Editor's Choice - Abdominal Compartment Syndrome After Surgery for Abdominal Aortic Aneurysm: A Nationwide Population Based Study

Management of acute mesenteric ischaemia in adult patients: a systematic review and meta-analysis

BACKGROUND

Guidance on managing acute mesenteric ischaemia (AMI) is largely based on expert opinion and retrospective studies pooling different subtypes of AMI. In clinical practice, management strategy is often selected based on the patient's severity of illness, whereas randomized controlled trials or even adjusted analyses comparing different strategies are rarely available. We aimed to perform a systematic review and meta-analysis on the effect of different management options when adjusted for the baseline severity of illness.

METHODS

A literature search was performed in PubMed, the Cochrane Library, Web of Science and Scopus. Studies recruiting patients after the year 2000, assessing at least 10 adult patients with reliably confirmed AMI, and comparing different management approaches were considered for inclusion. Thirteen study questions on different management strategies in different subtypes of AMI were formulated a priori. We included studies reporting results of adjusted analyses or reporting any variables reflecting the severity of illness in both study groups under comparison.

RESULTS

A total of 3324 publications were identified, 321 were selected for full-text review and 31 included in the review and analysis. Most of the studies comparing different management strategies of AMI did not report the severity of illness in the groups under comparison. Any variable that could be considered to reflect the severity of illness was reported in 26 studies. The available data only allowed one meta-regression analysis comparing initial endovascular revascularization versus open surgery in arterial occlusive AMI, including four studies that reported white blood cell count and lactate. The results indicate that the significant advantage of the endovascular approach suggested in the crude analysis may be abolished when adjusting for the severity of the illness. Narrative summaries and raw data are presented for other research questions.

CONCLUSIONS

The severity of illness plays an important role in the selection of management strategy and largely determines the outcome of any treatment, yet is generally not considered in available studies assessing the management of AMI. There is a major gap in the literature precluding appropriate analyses on treatment effects. Future studies should report subtypes of AMI and the severity of illness for each group.

STUDY REGISTRATION

PROSPERO CRD42024568497, date of registration: July 20th, 2024.

Abdominal Compartment Syndrome After Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: A Single-Center Experience of Total Endovascular Care for Ruptured Abdominal Aneurysms

OBJECTIVE

Open repair of ruptured abdominal aortic aneurysms (rAAA) has been increasingly replaced by endovascular aortic repair (EVAR) in many centers. Despite being a minimally invasive procedure, EVAR is associated with a risk of abdominal compartment syndrome (ACS), which can lead to significant morbidity and mortality. This study examines the incidence and clinical manifestation of ACS in a consecutive cohort of rAAA patients treated exclusively with EVAR at Örebro University Hospital over a 12-year period.

METHODS

This is a retrospective analysis of prospectively collected data. We identified 139 patients who had presented to Örebro University Hospital with rAAA between October 2009 and September 2021. Patients with isolated iliac artery, thoracic and thoracoabdominal aortic ruptures, previous aortic interventions (open or endovascular), and patients receiving palliative treatment were excluded. Patients developing ACS after rAAA were compared with those who did not develop ACS.

RESULTS

A total of 100 patients treated using EVAR were included in this study. ACS was identified in 17 patients, and these were compared with 83 patients who did not develop ACS. Mortality at 30 days was 53% in the ACS group (9/17) and 22% in the No-ACS group (18/83, p = 0.015). Regression analysis showed that advanced age and ACS were independent risk factors for death, with ACS increasing the hazard 4-fold (HR 4.26, CI 1.99-9.10, p < 0.001) and age increasing the hazard by 6% for every year (HR 1.06, CI 1.06-1.1, p = 0.004). The use of aortic balloon occlusion was not independently associated with the development of ACS.

CONCLUSIONS

ACS is a life-threatening complication of rAAA treated using EVAR and a significant number of patients developed ACS with high mortality and complication rates. All rAAA patients treated using EVAR should be monitored closely for ACS and treatment with decompressive laparotomy should be initiated without delay.Clinical ImpactOpen repair of ruptured abdominal aortic aneurysms (rAAA) has been increasingly replaced by endovascular aortic repair (EVAR). Despite being a minimally invasive procedure, EVAR is associated with a risk of abdominal compartment syndrome (ACS), which can lead to significant morbidity and mortality This article investigates abdominal compartment syndrome (ACS) in a cohort of total endovascular treated rAAA in a single centre and the treatment as well as the results, and gives insight on ACS in this patient group and might contribute to better understanding how to treat them and avoid this life-threatening complication.

[Ischemia-related compartment syndromes in vascular surgery]

Even after the endovascular revolution, acute compartment syndrome (CS) remains an important and frequently present differential diagnosis after many operations. Based on a qualitative review this article gives an overview of the most frequent forms of CS as well as some less frequent entities that require attention in the routine clinical practice. Additionally, the pathophysiology, diagnostics and treatment as well as current research topics for CS, especially concerning the lower leg, are dealt with in detail. In summary, nothing has essentially changed ever since the first description of CS in that the clinical estimation remains the gold standard. The detection and the adequate treatment especially of abdominal CS and CS of the lower leg remain a key competence of vascular surgeons.

