity score as a balancing score. DESIGN, SETTING, AND PARTICIPANTS This prospective, longitudinal comparative effectiveness study was conducted at a high-volume bariatric unit in Singapore from September 1, 2008, to November 30, 2017, with a cutoff date for analysis of September 2018. Patients who underwent adjustable gastric banding, biliopancreatic diversion procedures, and intragastric balloon procedures were excluded. All other patients who underwent bariatric procedures were included. Data were analyzed from September 23 to 30, 2018. MAIN OUTCOMES AND MEASURES Serial assessment of 13 biochemical parameters at 12 time points for up to 5 years after bariatric procedure. Inverse probability-of-treatment weights were used to obtain estimates of the mean associations of variables assessed with the bariatric surgical interventions. Longitudinal trajectories were analyzed using mixed-effects generalized linear models to apportion the temporal variation of serum micronutrients into fixed-effects and random-effects components. RESULTS A total of 688 patients were included in this study, of whom 499 underwent LSG (mean [SD] age, 41.5 [11.3] years; 318 [63.7%] women) and 189 underwent OAGB or LRYGB (mean [SD] age, 48.6 [9.4] years; 112 [59.3%] women). There were no differences during follow-up among patients who underwent LSG vs those who underwent OAGB or LRYGB in intact parathyroid hormone levels (mean difference, 7.05 [95% CI, -28.67 to 42.77] pg/mL; P = .70), serum 25-hydroxyvitamin D levels (mean difference, -0.72 [95% CI, -1.56 to 0.12] ng/mL; P = .09), or phosphate levels (mean difference, 0.006 [95% CI, -0.052 to 0.064] mg/dL; P = .83). Hemoglobin levels were a mean 0.63 (95% CI, 0.41 to 0.85) g/dL higher among patients who underwent LSG compared with those who underwent OAGB or LRYGB (P < .001), despite no differences in iron concentration levels (mean difference, 1.50 [95% CI, -1.39 to 4.39] µg/dL; P = .31), total iron-binding capacity (mean difference, 4.36 [95% CI, -5.25 to 13.98] µg/dL; P = .37), or ferritin levels (mean difference, 3.0 [95% CI, -13.0 to 18.9] ng/mL; P = .71). Compared with patients who underwent LSG procedures, patients who underwent OAGB or LRYGB had higher folate levels (mean difference, 2.376 [95% CI, 1.716 to 3.036] ng/mL; P < .001) but lower serum magnesium levels (mean difference, -0.25 [95% CI, -0.35 to -0.16] mg/dL; P < .001) and zinc levels (mean difference, -7.58 [95% CI, -9.92 to -5.24] µg/dL; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that LSG vs OAGB or LRYGB procedures have differential associations with various micronutrient and metabolic parameters. These differences should be recognized in guidelines for postbariatric nutritional surveillance and prevention.
Collapse
Affiliation(s)
- Nicholas L. Syn
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Phong Ching Lee
- Department of Endocrinology, Division of Medicine, Singapore General Hospital, Singapore
| | - Jean-Paul Kovalik
- Department of Endocrinology, Division of Medicine, Singapore General Hospital, Singapore
- Cardiovascular and Metabolic Diseases Programme, Duke-NUS Medical School, Singapore
| | - Kwang Wei Tham
- Department of Endocrinology, Division of Medicine, Singapore General Hospital, Singapore
| | - Hock Soo Ong
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore
| | - Weng Hoong Chan
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore
| | - Chuen Seng Tan
- Biostatistics and Modelling Domain, Saw Swee Hock School of Public Health, National University Health System, Singapore
| | - Chin Hong Lim
- Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore
| |
Collapse
|
17
|
|
18
|
Girdauskas E, Neumann N, Petersen J, Sequeira-Gross T, Naito S, von Stumm M, von Kodolitsch Y, Reichenspurner H, Zeller T. Expression Patterns of Circulating MicroRNAs in the Risk Stratification of Bicuspid Aortopathy. J Clin Med 2020; 9:jcm9010276. [PMID: 31963884 PMCID: PMC7020030 DOI: 10.3390/jcm9010276] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/27/2019] [Accepted: 01/14/2020] [Indexed: 11/16/2022] Open
Abstract
