Sexual Dysfunction After Abdominal Aortic Aneurysm Surgical Repair: Current Knowledge and Future Directions

Prevalence and Impact of Postoperative Sexual Dysfunction After Major Emergency Abdominal Surgery: A Prospective Cohort Study

INTRODUCTION

Sexual dysfunction is commonly reported after cancer surgery or pelvic surgery; however, the incidence following major emergency abdominal surgery remains unknown. This study aimed to investigate the incidence and sex differences in sexual dysfunction up to 90 days postoperatively after major emergency abdominal surgery.

METHODS

This single-center prospective cohort study included all consecutive patients undergoing major emergency abdominal surgery at Copenhagen University Hospital Herlev from March 2023 to March 2024. Follow-up was conducted at 30 and 90 days postoperatively. Sexual function was assessed using the Brief Sexual Symptom Checklist (BSSC), and patients were asked to report whether they were sexually active before and after surgery.

RESULTS

Of the 180 patients who responded at postoperative day (POD) 30, 69 patients (38.3%) reported being sexually active before surgery but only 31 patients (17.2%) remained active after surgery. At POD 90, 71 (48.3%) of 147 patients reported being sexually active before surgery, whereas 48 patients (32.7%) remained active postoperatively. A significant decrease in sexual activity was observed in both men (63.2% at POD 30 and 45.5% at POD 90) and women (45.2% at POD 30 and 21.1% at POD 90) (p < 0.001 for both time points). Out of the patients who completed the BSSC questionnaire, 32 patients (32.6%) reported dissatisfaction with their sexual function at POD 30, which slightly decreased to 22 patients (26.8%) at POD 90. No significant difference in dissatisfaction rates between men and women was found at either time point.

CONCLUSION

Sexual dysfunction was common after major emergency abdominal surgery in both men and women, with no significant sex differences observed. These findings highlight the need for proactive discussions, information, and management of sexual health in the perioperative period to improve patient outcomes and quality of life.

The dissection-based identification of the preaortic sympathetic plexus formation, anatomical relations, and clinical applications

The abdominal sympathetic nervous system provides sympathetic innervation to the abdominal organs and gonads. This system is part of an extensive neural network that extends from the base of the skull to the pelvis. The preaortic (or prevertebral) plexus is a key component of the abdominal sympathetic system and is represented by a variable nervous network located anterior to the abdominal aorta. The aim of our study was to identify all these sympathetic structures and describe the formation and relationships of the preaortic plexus. We examined five cadavers (aged 66-71) with no medical or surgical history, preserved in 9% formalin at the Anatomy Department from Carol Davila University. Regional dissections were performed in successive planes, highlighting the major abdominal plexuses, the lumbar splanchnic nerves, and the associated network of neural connections that contribute to the preaortic plexus. The plexus is formed by efferent fibers from the celiac and aortico-renal ganglia, as well as from the three lumbar splanchnic nerves. The lumbar splanchnic nerves originate in the paravertebral sympathetic chains. We identified all these sympathetic structures and described the formation and anatomical relationships of the plexus. The nerve fibers of various origins form a longitudinally oriented network located anterolateral to the abdominal aorta. The lower part of this network continues into the superior hypogastric plexus. This neural network is delicate, complex, and variable, making it challenging to identify anatomically and surgically. Situated deeply in the retroperitoneal space, it is prone to accidental injuries during surgery in this compartment.

Risk factors of 30-day and long-term mortality and outcomes in open repair of thoracoabdominal aortic aneurysm

BACKGROUND

Open repair of thoracoabdominal aortic aneurysm (TAAA) was characterized by significant risk of postoperative mortality and morbidity. The aim of this study was to determine the perioperative predictors of early and long-term mortality in patients undergoing open repair of TAAA. Besides, the postoperative outcomes in patients with open repair of TAAA were described.

METHODS

This is a single-center retrospective study, and 146 patients with open repair of TAAA from January 4, 2011, to November 22, 2018 was involved. Categorical variables were analyzed by the Chi-square test or Fisher's exact test, and continuous variables were analyzed by the independent sample t-test and the WilCoxon rank-sum test. Multivariate Logistic regression and Cox regression were applied to identify the predictors of 30-day and long-term mortality, respectively. The Kaplan Meier curves were used to illustrate survival with the Log-rank test.

