Editor's Choice – Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years

Effect of EVAR on International Ruptured AAA Mortality-Sex and Geographic Disparities

Background: We sought to investigate the differential impact of EVAR (endovascular aneurysm repair) vis-à-vis OSR (open surgical repair) on ruptured AAA (abdominal aortic aneurysm) mortality by sex and geographically. Methods: We performed a retrospective study of administrative data on EVAR from state statistical agencies, vascular registries, and academic publications, as well as ruptured AAA mortality rates from the World Health Organization for 14 14 states across Australasia, East Asia, Europe, and North America. Results: Between 2011-2016, the proportion of treatment of ruptured AAAs by EVAR increased from 26.1 to 43.8 percent among females, and from 25.7 to 41.2 percent among males, and age-adjusted ruptured AAA mortality rates fell from 12.62 to 9.50 per million among females, and from 34.14 to 26.54 per million among males. The association of EVAR with reduced mortality was more than three times larger (2.2 vis-à-vis 0.6 percent of prevalence per 10 percentage point increase in EVAR) among females than males. The association of EVAR with reduced mortality was substantially larger (1.7 vis-à-vis 1.1 percent of prevalence per 10 percentage point increase in EVAR) among East Asian states than European+ states. Conclusions: The increasing adoption of EVAR coincided with a decrease in ruptured AAA mortality. The relationship between EVAR and mortality was more pronounced among females than males, and in East Asian than European+ states. Sex and ethnic heterogeneity should be further investigated.

Creation of a Shared Medical Decision Support Tool for the Management of Abdominal Aortic Aneurysms

BACKGROUND

Patients with unruptured abdominal aortic aneurysm (AAA) at the surgical threshold may benefit from aneurysmal exclusion either by open surgery or endovascular repair. A patient decision aid (PtDA) could be useful to help patients and their surgeons choose between the 2 techniques. The aim of this study was to develop a shared medical decision support tool, in french language, for the surgical treatment of AAA.

METHODS

Following the steps recommended by the International Patient Decision Aids Standards, we carried out a qualitative study using semi-structured interviews with patients and vascular surgeons and focus group with patients to identify their main points of interest. After analyzing the interviews using grounded theory with independent double coding, the verbatims were discussed at a steering committee, at the end of which a prototype of the tool was created.

RESULTS

Four surgeons and 14 patients were interviewed. No new codes emerged from the last 2 interviews. At the end of the steering committee meeting, the information selected for inclusion in the PtDA tool were the definition of an AAA, a description of the 2 surgical techniques (approach, duration of operation), the main complications, the peri-operative mortality rate, and postoperative follow-up (length of hospital stay, monitoring frequency, and risk of re-intervention). It had to be produced on a synthetic paper format, with 6 illustrations and a simple vocabulary.

CONCLUSIONS

We developed a PtDA tool for use in a sharing decision making process with the patient during consultation with the vascular surgeon and the general practitioner. Further studies are needed to validate the tool and to test it in clinical practice.

Midterm outcomes of side branch embolization and endovascular abdominal aortic aneurysm repair

OBJECTIVE

To analyze the effects of total side branch embolization at endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms on the incidences of persistent type 2 endoleak (pT2EL), changes in sac diameter, and reintervention.

METHODS

Between 2013 and 2021, all patients who underwent primary EVAR with a few exceptions were included. Side branch embolization was considered during EVAR for inferior mesenteric artery (IMA) or IMA plus lumbar artery (LA) when feasible for contrast agent use. Outcomes measured were pT2EL, sac diameters, reintervention, ruptures, and aneurysm-related mortality. Radiation exposure and safety outcomes were also reported.

RESULTS

Among 732 patients who underwent EVAR, 616 (84.2%) were included. Of the 616 patients, 223 (36.2%) did not undergo side branch embolization (NO-E), whereas 228 (37.0%) underwent IMA only (IMA-E) and 165 (26.8%) underwent IMA+LA including median sacral artery (IMA+LA-E). The technical success rate of IMA and LA embolization was 97.0% and 74.7%, respectively. Crude incidences of pT2EL were significantly different from 6 months through 3 years (NO-E, 27.8%; IMA-E, 31.7%; IMA+LA-E, 9.4% at 3 years; P = .007). In the multivariate analysis adjusted for background differences, the incidences of pT2EL were significantly higher in the NO-E (odds ratio [OR], 3.21; 95% confidence intervals [CIs], 1.08-9.57; P = .004) and IMA-E (OR, 4.86; 95% CIs, 1.68-14.11; P = .004) compared with the IMA+LA-E group. Similarly, any reintervention until 3 years was significantly frequent in the NO-E (OR, 5.26; 95% CIs, 1.76-15.70; P = .003) and IMA-E group (OR, 4.19; 95% CIs, 1.38-12.67; P = .01). Surgical conversion and secondary rupture were seen only in 1 patient without any aneurysm-related mortality. Percent sac shrinkage from the baseline was significantly promoted in the IMA+LA group (NO-E, 12.1% ± 16.6%; IMA-E, 11.4% ± 16.7%; IMA+LA-E, 18.0% ± 18.8%; P = .047). Fluoroscopy time was significantly longer in the IMA+LA-E group (NO-E, 60.2 ± 47.4 minutes; IMA-E, 59.3 ± 39.5 minutes; IMA+LA-E, 75.5 ± 42.8 minutes; P < .0001), and so do the dose-area product (NO-E, 424.6 ± 333.4 Gy cm2; IMA-E, 477.7 ± 342.4 Gy cm2; IMA+LA-E, 631.8 ± 449.1 Gy cm2; P < .0001). No embolization-related complications or radiation-related adverse events were recorded.

CONCLUSIONS

Pre-emptive embolization of IMA, LAs, and median sacral artery at the time of EVAR reduced the incidences of pT2EL and any reintervention and promoted sac shrinkage during the follow-up period of 3 years.

Certification of Basic Skills in Endovascular Aortic Repair Through a Modular Simulation Course With Real Time Performance Assessment

OBJECTIVE

Endovascular aortic repair (EVAR) is being used increasingly for the treatment of infrarenal abdominal aortic aneurysms. Improvement in educational strategies is required to teach future vascular surgeons EVAR skills, but a comprehensive, pre-defined e-learning and simulation curriculum remains to be developed and tested. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE), an assessment tool for simulation based education (SBE) in EVAR, has previously been designed to assess EVAR skills, and a pass limit defining mastery level has been set. However, EVARATE was developed for anonymous video ratings in a research setting, and its feasibility for real time ratings in a standardised SBE programme in EVAR is unproven. This study aimed to test the effect of a newly developed simulation based modular course in EVAR. In addition, the applicability of EVARATE for real time performance assessments was investigated.

METHODS

The European Society of Vascular Surgery (ESVS) and Copenhagen Certification Programme in EVAR (ENHANCE-EVAR) was tested in a prospective cohort study. ENHANCE-EVAR is a modular SBE programme in EVAR consisting of e-learning and hands-on SBE. Participants were rated with the EVARATE tool by experienced EVAR surgeons.

RESULTS

Twenty-four physicians completed the study. The mean improvement in EVARATE score during the course was +11.8 (95% confidence interval 9.8 - 13.7) points (p < .001). Twenty-two participants (92%) passed with a mean number of 2.8 ± 0.7 test attempts to reach the pass limit. Cronbach's alpha coefficient was 0.91, corresponding to excellent reliability of the EVARATE scale. Differences between instructors' EVARATE ratings were insignificant (p = .16), with a maximum variation between instructors of ± 1.3 points.

CONCLUSION

ENHANCE-EVAR, a comprehensive certifying EVAR course, was proven to be effective. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE) is a trustworthy tool for assessing performance within an authentic educational setting, enabling real time feedback.

A Novel Method for the Rat Model of Abdominal Aortic Aneurysm Induced by Retroperitoneal Implantation of an Osmotic Pump System With Lipopolysaccharide

BACKGROUND

Few methods can cocurrently mimic the pathological characteristics and nature history of human abdominal aortic aneurysms (AAAs), especially for the exist of the self-healing tendency of rodents. This study tested a novel method for the AAA rat model induced by retroperitoneal implantation of an osmotic pump system with lipopolysaccharide (LPS) based on the hypothesis that chronic inflammation of perivascular adipose tissue directly influenced the development and progression of AAAs.

METHODS

20 male Sprague-Dawley rats (10-month-old) fed with the Paigen diet were randomly divided into 4 groups: the blank group ×2, the sham group ×4, the empty capsule group ×4, and the LPS capsule group ×10. The LPS capsule group received implantations of the ALZET® osmotic pump capsule with LPS (3.6 μg/day) parallel to the abdominal aorta through a retroperitoneal approach. Two weeks later, 6 rats were randomly selected from the LPS capsule group to form the anti-inflammatory group and received implantations of another osmotic pump capsule with interleukin (IL)-10 (75 ng/day) through the same approach. The changes in abdominal aortic diameter were observed by ultrasound every 2 weeks, and samples were harvested for histopathologic and immunohistochemical analysis 6 weeks later.

RESULTS

Within the 6 weeks after modeling, the LPS capsule group showed sustained and significant aortic dilatation (P < 0.01), while the anti-inflammatory group showed a rapid and obvious shrinkage 2 weeks after the IL-10 osmotic pump capsule implantation (P < 0.01). The LPS capsule group presented excellent pathological mimicking of human AAAs and showed severe medial degeneration with the least elastic content among the 5 groups at the end of the sixth week (P < 0.05). Notably, the anti-inflammatory group showed perfect medial preservation with the most elastic content (P < 0.05) and the highest elastin/collagen ratio (P < 0.01) at the end of the study. Matrix metalloproteinases (MMP) 2 and 9 and toll-like receptor 2 showed strong expression in the LPS capsule group at the end of the sixth week, which was significantly higher than that in the blank group and sham group. Interestingly, the anti-inflammatory group showed a slightly higher MMP9 expression than the LPS capsule group though there was no statistical difference between them.

CONCLUSIONS

This novel method for the rat AAA model induced by retroperitoneal implantation of an osmotic pump capsule with LPS can concurrently mimic the histological characteristics and natural history of human AAAs. Further studies were needed to improve the osmotic pump system.