Increasing Use of Prophylactic Open Abdomen Therapy With Vacuum Assisted Wound Closure and Mesh Mediated Fascial Traction After Repair of Ruptured Abdominal Aortic Aneurysm

OBJECTIVE

Open abdomen therapy (OAT) is commonly used to prevent or treat abdominal compartment syndrome (ACS) in patients with ruptured abdominal aortic aneurysms (rAAAs). This study aimed to evaluate the incidence, treatment, and outcomes of OAT after rAAA from 2006 to 2021. Investigating data on resuscitation fluid, weight gain, and cumulative fluid balance could provide a more systematic approach to determining the timing of safe abdominal closure.

METHODS

This was a single centre observational cohort study. The study included all patients treated for rAAA followed by OAT from October 2006 to December 2021.

RESULTS

Seventy-two of the 244 patients who underwent surgery for rAAA received OAT. The mean age was 72 ± 7.85 years, and most were male (n = 61, 85%). The most frequent comorbidities were cardiac disease (n = 31, 43%) and hypertension (n = 31, 43%). Fifty-two patients (72%) received prophylactic OAT, and 20 received OAT for ACS (28%). There was a 25% mortality rate in the prophylactic OAT group compared with the 50% mortality in those who received OAT for ACS (p = .042). The 58 (81%) patients who survived until closure had a median of 12 (interquartile range [IQR] 9, 16.5) days of OAT and 5 (IQR 4, 7) dressing changes. There was one case of colocutaneous fistula and two cases of graft infection. All 58 patients underwent successful abdominal closure, with 55 (95%) undergoing delayed primary closure. In hospital survival was 85%. Treatment trends over time showed the increased use of prophylactic OAT (p ≤ .001) and fewer ACS cases (p = .03) assessed by Fisher's exact test. In multivariable regression analysis fluid overload and weight reduction predicted 26% of variability in time to closure.

CONCLUSION

Prophylactic OAT after rAAA can be performed safely, with a high rate of delayed primary closure even after long term treatment.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review

BACKGROUND

The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery.

METHODS

A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen.

RESULTS

The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible.

CONCLUSION

Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.

Does the Routine Skin-Only Closure in Ruptured Abdominal Aortic Aneurysm Repair Safely Diminish Abdominal Compartment Syndrome? A Hypothesis Generating Retrospective Study

BACKGROUND

 Abdominal compartment syndrome (ACS) often complicates ruptured abdominal aortic aneurysm (rAAA) repair. We report results with routine skin-only abdominal wound closure after rAAA surgical repair.

METHODS

 This was a single-center retrospective study including consecutive patients undergoing rAAA surgical repair for the duration of 7 years. Skin-only closure was routinely performed, and if possible, secondary abdominal closure was performed during the same admission. Demographic information, preoperative hemodynamic condition, and perioperative information (ACS, mortality, rate of abdominal closure, and postoperative outcomes) were collected.

RESULTS

 During the study period, 93 rAAAs were recorded. Ten patients were too frail to undergo repair or refused treatment. Eighty-three patients underwent immediate surgical repair. The mean age was 72.4 ± 10.5 years, and the vast majority were male (82:1). Preoperative systolic blood pressure <90 mm Hg was recorded in 31 patients. Intraoperative mortality was recorded in nine cases. Overall in-hospital mortality was 34.9% (29/83). Primary fascial closure was performed in five patients, while skin-only closure was performed in 69. ACS was recorded in two cases in whom skin sutures were removed and negative pressure wound treatment was applied. Secondary fascial closure was feasible in 30 patients during the same admission. Among 37 patients not undergoing fascial closure, 18 died and 19 survived and were discharged with a planned ventral hernia repair. Median length of intensive care unit and hospital stay were 5 (1-24) and 13 (8-35) days, respectively. After a mean follow-up of 21 months, telephone contact was possible with 14/19 patients who left the hospital with an abdominal hernia. Three reported hernia-related complications mandating surgical repair, while in 11, this was well tolerated.

CONCLUSION

 Routine skin-only closure during rAAA surgical repair results in low rates of ACS at the expense of a high rate of patients being discharged with a planned ventral hernia which, however, seems to be well tolerated by the majority of patients.

Open abdominal management after ruptured abdominal aortic aneurysm repair: from a single-center study in Japan

PURPOSE

We investigated the utility of the open abdominal management (OA) technique for ruptured abdominal aortic aneurysm (rAAA).

METHODS

Between January 2016 and August 2021, 33 patients underwent open surgery for rAAA at our institution. The patients were divided into OA (n = 12) and non-OA (n = 21) groups. We compared preoperative characteristics, operative data, and postoperative outcomes between the two groups. The intensive care unit management and abdominal wall closure statuses of the OA group were evaluated.

