1
|
DeHaven C, Zil-E-Ali A, Lavanga E, Flohr TR, Krause K, Rossip M, Aziz F. Octogenarians fare better under local anesthesia for elective endovascular aortic aneurysm repair. J Vasc Surg 2024; 79:1079-1089. [PMID: 38141740 DOI: 10.1016/j.jvs.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE With an aging patient population, an increasing number of octogenarians are undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) in the United States. Multiple studies have shown that, for the general population, use of local anesthetic (LA) for EVAR is associated with improved short-term and long-term outcomes as compared with performing these operations under general anesthesia (GA). Therefore, this study aimed to study the association of LA for elective EVARs with perioperative outcomes, among octogenarians. METHODS The Vascular Quality Initiative database (2003-2021) was used to conduct this study. Octogenarians (Aged ≥80 years) were selected and sorted into two study groups: LA (Group I) and GA (Group II). Our primary outcomes were length of stay and mortality. Secondary outcomes included operative time, estimated blood loss, return to operating room, cardiopulmonary complications, and discharge location. RESULTS Of the 16,398 selected patients, 1197 patients (7.3%) were included in Group I, and 15,201 patients (92.7%) were in Group II. Procedural time was significantly shorter for the LA group (114.6 vs 134.6; P < .001), as was estimated blood loss (152 vs 222 cc; P < .001). Length of stay was significantly shorter (1.8 vs 2.6 days; P < .001), and patients were more likely to be discharged home (LA 88.8% vs GA 86.9%; P = .036) in the LA group. Group I also experienced fewer pulmonary complications; only 0.17% experienced pneumonia and 0.42% required ventilator support compared with 0.64% and 1.02% in Group II, respectively. This finding corresponded to fewer days in the intensive care unit for Group I (0.41 vs 0.69 days; P < .001). No significant difference was seen in 30-day mortality cardiac, renal, or access site-related complications. Return to operating room was also equivocal between the two groups. Multivariate regression analysis confirmed GA was associated with a significantly longer length of stay and significantly higher rates of non-home discharge (adjusted odds ratio [AOR], 1.59; P < .001 and AOR, 1.40; P = .025, respectively). When stratified by the New York Heart Association classification system, classes I, II, III, and IV (1.55; P < .001; 1.26; P = .029; 2.03; P < .001; 4.07; P < .001, respectively) were associated with significantly longer hospital stays. CONCLUSIONS The use of LA for EVARs in octogenarians is associated with shorter lengths of stay, fewer respiratory complications, and home discharge. These patients also experienced shorter procedure times and less blood loss. There was no statistically significant difference in 30-day mortality, return to operating room, or access-related complications. LA for octogenarians undergoing EVAR should be considered more frequently to shorten hospital stays and decrease complication rates.
Collapse
Affiliation(s)
- Christopher DeHaven
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Penn State University College of Medicine, Hershey, PA.
| | - Elizabeth Lavanga
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Tanya R Flohr
- Division of Vascular Surgery, Penn State University College of Medicine, Hershey, PA
| | - Kayla Krause
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Maxwell Rossip
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State University College of Medicine, Hershey, PA
| |
Collapse
|
2
|
Li B, Verma R, Beaton D, Tamim H, Hussain MA, Hoballah JJ, Lee DS, Wijeysundera DN, de Mestral C, Mamdani M, Al-Omran M. Predicting Outcomes Following Endovascular Abdominal Aortic Aneurysm Repair Using Machine Learning. Ann Surg 2024; 279:521-527. [PMID: 37389890 DOI: 10.1097/sla.0000000000005978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To develop machine learning (ML) models that predict outcomes following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). BACKGROUND EVAR carries non-negligible perioperative risks; however, there are no widely used outcome prediction tools. METHODS The National Surgical Quality Improvement Program targeted database was used to identify patients who underwent EVAR for infrarenal AAA between 2011 and 2021. Input features included 36 preoperative variables. The primary outcome was 30-day major adverse cardiovascular event (composite of myocardial infarction, stroke, or death). Data were split into training (70%) and test (30%) sets. Using 10-fold cross-validation, 6 ML models were trained using preoperative features. The primary model evaluation metric was area under the receiver operating characteristic curve. Model robustness was evaluated with calibration plot and Brier score. Subgroup analysis was performed to assess model performance based on age, sex, race, ethnicity, and prior AAA repair. RESULTS Overall, 16,282 patients were included. The primary outcome of 30-day major adverse cardiovascular event occurred in 390 (2.4%) patients. Our best-performing prediction model was XGBoost, achieving an area under the receiver operating characteristic curve (95% CI) of 0.95 (0.94-0.96) compared with logistic regression [0.72 [0.70-0.74)]. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.06. Model performance remained robust on all subgroup analyses. CONCLUSIONS Our newer ML models accurately predict 30-day outcomes following EVAR using preoperative data and perform better than logistic regression. Our automated algorithms can guide risk mitigation strategies for patients being considered for EVAR.