Trends in Abdominal Aortic Aneurysm Repair Incidence, Comorbidity, Treatment, and Mortality: A Danish Nationwide Cohort Study, 1996-2018

Background

Significant changes in Western populations' abdominal aortic aneurysm (AAA) epidemiology have been reported following the introduction of screening, endovascular AAA repair, and reduced tobacco consumption. We report incidence and mortality of AAA repair in Denmark from 1996 to 2018, where AAA screening was not implemented.

Methods

Nationwide cohort study of prospective data from population-based Danish registries covering 1996 to 2018. We identified 15,395 patients undergoing first-time AAA repair using the Danish Vascular Registry. Comorbidity was assessed by Charlson's Comorbidity Index (CCI). Incidence rate (IR) ratios and mortality rate ratios (MRR) were estimated by multivariable Poisson and Cox regression, respectively.

Results

Overall AAA repair IR decreased by 24% from 1996 through 2018, mainly reflecting a 53% IR reduction in ruptured AAA repairs in men. Overall, the IR decreased 52-63% in age groups below 70 years and increased 81% among octogenarians. The proportion of intact AAAs repaired endovascularly increased from 2% in 1996-1999 to 42% in 2015-2018. For both ruptured and intact AAAs the CCI score increased by 0.9% annually independently of age and sex. The adjusted five-year MRR in 2016-2018 vs.1996-2000 was 0.46 (95% confidence interval (CI): 0.39-0.54) following ruptured and 0.51 (95% CI: 0.44-0.59) following intact AAA repair.

Conclusion

In Denmark, overall AAA repair incidence decreased between 1996 and 2018, primarily reflecting a reduction among males and a shift to an older population requiring intervention. These trends mirror changes in tobacco consumption in Denmark. Regardless of age and comorbidity, AAA repair mortality decreased markedly during the study period.

Outcomes Following Intact and Ruptured Aneurysm Repair across Nations: Analysis of International Registry Data from the VASCUNET Collaboration 2014 - 2019

OBJECTIVE

To determine the peri-operative mortality rate for intact and ruptured abdominal aortic aneurysm (AAA) repair in 10 countries and to compare practice and outcomes over a six year period by age, sex, and geographic location.

METHODS

This VASCUNET study used prospectively collected data from vascular registries in 10 countries on primary repair of intact and ruptured AAAs undertaken between January 2014 and December 2019. The primary outcome was peri-operative death (30 day or in hospital). Logistic regression models were used to estimate the association between peri-operative death, patient characteristics, and type of procedure. Factors associated with the use of endovascular aortic aneurysm repair (EVAR) were also evaluated.

RESULTS

The analysis included 50 642 intact and 9 453 ruptured AAA repairs. The proportion of EVARs for intact repairs increased from 63.4% in 2014 to 67.3% in 2016 before falling to 62.3% in 2019 (p < .001), but practice varied between countries. EVAR procedures were more common among older patients (p < .001) and men (p < .001). Overall peri-operative mortality after intact AAA repair was 1.4% (95% confidence interval [CI] 1.3 - 1.5%) and did not change over time. Mortality rates were stable within countries. Among ruptured AAA repairs, the proportion of EVARs increased from 23.7% in 2014 to 35.2% in 2019 (p < .001). The average aortic diameter was 7.8 cm for men and 7.0 cm for women (p < .001). The overall peri-operative mortality rate was 31.3% (95% CI 30.4 - 32.2%); the rates were 36.0% (95% CI 34.9 - 37.2%) for open repair and 19.7% (95% CI 18.2 - 21.3%) for EVAR. This difference and shift to EVAR reduced peri-operative mortality from 32.6% (in 2014) to 28.7% (in 2019).

CONCLUSION

The international practice of intact AAA repair was associated with low mortality rates in registry reported data. There remains variation in the use of EVAR for intact AAAs across countries. Overall peri-operative mortality remains high after ruptured AAA, but an increased use of EVAR has reduced rates over time.

Increased Mortality in Octogenarians Undergoing Endovascular Aortic Aneurysm Repair for Smaller Aneurysms Warrants Caution

BACKGROUND

Geriatric patients constitute a growing portion of the general population, with particular increase in the prevalence of octogenarians. The incidence and prevalence of abdominal aortic aneurysms (AAAs) have been clearly shown to be associated with advancing age. The effect of advanced age in outcomes from endovascular aneurysm repair (EVAR) is unclear. We study the effect of advanced age, as an independent risk factor for mortality in octogenarian geriatric patients (OGPs) compared to nonoctogenarian geriatric patients (NOGPs) undergoing EVAR.

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Procedure-Targeted Vascular database was queried for geriatric patients (>65 years) undergoing EVAR for symptomatic and asymptomatic indications. A multivariable logistic regression analysis was performed comparing outcomes between OGPs and NOGPs.

RESULTS

Of the 10,490 geriatric patients who underwent EVAR, 7,508 (71.6%) were NOGPs and 2,982 (28.4%) were OGPs. Octogenarians were more often female (82.3% vs. 76.7%). In comparison to NOGPs, fewer OGPs were treated for AAA <5.5 cm (46.7% vs. 54.9%, P < 0.001) and AAA <5.0 cm (19.2% vs. 24.0%, P < 0.001). Nearly 90% of male and over 80% of female NOGPs and OGPs treated for AAA <5.0 cm were asymptomatic. Octogenarian geriatric patients (OGPs) had less dyspnea (15.3% vs. 17.3%, P = 0.01), chronic obstructive pulmonary disease (16.1% vs. 20.5%, P < 0.001), diabetes (12.7% vs. 17.8%, P < 0.001), and smoking (13.2% vs. 36.3%, P < 0.001) compared to NOGPs. Octogenarian geriatric patients (OGPs) were found to have a greater length of stay (2 days vs. 1 day, P < 0.001), as well as rate of mortality (3.4% vs. 1.7%, P < 0.001). Both symptomatic and asymptomatic OGPs had a higher rate of mortality than their NOGP counterparts (symptomatic 16% vs. 9.5%, P < 0.001; asymptomatic 1.3% vs. 0.5%, P < 0.001). Multivariate logistic regression analysis showed OGPs to have increased overall associated risk of mortality compared to NOGPs (odds ratio (OR) 1.88, confidence interval (CI) 1.39-2.54, P < 0.001), as well as in the symptomatic (OR 1.54, CI 1.06-2.23, P < 0.001) and asymptomatic cohorts (OR 2.66, CI 1.59-4.45, P < 0.001).

CONCLUSIONS

Octogenarian geriatric patients (OGPs) accounted for over a quarter of geriatric patients undergoing EVAR. This elderly group was associated with an increased rate and risk of mortality compared to NOGPs, even when controlling for known risk factors for mortality. Given this increased risk of mortality in OGPs undergoing EVAR, elective treatment of AAAs in this advanced age group should be performed with caution, particularly in those with diameters in which the risk of rupture may not warrant repair.

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.

Editor's Choice - The VASCUNExplanT Project: An International Study Assessing Open Surgical Conversion of Failed Non-Infected Endovascular Aortic Aneurysm Repair

OBJECTIVE

The need for open surgical conversion (OSC) after failed endovascular aortic aneurysm repair (EVAR) persists, despite expanding endovascular options for secondary intervention. The VASCUNExplanT project collected international data to identify risk factors for failed EVAR, as well as OSC outcomes. This retrospective cross sectional study analysed data after OSC for failed EVAR from the VASCUNET international collaboration.

METHODS

VASCUNET queried registries from its 28 member countries, and 17 collaborated with data from patients who underwent OSC (2005 - 2020). Any OSC for infection was excluded. Data included demographics, EVAR, and OSC procedural details, as well as post-operative mortality and complication rates.

RESULTS

There were 348 OSC patients from 17 centres, of whom 33 (9.4%) were women. There were 130 (37.4%) devices originally deployed outside of instructions for use. The most common indication for OSC was endoleak (n = 143, 41.1%); ruptures accounted for 17.2% of cases. The median time from EVAR to OSC was 48.6 months [IQR 29.7, 71.6]; median abdominal aortic aneurysm diameter at OSC was 70.5 mm [IQR 61, 82]. A total of 160 (45.6%) patients underwent one or more re-interventions prior to OSC, while 63 patients (18.1%) underwent more than one re-intervention (range 1 - 5). Overall, the 30 day mortality rate post-OSC was 11.8% (n = 41), 11.1% for men and 18.2% for women (p = .23). The 30 day mortality rate was 6.1% for elective cases, and 28.3% for ruptures (p < .0001). The predicted 90 day survival for the entire cohort was 88.3% (95% CI 84.3 - 91.3). Multivariable analysis revealed rupture (OR 4.23; 95% CI 2.05 - 8.75; p < .0001) and total graft explantation (OR 2.10; 95% CI 1.02 - 4.34; p = .04) as the only statistically significant predictive factors for 30 day death.

CONCLUSION

This multicentre analysis of patients who underwent OSC shows that, despite varying case mix and operative techniques, OSC is feasible but associated with significant morbidity and mortality rates, particularly when performed for rupture.

Long-Term Outcomes of Open Versus Endovascular Treatment for Abdominal Aortic Aneurysm: Systematic Review and Meta-Analysis With Reconstructed Time-to-Event Data

BACKGROUND

The advent of endovascular techniques has revolutionized the care of patients with uncomplicated abdominal aortic aneurysms. This analysis compares the overall survival and the freedom from reintervention rate between open surgical repair (OSR) and endovascular repair (EVAR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair.

METHODS

PubMed, Scopus, and Cochrane databases were searched for studies including patients who underwent either OSR or EVAR for uncomplicated AAA. All randomized controlled trials and propensity-score-matched cohort studies reporting on the outcomes of interest were considered eligible for inclusion. The systematic search of the literature was performed by 2 independent investigators in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We conducted 1-stage and 2-stage meta-analyses with Kaplan-Meier-derived time-to-event data and meta-analysis with a random-effects model.