RESULTS

The 30-day mortality was 9.59% (n = 14). Older than 50 years, the intraoperative volume of red blood cell (RBC) and epinephrine use were independently associated with postoperative 30-day mortality in open repair of TAAA. Long-term mortality was 17.12% (n = 25) (median of 3.5 years (IQR = 2-5 years) of follow-up). Prior open thoracoabdominal aortic aneurysm (TAAA) repair, aortic cross-clamping (ACC) time, intraoperative volume of RBC and use of epinephrine were independently correlated with long-term mortality.

CONCLUSIONS

Identifying perioperative risk factors of early and long-term mortaliy is crucial for surgeons. Intraoperative volume of RBC and use of epinephrine were predictors of both early and long-term mortality. In addition, patients of advanced age, prior open repair of TAAA and prolonged ACC time should be paid more attention.

Long-Term Outcomes of Endovascular Aneurysm Repair in Patients Aged ≤70 Years

Objectives: The efficacy of endovascular aneurysm repair (EVAR) against abdominal aortic aneurysm (AAA) in younger patients remains unknown. Hence, the current study aimed to investigate whether the aneurysm-related mortality rate of EVAR is acceptable among patients aged ≤70 years. Methods: Among 644 patients, 148 underwent EVAR (EVAR group), and 496 received open surgical repair (OSR group). The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events after AAA repair were evaluated using the cumulative incidence function in the presence of competing risks. Results: The EVAR group had higher prevalences of several comorbidities, and overall survival for the EVAR group was significantly inferior to that of the OSR group. The cumulative incidence rates of aneurysm-related death, any intervention, and serious aneurysm-related events at 5 years were 1.5%, 11.7%, and 6.4% in the EVAR group and 1.3%, 5.3%, and 5.9% in the OSR group, respectively. EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. However, it was an independent poor prognostic factor of any intervention. Conclusion: EVAR was not a significant prognostic factor of aneurysm-related mortality and serious aneurysm-related events. Therefore, it demonstrated acceptable procedure-related long-term outcomes, at least in high-risk young patients.

Sexual dysfunction after open abdominal aortic aneurysm repair: 16 years' experience in a quaternary center and literature review

Background

Open abdominal aortic aneurysm (AAA) repair can lead to sexual dysfunction (SD) in men.

Objectives

To determine the prevalence of SD following open AAA repair, explore whether surgical techniques for aortic reconstruction can have a differential impact on the occurrence of SD, and summarize current knowledge in this field.

Methods

Retrospective review of 100 patients submitted to open AAA repair between 1995 and 2010 in a quaternary center. Sexual dysfunction was assessed according to questions from the modified International Index of Erectile Function (IIEF), considering the condition before surgical repair and 3 months after surgery. The chi-square test, Fisher's exact test, and Student's t test were used for statistical analyses.

Results

100 patients were included (mean age = 66.4 years old). Normal sexual activity, no sexual activity, erectile dysfunction, and retrograde ejaculation with preserved erectile function were found in 36%, 21%, 18%, and 24% of patients, respectively. The group of patients with no sexual activity was older (mean age = 72.3 years old vs 64.5 years old, p < 0.001). Erectile dysfunction prevalence was higher in patients submitted to an aorto-bifemoral bypass (p = 0.032). Retrograde ejaculation was more frequent in patients submitted to an aorto-aortic bypass (p = 0.007).

Conclusions

Sexual function is a frequent condition intimately associated with the aortic reconstruction technique. The literature review found contradictory results regarding whether the endovascular approach is protective compared with open repair, but clearly demonstrated the importance of techniques targeting preservation of the internal iliac artery and the superior hypogastric plexus.

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.

Analysis of Repair Type and Hypogastric Artery Antegrade Perfusion and Erectile Function Following Repair of Abdominal Aortic Aneurysms

OBJECTIVES

Published reports suggest that exclusion of antegrade hypogastric artery flow may have deleterious effects on erectile function after abdominal aortic aneurysm repair. Off-label and open surgical hybrid procedures and, more recently, purpose-built branched devices have been developed to maintain antegrade pelvic perfusion in patients undergoing endovascular repair. Maintaining antegrade perfusion may reduce a spectrum of risks, including buttock claudication, colorectal ischemia, spinal cord ischemia when patients undergo subsequent thoracic aortic procedures, as well as erectile dysfunction. This project specifically focuses on erectile function, and analyzes baseline associations and relationships of hypogastric artery exclusion on changes in erectile function following aneurysm repair.