Objective: Aortic size-based criteria are of limited value in the prediction of aortic events, while most aortic events occur in patients with proximal aortic diameters < 50 mm. Serological biomarkers and especially circulating microRNAs (miRNAs) have been proposed as an elegant tool to improve risk stratification in patients with different aortopathies. Therefore, we aimed to evaluate the levels of circulating miRNAs in a surgical cohort of patients presenting with bicuspid aortic valve disease and distinct valvulo-aortic phenotypes. Methods: We prospectively examined a consecutive cohort of 145 patients referred for aortic valve surgery: (1) Sixty three patients (mean age 47 ± 11 years, 92% male) with bicuspid aortic valve regurgitation and root dilatation (BAV-AR), (2) thirty two patients (mean age 59 ± 11 years, 73% male) with bicuspid aortic valve stenosis (BAV-AS), and (3) fifty patients (mean age 56 ± 14 years, 55% male) with tricuspid aortic valve stenosis and normal aortic root diameters (TAV-AS) who underwent aortic valve+/-proximal aortic surgery at a single institution. MicroRNAs analysis included 11 miRNAs, all published previously in association with aortopathies. Endpoints of our study were (1) correlation between circulating miRNAs and aortic diameter and (2) comparison of circulating miRNAs in distinct valvulo-aortic phenotypes. Results: We found a significant inverse linear correlation between circulating miRNAs levels and proximal aortic diameter in the whole study cohort. The strongest correlation was found for miR-17 (r = −0.42, p < 0.001), miR-20a (r = −0.37, p < 0.001), and miR-106a (r = −0.32, p < 0.001). All miRNAs were significantly downregulated in BAV vs. TAV with normal aortic root dimensions Conclusions: Our data demonstrate a significant inverse correlation between circulating miRNAs levels and the maximal aortic diameter in BAV aortopathy. When comparing miRNAs expression patterns in BAV vs. TAV patients with normal aortic root dimensions, BAV patients showed significant downregulation of analyzed miRNAs as compared to their TAV counterparts. Further multicenter studies in larger cohorts are needed to further validate these results.
Collapse
Affiliation(s)
- Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
- Correspondence: ; Tel.: +40-7410-57853; Fax: +40-7410-54931
| | - Niklas Neumann
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
| | - Johannes Petersen
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
| | - Tatiana Sequeira-Gross
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
| | - Shiho Naito
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
| | - Maria von Stumm
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
| | - Yskert von Kodolitsch
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
- Department of Cardiology, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
| | - Tanja Zeller
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
- Department of Cardiology, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany
| |
Collapse
|
19
|
Bull LM, Lunt M, Martin GP, Hyrich K, Sergeant JC. Harnessing repeated measurements of predictor variables for clinical risk prediction: a review of existing methods. Diagn Progn Res 2020; 4:9. [PMID: 32671229 PMCID: PMC7346415 DOI: 10.1186/s41512-020-00078-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/28/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Clinical prediction models (CPMs) predict the risk of health outcomes for individual patients. The majority of existing CPMs only harness cross-sectional patient information. Incorporating repeated measurements, such as those stored in electronic health records, into CPMs may provide an opportunity to enhance their performance. However, the number and complexity of methodological approaches available could make it difficult for researchers to explore this opportunity. Our objective was to review the literature and summarise existing approaches for harnessing repeated measurements of predictor variables in CPMs, primarily to make this field more accessible for applied researchers. METHODS MEDLINE, Embase and Web of Science were searched for articles reporting the development of a multivariable CPM for individual-level prediction of future binary or time-to-event outcomes and modelling repeated measurements of at least one predictor. Information was extracted on the following: the methodology used, its specific aim, reported advantages and limitations, and software available to apply the method. RESULTS The search revealed 217 relevant articles. Seven methodological frameworks were identified: time-dependent covariate modelling, generalised estimating equations, landmark analysis, two-stage modelling, joint-modelling, trajectory classification and machine learning. Each of these frameworks satisfies at least one of three aims: to better represent the predictor-outcome relationship over time, to infer a covariate value at a pre-specified time and to account for the effect of covariate change. CONCLUSIONS The applicability of identified methods depends on the motivation for including longitudinal information and the method's compatibility with the clinical context and available patient data, for both model development and risk estimation in practice.