RESULTS

Thirteen studies met our eligibility criteria, incorporating 13 409 and 13 450 patients in the OSR and EVAR arms, respectively. Patients who underwent open repair had improved overall survival rates compared with those who underwent EVAR (hazard ratio [HR]=0.93, 95% confidence interval [CI]=0.88-0.98, p=0.004) during a mean follow-up of 53.8 (SD=29.8) months and this was validated by the 2-stage meta-analysis (HR=0.89, 95% CI=0.8-0.99, p=0.03, I2=62.25%). Splitting timepoint analysis suggested that EVAR offers better survival outcome compared with OSR in the first 11 months following elective intervention (HR=1.37, 95% CI=1.22-1.54, p<0.0001), while OSR offers a significant survival advantage after the 11-month timepoint and up to 180 months (HR=0.84, 95% CI=0.8-0.89, p<0.0001). Similarly, freedom from reintervention was found to be significantly better in EVAR patients (HR=1.28, 95% CI=1.14-1.44, p<0.0001) within the first 30 days. After the first month postrepair, however, OSR demonstrated higher freedom-from-reintervention rates compared with EVAR that remained significant for up to 168 months during follow-up (HR=0.73, 95% CI=0.66-0.79, p<0.0001).

CONCLUSIONS

Despite the first-year survival advantage of EVAR in patients undergoing elective AAA repair, OSR was associated with a late survival benefit and decreased risk for reintervention in long-term follow-up.

CLINICAL IMPACT

Open surgical repair for uncomplicated abdominal aortic aneurysm offers better long-term outcomes in terms of survival and freedom from reintervention rate compared to the endovascular approach but in the first year it carries a higher risk of mortality. The novelty of our study lies that instead of comparing study-level effect estimates, we analyzed reconstructed individual patient-level data. This offered us the opportunity to perform our analyses with mathematically robust and flexible survival models, which was proved to be crucial since there was evidence of different hazard over time. Our findings underline the need for additional investigation to clarify the significance of open surgical repair when compared to the latest endovascular devices and techniques within the evolving era of minimally invasive procedures.

Pulsatile Changes of the Aortic Diameter May Be Irrelevant Regarding Endograft Sizing in Patients With Aortic Disease

PURPOSE

Endovascular aortic repair has become the preferred elective treatment of infrarenal aortic aneurysms. Aortic pulsatility may pose problems regarding endograft sizing. The aims of this study are to determine the aortic pulsatility in patients with aortic disease and to evaluate the effect of pulsatility on the growth of aneurysms.

MATERIALS AND METHODS

In this retrospective study, analyses of computed tomography angiography (CTA) images of 31 patients under conservative treatment for small abdominal aortic aneurysms were performed. Reconstructions of the raw electrocardiography (ECG) gated dataset at 30% and 90% of the R-R cycle were used. After lumen segmentation, total aortic cross-sectional area was measured in diastole and systole in the following zones: Z0, Z3, Z5, Z6, Z8, and Z9. Effective diameters (EDs) were calculated from the systolic (ED_sys) and diastolic (ED_dia) cross-sectional areas to determine absolute (ED_sys - ED_dia, mm) and relative pulsatility [(ED_sys - ED_dia) / ED_dia, %]. Diameter of the aneurysms was measured on baseline images and the last preoperative follow-up study of each patient.

RESULTS

A total of 806 measurements were completed, 24 pulsatility and 2 growth measurements per patient. The mean pulsatility values at each point were as follows: Z0: 0.7±0.8 mm, Z3: 1.0±0.6 mm, Z5: 1.0±0.6 mm, Z6: 0.8±0.7 mm, Z8: 0.7±1.0 mm, Z9: 0.9±0.9 mm. Follow-up time was 5.5±2.2 years during which a growth of 13.42±9.09 mm (2.54±1.55 mm yearly) was observed. No correlation was found between pulsatility values and growth rate of the aneurysms.

CONCLUSION

The pulsatility of the aorta is in a submillimetric range for the vast majority of patients with aortic disease, thus probably not relevant regarding endograft sizing. Pulsatility of the ascending aorta is smaller than that of the descending segment, making an additional oversize of a Z0 implantation questionable.

CLINICAL IMPACT

Endovascular aortic repair reqiures precise preoperative planning. Pulsatile changes of the aortic diameter may pose issues regarding endograft sizing. In our retrospective single-centre study, aortic pulsatility of patients with AAA was measured on ECG gated CTA images. Pulsatility values reached a maximum at the descending aorta, however absolute pulsatility values did not exceed 1 mm at any point along the aorta. Therefore, significance of aortic pulsatility regarding the sizing of EVAR prostheses is questionable. Correlation between pulsatility and AAA growth was not found.

BMI-Based organ doses in endovascular aneurysm repair interventions utilising Monte Carlo simulation

In this study, the effect of body-mass-index (BMI) on organ doses (ODs) during infrarenal endovascular-aneurysm-repair (EVAR) procedures was evaluated. Patient- and intra-operative data from fifty-nine EVAR procedures were inserted into VirtualDose-IR software to calculate ODs. For overweight, obesity class-I and obesity class-II, ODs were up to 147%, 412% and 775% higher than those for normal weight-patients, respectively. A large variation was observed in ODs published in literature mainly due to the differences in the software and the technical parameters used for the calculations.

Outcomes of EVAR Conversion in Octogenarians Treated at a High-Volume Aorta Center

INTRODUCTION

Endovascular aortic aneurysm repair(EVAR) is the dominant treatment strategy for infrarenal abdominal aortic aneurysms(AAA) but is especially preferred among octogenarian(age ≥80-years) patients due to concerns surrounding comorbidity severity and physiological frailty. Correspondingly, EVAR failure resulting in subsequent open conversion(EVAR-c) has been increasingly reported in older patients but there is a paucity of literature focusing on outcomes in this subgroup. The purpose of this analysis was to evaluate our experience with EVAR-c in octogenarians(≥80-years) compared to younger patients(age <80-years).

METHODS

A retrospective review of all non-mycotic EVAR-c procedures(2002-2020) at a single high-volume academic hospital with a dedicated aorta center(https://www.uf-health-aortic-disease-center) was performed. Patients(n=162) were categorized into octogenarian(age ≥80; n=43) and non-octogenarian(age<80; n=119) cohorts and subsequently compared. The primary end-point was 30-day mortality. Secondary end-points included complications, 90-day mortality, and overall survival. Cox regression determined effects of selected covariates on mortality risk. Kaplan-Meier methodology estimated survival.

RESULTS

No difference in pre-admission EVAR re-intervention rates was present(octogenerians-42% vs. non-octogenerians-43%;p=1) although time to first re-intervention was greater in octogenarians(41 vs. non-octogenarians, 15-months;p=.01). Concordantly, time to EVAR-c was significantly longer among octogenarian patients(61 vs. non-octogenarians, 39-months;p<.01). No difference in rupture presentation was evident(14% vs. 10%;p=.6); however, elective EVAR-c occurred less frequently(octogenerians-42% vs. non-octogenerians-59%;p=.07). AAA diameter was significantly larger for elective octogenarian EVAR-c(7.8±1.9cm vs. non-octogenarians, 7.0±1.5cm;p=.02) and type 1a endoleak was the most common indication overall(58%;n=91). Among all presentations, a trend in higher 30-day mortality was evident for octogenarian patients(16% vs. non-octogenarians, 7%;p=.06). Similarly 90-day mortality was greater among octogenarians(26% vs. non-octogenarians, 10%;p=.02). However, incidence of any complication(56% vs. 49%;p=.5), readmission(12% vs. 6%;p=.3), unplanned re-operation(10% vs. 5%;p=.5) and LOS(11 vs. 9 days;p=.3) was not significantly different. Age ≥80 was predictive of short-term mortality after non-elective but not elective cases; however, increasing comorbidity number, non-elective admission and renal/mesenteric revascularization had the strongest association with mortality risk. One- and three-year survival was not different between groups when comparing all patients after the first 90-days postoperatively.

CONCLUSION

Although higher unadjusted peri-operative mortality occurred among octogenarian patients, risk-adjusted elective outcomes were comparable to younger EVAR-c subjects when treated at a high-volume aortic surgery center. This underscores the importance of appropriate patient selection and modulation of operative complexity when feasible to achieve optimal results. Providers caring for octogenarian patients with EVAR failure should consider timely elective referral to high-volume aorta centers to reduce resource utilization and frequency of non-elective presentations.

Molecular Imaging of Aortic Aneurysm and Its Translational Power for Clinical Risk Assessment

Aortic aneurysms (AAs) are dilations of the aorta, that are often fatal upon rupture. Diagnostic radiological techniques such as ultrasound (US), magnetic resonance imaging (MRI), and computed tomography (CT) are currently used in clinical practice for early diagnosis as well as clinical follow-up for preemptive surgery of AA and prevention of rupture. However, the contemporary imaging-based risk prediction of aneurysm enlargement or life-threatening aneurysm-rupture remains limited as these are restricted to visual parameters which fail to provide a personalized risk assessment. Therefore, new insights into early diagnostic approaches to detect AA and therefore to prevent aneurysm-rupture are crucial. Multiple new techniques are developed to obtain a more accurate understanding of the biological processes and pathological alterations at a (micro)structural and molecular level of aortic degeneration. Advanced anatomical imaging combined with molecular imaging, such as molecular MRI, or positron emission tomography (PET)/CT provides novel diagnostic approaches for in vivo visualization of targeted biomarkers. This will aid in the understanding of aortic aneurysm disease pathogenesis and insight into the pathways involved, and will thus facilitate early diagnostic analysis of aneurysmal disease. In this study, we reviewed these molecular imaging modalities and their association with aneurysm growth and/or rupture risk and their limitations. Furthermore, we outline recent pre-clinical and clinical developments in molecular imaging of AA and provide future perspectives based on the advancements made within the field. Within the vastness of pre-clinical markers that have been studied in mice, molecular imaging targets such as elastin/collagen, albumin, matrix metalloproteinases and immune cells demonstrate promising results regarding rupture risk assessment within the pre-clinical setting. Subsequently, these markers hold potential as a future diagnosticum of clinical AA assessment. However currently, clinical translation of molecular imaging is still at the onset. Future human trials are required to assess the effectivity of potentially viable molecular markers with various imaging modalities for clinical rupture risk assessment.

The Association between Device Instructions for Use Adherence and Outcomes after Elective Endovascular Aortic Abdominal Aneurysm Repair

OBJECTIVE

Aortic neck anatomy has a significant impact on the complexity of endovascular aortic aneurysm repair (EVAR), with concern that neck characteristics outside of instructions for use (IFU) may result in worse outcomes. Therefore, this study determined the impact of neck characteristics outside of IFU on perioperative and one-year outcomes and mid-term survival after EVAR.