METHODS

Male patients in the Veterans Affairs Open Versus Endovascular Repair (CSP#498; OVER) Trial had erectile function assessed pre- and postoperatively by administration of the International Index of Erectile Function-5 questionnaire. Bayesian mixed-effects regression models were created with the outcome variable (erectile function) treated as a latent variable. Primary effects of differences in erectile function between groups with and without preservation of bilateral antegrade hypogastric flow were compared.

RESULTS

876 men (442 randomized to endovascular repair) were enrolled in the trial and included in the analysis comparing treatment assignment. There is significant erectile dysfunction in elderly men with aortic aneurysm at baseline. Over five years of follow up, there is modest decrease in erectile function and the endovascular group has improved function compared to open repair (0.082; 95% credible interval 0.008 and 0.155). A fifth of patients did not have bilateral preservation of antegrade hypogastric artery perfusion, with no difference in erectile function by univariate analysis. A more detailed regression analysis was applied--and after adjustment for baseline score, age, beta blocker use, diabetes, activity level, ejection fraction, preoperative ABIs and time--preservation of both antegrade hypogastric arteries' perfusion showed transient improvement in survey scores compared to occlusion of at least one hypogastric artery at 6 months and 12 months after treatment, although this was not sustained at 60 months (score change: 0.046; 95% credible interval: -0.123, 0.215). Retesting this model in the cohort with complete data as a sensitivity analysis did not meaningfully change the conclusions.

CONCLUSIONS

In this large prospective aneurysm treatment trial with systematic measurement of erectile function with a validated instrument, endovascular repair is associated with improved erectile function. Preservation of antegrade hypogastric flow with any repair is associated with early improved erectile function; however, it is not a sustained benefit. There is limited benefit of maintaining bilateral hypogastric artery perfusion for this specific indication in unselected men undergoing AAA repair.

Adjunct internal iliac artery procedures in the context of endovascular abdominal aortic aneurysm repair: anything to stress on the consent form?

Adjunct internal iliac artery (IIA) procedures, such as preoperative embolisation or coverage with iliac branch extensions, are not infrequent in the context of endovascular repair of abdominal aortic aneurysms. Moreover, on many occasions, these procedures are performed in a multi-stage approach by interventional radiologists prior to the main operation. Bearing in mind the potential complications of IIA occlusion when revascularization is not initially deemed necessary, various issues arise spanning from appropriate patient counselling to medicolegal consequences. Herein, we aim to provide a roadmap regarding appropriate patient consenting, highlighting the need for multidisciplinary approach of these patients.

Prevalence of Erectile Dysfunction in Patients With Abdominal Aortic Aneurysm: An Exploratory Study

Introduction

Erectile dysfunction (ED) is defined as the recurrent inability to achieve and maintain a satisfactory erection for sexual intercourse. Many studies have highlighted that ED shares common cardiovascular risk factors with cardiovascular disease. No data are reported about the prevalence of ED in patients with the abdominal aortic aneurysm (AAA). The aim of our study was to investigate the preoperative information given about sexual functions of patients undergoing endovascular aneurysm repair (EVAR) and to compare it with the presence and severity of steno-occlusive atherosclerotic lesions of the pelvic arterial tree at pre-operative Computed Tomography Angiography (CTA).

Methods

We prospectively enrolled all men patients who underwent elective EVAR from September to November 2021. Preoperative ED was evaluated using the International Index of Erectile Function (IIEF-5) questionnaire. Preoperative imaging was routinely performed with CTA scan of the abdominal aorta and iliac-pelvic district. An innovative score of pelvic arterial disease associated to AAA was defined, dividing the iliac district in 4 zones attributing a grading of severity for each zone bilaterally (score ranges 0–24). Linear regression analysis was used to correlate IIEF-5 score to anatomical score of pelvic arterial steno-occlusive disease.

