Preoperative Spirometry Results as a Determinant for Long-term Mortality after EVAR for AAA

[Summary of the S3 guideline on abdominal aortic aneurysm from an anesthesiological perspective]

The current article is a summary of the 2018 revised S3 guideline on screening, diagnosis, therapy, and follow-up of the abdominal aortic aneurysm (AAA) from an anesthesiological point of view. It is the only interdisciplinary guideline that describes in particular the perioperative anesthesiological and intensive care management.

Development and internal validation of a prognostic model for mortality of patients with abdominal aortic aneurysms treated with endovascular aneurysm repair

Background: Morbidity and mortality associated with elective endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA) must be balanced against the impending risk of aneurysm rupture and the estimated remaining lifetime. The aim of this study is to develop and validate a prognostic model for mortality of patients with AAA treated with EVAR. Methods: This retrospective observational study included 251 consecutive patients treated with EVAR for asymptomatic AAA between January 2001 and December 2012 at the University Hospital in Bern, Switzerland. Pre-selection of variables was based on a literature review; least absolute shrinkage and selection operator technique was used for the final variable selection. A Firth's bias reduced Cox proportional hazard model was developed and validated using 10,000 bootstrap samples to predict survival after EVAR. Results: The median follow-up time was 5.3 years (range 0.1 to 15.9). At the study closing date 95% of follow-up information was available. The mortality rates were 31.9% at 5 years and 50.5% at the study closing date, respectively. Identified predictors for overall mortality after EVAR were age, hazard ratio (HR) = 2.24 per 10-year increase (95% CI 1.64 to 3.09), the presence of chronic obstructive pulmonary disease (COPD), HR = 2.22 (95% CI 1.48 to 3.31), and lower estimated glomerular filtration rate, HR = 1.24 per 10 ml/min/1.73 m² decrease (95% CI 1.12 to 1.39). The model showed good discrimination ability, Harrell's C = 0.722 (95% CI 0.667 to 0.778) and was very robust in the bootstrap in-sample validation Harrell's C = 0.726 (95% CI 0.662 to 0.788). Conclusion: Higher age, the presence of COPD and impaired kidney function are independent predictors for impaired survival after EVAR. The expected remaining lifetime should be considered in patients with AAA. This prognostic model can help improving patient care; however, external validation is needed prior to clinical implementation.

Malnutrition provides important long-term prognostic information in patients undergoing endovascular abdominal aortic aneurysm repair

OBJECTIVES

Malnutrition has been shown to be associated with survival in a variety of diseases. Our aim is to evaluate the prognostic value of objective nutritional indexes indicating malnutrition, in patients underwent endovascular aortic replacement.

METHODS

We retrospectively evaluated 149 consecutive patients who underwent technically successful endovascular aortic replacement operation between October 2010 and August 2019. Objective nutritional indexes, prognostic nutritional index, geriatric nutritional risk index and controlling nutritional status, scores were calculated using the preoperative data. Optimal cut-off values were obtained by receiver operating characteristic analysis. According to the cut-off values, we investigated the relationship between indexes and the long-term all-cause mortality.

RESULTS

During mean 48.0 ± 30.3 months follow-up duration, in 47 of patients (31.5%), all-cause mortality were documented. In mortality group, prognostic nutritional index (42.8 ± 7.1 vs 51.3 ± 5.2, p < 0.001) and geriatric nutritional risk index (100.7 ± 10.1 vs 107.6 ± 9.2, p < 0.001) were significantly lower, controlling nutritional status score (2.0 (1.0-4.0) vs 1.0 (0.0-2.0), p < 0.001) was higher when compared to survivor group. Kaplan-Meier curves presented higher mortality incidence in malnutrition patients evaluated with objective nutritional indexes (Log-rang test, for all three indexes p < 0.001). Besides Cox-proportional hazard analysis showed all three nutritional indexes may be a predictive marker for all-cause mortality, prognostic nutritional index introduced more valuable data than other two indexes.

CONCLUSIONS

Malnutrition is associated with significant increase in postoperative long-term mortality in endovascular aortic replacement patients. Preoperatively calculated objective nutritional indexes especially prognostic nutritional index can be used as an important prognostic tool.