METHODS

We identified all patients undergoing elective infrarenal EVAR from December 2014 to May 2020 in the Vascular Quality Initiative database. Neck characteristics outside of IFU were determined based the specific device IFU neck characteristics (Neck diameter, length, and angulation). Patients without one-year follow-up were excluded for the 1-year outcomes analyses (n=6,138 (40%)). We used multivariable adjusted logistic regression and Cox proportional hazard models to identify the independent associations between neck characteristics outside of IFU and our outcomes.

RESULTS

Of the 15,448 patients identified, 22.1% had neck characteristics outside of IFU, including 6.6% with a infrarenal angle, 6.8% with a neck length, 10.4% with a neck diameter, and 1.1% with a suprarenal angulation outside of IFU. Of these, 2.4% had more than one neck characteristic outside of IFU. Patients with neck characteristics outside of IFU were more often female (27.9% vs. 15.0%, P<.001) and were older (median age 75 vs. 73, P<.001). EVAR patients with neck characteristics outside of IFU had higher rates of type Ia endoleaks at completion (4.8% vs. 2.5%, P<.001), perioperative mortality (1.2% vs. 0.6%, P<.001), one-year sac expansion (7.1% vs. 5.3%, P=.017), and one-year reinterventions (4.4% vs. 3.2%, P=.03). In multivariable adjusted analyses, neck characteristics outside of IFU were independently associated with type Ia completion endoleaks (OR 1.6, [1.3-2.0], P<.001), perioperative mortality (OR 1.8; [1.2-2.7]; P=.005), one-year sac expansion (OR 1.4; [1.0-1.8]; P=.025) and one-year reinterventions (OR 1.4; [1.0-1.9]; P=.039). Unadjusted mid-term survival was lower for patients with neck characteristics outside of IFU than for patients without (5-year survival 84.0% vs. 86.7%, log-rank<.001). However, after adjustment, survival was similar for patients with neck characteristics outside of IFU to those within (HR: 1.1; [1.0-1.3]; P=.22).

CONCLUSION

Neck characteristics outside of IFU are independently associated with completion type Ia endoleaks, perioperative mortality, one-year sac expansion and one-year reinterventions among patients undergoing elective EVAR. These results indicate that continued effort is needed to improve the proximal seal in patients with neck characteristics outside of IFU undergoing EVAR. Also, in patients with severe hostile neck characteristics, alternative approaches such as open repair, use of a fenestrated or branched device, or endoanchors should be considered.

Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study

OBJECTIVE

The Dutch Surgical Aneurysm Audit (DSAA) initiative was established in 2013 to monitor and improve nationwide outcomes of aortic aneurysm surgery. The objective of this study was to examine whether outcomes of surgery for intact abdominal aortic aneurysms (iAAA) have improved over time.

METHODS

Patients who underwent primary repair of an iAAA by standard endovascular (EVAR) or open surgical repair (OSR) between 2014 and 2019 were selected from the DSAA for inclusion. The primary outcome was peri-operative mortality trend per year, stratified by OSR and EVAR. Secondary outcomes were trends per year in major complications, textbook outcome (TbO), and characteristics of treated patients. The trends per year were evaluated and reported in odds ratios per year.

RESULTS

In this study, 11 624 patients (74.8%) underwent EVAR and 3 908 patients (25.2%) underwent OSR. For EVAR, after adjustment for confounding factors, there was no improvement in peri-operative mortality (aOR [adjusted odds ratio] 1.06, 95% CI 0.94 - 1.20), while major complications decreased (2014: 10.1%, 2019: 7.0%; aOR 0.91, 95% CI 0.88 - 0.95) and the TbO rate increased (2014: 68.1%, 2019: 80.9%; aOR 1.13, 95% CI 1.10 - 1.16). For OSR, the peri-operative mortality decreased (2014: 6.1%, 2019: 4.6%; aOR 0.89, 95% CI 0.82 - 0.98), as well as major complications (2014: 28.6%, 2019: 23.3%; aOR 0.95, 95% CI 0.91 - 0.99). Furthermore, the proportion of TbO increased (2014: 49.1%, 2019: 58.3%; aOR 1.05, 95% CI 1.01 - 1.10). In both the EVAR and OSR group, the proportion of patients with cardiac comorbidity increased.

CONCLUSION

Since the establishment of this nationwide quality improvement initiative (DSAA), all outcomes of iAAA repair following EVAR and OSR have improved, except for peri-operative mortality following EVAR which remained unchanged.

Outcomes after Elective Open Abdominal Aortic Aneurysm Repair in Octogenarians Compared to Younger Patients in Korea

BACKGROUND

Although the first choice of treatment for abdominal aortic aneurysm (AAA) is endovascular aneurysm repair, especially in elderly patients, some patients require open surgical repair. The purpose of this study was to compare the mortality outcomes of open AAA repair between octogenarians and younger counterparts and to identify the risk factors associated with mortality.

METHODS

All consecutive patients who underwent elective open AAA repair due to degenerative etiology at a single tertiary medical center between 1996 and June 2020 were included in this retrospective review. Medical records and imaging studies were reviewed to collect the following information: demographics, comorbid medical conditions, clinical presentations, radiologic findings, surgical details, and morbidity and mortality rates. For analysis, patients were divided into two groups: older and younger than 80 years of age. Multivariate analysis was performed to identify factors associated with mortality after elective open AAA repair.

RESULTS

Among a total of 650 patients who underwent elective open AAA repair due to degenerative AAA during the study period, 58 (8.9%) were octogenarians and 595 (91.1%) were non-octogenarians. Patients in the octogenarian group were predominantly female and more likely to have lower body weight and body mass index (BMI), hypertension, chronic kidney disease, and lower preoperative serum hemoglobin and albumin compared with patients in the non-octogenarian group. Maximal aneurysm diameter was larger in octogenarians. During the median follow-up duration of 34.4 months for 650 patients, the median length of total hospital and intensive care unit stay was longer in octogenarians. The 30-day (1.7% vs. 0.7%, P = 0.374) and 1-year (6.9% vs. 2.9%, P = 0.108) mortality rates were not statistically significantly different between the two groups. Multivariate analysis showed that low BMI was associated with increased 30-day (odds ratio [OR], 16.339; 95% confidence interval [CI], 1.192-224.052; P = 0.037) and 1-year (OR, 8.236; CI, 2.301-29.477; P = 0.001) mortality in all patients.

CONCLUSION

Because the mortality rate of octogenarians after elective open AAA repair was not significantly different compared with their younger counterparts, being elderly is not a contraindication for open AAA repair. Low BMI might be associated with increased postoperative mortality.

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

Background

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

Methods

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

Results

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

Conclusion

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

Long Term Outcome of Screen Detected Sub-Aneurysmal Aortas in 65 Year Old Men: a Single Scan After Five Years Identifies Those at Risk of Needing AAA Repair

OBJECTIVE

The epidemiology of sub-aneurysmal aortic dilatation (SAA) 25 - 29 mm is not fully understood, and the management of SAA is debated. Lack of evidence is particularly problematic in the screening setting. This study aimed to evaluate the long term outcome of men with screen detected SAAs, focusing on progression to an abdominal aortic aneurysm (AAA), and on the AAAs reaching the threshold diameter for surgical repair.

METHODS

Between 2006 and 2015, all 65 year old men with a screen detected SAA in middle Sweden were re-examined with ultrasound after five and 10 years. The primary outcomes were expansion to AAA ≥ 30 mm and progression to AAA ≥ 55 mm. Secondary outcomes were risk factors for progression, repair rate, and mortality.

RESULTS

A total of 1 020 65 year old men with a SAA were identified, of whom 940 (92.2%; 95% confidence interval 91.0 - 93.8) had follow up. The Kaplan-Meier estimated incidence of AAA ≥ 30 mm development after the five year follow up (which was de facto carried out after a mean of 4.9 years) was 65.8% (61.6 - 69.4), all < 55 mm. The corresponding KM-estimated incidence after the 10 year follow up (carried out after a mean of 11.9 years) was 95.1% (90.1 - 97.4), and 29.7% (18.0 - 39.7) reached ≥ 55 mm. All 41 SAAs eventually expanding to ≥ 55 mm were ≥ 30 mm at the five year follow up. Of these, 32 had surgical repair with 100% survival, six have scheduled repairs, and three (7.3%) were unfit for repair. The KM estimated all cause mortality rates at five and 10 years were 7.0% and 17.9%, respectively, with no proven AAA related deaths.

CONCLUSION

A majority of SAAs eventually progress to an AAA, of which 30% are estimated to eventually reach the threshold for repair within 10 years. A follow up policy with an ultrasound examination after five years can safely and effectively identify those SAAs at risk of developing into clinically significant AAAs needing repair and may be considered for anyone with reasonably good life expectancy.

Nationwide Study of Ruptured Abdominal Aortic Aneurysms During Twenty Years (1994-2013)

OBJECTIVE

To analyze the epidemiology of ruptured abdominal aortic aneurysms (RAAA) in Sweden over 20 years, and assess the effect of endovascular repair (EVAR) on surgical treatment rate and outcome.

METHODS

All Swedish citizens >50 years with RAAA 1994 to 2013 were extracted from 3 national (Cause of Death, Patient, and Vascular Surgical) registries. Incidence, proportion repaired, surgical techniques, and 90-day mortality were assessed based on sex and age groups, with regression analysis.

RESULTS

18,726 individuals with RAAA were identified, 74.0% men. The incidence of RAAA decreased from 33.1/100,000: 1994 to 21.3/100,000: 2013 (relative change -35.6%, P < 0.001). The proportion of men with RAAA undergoing repair was 44.5%: 1994-1998, 49.7%: 2009-2013 (+11.7%, P < 0.001). In women, 22.3% were repaired in 1994-1998, versus 28.2%: 2009-2013 (+26.4%, P < 0.001). The proportion undergoing repair increased in octogenarians (men: +44.3%, P < 0.001; women +49.3%, P = 0.001). EVAR increased from 0% initially to 42.3% in men and 41.2% in women 2013. Overall, mortality rate among all individuals with RAAA decreased, men 75.8%: 1994-1998, 64.8%: 2009-2013 (-14.5%, P < 0.001); women 88.5%: 1994-1998, 82.2%: 2009-2013 (-7.1%, P < 0.001). Among those who underwent repair, mortality was 47.0% in men: 1994-1998, 31.8%: 2009-2013 (-32.3%, P < 0.001); women 51.8%: 1994-1998, 41.4%: 2009-2013 (-20.1%, P = 0.010).