Results

A total of 25 patients were enrolled. Median age was 74 ± 5.3 years. IIEF-5 average score was 14.8 ± 7.1. Eight cases (32%) had severe ED; one case (4%) had moderate, five patients (20%) had mild to moderate ED; five patients (20%) had mild ED, and 6 (24%) patients had no ED. CTA evaluation revealed an average anatomical score of 7.9 ± 4.5. Pelvic disease was considered moderate-severe in 20 cases (80%) and not significant in 20% (five cases). Linear regression analysis confirmed the hypothesis that a more diseased pelvic arterial tree was correlated to a more severe ED (Y = −1.531^* × + 26.35 [slope CI: −1.946 to −1.117, p < 0.0001]).

Conclusion

Although typically unreported, the prevalence of ED associated to AAA was found to be high. A vasculogenic origin of ED in patients with AAA is plausible and may be easily confirmed by the evaluation of pelvic arterial distribution at angio-CT performed for EVAR planning. Our proposed “MAPPING AND SCORING SHEET” may help to identify the vasculogenic origin of ED in AAA patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Debate on Infrarenal AAA in Young and Fit Patients ('Fit for Open Repair'): Open Repair is Safe and Long-term Results are Better]

Endovascular aortic repair, initially developed for patients at prohibitively high risk for an open repair, has undergone significant technical evolution and refinement and has emerged as the preferred treatment option for patients with an infrarenal aortic aneurysm. However, analysis of long-term data of the randomised studies revealed inferior results with regards to survival and freedom-from-reintervention after eight years. Open aortic repair has been performed for more than seven decades and especially for the younger patients with few comorbidities, results are excellent. Potential drawbacks of open repair like incisional hernias, erectile dysfunction and quality of life can either be effectively prevented (mesh reinforcement) or actually failed to show a significant difference compared to open repair in recent studies. Therefore, meticulous assessment of patient comorbidites using validated parameters is the key element for decision-making and parameters such as young age, low comorbidity profile, large aneurysm and presence of atopic renal arteries or a dominant inferior mesenteric artery should prompt a recommendation of open repair.

Erectile dysfunction resulting from pelvic surgery is associated with changes in cavernosal gene expression indicative of cavernous nerve injury

Pelvic surgery, even without direct cavernous nerve injury, carries a high risk of post-operative erectile dysfunction. The present studies were aimed at identifying molecular mechanisms by which pelvic surgery results in erectile dysfunction. As a model of pelvic surgery, male Sprague-Dawley rats underwent pelvic laparotomy, avoiding direct cavernous nerve injury. A second group of animals, serving as a model of direct cavernous nerve injury, underwent bilateral transection of the cavernous nerve. Cavernosometry demonstrated, that even in the absence of direct nerve injury, the pelvic surgery model exhibited significant erectile dysfunction 3 days post-operatively. Gene expression profiling also demonstrated that even in this animal model of nerve-sparing pelvic surgery, the profile of differentially expressed genes in cavernosal tissue was indicative of cavernous nerve injury. In addition, although 6 hr after surgery there were significant changes in circulating cytokine/chemokine levels, an inflammatory response in the major pelvic ganglion, cavernous nerve and cavernosal tissue was only observed 3 days post-surgery. Our results validate a rat model of pelvic surgery exhibiting erectile dysfunction and suggest systemic release of cytokines/chemokines following surgical trauma might mediate a pathological inflammatory response in tissues distal to the site of surgical trauma, indirectly resulting in cavernous nerve injury and erectile dysfunction.

Sexual Dysfunction Before and after Treatment of Infrarenal Aortic Aneurysm Patients

OBJECTIVE

Sexual dysfunction is supposed to be one major complication after treatment of infrarenal aortic aneurysms. It is still controversial how many patients suffer from a sexual dysfunction already before their operation and if there are any procedure-specific differences in postoperative sexual function depending on the operative procedure performed, for example, open (OAR) or endovascular aortic repair (EVAR).

METHODS

To answer these questions we conducted this prospective unicentric study using the International Index of Erectile Function (IIEF) and analyzed the sexual function of 56 male patients with an infrarenal aortic aneurysm before as well as 3, 6, and 12 months after their operation. 23 patients (median age 66.5 years) were treated by OAR and 33 patients (median age 75.8 years) by EVAR.