RESULTS

The OA group included significantly more cases of a preoperative shock than the non-OA group. The operation time was also significantly longer in the OA group than in the non-OA group. The need for intraoperative fluids, amount of bleeding, and need for blood transfusion were significantly higher in the OA group than in the non-OA group. Negative pressure therapy (NPT) systems are useful in OA. In five of the six survivors in the OA group, abdominal closure was able to be achieved using components separation (CS) technique.

CONCLUSIONS

NPT and the CS technique may increase the abdominal wall closure rate in rAAA surgery using OA and are expected to improve outcomes.

Guidelines on the management of abdominal aortic aneurysms: updates from the Italian Society of Vascular and Endovascular Surgery (SICVE)

The objective of these Guidelines was to revise and update the previous 2016 Italian Guidelines on Abdominal Aortic Aneurysm Disease, in accordance with the National Guidelines System (SNLG), to guide every practitioner toward the most correct management pathway for this pathology. The methodology applied in this update was the GRADE-SIGN version methodology, following the instructions of the AGREE quality of reporting checklist as well. The first methodological step was the formulation of clinical questions structured according to the PICO (Population, Intervention, Comparison, Outcome) model according to which the Recommendations were issued. Then, systematic reviews of the Literature were carried out for each PICO question or for homogeneous groups of questions, followed by the selection of the articles and the assessment of the methodological quality for each of them using qualitative checklists. Finally, a Considered Judgment form was filled in for each clinical question, in which the features of the evidence as a whole are assessed to establish the transition from the level of evidence to the direction and strength of the recommendations. These guidelines outline the correct management of patients with abdominal aortic aneurysm in terms of screening and surveillance. Medical management and indication for surgery are discussed, as well as preoperative assessment regarding patients' background and surgical risk evaluation. Once the indication for surgery has been established, the options for traditional open and endovascular surgery are described and compared, focusing specifically on patients with ruptured abdominal aortic aneurysms as well. Finally, indications for early and late postoperative follow-up are explained. The most recent evidence in the Literature has been able to confirm and possibly modify the previous recommendations updating them, likewise to propose new recommendations on prospectively relevant topics.

Derivation and Validation of a Risk Score for Abdominal Compartment Syndrome after Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms

BACKGROUND

Abdominal compartment syndrome (ACoS) is a devastating complication after endovascular aneurysm repair for ruptured abdominal aortic aneurysms (rEVAR). This study sought to develop a risk score for ACoS to identify patients who would benefit from early decompressive laparotomy.

METHODS

Model derivation was performed with VQI data for rEVAR from 2013-2020. The primary outcome was evacuation of abdominal hematoma. Multivariable logistic regression was used to create and validate a scoring system to predict ACoS. The model was validated using institutional data for rEVAR from 1998-2019.

RESULTS

The derivation cohort included 2,310 patients with rEVAR. Abdominal hematoma evacuation occurred in 265 patients (11.5%). Factors associated with abdominal hematoma evacuation on multivariable analysis included transfer from an outside hospital, preoperative creatinine ≥1.4 mg/dl, preoperative systolic blood pressure ≤85 mmHg, preoperative altered mental status, ≥3.0 liters intraoperative crystalloid, and ≥4 units of red blood cells transfused intraoperatively. The validation cohort consisted of 67 rEVAR; ACoS occurred in 8 patients (11.9%). The c-statistic was 0.84 in the derivation and 0.87 in the validation cohort, while Hosmer-Lemeshow was p= 0.15 in the derivation and 0.84 in the validation cohorts, suggesting good model discrimination and calibration. Points were applied based on β-coefficients to produce a risk score ranging from -1 to 13. A cutoff of risk score ≥8 resulted in a sensitivity and specificity of 87.5% and 83.1% for detecting patients with ACoS, respectively. ACoS conveyed a significantly higher mortality in both the derivation (ACoS: 49.8% vs No ACoS: 17.8%; p<0.001) and validation cohorts (ACoS: 75.0% vs No ACoS: 15.2%; p<0.001).

CONCLUSION

In patients with equivocal signs/symptoms of ACoS, this scoring system can be used to guide surgeons on when to perform decompressive laparotomy prior to leaving the operating room for rEVAR. Patients with a risk score ≥8 would benefit from decompressive laparotomy at index rEVAR.

Treatment Strategies for Improving the Surgical Outcomes of Ruptured Abdominal Aortic Aneurysm: Single-Center Experience in Japan

Objective: We aimed to examine the surgical outcomes of ruptured abdominal aortic aneurysm cases at our hospital and considered strategies for improvement.

Material and Methods: We examined the preoperative characteristics of hospital mortality, postoperative complications, and long-term outcomes of 91 surgical cases of ruptured abdominal aortic aneurysm performed between January 2009 and December 2020 at our hospital.

Results: Of the 91 cases, 24 died at the hospital (mortality, 26.3%). Mortality was mostly due to hemorrhage/disseminated intravascular coagulation and intestinal necrosis. Ten patients required preoperative aortic clamp by thoracotomy or insertion of intra-aortic balloon occlusion, and eight of them died. Ten patients required open abdominal management due to abdominal compartment syndrome, and five of them died. There was no significant difference between the two groups in terms of the long-term results of the open repair and abdominal endovascular aneurysm repair (EVAR).