CONCLUSION

RAAA mortality among men decreased, mainly attributed to falling incidence of RAAA. The mortality was further reduced by more patients being offered repair, increasingly often with EVAR, and improved survival after repair. Incidence of rupture remained unchanged among women, who had higher RAAA mortality. Focused efforts to reduce RAAA mortality among women are warranted.

Editor's Choice - Systematic Review and Meta-Analysis of Sex Specific Differences in Adverse Events After Open and Endovascular Intact Abdominal Aortic Aneurysm Repair: Consistently Worse Outcomes for Women

OBJECTIVE

Previously, reports have shown that women experience a higher mortality rate than men after elective open (OAR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With recent improvements in overall AAA repair outcomes, this study aimed to identify whether sex specific disparity has been ameliorated by modern practice, and to define sex specific differences in peri- and post-operative complications and pre-operative status; factors which may contribute to poor outcome.

METHODS

This was a systematic review, meta-analysis, and meta-regression of sex specific differences in 30 day mortality and complications conducted according to PRISMA guidance (Prospero registration CRD42020176398). Papers with ≥ 50 women, reporting sex specific outcomes, following intact primary AAA repair, from 2000 to 2020 worldwide were included; with separate analyses for EVAR and OAR. Data sources were Medline, Embase, and CENTRAL databases 2005 - 2020 searched using ProQuest Dialog.

RESULTS

Twenty-six studies (371 215 men, 65 465 women) were included. Meta-analysis and meta-regression indicated that sex specific odds ratios (ORs) for 30 day mortality were unchanged from 2000 to 2020. Mortality risk was higher in women for OAR and more so for EVAR (OR [95% CI] 1.49 [1.37 - 1.61]; 1.86 [1.59 - 2.17], respectively) and this remained following multivariable risk adjustment. Transfusion, pulmonary complications, and bowel ischaemia were more common in women after OAR and EVAR (OAR: ORs 1.81 [1.60 - 2.04], 1.40 [1.28 - 1.53], 1.54 [1.36 - 1.75]; EVAR: ORs 2.18 [2.08 - 2.29] 1.44 [1.17 - 1.77], 1.99 [1.51 - 2.62], respectively). Arterial injury, limb ischaemia, renal and cardiac complications were more common in women after EVAR (ORs 3.02 [1.62 - 5.65], 2.13 [1.48 - 3.06], 1.46 [1.22 - 1.72] and 1.19 [1.03 - 1.37], respectively); the latter was associated with greater mortality risk on meta-regression.

CONCLUSION

Increased mortality risk for women following AAA repair remains. Women had a higher incidence of transfusion, pulmonary and bowel complications after EVAR and OAR. Higher mortality risk ratios for EVAR may result from cardiac complications, additional arterial injury, and embolisation, leading to renal and limb ischaemia. These findings indicate possible causes for observed outcome disparities and targets for quality improvement.

Editor's Choice - Variation in Intact Abdominal Aortic Aneurysm Repair Outcomes by Country: Analysis of International Consortium of Vascular Registries 2010 - 2016

OBJECTIVE

Outcomes for intact abdominal aortic aneurysm (AAA) repair vary over time and by healthcare system, country, and surgeon. The aim of this study was to analyse peri-operative mortality for intact AAA repair in 11 countries over time and compare outcomes by gender, age, and geographical location.

METHODS

Prospective data on primary repair of intact AAA were collected from 11 countries through the International Consortium of Vascular Registries (ICVR) and analysed for two time periods, 2010 - 2013 and 2014 - 2016. The primary outcome was peri-operative mortality after endovascular aneurysm repair (EVAR) and open surgical repair (OSR). Multivariable logistic regression models were used to adjust for differences in patient characteristics.

RESULTS

A total of 103 715 patients were included. The percentage of patients undergoing EVAR increased from 63.6% to 71.2% (p < .001) over the study period. This proportion varied by country from 35% in Hungary to 81% in the United States. Overall peri-operative mortality decreased from 2.1% to 1.6 % (p < .001). Mortality also declined significantly over time for both OSR 4.2% to 3.6 % (p = .002) and EVAR 1.0% to 0.7% (p = .002). Mortality was significantly higher for female than male patients (3.0% vs. 1.6% p < .001). The percentage of patients > 80 years old undergoing AAA repair remained constant at 23.6% (p = .91). Peri-operative mortality was higher for patients > 80 years than for those < 80 years old (2.7% vs. 1.6% p < .001). Forty-six per cent (n = 275) of all EVAR deaths occurred in the over 80s.

CONCLUSION

The proportion of AAA repairs performed using EVAR has increased over time. Peri-operative mortality continues to decline for both OSR and EVAR. Outcomes however were significantly worse for both women and those aged over 80, so efforts should be focused on these patient groups to further reduce elective AAA mortality rates.

Effects of hospital preference for endovascular repair on postoperative mortality after elective abdominal aortic aneurysm repair: analysis of the Dutch Surgical Aneurysm Audit

BACKGROUND

Increased use of endovascular aneurysm repair (EVAR) and reduced open surgical repair (OSR), has decreased postoperative mortality after elective repair of abdominal aortic aneurysms (AAAs). The choice between EVAR or OSR depends on aneurysm anatomy, and the experience and preference of the vascular surgeon, and therefore differs between hospitals. The aim of this study was to investigate the current mortality risk difference (RD) between EVAR and OSR, and the effect of hospital preference for EVAR on overall mortality.

METHODS

Primary elective infrarenal or juxtarenal aneurysm repairs registered in the Dutch Surgical Aneurysm Audit (2013-2017) were analysed. First, mortality in hospitals with a higher preference for EVAR (high-EVAR group) was compared with that in hospitals with a lower EVAR preference (low-EVAR group), divided by the median percentage of EVAR. Second, the mortality RD between EVAR and OSR was determined by unadjusted and adjusted linear regression and propensity-score (PS) analysis and then by instrumental-variable (IV) analysis, adjusting for unobserved confounders; percentage EVAR by hospital was used as the IV.

RESULTS

A total of 11 997 patients were included. The median hospital rate of EVAR was 76.6 per cent. The overall mortality RD between high- and low-EVAR hospitals was 0.1 (95 per cent -0.5 to 0.4) per cent. The OSR mortality rate was significantly higher among high-EVAR hospitals than low-EVAR hospitals: 7.3 versus 4.0 per cent (RD 3.3 (1.4 to 5.3) per cent). The EVAR mortality rate was also higher in high-EVAR hospitals: 0.9 versus 0.7 per cent (RD 0.2 (-0.0 to 0.6) per cent). The RD following unadjusted, adjusted, and PS analysis was 4.2 (3.7 to 4.8), 4.4 (3.8 to 5.0), and 4.7 (4.1 to 5.3) per cent in favour of EVAR over OSR. However, the RD after IV analysis was not significant: 1.3 (-0.9 to 3.6) per cent.

CONCLUSION

Even though EVAR has a lower mortality rate than OSR, the overall effect is offset by the high mortality rate after OSR in hospitals with a strong focus on EVAR.

Outcomes in Octogenarians and the Effect of Comorbidities After Intact Abdominal Aortic Aneurysm Repair in the Netherlands: A Nationwide Cohort Study

OBJECTIVE

Age is an independent risk factor for mortality after both elective open surgical repair (OSR) and endovascular aneurysm repair (EVAR). As a result of an ageing population, and the less invasive nature of EVAR, the number of patients over 80 years (octogenarians) being treated is increasing. The mortality and morbidity following aneurysm surgery are increased for octogenarians. However, the mortality for octogenarians who have either low or high peri-operative risks remains unclear. The aim of this study was to provide peri-operative outcomes of octogenarians vs. non-octogenarians after OSR and EVAR for intact aneurysms, including separate subanalyses for elective and urgent intact repair, based on a nationwide cohort. Furthermore, the influence of comorbidities on peri-operative mortality was examined.

METHODS

All patients registered in the Dutch Surgical Aneurysm Audit (DSAA) undergoing intact AAA repair between 2013 and 2018, were included. Patient characteristics and peri-operative outcomes (peri-operative mortality, and major complications) of octogenarians vs. non-octogenarians for both OSR and EVAR were compared using descriptive statistics. Multivariable logistic regression analyses were used to examine whether age and the presence of cardiac, pulmonary, or renal comorbidities were associated with mortality.

RESULTS

This study included 12 054 EVAR patients (3 015 octogenarians), and 3 815 OSR patients (425 octogenarians). Octogenarians in both the EVAR and OSR treatment groups were more often female and had more comorbidities. In both treatment groups, octogenarians had significantly higher mortality rates following intact repair as well as higher major complication rates. Mortality rates of octogenarians were 1.9% after EVAR and 11.8% after OSR. Age ≥ 80 and presence of cardiac, pulmonary, and renal comorbidities were associated with mortality after EVAR and OSR.

CONCLUSION

Because of the high peri-operative mortality rates of octogenarians, awareness of the presence of comorbidities is essential in the decision making process before offering aneurysm repair to this cohort, especially when OSR is considered.

Endovascular Aortic Repair in Nonagenarian Patients

BACKGROUND

The increasing proportion of elderly patients being treated for abdominal aortic aneurysm (AAA) in the endovascular era is controversial.

OBJECTIVES

This study compared 30-day outcomes of endovascular aortic repair (EVAR) in nonagenarians (NAs) with non-nonagenarians (NNAs).

METHODS

This retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database included EVAR procedures performed from 2011 to 2017. Multivariate logistic regression in the unadjusted cohort, followed by propensity-score matching (PSM), was performed. Primary outcomes were 30-day mortality and 30-day major adverse events.