RESULTS

We observed that the majority of the 56 patients analyzed (91.3% of the 23 OAR patients and 96.8% of the 33 EVAR patients) suffered from a sexual dysfunction already before their operation. A 56.5% of the OAR patients and 67.7% of the EVAR patients even disclaimed a severe sexual dysfunction prior to surgery. Age and operation method showed no significant influence on the IIEF score (P= 0.647 and P= 0.621, respectively). The change of the IIEF score over the 4 time points also did not significantly differ for age and operation method (P= 0.713 and P= 0.624, respectively). The IIEF scores were significantly different between time points T1 and T4 (P= 0.042), whereas between the other time points no significant differences were found.

CONCLUSIONS

Sexual dysfunction is very common in infrarenal aortic aneurysm patients even before their operation. OAR and EVAR do not cause a procedure-specific deterioration of the sexual function.

Towards a Core Outcome Set for Abdominal Aortic Aneurysm: Systematic Review of Outcomes Reported Following Intact and Ruptured Abdominal Aortic Aneurysm Repair

OBJECTIVE

To encompass the needs of all stakeholders and allow effective data synthesis from trials, registries, and other studies; a core outcome set for infrarenal abdominal aortic aneurysm (AAA) repair is needed. In this first stage, the aim was to report the range, frequency, and time of pre-specified outcomes reported following AAA repair.

DATA SOURCES

Medline, Embase, and CENTRAL databases 2010 - 2019 were searched using ProQuest Dialog™.

REVIEW METHODS

The systematic review was reported to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA), PROSPERO registration CRD42019130119. Outcomes were coded using Core Outcome Measures in Effectiveness Trials (COMET) taxonomy and presented separately for intact and rupture repairs, endovascular aneurysm repair (EVAR) and open repair, and time from repair (acute < 90 days vs. ≥ 1 year) (COMET Initiative 1582).

RESULTS

For intact AAA and rupture repair, a total of 231 and 70 reports with 589 255 and 177 465 patients respectively were included: only 98 and 19 respectively provided ≥ 1 year outcomes. Most studies were retrospective, with 13 randomised trials of intact AAA repair and five randomised trials of ruptured AAA repair. For intact AAA, the most common pre-specified COMET taxonomy outcomes were mortality (181), vascular complications (137), and re-intervention (52). EVAR studies dominated the vascular outcomes in acute and later time periods: excluding 47 reports from device registries, reduced vascular outcomes to 83. For ruptured AAA, the three most common outcomes were mortality (64), vascular (11), and hospital stay (10). The range of outcomes reported was wide with functioning outcomes reported from most randomised trials but few retrospective studies.

CONCLUSION

This review identifies the paucity of long term data and the disproportionate attention paid to vascular complications vs. patient functioning outcomes, this skew being accentuated by reporting from EVAR device registries. These data will inform focus groups, prior to a pan-European Delphi consensus, involving clinicians, patients, carers and providers, for developing core outcomes for repair of intact and ruptured AAA.

Numerical Simulation of Blood Flows in Patient-specific Abdominal Aorta with Primary Organs

The abdominal aorta is the largest artery in the abdominal cavity that supplies blood flows to vital organs through the complex visceral arterial branches, including the celiac trunk (the liver, stomach, spleen, etc.), the renal arteries (the kidneys) and the superior and inferior mesenteric arteries (the small and large intestine, pancreas, etc.). An accurate simulation of blood flows in this network of arteries is important for the understanding of the hemodynamics in various organs of healthy and diseased patients, but the computational cost is very high. As a result, most researchers choose to focus on a portion of the artery or use a low-dimensional approximation of the artery. In the present work, we introduce a parallel algorithm for the modeling of pulsatile flows in the abdominal aorta with branches to the primary organs, and an organ-based two-level method for calculating the resistances for the outflow boundary conditions. With this highly parallel approach, the simulation of the blood flow for a cardiac cycle of the anatomically detailed aorta can be obtained within a few hours, and the blood distribution to organs including liver, spleen and kidneys are also computed with certain accuracy. Moreover, we discuss the significant hemodynamic differences resulted from the influence of the peripheral branches. In addition, we examine the accuracy of the results with respect to the mesh size and time-step size and show the high parallel scalability of the proposed algorithm with up to 3000 processor cores.