Pulmonary complications and survival after elective infrarenal endovascular abdominal aneurysm repair in patients with documented chronic obstructive pulmonary disease

BACKGROUND

Elective abdominal aortic aneurysm (AAA) repair is advocated in patients where risk of rupture exceeds the risks of peri-procedural morbidity and mortality. Chronic obstructive pulmonary disease (COPD) is a known risk factor for AAA and increased operative morbidity in general. Since literature on the correlation between the clinical classification of COPD and morbidity following endovascular infrarenal AAA repair (EVAR) is scarce, assessment per individual remains a challenge.

OBJECTIVE

To analyse the pulmonary and all-cause morbidity and mortality in patients with documented COPD and relate this to their GOLD classification.

METHODS

Sixty-eight patients with COPD, documented by a lung function test, who underwent elective EVAR between July 2002 and July 2018 were retrospectively reviewed. The primary endpoint was the incidence of 30-day pulmonary adverse events. Procedural characteristics, length of hospital stay, pulmonary and all-cause morbidity including major adverse events (MAEs) during follow-up and five-year survival divided per GOLD classification were the secondary endpoints.

RESULTS

There was no statistically significant difference in the incidence of pulmonary adverse events between GOLD I/II and GOLD III/IV patients. There was neither procedural nor 30-day mortality in either group. Through 30 days and 1 year, there was no difference in pulmonary and all-cause morbidity between groups. Three MAEs occurred in the GOLD I/II group versus 2 MAE in the GOLD III/IV group during the first postoperative year. The five-year survival was 66.0%, 60.9% and 61.9% for patients with GOLD I, GOLD II and GOLD III, respectively. Three of four GOLD IV died within the first year after EVAR.

CONCLUSION

EVAR can be safely performed in patients with COPD, with low 30-day morbidity and mortality rates. Although severe co-morbidity should be taken into account, EVAR seems to be justified in patients with COPD with a GOLD classification I, II or III. Further research should focus on optimising the pulmonary condition in patients selected for EVAR.

Preoperative Predictors of Long-Term Mortality after Elective Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm

OBJECTIVE

This study aimed to clarify long-term mortality and its predictors in patients with abdominal aortic aneurysm (AAA) who underwent endovascular aneurysm repair (EVAR).

MATERIALS AND METHODS

Patients with AAA who underwent elective EVAR at Tokyo Medical and Dental University hospital between 2008 and 2011 were reviewed. The patients' data were retrospectively collected from medical records.

RESULTS

Sixty-four patients were identified for this study. In long-term follow-up, the survival rate was significantly lower in patients with high preoperative C-reactive protein (CRP) levels. Patients with obstructive lung disease (FEV1/FVC <70%) or anemia tended to have a poorer prognosis but the association was not statistically significant. Age, concurrent hyperlipidemia, and blood pressure levels were not predictors of mortality rates.

DISCUSSION

High CRP level, COPD, and anemia reflect inflammation, which is associated with the pathogenesis of AAA. These inflammatory markers are predictors of long-term mortality after EVAR for AAA as well as for other diseases.

CONCLUSIONS

A high preoperative CRP level was a predictor of increased long-term mortality in patients with AAA who underwent EVAR. No specific leading causes of death were identified for this increase in the mortality rate.

Preoperative risk assessment--from routine tests to individualized investigation

BACKGROUND

Risk assessment in adults who are about to undergo elective surgery (other than cardiac and thoracic procedures) involves history-taking, physical examination, and ancillary studies performed for individual indications. Further testing beyond the history and physical examination is often of low predictive value for perioperative complications.

METHOD

This review is based on pertinent articles that were retrieved by a selective search in the Medline and Cochrane Library databases and on the consensus-derived recommendations of the German specialty societies.

RESULTS

The history and physical examination remain the central components of preoperative risk assessment. Advanced age is not, in itself, a reason for ancillary testing. Laboratory testing should be performed only if relevant organ disease is known or suspected, or to assess the potential side effects of pharmacotherapy. Electrocardiography as a screening test seems to add little relevant information, even in patients with stable heart disease. A chest X-ray should be obtained only if a disease is suspected whose detection would have clinical consequences in the perioperative period.

CONCLUSION

In preoperative risk assessment, the history and physical examination are the strongest predictors of perioperative complications. Ancillary tests are indicated on an individual basis if the history and physical examination reveal that significant disease may be present.