RESULTS

A total of 12,267 patients were included (365 NAs). Ruptured aneurysms accounted for 6.7% (n = 819): 15.7% (n = 57) in NAs versus 6.5% (n = 762) in NNAs (p < 0.001). Mean aneurysm diameter was 6.5 ± 1.8 cm in NAs versus 5.8 ± 1.7 cm in NNAs (p < 0.001). The unadjusted 30-day mortality was 9.9% in NA versus 2.2% in NNAs (p < 0.001). Multivariate analysis revealed age ≥90 years (odds ratio [OR]: 3.36), male sex (OR: 1.78), functional status (OR: 4.22), pre-operative ventilator dependency (OR: 3.80), bleeding disorders (OR: 1.52), dialysis (OR: 2.56), and ruptured aneurysms (OR: 17.21) as independent predictors of mortality. After PSM, no differences in 30-day mortality (intact AAA [iAAA]: 5.3% NA vs. 3% NNA [p = 0.15]; ruptured AAA [rAAA]: 38% NA vs. 28.6% NNA [p = 0.32]) or 30-day major adverse events (iAAA: 7% NA vs. 4.6% NNA [p = 0.22]; rAAA: 28% NA vs. 36.7% NNA [p = 0.35]) were observed.

CONCLUSIONS

Age was identified as an independent predictor of 30-day mortality after EVAR on multivariate analysis. However, no differences were found after PSM, suggesting that being ≥90 years of age but with similar comorbidities to younger patients is not associated with a higher short-term mortality after EVAR. Age ≥90 years alone should not exclude patients from EVAR, and tailored indications and carefully balanced risk assessment are advised.

Editor's Choice - Optimal Threshold for the Volume-Outcome Relationship After Open AAA Repair in the Endovascular Era: Analysis of the International Consortium of Vascular Registries

OBJECTIVE

As open abdominal aortic aneurysm (AAA) repair (OAR) rates decline in the endovascular era, the endorsement of minimum volume thresholds for OAR is increasingly controversial, as this may affect credentialing and training. The purpose of this analysis was to identify an optimal centre volume threshold that is associated with the most significant mortality reduction after OAR, and to determine how this reflects contemporary practice.

METHODS

This was an observational study of OARs performed in 11 countries (2010 - 2016) within the International Consortium of Vascular Registry database (n = 178 302). The primary endpoint was post-operative in hospital mortality. Two different methodologies (area under the receiving operating curve optimisation and Markov chain Monte Carlo procedure) were used to determine the optimal centre volume threshold associated with the most significant mortality improvement.

RESULTS

In total, 154 912 (86.9%) intact and 23 390 (13.1%) ruptured AAAs were analysed. The majority (63.1%; n = 112 557) underwent endovascular repair (EVAR) (OAR 36.9%; n = 65 745). A significant inverse relationship between increasing centre volume and lower peri-operative mortality after intact and ruptured OAR was evident (p < .001) but not with EVAR. An annual centre volume of between 13 and 16 procedures per year was associated with the most significant mortality reduction after intact OAR (adjusted predicted mortality < 13 procedures/year 4.6% [95% confidence interval 4.0% - 5.2%] vs. ≥ 13 procedures/year 3.1% [95% CI 2.8% - 3.5%]). With the increasing adoption of EVAR, the mean number of OARs per centre (intact + ruptured) decreased significantly (2010 - 2013 = 35.7; 2014 - 2016 = 29.8; p < .001). Only 23% of centres (n = 240/1 065) met the ≥ 13 procedures/year volume threshold, with significant variation between nations (Germany 11%; Denmark 100%).

CONCLUSION

An annual centre volume of 13 - 16 OARs per year is the optimal threshold associated with the greatest mortality risk reduction after treatment of intact AAA. However, in the current endovascular era, achieving this threshold requires significant re-organisation of OAR practice delivery in many countries, and would affect provision of non-elective aortic services. Low volume centres continuing to offer OAR should aim to achieve mortality results equivalent to the high volume institution benchmark, using validated data from quality registries to track outcomes.

A population-based study of post-endovascular aortic repair rupture during 15 years

OBJECTIVE

The devastating event of a ruptured abdominal aortic aneurysm (rAAA) in patients who have survived a previous AAA repair, either elective or urgent, is a feared and quite uncommon event. It has been suggested to partly explain the loss of the early survival benefit for endovascular aortic repair (EVAR) vs open surgical repair (OSR). The main objective of this study was to report the national incidence rate, risk factors and outcome of post-EVAR ruptures. Secondarily, the national incidence rate of ruptures after OSR (post-OSR ruptures) was investigated.

METHODS

We conducted a nationwide, population-based, retrospective cohort study using the inpatient and outpatient entries for all patients >40 years of age, receiving their first (index) surgical procedure for AAA, from 2001 to 2015. Only patients surviving their index procedure were included. The primary outcome was rAAA, registered after discharge from the index procedure (EVAR or OSR), identified in the Swedish National Patient Registry and the Cause of Death Registry.

RESULTS

In total, 14,859 patients survived their primary (index) AAA procedure. There were 6470 EVAR procedures, 5893 for intact AAA (iAAA) and 577 for rAAA. Of the 6470 EVAR patients, 86 cases of post-EVAR rupture were identified, corresponding with a cumulative incidence of 1.3% over a mean follow-up time of 3.9 years. The incidence rate was 3.4 (95% confidence interval [CI], 2.7-4.2)/1000 person-years. The independent risk factors identified for post-EVAR rupture were rAAA at index surgery HR 2.4 (95% CI, 1.4-4.1, p 0.002) and age (hazard ratio, 1.1; 95% CI, 1.0-1.1; P < .001). Freedom from post-EVAR rupture was 99%, 98%, and 96% at 3, 5, and 10 years, respectively. Total and postoperative mortality after post-EVAR rupture were 42% and 17% (30 days), 45% and 22% (90 days), and 53% and 33% (1 year). The incidence rate of post-OSR rupture was 0.9/1000 person-years (95% CI, 0.7-1.2).

CONCLUSIONS

Post-EVAR rupture is a rare complication that can occur at any time after the index EVAR procedure. This finding may have implications for the discussion of limited follow-up programs and for the choice of procedure in patients with an AAA with a long life expectancy. An rAAA as the indication for the index surgery and age were identified as risk factors for post-EVAR rupture. The mortality associated with post-EVAR rupture is high, but lower than that of primary rAAA. The much lower risk of post-OSR rupture was confirmed, but must not be neglected as a possible late complication.

Female Sex and Outcomes after Endovascular Aneurysm Repair for Abdominal Aortic Aneurysm: A Propensity Score Matched Cohort Analysis

OBJECTIVE

Previous studies have showed a potential disadvantage of female patients who underwent abdominal aortic aneurysm (AAA) repair. The current study aims to determine sex-specific perioperative and long-term outcomes using propensity score matched unselected nationwide health insurance claims data.

METHODS

Insurance claims from a large German fund were used, covering around 8% of the insured German population. Patients who underwent endovascular aortic repair (EVAR) for intact AAA from 1 January 2011 to 30 April 2017 were included in the cohort. A 1:2 female to male propensity score matching was applied to adjust for confounding variables. Perioperative and long-term outcomes after 5 years were determined using matching and regression methods.

RESULTS

Among a total of 3736 patients (19.3% females, mean 75 years) undergoing EVAR for intact AAA, we identified 1863 matched patients. Before matching, females were more likely to be previously diagnosed with hypothyroidism, electrolyte disorders, rheumatoid disorders, and depression, while males were more often diabetics. In the matched sample, 23.4% of the females and 25.8% of the males died during a median follow-up of 776 and 792 days, respectively. Perioperatively, females were more likely to exhibit acute limb ischemia (5.3% vs. 3.2%, p = 0.031) and major bleeding (22.0% vs. 15.9%, p = 0.001) before they were discharged to rehabilitation (5.5% vs. 1.5%, p < 0.001) when compared to males. No statistically significant difference in perioperative (odds ratio 1.12, 95% CI 0.54-2.16) or long-term mortality (hazard ratio 0.91, 95% CI 0.76-1.08) was observed between sexes. This was also true regarding aortic reintervention rates after 1 year (2.0% vs. 2.9%) and 5 years (10.9% vs. 8.1%).

CONCLUSION

The current retrospective matched analysis of insurance claims revealed high early access-related morbidity in females when compared to their male counterparts. Short-term or long-term survival and reintervention outcomes were similar between sexes.

Simulation Based Training and Assessment in Open Vascular Surgery: A Systematic Review

OBJECTIVE

The aim of this study was to systematically review the literature and give evidence based recommendations for future initiatives for simulation based training (SBT) and assessment in open vascular surgery.

DATA SOURCES

PubMed, Embase, and the Cochrane Library.

REVIEW METHODS

A systematic review of PubMed, Embase, and the Cochrane Library was performed, with the last search on 31 March 2020, to identify studies describing SBT and assessment in open vascular surgery. Kirkpatrick's levels for efficacy of training were evaluated. Validity evidence for assessment tools was evaluated according to the recommended contemporary framework by Messick.

RESULTS

Of 2 844 studies, 51 were included for data extraction. A high degree of heterogeneity in reporting standards and varying types of simulation was found. Vascular anastomosis was the most frequently simulated technical skill (43%). Assessment was mostly carried out using the Objective Structured Assessment of Technical Skills (55%). Validity evidence for assessment tools was found using outdated frameworks, and only one study used Messick's framework. Self directed training is valuable, the low trainer to trainee ratio is important to maximise efficiency, and experienced vascular surgeons are the most effective trainers.

CONCLUSION

Carefully designed and structured SBT is effective and can improve technical skills, especially in less experienced trainees. However, the supporting evidence lacks homogeneity in the reporting standards and types of simulations. Pass/fail standards that support proficiency based learning and studies investigating skills transfer should be the focus in future studies. Validity evidence of assessment tools needs to be addressed using contemporary frameworks.

Learning Curves and Competences of Vascular Trainees Performing Open Aortic Repair in a Simulation-Based Environment

BACKGROUND

The aim of this study was to analyze learning curves and competency gains of novice vascular trainees when performing open aortic repair in a simulation-based environment.