Outcomes Analysis of Surgical Conversion for Kissing-Stent Occlusion

BACKGROUND

We aimed to describe the operative outcomes following open aortoiliac/femoral graft reconstruction for bilateral kissing-stent (KS) occlusion.

METHODS

This is a bicentric, retrospective, observational cohort study. Between September 2007 and December 2019, 205 patients were treated with KS for aortoiliac reconstruction. Only those who had bilateral KS occlusion with subsequent aortoiliac/femoral graft replacement were included in this analysis. Primary outcomes were early (<30 days) and late survival, postoperative (<30 days) complications, and patency rates.

RESULTS

Nine patients (male, n = 7) were analyzed. The patient's mean age was 60 ± 5 years (range 55-62). Median delay from initial KS procedure was 36 months (interquartile range [IQR] 19-252). On admission, all patients presented with a worse Rutherford class compared to their initial pre-KS clinical presentation. Aortobifemoral bypass was performed in 5 patients, and aortobi-iliac reconstruction in 4 patients. There were no perioperative deaths and only 1 new case of erectile dysfunction occurred. At a median follow-up time of 24 months (IQR 12-54), primary patency rate was 88.9%.

CONCLUSIONS

Open aortic reconstruction after KS occlusion was feasible and effective. Endovascular repair for aortoiliac obstructive disease may be pursued as first-line treatment even in complex lesions.

Vascular Surgeons' Views on Ejaculation Disorders After Abdominal Aortic Surgery: Results of a Dutch Survey

BACKGROUND

The aim of this study is to evaluate vascular surgeons' knowledge and appreciation of ejaculatory dysfunction after open aortic aneurysm repair and the knowledge of possible nerve-preserving techniques.

METHODS

A Dutch national survey was conducted on sexual counseling in the case of open aortic surgery. For this purpose, a designed questionnaire based on a review of the literature in the field and on other surveys aiming to analyze care for sexual health by medical specialists was used.

RESULTS

The response rate was almost 60%. All responders were familiar with the occurrence of postoperative neurogenic complications. Sixty percent preoperatively informs their patients, but only one-third inquires whether such complications have occurred postoperatively. Most respondents estimated the incidence of postoperative neurogenic complications due to dissection of the periaortic tissues between 5% and 25%. Almost 75% take nerve anatomy into consideration when exposing the abdominal aorta, but only 29% mention the correct structures, and only 37% mention possible correct nerve-sparing techniques.

CONCLUSIONS

Dutch vascular surgeons are well aware of the occurrence of postoperative sexual disorders after infrarenal aortic reconstruction. A gap in knowledge of pathophysiology and anatomy exists. Furthermore, a significant part of vascular surgeons seems to lack skills in sexual counseling. Therefore, more education should be offered during vascular surgical training.

WHAT THIS ARTICLE ADDS

This article addresses iatrogenic neurogenic complications affecting sexual health following open aortic surgery. It opens the discussion on possible gaps in modern training of vascular surgeons and on sexual health in relation to postoperative quality of life and shared decision-making.

Impact of Endourological procedures with or without double-J stent on sexual function: a systematic review and meta-analysis

BACKGROUND

Endourological procedures are widely used to treat benign urinary disorders and the double-J stent is routinely used. However, its potential impact on sexual function remains unclear. Therefore, we performed a quantitative systematic review to determine the relationship between endourological procedures with or without double-J stent and post-operative sexual function.

METHODS

We conducted a search of PubMed, EMBASE, Web of Science, and Cochrane Library databases up to December 2018 for studies that compared sexual function before and after endourological procedures. The quality of the included studies was evaluated using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I). We performed subgroup analyses to explore heterogeneity. A random effects model was used to combine the results.