Collapse
Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Derek Beaton
- Data Science and Advanced Analytics, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
| | - Hani Tamim
- Faculty of Medicine, Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
- College of Medicine, Alfaisal University, Riyadh, Kingdom of Saudi Arabia
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jamal J Hoballah
- Department of Surgery, Division of Vascular and Endovascular Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Douglas S Lee
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Charles de Mestral
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada
- Data Science and Advanced Analytics, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- ICES, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada
- College of Medicine, Alfaisal University, Riyadh, Kingdom of Saudi Arabia
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| |
Collapse
|
3
|
Li B, Aljabri B, Verma R, Beaton D, Eisenberg N, Lee DS, Wijeysundera DN, Forbes TL, Rotstein OD, de Mestral C, Mamdani M, Roche-Nagle G, Al-Omran M. Using machine learning to predict outcomes following open abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:1426-1438.e6. [PMID: 37634621 DOI: 10.1016/j.jvs.2023.08.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/15/2023] [Accepted: 08/19/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE Prediction of outcomes following open abdominal aortic aneurysm (AAA) repair remains challenging with a lack of widely used tools to guide perioperative management. We developed machine learning (ML) algorithms that predict outcomes following open AAA repair. METHODS The Vascular Quality Initiative (VQI) database was used to identify patients who underwent elective open AAA repair between 2003 and 2023. Input features included 52 preoperative demographic/clinical variables. All available preoperative variables from VQI were used to maximize predictive performance. The primary outcome was in-hospital major adverse cardiovascular event (MACE; composite of myocardial infarction, stroke, or death). Secondary outcomes were individual components of the primary outcome, other in-hospital complications, and 1-year mortality and any reintervention. We split our data into training (70%) and test (30%) sets. Using 10-fold cross-validation, six ML models were trained using preoperative features (Extreme Gradient Boosting [XGBoost], random forest, Naïve Bayes classifier, support vector machine, artificial neural network, and logistic regression). The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). Model robustness was evaluated with calibration plot and Brier score. The top 10 predictive features in our final model were determined based on variable importance scores. Performance was assessed on subgroups based on age, sex, race, ethnicity, rurality, median area deprivation index, proximal clamp site, prior aortic surgery, and concomitant procedures. RESULTS Overall, 12,027 patients were included. The primary outcome of in-hospital MACE occurred in 630 patients (5.2%). Compared with patients without a primary outcome, those who developed in-hospital MACE were older with more comorbidities, demonstrated poorer functional status, had more complex aneurysms, and were more likely to require concomitant procedures. Our best performing prediction model for in-hospital MACE was XGBoost, achieving an AUROC of 0.93 (95% confidence interval, 0.92-0.94). Comparatively, logistic regression had an AUROC of 0.71 (95% confidence interval, 0.70-0.73). For secondary outcomes, XGBoost achieved AUROCs between 0.84 and 0.94. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.05. These findings highlight the excellent predictive performance of the XGBoost model. The top three predictive features in our algorithm for in-hospital MACE following open AAA repair were: (1) coronary artery disease; (2) American Society of Anesthesiologists classification; and (3) proximal clamp site. Model performance remained robust on all subgroup analyses. CONCLUSIONS Open AAA repair outcomes can be accurately predicted using preoperative data with our ML models, which perform better than logistic regression. Our automated algorithms can help guide risk-mitigation strategies for patients being considered for open AAA repair to improve outcomes.