METHODS

This was a prospective study of 16 vascular trainees performing infrarenal open aortic repair on an inanimate abdominal aortic aneurysm simulator with pulsatile pressure and flow. Each participant performed 4 procedures as a primary surgeon while getting structured feedback by a supervising experienced vascular surgeon. All sessions were video recorded and were anonymously and independently assessed by 3 rater-trained experts on an online platform using the newly validated open abdominal aortic aneurysm repair of technical expertise assessment tool. All supervisor interferences and procedure time was noted.

RESULTS

Reliability between raters was excellent (intraclass correlation coefficient = 0.92). Participants' mean scores almost doubled during the course between the first (13.4, 95% confidence interval [CI], 6.8-20) and fourth session (29.8, 95% CI, 26.3-33.3) with a mean difference of 14.6 (P < 0.001). Supervisor interference also decreased significantly from mean 3.0 (95% CI, 1.5-3.6) in the first to 0.7 (95% CI, 0.4-1.0) in the fourth session (P = 0.004). Procedure time decreased with a mean of 24 minutes: from 81 min (95% CI, 71.8-90.3) to 57 min (95% CI, 51.1-63.2, P < 0.001). There was a significant negative correlation between procedure time and the Open Abdominal Aortic Aneurysm Repair of Technical Expertise score (Pearson's r = -0.72, P < 0.01). Only half of the participants passed the pass/fail score of 27.7 points during the course.

CONCLUSIONS

Novice vascular trainees achieve skills and competencies in open aortic repair in a simulated setting with dedicated supervision and feedback and can become ready for supervised surgery on real patients. Learning rates are individual, and it is important to construct training programs with emphasis on proficiency and not merely attending a course.

Management of Abdominal Aortic Aneurysm Disease: Similarities and Differences Among Cardiovascular Guidelines and NICE Guidance

The development of endovascular techniques has improved abdominal aortic aneurysm (AAA) management over the past 2 decades. Different cardiovascular societies worldwide have recommended the endovascular approach as the standard of care in their currently available guidelines. While endovascular treatment has established its role in daily clinical practice, a new debate has arisen regarding the indications, appropriateness, limitations, and role of open surgery. To inform this debate, the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched from 2010 to May 2020; the systematic search identified 5 articles published between 2011 and 2020 by 4 cardiovascular societies and the National Institute of Health and Care Excellence (NICE). Four debatable domains were assessed and analyzed: diagnostic methods and screening, preoperative management, indications and treatment modalities, and postoperative follow-up and endoleak management. The review addresses controversial proposals as well as widely accepted recommendations and "gray zone" issues that need to be further investigated and analyzed, such as screening in women, medical management, and follow-up imaging. While the recommendations for AAA management have significant overlap and agreement among international cardiovascular societies, the NICE guidelines diverge regarding the role of open repair in aortic disease, recommending conventional surgery in most elective cases.

Editor's Choice - Volume-Outcome Relationships in Elective Abdominal Aortic Aneurysm Surgery: Analysis of the UK Hospital Episodes Statistics Database for the Getting It Right First Time (GIRFT) Programme

OBJECTIVE

To investigate whether a volume-outcome relationship exists for elective abdominal aortic aneurysm (AAA) surgery conducted within the National Health Service (NHS) in England.

METHODS

This was an analysis of administrative data. Data were extracted from the Hospital Episodes Statistics database for England from April 2011 to March 2019 for all adult admissions for elective infrarenal AAA surgery. Data were extracted for the NHS trust and surgeon undertaking the procedure, the surgical technique used (open or endovascular), the financial year of admission, length of hospital and critical care stay during the procedure and subsequent emergency re-admissions (primary outcome) and deaths within 30 days. Multilevel modelling was used to adjust for hierarchy and confounding.

RESULTS

A dataset of 31 829 procedures (8867 open, 22 962 endovascular) was extracted. For open surgery, lower trust annual volume was associated with higher 30 day emergency re-admission rates and higher 30 day mortality. For open surgery, lower surgeon annual volume was associated with higher 30 day mortality and length of hospital stay greater than the median. For endovascular surgery, lower surgeon annual volume was associated with not having an overnight stay in critical care. None of the other volume-outcome relationships investigated was significant.

CONCLUSION

For elective infrarenal AAA surgery in the UK NHS, there was strong evidence of a volume-outcome relationship for open surgery. However, evidence for a volume-outcome relationship is dependent on the specific procedure undertaken and the outcome of interest.

Analysis of Endovascular Aneurysm Repair for Small Abdominal Aortic Aneurysms in Males

BACKGROUND

Current guidelines recommend repair of abdominal aortic aneurysms (AAAs) when ≥5.5 cm. This study sought to evaluate the incidence of male patients undergoing endovascular aneurysm repair (EVAR) for AAAs of various diameters (small <4 cm; intermediate 4-5.4 cm; standard ≥5.5 cm). We analyzed predictors of mortality, hypothesizing that smaller AAAs (<5.5 cm) have no differences in associated risk of mortality compared to standard AAAs (≥5.5 cm).

METHODS

The 2011-2017 American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Vascular database was queried for male patients undergoing elective EVAR. Patients were stratified by aneurysm diameter. A multivariable logistic regression analysis for clinical outcomes, adjusting for age, clinical characteristics, and comorbidities, was performed.

RESULTS

A total of 8037 male patients underwent EVAR with 3926 (48.9%) performed for AAAs <5.5 cm. There was no difference in mortality, readmission, major complications, myocardial infarction, stroke, or ischemic complications among the 3 groups (P > 0.05). In AAAs <5.5 cm, predictors of mortality included prior abdominal surgery (odds ratio [OR], 5.77; confidence interval [CI], 1.38-24.13; P = 0.016), weight loss (OR, 43.4; CI, 3.78-498.7; P = 0.002), disseminated cancer (OR, 17.9; CI, 1.30-245.97; P = 0.031), and diabetes (OR, 6.09; CI, 1.52-24.36; P = 0.011).

CONCLUSIONS

Nearly 50% of male patients undergoing elective EVAR were treated for AAAs <5.5 cm. There was no difference in associated risk of mortality for smaller AAAs compared to standard AAAs. The strongest predictors of mortality for patients with smaller AAAs were prior abdominal surgery, weight loss, disseminated cancer, and diabetes.

Paradigm shifts in abdominal aortic aneurysm management based on vascular registries

Abdominal aortic aneurysm (AAA) is a relatively common and potentially fatal disease. The management of AAA has undergone extensive changes in the last two decades. High quality vascular surgical registries were established early and have been found to be instrumental in the evaluation and monitoring of these changes, most notably the wide implementation of minimally invasive endovascular surgical technology. Trends over the years showed the increased use of endovascular aneurysm repair (EVAR) over open repair, the decreasing perioperative adverse outcomes and the early survival advantage of EVAR. Also, data from the early EVAR years changed the views on endoleak management and showed the importance of tracking the implementation of new techniques. Registry data complemented the randomized trials performed in aortic surgery by showing the high rate of laparotomy-related reinterventions after open repair. Also, they are an essential tool for the understanding of outcomes in a broad patient population, evaluating the generalizability of findings from randomized trials and analysing changes over time. By using large-scale data over longer periods of time, the importance of centralization of care to high-volume centres was shown, particularly for open repair. Additionally, large-scale databases can offer an opportunity to assess practice and outcomes in patient subgroups (e.g. treatment of AAA in women and the elderly) as well as in rare aortic pathologies. In this review article, we point out the most important paradigm shifts in AAA management based on vascular registry data.

Top 10 candidate aortic disease trials

Aortic pathologies such as aneurysm, dissection and trauma are relatively common and potentially fatal diseases. Over the past two decades, we have experienced unprecedented technical and medical developments in the field. Despite this, there is a great need, and great opportunities, to further explore the area. In this review, we have identified important areas that need to be further studied and selected priority aortic disease trials. There is a pressing need to update the AAA natural history and the role for endovascular AAA repair as well as to define biomarkers and genetic risk factors as well as influence of gender for development and progression of aortic disease. A key limitation of contemporary treatment strategies of AAA is the lack of therapy directed at small AAA, to prevent AAA expansion and need for surgical repair, as well as to reduce the risk for aortic rupture. Currently, the most promising potential drug candidate to slow AAA growth is metformin, and RCTs to verify or reject this hypothesis are warranted. In addition, the role of endovascular treatment for ascending pathologies and for uncomplicated type B aortic dissection needs to be clarified.

Mortality from abdominal aortic aneurysm: trends in European Union 15+ countries from 1990 to 2017

BACKGROUND

This observational study assessed trends in abdominal aortic aneurysm (AAA) death rates in European Union (EU) 15+ countries for the years 1990 to 2017.

METHODS

Age-standardized death rates (ASDRs) were extracted from the Global Burden of Disease Study Global Health Data Exchange. Trends were analysed using joinpoint regression analysis.

RESULTS

Between 1990 and 2017, ASDRs from AAA decreased in all 19 EU15+ countries for women, and in 18 of 19 countries for men. Increasing AAA mortality was observed only for men in Greece (+5·3 per cent). The largest relative decreases in ASDR between 1990 and 2017 were observed in Australia (men -65·6 per cent, women -50·4 per cent) and Canada (men -60·8 per cent, women -48·6 per cent). Over the 28-year interval, the smallest decreases in ASDR for women were noted in Greece (-2·3 per cent) and in Italy (-2·5 per cent). In 2017, the highest mortality rates were observed in the UK for both men and women (7·5 per 100 000 and 3·7 per 100 000 respectively). The lowest ASDR was observed in Portugal for men (2·8 per 100 000) and in Spain for women (1·0 per 100 000). ASDRs for AAA in 2017 were higher for men than women in all 19 EU15+ countries. The most recent trends demonstrated increasing AAA ASDRs in 14 of 19 countries for both sexes; the increases were relatively small compared with the improvements in the preceding years.

CONCLUSION

This observational study identified decreasing mortality from AAA across EU15+ countries since 1990. The most recent trends demonstrated relatively small increases in AAA mortality across the majority of EU15+ countries since 2012.