RESULTS

Five prospective studies involving 485 sexually active participants were identified. Pooled results showed that, in patients without a double-J stent, the change in sexual function after endourological procedures was not significant in men (mean difference [MD]: - 0.61, 95% confidence interval [CI]: - 1.43 to 0.22, p = 0.148) or women (MD: 0.53, 95% CI: - 0.52 to 1.57, p = 0.322). However, in patients with indwelling double-J stent, sexual function scores significantly declined after the procedure in both men (MD: -4.25, 95% CI: - 6.20 to - 2.30, p < 0.001) and women (MD: -7.17, 95% CI: - 7.88 to - 6.47, p < 0.001).

CONCLUSIONS

Our meta-analysis suggests that indwelling double-J stent after endourological procedures could be a crucial factor causing temporary sexual dysfunction post-operatively. Our results may be used to provide evidence-based advice to patients.

Sexual dysfunction after elective laparoscopic or endovascular abdominal aortic aneurysm repair in men

INTRODUCTION

Infrarenal abdominal aortic aneurysm (AAA) repair can lead to ejaculation and erection troubles in men. There are few studies on sexual dysfunction after endovascular repair (EVAR) but they suggest less retrograde ejaculation than after open repair. We assessed the sexual dysfunction and ejaculation troubles after elective laparoscopic repair or EVAR.

METHODS

We conducted a monocentric prospective study on 124 patients undergoing AAA repair between 2013 and 2015. Sexual function was evaluated using the IIEF-15 questionnaire and questions on ejaculation.

RESULTS

Only 45 patients (36.3%) accepted to complete the IIEF preoperatively with 20-37.8% having preoperative sexual dysfunction. Among them, 21 (46.7%) accepted to complete the questionnaire at 3, 6 and 12 months. Mean age at inclusion was 65±5.6 years in the laparoscopic group and 77±10.5 years in the EVAR group (P=0.003). Erectile and sexual function were slightly improved at 12 months in the laparoscopic group (+1.4 for erectile score and +4.6 for IIEF score) with no significant difference (P=0.83 and 0.74) whereas 8 patients (61.5%) had persistent ejaculation troubles at 3 months. In the EVAR group, patients had moderate sexual dysfunction at baseline without improvement at 12 months, but only one patient reported ejaculation troubles.

CONCLUSIONS

Most patients eligible for AAA repair present with baseline erectile and sexual dysfunction. Laparoscopic AAA repair provides no onset of erectile or sexual dysfunction but a global improvement after surgery. Ejaculation troubles are frequent and persistent at 1 year. However, EVAR treatment, doesn't allow recovering of sexual function at 1 year.

LEVEL OF EVIDENCE

4.

Surgical Complications after Open Abdominal Aortic Aneurysm Repair: Intestinal Ischemia, Buttock Claudication and Sexual Dysfunction

While surgical treatment for abdominal aortic aneurysm (AAA) is a standard operation, prevention of complication is important. Intestinal ischemia of the sigmoid colon and/or rectum after AAA surgery is severe and has a high mortality rate although occurrence frequency is low. The most important thing to prevent is the preoperative and intraoperative evaluation of the left hemicolon and rectal circulation. Measurement of inferior mesenteric artery stump pressure is also useful. From the viewpoint of prevention of buttock claudication, it is desirable that internal iliac artery (IIA) blood flow is preserved, but aggressive IIA reconstruction adaptation is considered to be low. For erectile function, it is important that the antegrade blood flow from the IIA to the internal pudendal artery on at least one side is preserved or reconstructed. To prevent retrograde ejaculation, it is important to preserve the superior hypogastric plexus and one side of the lumbar splanchnic nerve, and the hypogastric nerve. Understanding and mastering local anatomy and pathophysiology is important in preventing complications, and we must also remember that we always keep watchful surgical operations in mind in order to prevent tissue damage. (This is a translation of Jpn J Vasc Surg 2019; 28: 99-103.).

Open repair versus endovascular treatment of complex aortoiliac lesions in low risk patients

OBJECTIVE

The aim of the present study was to compare open surgical repair (OSR) versus endovascular repair (ER) using self-expanding covered stents for complex TransAtlantic Inter-Society Consensus II (TASC) class C or D aortoiliac lesions in low-risk patients, with a specific subanalysis for younger patients.