Collapse
Affiliation(s)
- Lucy M. Bull
- grid.5379.80000000121662407Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- grid.5379.80000000121662407Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Mark Lunt
- grid.5379.80000000121662407Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Glen P. Martin
- grid.5379.80000000121662407Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Kimme Hyrich
- grid.5379.80000000121662407Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- grid.498924.aNational Institute for Health Research Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Jamie C. Sergeant
- grid.5379.80000000121662407Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- grid.5379.80000000121662407Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| |
Collapse
|
20
|
D'Oria M, Mastrorilli D, Ziani B. Natural History, Diagnosis, and Management of Type II Endoleaks after Endovascular Aortic Repair: Review and Update. Ann Vasc Surg 2020; 62:420-431. [PMID: 31376537 DOI: 10.1016/j.avsg.2019.04.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/02/2019] [Accepted: 04/28/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Mayo Clinic Gonda Vascular Center, Rochester, MN; Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy.
| | - Davide Mastrorilli
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| | - Barbara Ziani
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Cattinara ASUITs, Trieste, Italy
| |
Collapse
|
21
|
Ferda J, Baxa J, Ferdova E, Kucera R, Topolcan O, Molacek J. Abdominal aortic aneurysm in prostate cancer patients: the "road map" from incidental detection to advanced predictive, preventive, and personalized approach utilizing common follow-up for both pathologies. EPMA J 2019; 10:415-423. [PMID: 31832115 PMCID: PMC6882970 DOI: 10.1007/s13167-019-00193-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/01/2019] [Indexed: 12/16/2022]
Abstract
Abdominal aortic aneurysm (AAA) is often a hidden pathological process showing no clinical symptoms. Genetic burden, smoking, male gender, age > 65 years, and white race have been identified as the main risk factors. A regular screening program has been introduced but is, as yet, unclear and is not performed in most countries. Prostate cancer is the most frequent male malignant disease in Western countries. Prostate cancer is a disease of older age with a median primary diagnosis of over 60 years. In recent years, advanced imaging methods have been established as important diagnostic tools in prostate cancer diagnostics. The incidental detection of AAA during diagnostic imaging performed due to prostate cancer diagnosis could reveal some asymptomatic aneurysms. Using our experience, the incidental detection of AAA during 18F-fluoromethylcholine PET/CT imaging, performed due to the staging, follow-up, and restaging of the prostate cancer, was reworked into a regular tool of secondary prevention within the framework of personalized medicine strategies. Experience with this type of AAA detection is demonstrated by a cohort of 500 patients who underwent 18F-fluorometylcholine PET/CT examination due to the staging or restaging of prostate cancer. A total of 28 aneurysms were detected (26 aneurysms < 50 mm, 2 aneurysms > 50 mm). In 2 cases (diameter < 50 mm), serious complications were found (penetrating aortic ulcer). The detection and monitoring of AAA in patients undergoing 18F-fluorometylcholine PET/CT due to the prostate cancer offers the possibility of a secondary prevention of AAA, patient stratification, and common follow-up for both pathologies.
Collapse
Affiliation(s)
- Jiri Ferda
- Department of Imaging Methods, University Hospital and Faculty of Medicine in Pilsen, Pilsen, Czech Republic
| | - Jan Baxa
- Department of Imaging Methods, University Hospital and Faculty of Medicine in Pilsen, Pilsen, Czech Republic
| | - Eva Ferdova
- Department of Imaging Methods, University Hospital and Faculty of Medicine in Pilsen, Pilsen, Czech Republic
| | - Radek Kucera
- Department of Immunochemistry Diagnostics, University Hospital and Faculty of Medicine in Pilsen, Pilsen, Czech Republic
| | - Ondrej Topolcan
- Department of Immunochemistry Diagnostics, University Hospital and Faculty of Medicine in Pilsen, Pilsen, Czech Republic
| | - Jiri Molacek
- Department of Surgery, University Hospital and Faculty of Medicine in Pilsen, Pilsen, Czech Republic
| |
Collapse
|
22
|
Liapis CD, Avgerinos ED, Eckstein HH. Proposed NICE Abdominal Aortic Aneurysm Repair Guidelines: Swinging the Pendulum too Far? Eur J Vasc Endovasc Surg 2019; 58:637-638. [DOI: 10.1016/j.ejvs.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/01/2019] [Accepted: 07/04/2019] [Indexed: 12/21/2022]
|
23
|
Optimizing Surveillance and Re-intervention Strategy Following Elective Endovascular Repair of Abdominal Aortic Aneurysms. Ann Surg 2019; 274:e589-e598. [PMID: 31592810 DOI: 10.1097/sla.0000000000003625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND EVAR for abdominal aortic aneurysm has an initial survival advantage over OR, but more frequent complications increase costs and long-term aneurysm-related mortality. Randomized controlled trials of EVAR versus OR have shown EVAR is not cost-effective over a patient's lifetime. However, in the EVAR-1 trial, postoperative surveillance may have been sub-optimal, as the importance of sac growth as a predictor of graft failure was overlooked. METHODS Real-world data informed a discrete event simulation model of postoperative outcomes following EVAR. Outcomes observed EVAR-1 were compared with those from 5 alternative postoperative surveillance and re-intervention strategies. Key events, quality-adjusted life years and costs were predicted. The impact of using complication and rupture rates from more recent devices, imaging and re-intervention methods was also explored. RESULTS Compared with observed EVAR-1 outcomes, modeling full adherence to the EVAR-1 scan protocol reduced abdominal aortic aneurysm (AAA) deaths by 3% and increased elective re-interventions by 44%. European Society re-intervention guidelines provided the most clinically effective strategy, with an 8% reduction in AAA deaths, but a 52% increase in elective re-interventions. The cheapest and most cost-effective strategy used lifetime annual ultrasound in primary care with confirmatory computed tomography if necessary, and reduced AAA-related deaths by 5%. Using contemporary rates for complications and rupture did not alter these conclusions. CONCLUSIONS All alternative strategies improved clinical benefits compared with the EVAR-1 trial. Further work is needed regarding the cost and accuracy of primary care ultrasound, and the potential impact of these strategies in the comparison with OR.