Conclusion: To improve the surgical outcomes of ruptured abdominal aortic aneurysms, it is necessary to start surgery immediately. Therefore, the choice of surgical method (open surgery or EVAR) should be based on the resources and discretion of the hospital. To prevent postoperative intestinal necrosis, risk factors for acute compartment syndrome should be considered, and open abdominal management should be introduced.

Risk Factors for Abdominal Compartment Syndrome After Endovascular Repair for Ruptured Abdominal Aortic Aneurysm: A Case Control Study

OBJECTIVE

Ruptured abdominal aortic aneurysms (rAAA) are treated by endovascular aneurysm repair (rEVAR) increasingly often. Despite rEVAR being a minimally invasive method, abdominal compartment syndrome (ACS) remains a significant post-operative threat. The aim of this study was to investigate risk factors for ACS after rEVAR, including aortic morphological features.

METHODS

The Swedish vascular registry (Swedvasc) was assessed for ACS after rEVAR in the period 2008 - 2015. All patients identified were compared with controls (i.e., patients who did not develop ACS after rEVAR), matched by centre and repair date. Case records were reviewed, and radiology images analysed in a core laboratory. Comparisons were performed with respect to physiological and radiological risk factors.

RESULTS

The study population consisted of 40 patients with ACS and 68 controls. Pre-operatively, patients with ACS had a lower blood pressure (BP) than controls (median 70 mmHg vs. 97 mmHg; p < .001). Intra-operatively, they had aortic balloon occlusion more often (55.0% vs. 10.3%; p < .001) and received more transfusions than controls (median nine units of packed red blood cells [pRBC] vs. two units; p < .001). Ninety-seven per cent of those who developed ACS had a pre-operative BP < 70 mmHg, aortic balloon occlusion, or received more than five pRBC unit transfusions. Treatment outside the instructions for use did not differ between patients and controls (57.5% vs. 54.4%; p = .84), and neither did the pre-operative patency of the inferior mesenteric artery (57.1% vs. 63.9%; p = .52) nor the number of visible lumbar arteries on pre-operative imaging (2 vs. 4; p = .014). In multivariable logistic regression, the number of intra-operative transfusions were predictive of ACS (p < .001), while pre-operative hypotension (p = .32) and aortic balloon occlusion (p = .018) were not.

CONCLUSION

ACS after rEVAR is mainly associated with physiological factors and is unlikely to develop without the presence of a pre-operative BP < 70 mmHg, the need for an aortic occlusion balloon, or more than five intra-operative pRBC unit transfusions. Treatment outside the IFU or any other morphological factor were not associated with a risk of ACS.

Managing the Open Abdomen in Damage Control Surgery: Should Skin-Only Closure be Abandoned?

During damage control laparotomy, surgery is abbreviated to allow for the correction of physiologic disturbances, with a plan to return to the operating theatre for definitive surgical repair. Re-entry into the abdomen is facilitated by temporary abdominal closure (TAC). Skin-only closure is one of the many techniques described for TAC Numerous sources advise against the use of this technique because of the risk of complications. This case report describes the use of skin-only closure during a damage control laparotomy. We reviewed the literature surrounding the various options for TAC to elucidate the potential role of skin-only closure after damage control laparotomy.

Surveillance to detect colonic ischemia with extraluminal pH measurement after open surgery for abdominal aortic aneurysm

OBJECTIVE

Colonic ischemia (CI) is a life-threatening complication after aortic surgery. Postoperative surveillance of colonic perfusion might be warranted. The aim of the present study was to evaluate the safety and feasibility of postoperative extraluminal pH measurement (pHe) using colonic tonometry after open abdominal aortic aneurysm (AAA) repair.

METHODS

Before closing the abdomen after open AAA repair, a tonometric catheter was placed transabdominally in contact with the sigmoid colon serosa, similar to a drainage catheter. Extraluminal partial pressure of carbon dioxide was measured postoperatively and combined with arterial blood gas analysis to calculate the pHe. The measurements were repeated every 4 hours with simultaneous intra-abdominal pressure measurements. The threshold for colonic malperfusion was set at pHe <7.2.

RESULTS

A total of 27 patients were monitored, 12 had undergone surgery for ruptured AAAs and 15 for intact AAAs. Of the 27 patients, 4 developed clinically significant CI requiring surgery. All four cases were preceded by a prolonged (>5 hours) pHe <7.2 indicating malperfusion. A fifth patient, who, during monitoring, had had the lowest pHe of 7.21, developed mild CI with the onset after completion of monitoring, which was successfully managed conservatively. Seven patients who had had brief durations (<5 hours) of pHe <7.2 did not develop clinical signs of CI or any related adverse events.

CONCLUSIONS

Measurements of pHe using colonic tonometry indicated malperfusion in all four patients who had developed clinically significant CI. A shorter duration of low pHe was well tolerated without any signs of CI. Measurement of pHe was safe and reliable for the surveillance of colonic perfusion after open aortic surgery, indicating a promising technique. However, larger studies are needed.