METHODS

A single-center retrospective review of TASC C/D lesions treated from January 2008 to December 2017 was conducted. Patients with associated aortic aneurysm or lesions involving the entire infrarenal aorta were excluded. Thirty-day outcomes, long-term patency, limb salvage, and freedom from related reinterventions were compared between OSR and ER. "Low surgical risk" was defined as a Society for Vascular Surgery comorbidity score of ≤0.7 and age <75 years. Patients were considered "young" if aged ≤60 years. The follow-up results were analyzed using Kaplan-Meier curves. Major clinical and anatomic characteristics were evaluated for their association with patency using Cox proportional hazards.

RESULTS

Overall, 114 patients (OSR, n = 56; ER, n = 58) were treated, of whom, 70 patients (63%) had bilateral iliac disease involvement, for a total of 182 limbs revascularized (OSR, n = 96; ER, n = 86). Iliac lesions were classified by limb as TASC C (n = 71; 39%) or D (n = 111; 61%). Their mean age was 61.4 ± 8.4 years, and the mean Society for Vascular Surgery comorbidity score was 0.51 ± 0.39, without statistically significant differences between the OSR and ER groups (0.48 ± 0.29 vs 0.56 ± 0.47; P = .357). At 30 days, the ER group had had a shorter length of hospitalization (8.5 ± 6.2 vs 2.6 ± 0.8 days; P < .001) and intensive care unit stay (0.1 ± 0.6 vs 0.9 ± 0.5 day; P < .001) than the OSR group. The cumulative medical (OSR, 7%; ER, 5%; P = .714) and surgical (OSR, 10%; ER, 8%; P = .759) complication rates were similar. At 5 years, the primary patency rate was similar between the two groups (OSR, 87.3%; ER, 81.4%; P = .317). This result was confirmed in the subgroup of "young" patients (OSR, 84.7; ER, 75.0; P = .272). The limb salvage (OSR, 98.9%; ER, 98.4%; P = .920) and freedom from related reintervention (OSR, 74.4%; ER, 73.0%; P = .703) rates were similar. This trend was also confirmed in the "young" patients for both limb salvage (OSR, 98.5%; ER, 97.6%; P = .896) and freedom from related reintervention (OSR, 76.9%; ER, 63.6%; P = .223). Multivariate analysis indicated that the only independent negative predictor of patency was female gender in the ER group (hazard ratio, 2.89; 95% confidence interval, 1.45-26.60; P = .024).

CONCLUSIONS

In the case of severe aortoiliac obstructive lesions in low-risk and young patients, ER using a covered stent can be considered as valid as OSR. In addition, it allows for shorter hospitalization and maintains a similar patency rate in the long term. However, for female patients, OSR remains the reference standard of treatment.

Our early and mid-term results for endovascular repair of abdominal aortic aneurysms

Background

In this study, we present our early and mid-term results of endovascular aneurysm repair in patients with infrarenal abdominal aortic aneurysms.

Methods

Between December 2011 and January 2017, a total of 154 patients (136 males, 18 females; mean age 71.7 years; range, 55 to 94 years) who underwent endovascular aneurysm repair were retrospectively analyzed. Data including demographic characteristics of the patients, pre-procedural additional diagnoses, mortality and morbidity rates, length of intensive care unit and hospital stays, amounts of blood products used, complications and reinterventions were recorded.

Results

Seven patients underwent intervention in the emergency setting due to aneurysm rupture, while 147 patients received elective surgery. The mean follow-up was 35 (range, 12 to 72) months, the mean length of intensive care unit stay was 1.1 (range, 1 to 4) days, and the mean length of hospital stay was 3.1 (range, 3 to 7) days. A mean 0.3 units of erythrocyte suspension was used during the treatment. Endoleak developed in 16 patients, occlusion in the graft leg in two patients, increased aneurysmal diameter in six patients, and wound healing problems in five patients. Cross femoral bypass was applied in two patients, balloon dilation in three patients, proximal extension in three patients, and distal extension in four patients. Intraoperative mortality occurred in one patient. The total mortality rate was 7% and first 30-day mortality rate was 2%.

Conclusion

Our study results suggest that endovascular aneurysm repair has certain advantages including a low operative mortality rate, short intensive care unit and hospital stays, and less blood product use. In addition, this technique can be performed with regional anesthesia in high-risk comorbid patients.

Abdominal aortic aneurysms

An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.