To assess hemodynamic disturbances to the ostia of the renal arteries generated by the implantation of EVAR with a suprarenal fixation

INTRODUCTION

The treatment of abdominal aortic aneurysm (AAA) is increasingly performed via endovascular aneurysm repair (EVAR). Different types of fixation are possible with EVAR, i.e., below (infrarenal fixation) or above (suprarenal fixation) the renal arteries. Hemodynamic alterations in renal arterial flow with suprarenal (SR) fixation remain to be demonstrated. The IFIXEAR (Impact of Supra-renal Fixation of EVAR on Hemodynamics of Renal Arteries) study is designed to assess the hemodynamic effects at the ostia of at least 1 renal artery, generated immediately post-surgery by the implantation of an aortic stent with SR fixation.

METHODS

IFIXEAR is a prospective, 2 center study. Every patient undergoing elective EVAR with SR fixation is eligible for inclusion. Patients with previous hemodynamic disturbances to the ostia of 1 of the renal arteries are not eligible. All patients undergo echocardiography and renal arteries duplex ultrasound within a month before surgery, and at 1 and 12 months after surgery. The primary endpoint is hemodynamic disturbance, defined as a peak systolic velocity greater than 120 cm/second, at the ostia of 1 of the renal arteries in the immediate postoperative period.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee "Comité de Protection des Personnes Ouest V" under the number 18/019-2 on April 20, 2018. All patients provide written informed consent before inclusion. The University Hospital of Besancon is the trial sponsor. Results of the study will be submitted for publication in a peer-reviewed international medical journal.

REGISTRATION

The trial is registered with ClinicalTrials.gov (Identifier: NCT03594786, principal investigator: Dr Patricia Costa, Registered on April 24, 2018).

Clinical evaluation of endovascular repair of abdominal aortic aneurysm based on long-term experiences

Introduction

The endovascular method as a less invasive treatment for patients with abdominal aortic aneurysm (AAA) has become an alternative to conventional open surgery.

Aim

The objective of the present study was to analyse the outcomes of endovascular treatment of AAA patients in long-term observation.

Material and methods

A group of 236 AAA patients subjected to planned endovascular aneurysm repair (EVAR) between 2010 and 2015 was reviewed. Rates of mortality, surgical complications and re-interventions were collected in the separate time periods, i.e. up to 30 days after surgery, 30 days to 3 years, and from 3 to 5 years after surgery. Cumulative rates of these parameters were evaluated in the short-term (up to 30 days after surgery), medium-term (up to 3 years), and long-term (up to 5 years after surgery) perspective.

Results

The median age of patients was 75 years, and the most common comorbidities were arterial hypertension (54%) and ischaemic heart disease (52%). Cumulative short-, medium- and long-term mortality rates were 2.5%, 14.2% and 28.9%, respectively. Total rates of surgical complications in short-, medium- and long-term observation were 7.6%, 12.6% and 17.5%, respectively. The cumulative rate of re-interventions ranged from 4.2% to 11.4%.

Conclusions

In the consecutive time periods, the increase in the percentage of surgical complications and re-interventions increased gradually, in contrast to mortality, where the curve grew significantly, which is expected due to the aging and numerous comorbidities in the observed group of patients.

Editor's Choice - Detection of Late Complications After Endovascular Abdominal Aortic Aneurysm Repair and Implications for Follow up Based on Retrospective Assessment of a Two Centre Cohort

OBJECTIVE

Endovascular aortic aneurysm repair (EVAR) is associated with the risk of late complications and mandates follow up. This retrospective study assessed post-EVAR complications in a two centre cohort. The study evaluated the rate of complications presenting with symptoms vs. those detected by imaging follow up. Additionally, the agreement between DUS and CTA in detecting complications was assessed in patients with both.

METHODS

All EVAR patients from 1998 to 2012 in two centres were included. Complications were classified based on whether they were symptomatic or detected by imaging, as well as based on imaging detection modality (DUS or CTA). For patients who had undergone DUS and CTA within three months of each other, the kappa coefficient of agreement was assessed.

RESULTS

Four hundred and fifty-four patients treated by EVAR were identified. The median follow up time was 5.2 (IQR 2.8-7.6) years. One hundred and eighteen patients (26%) developed 176 complications. One hundred and six (60.2%) of the complications were asymptomatic, and 70 (39.8%) were symptomatic. Two hundred and fifty-three patients had imaging with both modalities within three months of each other; the kappa coefficient for agreement between CTA and DUS for detecting clinically significant complications was 0.91. Regarding CTA as the standard modality, DUS had a sensitivity of 88.8% (95% CI 77.3-95.8%) and a specificity of 99.4% (95% CI 97.1-99.9%). Three of the complications missed by DUS were related to loss of proximal and distal seal, all occurring in patients with short sealing length on first post-operative CT scan.

CONCLUSION

Approximately a quarter of the patients developed complications, the majority of which were asymptomatic, underlining the importance of adequate surveillance. There was good agreement between CTA and DUS in detecting complications. Clinically significant complications related to inadequate seal were missed by DUS, suggesting that CTA still plays an important role in EVAR surveillance.

Ensuring Competency in Open Aortic Aneurysm Repair - Development and Validation of a New Assessment Tool

OBJECTIVE

The aims of this study were to develop a procedure specific assessment tool for open abdominal aortic aneurysm (AAA) repair, gather validity evidence for the tool and establish a pass/fail standard.

METHODS

Validity was studied based on the contemporary framework by Messick. Three vascular surgeons experienced in open AAA repair and an expert in assessment and validation within medical education developed the OPEn aortic aneurysm Repair Assessment of Technical Expertise (OPERATE) tool. Vascular surgeons with varying experiences performed open AAA repair in a standardised simulation based setting. All procedures were video recorded with the faces anonymised and scored independently by three experts in a mutual blinded setup. The Angoff standard setting method was used to establish a credible pass/fail score.

RESULTS

Sixteen novices and nine experienced open vascular surgeons were enrolled. The OPERATE tool achieved high internal consistency (Cronbach's alpha .92) and inter-rater reliability (Cronbach's alpha .95) and was able to differentiate novices and experienced surgeons with mean scores (higher score is better) of 13.4 ± 12 and 25.6 ± 6, respectively (p = .01). The pass/fail score was set high (27.7). One novice passed the test while six experienced surgeons failed.

CONCLUSION

Validity evidence was established for the newly developed OPERATE tool and was able to differentiate between novices and experienced surgeons providing a good argument that this tool can be used for both formative and summative assessment in a simulation based environment. The high pass/fail score emphasises the need for novices to train in a simulation based environment up to a certain level of competency before apprenticeship training in the clinical environment under the tutelage of a supervisor. Familiarisation with the simulation equipment must be ensured before performance is assessed as reflected by the low scores in the experienced group's first attempt.

The effect of Endovascular Aneurysm Repair on Renal Function in Patients Treated for Abdominal Aortic Aneurysm

Aim:

The effect of endovascular aneurysm repair in patients treated for abdominal aortic aneurysm has not been clearly defined. The objective of the present article was to provide a contemporary literature review and perform an analysis to determine the effect of EVAR on renal function in the early post-operative period and during follow-up.

Methods:

A systematic review of the literature was undertaken to identify all studies reporting the effect of EVAR on renal function. Outcome data were pooled and combined overall effect sizes were calculated using fixed or random-effects models.

Results:

Thirty-two studies reporting on 24846 patients were included. Acute renal failure after EVAR occurred with an estimated frequency of 9% (95%CI: 5-16%; I2=97%). Median follow-up period was 19.5 months (range 1-60 months). The estimated frequency of chronic renal failure during follow-up was 7% (95%CI: 3-17%; I2=98%). Hemodialysis was required in 2% (1-3%; I2=97%) of the cases.

Conclusion:

High-level evidence demonstrating the effect of EVAR on the incidence of acute and chronic renal failure is lacking. Based on the current available data, nearly 10% of patients undergoing EVAR for AAA have an increased risk for renal dysfunction after the procedure. Whether this deterioration may lead to a worse outcome has not been adequately proved.

Primary Care Screening for Abdominal Aortic Aneurysm: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Ruptured abdominal aortic aneurysms (AAAs) have mortality estimated at 81%.

OBJECTIVE

To systematically review the evidence on benefits and harms of AAA screening and small aneurysm treatment to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed (publisher supplied only), Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials for relevant English-language studies published through September 2018. Surveillance continued through July 2019.

STUDY SELECTION

Trials of AAA screening benefits and harms; trials and cohort studies of small (3.0-5.4 cm) AAA treatment benefits and harms.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently reviewed abstracts and full-text articles and extracted data. The Peto method was used to pool odds ratios (ORs) for AAA-related mortality, rupture, and operations; the DerSimonian and Laird random-effects model was used to pool calculated risk ratios for all-cause mortality.

MAIN OUTCOMES AND MEASURES

AAA and all-cause mortality; AAA rupture; treatment complications.

RESULTS

Fifty studies (N = 323 279) met inclusion criteria. Meta-analysis of population-based randomized clinical trials (RCTs) estimated that a screening invitation to men 65 years or older was associated with a reduction in AAA-related mortality over 12 to 15 years (OR, 0.65 [95% CI, 0.57-0.74]; 4 RCTs [n = 124 926]), AAA-related ruptures over 12 to 15 years (OR, 0.62 [95% CI, 0.55-0.70]; 4 RCTs [n = 124 929]), and emergency surgical procedures over 4 to 15 years (OR, 0.57 [95% CI, 0.48-0.68]; 5 RCTS [n = 175 085]). In contrast, no significant association with all-cause mortality benefit was seen at 12- to 15-year follow-up (relative risk, 0.99 [95% CI 0.98-1.00]; 4 RCTs [n = 124 929]). One-time screening was associated with significantly more procedures over 4 to 15 years in the invited group compared with the control group (OR, 1.44 [95% CI, 1.34-1.55]; 5 RCTs [n = 175 085]). Four trials (n = 3314) of small aneurysm surgical treatment demonstrated no significant difference in AAA-related mortality or all-cause mortality compared with surveillance over 1.7 to 12 years. These 4 early surgery trials showed a substantial increase in procedures in the early surgery group. For small aneurysm treatment, registry data (3 studies [n = 14 424]) showed that women had higher surgical complications and postoperative mortality compared with men.

CONCLUSIONS AND RELEVANCE

One-time AAA screening in men 65 years or older was associated with decreased AAA-related mortality and rupture rates but was not associated with all-cause mortality benefit. Higher rates of elective surgery but no long-term differences in quality of life resulted from screening.