Collapse
|
24
|
Columbo JA, Ramkumar N, Martinez-Camblor P, Kang R, Suckow BD, O'Malley AJ, Sedrakyan A, Goodney PP. Five-year reintervention after endovascular abdominal aortic aneurysm repair in the Vascular Quality Initiative. J Vasc Surg 2019; 71:799-805.e1. [PMID: 31471231 DOI: 10.1016/j.jvs.2019.05.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 05/14/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patients who undergo endovascular abdominal aortic aneurysm repair (EVR) remain at risk for reintervention and rupture. We sought to define the 5-year rate of reintervention and rupture after EVR in the Vascular Quality Initiative (VQI). METHODS We identified all patients in the VQI who underwent EVR from 2003 to 2015. We linked patients in the VQI to Medicare claims for long-term outcomes. We stratified patients on baseline clinical and procedural characteristics to identify those at risk for reintervention. Our primary outcomes were 5-year rates of reintervention and late aneurysm rupture after EVR. We assessed these with Kaplan-Meier survival estimation. RESULTS We studied 12,911 patients who underwent EVR. The mean age was 75.5 years, 79.9% were male, 3.9% were black, and 89.1% of operations were performed electively. The 5-year rate of reintervention for the entire cohort was 21%, and the 5-year rate of late aneurysm rupture was 3%. Reintervention rates varied across categories of EVR urgency. Patients who underwent EVR electively had the lowest 5-year rate of reintervention at 20%. Those who underwent surgery for symptomatic aneurysms had higher rates of reintervention at 25%. Patients undergoing EVR emergently for rupture had the highest rate of reintervention, 27% at 4 years (log-rank across the three groups, P < .001). Black race and aneurysm size of 6.0 cm or greater were associated with significantly elevated reintervention rates (black, 31% vs white, 20% [log-rank, P < .001]; aneurysm size 6.0 cm or greater, 27% vs all others, <20% [log-rank, P < .001]). There were no significant associations between age or gender and the 5-year rate of reintervention. CONCLUSIONS More than one in five Medicare patients undergo reintervention within 5 years after EVR in the VQI; late rupture remains low at 3%. Black patients, those with large aneurysms, and those who undergo EVR urgently and emergently have a higher likelihood of adverse outcomes and should be the focus of diligent long-term surveillance.
Collapse
Affiliation(s)
- Jesse A Columbo
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
| | - Niveditta Ramkumar
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Pablo Martinez-Camblor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Ravinder Kang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Bjoern D Suckow
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Art Sedrakyan
- Department of Surgery, Weill-Cornell Medical School, New York, NY
| | - Philip P Goodney
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| |
Collapse
|
25
|
Grima MJ, Karthikesalingam A, Holt PJ, Kerr D, Chetter I, Harrison S, Sayers R, Roy I, Vallabhaneni SR, Dominic P, Bachoo P, Griffin J, Lewis D, Hardman J, Rihan A, Brooks M, Woodburn K, Godfrey D, Nordon I, Vidal-Diez A, Stenson K, Bahia S, Patterson B, Oladokun D, De Bruin J, Loftus I, Thompson MM, Lowe C, Ashrafi M, Ghosh J, Ashleigh R. Multicentre Post-EVAR Surveillance Evaluation Study (EVAR-SCREEN). Eur J Vasc Endovasc Surg 2019; 57:521-526. [DOI: 10.1016/j.ejvs.2018.10.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 10/27/2018] [Indexed: 11/29/2022]
|