Collapse
Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada
| | - Badr Aljabri
- Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Derek Beaton
- Data Science and Advanced Analytics, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Douglas S Lee
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Thomas L Forbes
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Ori D Rotstein
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Division of General Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Charles de Mestral
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Muhammad Mamdani
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada; Data Science and Advanced Analytics, Unity Health Toronto, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Graham Roche-Nagle
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Mohammed Al-Omran
- Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada; Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| |
Collapse
|
4
|
Naoum I, Eitan A, Galili O, Hayeq H, Shiran A, Zissman K, Sliman H, Jaffe R. Strategy for Totally Percutaneous Management of Vascular Injury in Combined Transfemoral Transcatheter Aortic Valve Replacement and Endovascular Aortic Aneurysm Repair Procedures. Am J Cardiol 2023; 207:130-136. [PMID: 37738782 DOI: 10.1016/j.amjcard.2023.08.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 09/24/2023]
Abstract
Minimally invasive treatment of severe aortic stenosis by transcatheter aortic valve replacement (TAVR) and infrarenal abdominal aortic aneurysm by endovascular aortic aneurysm repair (EVAR) requires large-bore vascular access. These percutaneous transfemoral interventions may be performed as a combined procedure, however, vascular injury may necessitate surgical vascular repair. We implemented a strategy designed to enable percutaneous vascular repair, with stent-graft implantation, if necessary, after these combined procedures. We identified all combined percutaneous TAVR and EVAR procedures which were performed at our institution. Patient and procedural characteristics and clinical outcomes were analyzed. Six consecutive patients underwent total percutaneous combined TAVR and EVAR procedures. In all cases, TAVR was performed first and was followed by EVAR. Both common femoral arteries served as primary access sites for delivery of the implanted devices and hemostasis was achieved by deployment of vascular closure devices. Secondary access sites included the right brachial artery in all patients and superficial femoral arteries in 50% of the patients. In all cases an "0.014" 300-cm length "safety" wire was delivered to the common femoral artery or descending aorta by way of a secondary access site to facilitate stent graft delivery. Successful device implantation was achieved in all cases. Vascular closure device failure occurred in 2 patients and was treated by stent graft implantation by way of the brachial and superficial femoral arteries, without need for surgical vascular repair. A strategy designed to facilitate percutaneous vascular repair after combined EVAR and TAVR procedures may enable a truly minimally invasive procedure.
Collapse
Affiliation(s)
| | | | - Offer Galili
- Department of Vascular & Endovascular Surgery, Carmel Medical Center, Haifa, Israel
| | - Hashem Hayeq
- Department of Vascular & Endovascular Surgery, Carmel Medical Center, Haifa, Israel
| | | | | | | | | |
Collapse
|
5
|
Krebs JR, Fazzone B, Anderson EM, Ueland W, Spratt JR, Back MR, Shahid Z, Huber TS, Upchurch GR, Cooper MA. Presentation and Outcomes of Elective and Nonelective Complex Endovascular Repair for Thoracoabdominal and Juxtarenal Aortic Aneurysms. Ann Vasc Surg 2023; 97:248-256. [PMID: 37714262 DOI: 10.1016/j.avsg.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/17/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Endovascular repair of thoracoabdominal aortic aneurysms (TAAA) and juxtarenal aortic aneurysms (JAA) with fenestrated and/or branched endografts (B/FEVAR) has become common. Physician modified endografts for patients presenting with symptomatic or contained ruptures has made B/FEVAR a feasible option in nonelective settings. The purpose of this study was to describe our 10-year institutional experience with endovascular interventions for TAAA in elective and nonelective cases to evaluate differences in outcomes and the clinical risk factors associated with nonelective presentation. METHODS A prospectively maintained database was retrospectively queried for patients undergoing B/FEVAR for TAAA and JAA at a single tertiary care academic institution between 1/2011 and 12/2020. Data collected included demographics, comorbidities, presenting symptoms, aneurysm characteristics, and clinical outcomes. Nonelective repair was defined as any patient that presented through the Emergency Department, as a hospital transfer, or as a direct admission from clinic and had aortic repair performed during the same admission. Univariate analyses were used to compare patients. The primary outcomes were 30-day and 1-year mortality. Secondary outcomes included perioperative complications and nonhome discharge. RESULTS Between 1/201 and 12/2020, a total of 208 patients underwent B/FEVAR for TAAA (173) and JAA (35). Nonelective repair was performed in 44 (21%) patients with 39 for TAAA (23%) and 5 for JAA (14%). Nonelective patients were younger (71 ± 11 vs. 74 ± 7 years, P = 0.03), more likely to be self-pay or have Medicaid (11% vs. 2%, P = 0.02) and had a different race distribution compared to the elective cohort (P < 0.01). Thirty-day mortality was 4% (n = 6) in elective repairs and 7% (n = 3) in nonelective repairs. One-year mortality was 13% (n = 22) in elective repairs and 18% (n = 8) in nonelective repairs. There were no differences between patients receiving elective versus nonelective repair in 30-day (P = 0.40) or 1-year mortality (P = 0.47). Nonelective patients had longer median duration of stay (11 interquartile range (IQR) 6-15 vs. 5 IQR 4-8, P < 0.01), postoperative length of stay (7 IQR 5-12 vs. 4 IQR 3-7, P < 0.01), and more intensive care unit days (6 IQR 3-8 vs. 3 IQR 2-5, P < 0.01). There were no differences in other secondary outcomes between elective and nonelective patients including inpatient and access-related complications, re-interventions, and nonhome discharge (P > 0.05 for all comparisons). A composite "any complication" occurred more frequently in patients with nonelective repair (50% vs. 35%, P = 0.03). CONCLUSIONS Endovascular repair for TAAA or JAA is a good option in patients undergoing nonelective surgical intervention, with comparable 30-day mortality, 1-year mortality, and perioperative morbidity to that of patients undergoing elective B/FEVAR.