Abdominal aortic aneurysms part two: Surgical management, postoperative complications and surveillance

Large, symptomatic and ruptured abdominal aortic aneurysms are usually treated surgically if patients are deemed fit enough. This may be achieved through endovascular or open surgical repair. The type of treatment that a patient receives is dependant on many factors, such as the rupture status of the aneurysm. Each approach is also associated with different risks and postoperative complications. Multiple guidelines exist to inform the surgical management of abdominal aortic aneurysms. This literature review combines these recommendations and explores the evidence upon which they are based. In addition, it highlights the key perioperative considerations that need to be considered in cases of unruptured and ruptured abdominal aortic aneurysms.

Abdominal compartment syndrome after r-EVAR: a systematic review with meta-analysis on incidence and mortality

INTRODUCTION

Endovascular aneurysm repair for ruptured abdominal aortic aneurysms (r-EVAR) sometimes complicates with abdominal compartment syndrome (ACS) due to extensive retroperitoneal hematoma, with significant prognostic implications. This systematic review aimed to analyze the incidence of the syndrome and assess the impact of ACS on mortality. Mortality after decompressive laparotomy was also assessed.

EVIDENCE ACQUISITION

Two databases were searched: Medline and Web of Science. The search was conducted through October 2019. The titles and abstracts of the retrieved articles were independently reviewed. All studies reporting on the ACS incidence after r-EVAR were initially included. From each study, eligibility was determined and descriptive, methodological, and outcome data was extracted. The incidence was calculated with summary proportion. Odds ratio was used to compare the mortality rate. Meta-analysis was performed with fixed effect model when calculating the ACS incidence in r-EVAR patients and when assessing the impacts of ACS and DL in the mortality rate.

EVIDENCE SYNTHESIS

A total of 46 studies were included, with a cumulative cohort of 3064 patients. Two hundred and fifty-two (8.2%) patients developed ACS. The ACS pooled incidence was 9% with a 95% confidence interval of [0.08; 0.11]. Among the 46 included studies, 19 studies reported data on the mortality rate, corresponding to 1825 of the 3064 patients. Of these, 169 (9.3%) had developed ACS and 94 (55.6%) of them died by multi organ failure. Among the 1656 patients without ACS, 328 died (19.8%). The mortality odds ratio meta-analysis was 6.25 with a 95% confidence interval of [4.44, 8.80]. Decompressive laparotomy was performed in 41 patients, decreasing mortality in 47%.

CONCLUSIONS

ACS affects approximately 9% of patients submitted to r-EVAR, and significantly increases perioperative mortality. Close postoperative surveillance to clinical signs of ACS is vital in these patients.

Successful Endovascular Treatment of a Ruptured Giant Lumbar Arteriovenous Malformation

Arteriovenous malformations (AVMs) are rare congenital vascular anomalies where rupture can be fatal. This report describes a case of a 69-year-old woman who presented with sudden severe lower back pain radiating to her left buttock and thigh and an inability to move her left leg. Computed tomography angiography (CTA) showed an extensive ruptured retroperitoneal AVM on the left paravertebral side with active bleeding and a large hematoma. Cardiopulmonary resuscitation with considerable blood transfusion was required. The AVM was effectively treated with coil embolization of the feeding lumbar arteries. Shortly after the intervention, the patient developed abdominal compartment syndrome. Urgent laparotomy with evacuation of the retroperitoneal hematoma was required. The patient was discharged 16 days after admission in a good physical condition and has been free of symptoms for more than a year after intervention. However, follow-up CTA showed residual contrast enhancement in the AVM and further surveillance is required.

Operative Strategy of Ruptured Abdominal Aortic Aneurysms and Management of Postoperative Complications

In addition to traditional open surgical repair (OSR), endovascular aneurysm repair (EVAR) is currently another strong option to treat RAAA. All vascular surgeons who try to save RAAA patients must be deeply versed in both OSR and EVAR. In this article, current trend of RAAA treatment and abdominal compartment syndrome, which has been most important postoperative complication, are reviewed. (This is a translation of Jpn J Vasc Surg 2019; 28: 127–132.)

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.

Routine open abdomen treatment compared with on-demand open abdomen or direct closure following open repair of ruptured abdominal aortic aneurysms: A propensity score-matched study

Objective:

To investigate whether a strategy of treatment with a primarily open abdomen improves outcome in terms of mortality and major complications in patients treated with open repair for a ruptured abdominal aortic aneurysm compared to a strategy of primary closure of the abdomen.

Design:

Retrospective cohort study.

Methods:

Patients treated with a primarily open abdomen at a centre where this strategy was routine in most ruptured abdominal aortic aneurysm patients were compared to a propensity score–matched control group of patients who had the abdomen closed at the end of the primary operation in a majority of the cases.

Results:

In total, 79 patients treated with a primarily open abdomen after open repair for ruptured abdominal aortic aneurysm at Sahlgrenska University Hospital were compared to a propensity score–matched control group of 148 patients. The abdomen was closed at the end of the procedure in 108 (73%) of the control patients. There was no difference in 30-day mortality between patients treated with a primarily open abdomen at Sahlgrenska University Hospital and the controls, 21 (26.6%) versus 49 (33.1%), p = 0.37. The adjusted odds ratio for mortality at 30 days was 0.66 (95% confidence interval: 0.35–1.25) in patients treated with a primarily open abdomen at Sahlgrenska University Hospital compared to the controls. No difference was observed between the groups regarding 90-day mortality, postoperative renal failure requiring renal replacement therapy, postoperative intestinal ischaemia necessitating bowel resection or postoperative bleeding requiring reoperation.

Conclusions:

The study did not show any survival advantage or difference in major complications between patients treated with a primarily open abdomen after open repair for ruptured abdominal aortic aneurysm and propensity-matched controls where the abdomen was primarily closed in a majority of the cases.

Systematic review and meta-analysis of the risk of bowel ischemia after ruptured abdominal aortic aneurysm repair

OBJECTIVE

Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR).

METHODS

This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis.

RESULTS

A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias.

CONCLUSIONS

The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.

Treatment of aortic aneurysms registered in Swedvasc: Development reflected in a national vascular registry with an almost 100% coverage

Swedvasc is a registry for vascular surgical procedures, both open and endovascular. It was started in 1987 and since 1994 the whole population of Sweden is covered, at present around 10 million inhabitants. In a recent external validation, it was found to be highly accurate with abdominal aortic aneurysm surgery correctly reported in >96%. In this paper various factors explaining the almost 100% coverage are discussed, one important being that the registry has been developed and maintained within the profession of vascular surgery and not dictated by authorities. Another factor of importance is the possibility to use data in various research projects and so far 15 PhD theses have used Swedvasc data. To exemplify the practical use of the registry, the treatment of abdominal aortic aneurysms is scrutinized and among the various complications abdominal compartment syndrome is analyzed. Several significant temporal changes have been observed over the almost 25 years of Swedvasc: increasing use of endovascular surgery, treatment of aneurysms detected by screening , decreasing treatment for rupture, improved outcome, increasing treatment of older patients and patients with comorbid conditions. In conclusion, a high quality national vascular registry can be valid with high compliance and can be used to study population-based development of treatment and outcome. It can also be used to perform international comparisons with other registries, thereby getting an indication of the quality of care.

Endovascular Aneurysm Repair-First Strategy for Ruptured Aneurysm Focuses on Fitzgerald Classification and Vein Thrombosis

BACKGROUND

Recent study have demonstrated the good results of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (RAAAs). We report on the results of our EVAR-first strategy for RAAAs focuses on Fitzgerald (F) classification and vein thrombosis.

MATERIALS AND METHODS

From 2011 to 2017, 31 patients with RAAA underwent EVAR at our hospital. We compared F-1 patients (group A) with F-2 to F-4 patients with obvious retroperitoneal hematoma (group B).

RESULTS

The baseline characteristics in group A (n = 9) and group B (n = 22) were similar. In group B, there were 8 cases of F-2, 10 cases of F-3, and 4 cases of F-4. Of the 22 cases in group B, 16 (73%) cases involved preoperative shock. Operation time was not significantly different (group A: 147 min and group B: 131 min, P = 0.48). The total mortality rate of group A and group B combined was 77.4%. The 30-day mortality was 0% for group A and 23.8% for group B, in which there were 2 F-4 cases and 3 F-3 cases. In group B, hematoma-related complications developed in 6 cases (deep vein thrombosis: 4 cases, abdominal compartment syndrome: 1 case, and hematoma infection: 1 case), and 1 case with deep vein thrombosis developed a pulmonary embolism that resulted in cardiac arrest. The 3-year survival rate was significantly higher for group A (100% vs. 52.3%, P = 0.016), but the freedom from aortic death rate was not significantly different (100% vs. 66.7%, P = 0.056).

CONCLUSIONS

Using EVAR for RAAA is a valid strategy. Certain complications that are associated with peritoneal hematoma, especially venous thrombosis, should receive particular attention.

Short-term and midterm survival of ruptured abdominal aortic aneurysms in the contemporary endovascular era

OBJECTIVE

Endovascular aneurysm repair (EVAR) has been shown to reduce mortality in the emergent repair of ruptured abdominal aortic aneurysms (AAAs). However, long-term survival data for this group of patients are lacking with contemporary endovascular endografts. The purpose of this study was to evaluate both 30-day mortality rates and 1-year survival in patients undergoing emergent EVAR in a 43-facility hospital system with a quaternary referral center with an established ruptured aneurysm protocol.

METHODS

Retrospective analysis of patients captured prospectively in an Institutional Review Board-approved registry for patients treated emergently for AAA were reviewed between 2012 and 2017 was conducted. Primary outcome measures were 30-day mortality and 1-year survival for the entire group as well as for symptomatic and ruptured aneurysms. Data were analyzed using logistic regression survival curves, and a log-rank test was performed to compare survival between open and endovascular repair. Patients were evaluated on an intent-to-treat basis, and outcomes were evaluated in a multivariate model.

RESULTS

A total of 249 patients were referred as part of the protocol. Of these, 102 (41%) were treated emergently. Kaplan-Meier estimates of 30-day and 1-year survival were 64% and 53% for all patients, 58% and 46% for ruptured patients, and 86% and 81% for symptomatic patients. EVAR resulted in improved 30-day survival (64% vs 31%; odds ratio, 4.0; P = .03) and 1-year survival (40% vs 23%; odds ratio, 2.3; P = .4) over open repair. Significant predictors for 30-day mortality included hypotension (P = .0003), blood transfusion (P < .0001), length of stay (P = .0005), extravasation (P = .01), preoperative cardiopulmonary resuscitation (P = .04), open repair (P = .007), aortouni-iliac reconstruction (P = .008), and abdominal compartment syndrome (P = .007). Significant predictors for 1-year mortality included advanced age (P = .04), hypotension (P = .01), blood transfusion (P = .006), extravasation (P = .03), reintubation (P = .03), and abdominal compartment syndrome (P = .03). There were no differences in outcomes based on race, gender, or outside transfer. Peripheral arterial disease (P = .04), hypertension (P = .04), coronary artery disease (P = .03), and familial history of aneurysms (P = .05) were related to increased 30-day mortality. Peripheral arterial disease (P = .06) and coronary artery disease (P = .07) were nearly significant, with increased 1-year mortality.

CONCLUSIONS

EVAR is associated with improved survival compared with open repair in patients requiring emergent AAA repair. However, in the first year, there is a significant risk of death based on initial presentation as well as underlying comorbidities. To improve long-term survival, aggressive medical management and medical surveillance are warranted.

The open abdomen in trauma and non-trauma patients: WSES guidelines

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

Low mortality rates after endovascular aortic repair expand use to high-risk patients

OBJECTIVE

The 2010 endovascular aneurysm repair (EVAR) trial 2 (EVAR 2) reported that patients with comorbidity profiles rendering them unfit for open aneurysm repair who underwent EVAR did not experience a survival advantage compared with those who did not undergo intervention. These patients experienced a 30-day mortality of 7.3%, whereas reports from similar cohorts reported far lower mortality rates. The primary objective of our study was to compare the incidence of 30-day mortality in low- and high-risk patients undergoing EVAR in a contemporary data set, using patient risk stratification criteria from EVAR 2. Secondarily, we sought to identify risk factors associated with a disproportionate contribution to 30-day mortality risk.

METHODS

Data were obtained from the 2005 to 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data Files (N = 24,813). Patients were included in the high-risk cohort with the presence of renal, respiratory, or cardiac preoperative criteria alone or in combination. Renal impairment criteria were defined as dialysis and creatinine concentration >2.26 mg/dL. Respiratory impairment criteria included history of chronic obstructive pulmonary disease and preoperative ventilator support. Cardiac impairment criteria included history of myocardial infarction, congestive heart failure, angina, and prior coronary intervention. Patient and procedural characteristics and 30-day postoperative outcomes were compared using Pearson χ2 tests for categorical variables and Wilcoxon rank sum tests for continuous variables.

RESULTS

Among 24,813 patients undergoing EVAR, 12,043 (48%) patients were characterized as high risk (at least one impairment criterion); 12,770 (52%) patients were stratified as low risk. The 30-day mortality rate was 1.9% in the high-risk cohort compared with the 7.3% reported by EVAR 2, and it was higher in the high-risk cohort compared with the low-risk cohort (1.9% vs 0.9%; P < .001). Whereas the presence of each comorbidity increased the odds of 30-day mortality (respiratory odds ratio [OR], 1.62; 95% confidence interval [CI], 1.16-2.26; P = .005; cardiac OR, 1.55; 95% CI, 1.14-2.10; P = .005), the presence of renal criteria disproportionately increased the odds of mortality threefold (OR, 3.42; 95% CI, 2.31-5.09; P < .001).

CONCLUSIONS

Contemporary 30-day mortality after EVAR in high-risk patients is substantially lower than that reported in the EVAR 2 trial. Whereas low- and high-risk stratification by current comorbidity criteria is appropriate, attention needs to be paid to disproportionate risk contribution from renal disease to mortality compared with cardiac and pulmonary comorbidities. Given the lower mortality risk than previously described, patients stratified as high risk should be thoughtfully considered for definitive EVAR.

Open Abdomen Therapy with Vacuum and Mesh Mediated Fascial Traction After Aortic Repair: an International Multicentre Study

OBJECTIVES

Open abdomen therapy may be necessary to prevent or treat abdominal compartment syndrome (ACS). The aim of the study was to analyse the primary delayed fascial closure (PDFC) rate and complications after open abdomen therapy with vacuum and mesh mediated fascial traction (VACM) after aortic repair and to compare outcomes between those treated with open abdomen after primary versus secondary operation.

METHODS

This was a retrospective cohort, multicentre study in Sweden, Finland, and Norway, including consecutive patients treated with open abdomen and VACM after aortic repair at six vascular centres in 2006-2015. The primary endpoint was PDFC rate.

RESULTS

Among 191 patients, 155 were men. The median age was 71 years (IQR 66-76). Ruptured abdominal aortic aneurysm (RAAA) occurred in 69.1%. Endovascular/hybrid and open repairs were performed in 49 and 142 patients, respectively. The indications for open abdomen were inability to close the abdomen (62%) at primary operation and ACS (80%) at secondary operation. Duration of open abdomen was 11 days (IQR 7-16) in 157 patients alive at open abdomen termination. The PDFC rate was 91.8%. Open abdomen initiated at primary (N=103), compared with secondary operation (N=88), was associated with less severe initial open abdomen status (p=.006), less intestinal ischaemia (p=.002), shorter duration of open abdomen (p=.007), and less renal replacement therapy (RRT, p<.001). In hospital mortality was 39.3%, and after entero-atmospheric fistula (N=9) was 88.9%. Seven developed graft infection within 6 months, 1 year mortality was 28.6%. Intestinal ischaemia (OR 3.71, 95% CI 1.55-8.91), RRT (OR 3.62, 95% CI 1.72-7.65), and age (OR 1.12, 95% CI 1.06-1.12), were independent factors associated with in hospital mortality, but not open abdomen initiated at primary versus secondary operation.

CONCLUSIONS

VACM was associated with a high PDFC rate after prolonged open abdomen therapy following aortic repair. Patient outcomes seemed better when open abdomen was initiated at primary, compared with secondary operation but a selection effect is possible.

The role of open abdomen in non-trauma patient: WSES Consensus Paper

The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.

Is Conventional Open Repair for Abdominal Aortic Aneurysm Feasible in Nonagenarians?

Background: Although endovascular repair for abdominal aortic aneurysm has been found to be beneficial in very elderly patients, some patients have contraindications to this procedure. For nonagenarians, the results of open repair remain unclear. The purpose of this study was to compare the outcomes of open vs. endovascular repair for abdominal aortic aneurysm in nonagenarian patients.

Methods and Results: Fourteen patients undergoing open surgical repair and 24 undergoing endovascular repair for abdominal aortic aneurysm were evaluated. There was no significant difference in early mortality between the open and endovascular groups (0% vs. 4.1%, p=0.16). The open repair group required much longer hospital stays (26.4 vs. 10.6 days, respectively, p=0.003). Finally, 12 patients (86%) undergoing open repair vs. 21 (88%) undergoing endovascular repair returned home (p=0.49). During a mean follow-up period of 23.4±23.5 months, cumulative estimated 1- and 3-year survival rates were 90.0% and 48.0%, respectively in the open repair group and 90.6% and 54.9%, respectively in the endovascular repair group (p=0.51).

Conclusion: Although endovascular repair for abdominal aortic aneurysm was superior in terms of recovery, the results of conventional open repair were acceptable even in nonagenarian patients. Open repair remains an alternative for patients with contraindications to endovascular repair.

Correlations of perioperative coagulopathy, fluid infusion and blood transfusions with survival prognosis in endovascular aortic repair for ruptured abdominal aortic aneurysm

BACKGROUND

Factors associated with survival prognosis among patients who undergo endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysms (rAAA) have not been sufficiently investigated. In the present study, we examined correlations between perioperative coagulopathy and 24-h and 30-day postoperative survival. Relationships between coagulopathy and the content of blood transfusions, volumes of crystalloid infusion and survival.

METHODS

This was a retrospective study of the medical records of all patients who underwent EVAR for rAAA at Chiba-Nishi General Hospital during the period from October 2013 to December 2015. Major coagulopathy was defined using the international normalized ratio or activated partial thromboplastin time (APTT) ratio of at least 1.5, or platelet count less than 50 × 10/l. We quantified the amounts of blood transfusions and crystalloid infusions administered from arrival to the hospital to admission to ICU following operations.

RESULTS

Coagulopathy among patients with rAAA was found to progress even after they had presented at the hospital. No statistically significant correlation between preoperative coagulopathy and mortality was found, although a significantly greater degree of postoperative coagulopathy was seen among patients who died both within 24-h and 30 days postoperatively. Among patients with postoperative coagulopathy, lesser quantities of fresh frozen plasma (FFP) compared with red cell concentrate (RCC) were used during the period from hospital arrival to postoperative ICU entry. In both groups of patients who did not survive after 24-h and 30 days, FFP was used less than RCC. Large transfusions of crystalloids administered during the periods from hospital arrival to surgery and from hospital arrival to the end of surgery were associated with postoperative incidence of major coagulopathy, death within 24-h, and death within 30 days.

CONCLUSION

Coagulopathy progressed during care in the emergency outpatient clinic and operations. Postoperative coagulopathy was associated with poorer outcomes. Smaller FFP/RCC ratios and larger volumes of crystalloid infusion were associated with development of coagulopathy and poorer prognosis of survival.

TRIAL REGISTRATION

This study is retrospectively registered in UMIN Clinical Trials Registry (Registration 19 April 2016, registered number is R000025334 UMIN000021978).