Collapse
Affiliation(s)
- Jonathan R Krebs
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Brian Fazzone
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Erik M Anderson
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Walker Ueland
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - John R Spratt
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Martin R Back
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Zain Shahid
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL
| | - Michol A Cooper
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL.
| |
Collapse
|
6
|
Torabi N, Shafiee A, Heidari A, Hajizeinali M, Jalali A, Hajizeinali A. Predictors of Five-Year Survival after EVAR: 10-Year Experience of Single-Center Cohort Study. Ann Vasc Surg 2023; 96:115-124. [PMID: 37068627 DOI: 10.1016/j.avsg.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Endovascular abdominal aortic repair (EVAR) is the main therapeutic option for repairing abdominal aortic aneurysms (AAAs). We aimed to determine the long-term outcomes of patients who underwent EVAR at our center. METHODS In this retrospective cohort study, patients who underwent EVAR for intact isolated AAA at Tehran Heart Center between 2007 and 2017 were included. Clinical outcomes and the frequency of mortality were analyzed for follow-up periods. We calculated the 5-year survival rate and its predictors for our patients using Kaplan-Meier estimation. RESULTS We included the data of all patients (154 patients, mean age = 70.7 [± 8.0] years, 96.1% men) who successfully underwent EVAR at our center. The most common risk factors were coronary artery disease (70.1%), hypertension (68.2%), smoking (64.9%), and dyslipidemia (39.6%). There was no mortality during the procedure. The median follow-up was 65.5 months. An average decrease of 9.07 mm (95% confidence interval: 6.9-11.2) occurred in the size of the AAA. During follow-up, 12 patients developed some complications, 49 died, and 7 did not complete the follow-up. The 5-year survival rate was 75% (3.9%). The independent predictors for 5-year survival were age (hazard ratio [HR] = 1.06, P = 0.002) and anemia (HR = 1.91, P = 0.029). Despite not being statistically significant, dyslipidemia (HR = 0.573, P = 0.078) and long intensive care unit/cardiac care unit stays (HR = 1.08, P = 0.070) were borderline mortality predictors. CONCLUSIONS This study depicted an acceptable survival rate for patients who underwent EVAR at our center. Age and anemia, 2 modifiable predictors of 5-year survival, can probably prolong the survival rate of patients, which requires evaluation later.
Collapse
Affiliation(s)
- Nasim Torabi
- Department of Cardiology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Akbar Shafiee
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Heidari
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Mohammadmohsen Hajizeinali
- Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Alimohammad Hajizeinali
- Interventional Cardiology Department, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
7
|
Medda M, Casilli F, Bande M, Glauber M, Tespili M, Cirri S, Donatelli F. Percutaneous treatment of abdominal aortic aneurysm and aortic valve stenosis with 'staged' EVAR and TAVR: a case series. J Cardiothorac Surg 2023; 18:231. [PMID: 37443033 DOI: 10.1186/s13019-023-02338-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
Symptomatic aortic valve stenosis (AS) and abdominal aortic aneurysm (AAA) are critical clinical conditions, increasingly more prevalent with aging of the population. Calcific aortic stenosis is the most common structural cardiac disease in the elderly population, and medical management of severe aortic stenosis of the elderly population is associated with poor outcomes as compared to surgical treatment. Transcatheter aortic valve replacement (TAVR) is a treatment of choice in inoperable, often elderly, patients with symptomatic severe AS and in intermediate-to-high surgical risk patients. It is not yet clarified the incidence of AAA and its impact on procedural and clinical outcomes among patients undergoing TAVR. It is known that after AS resolution with aortic valve replacement or TAVR there is an increase in blood pressure that increases the risk of dissection or abdominal aortic aneurysm rupture if AAA repair is delayed. The purpose of this report is to describe the anatomical details and technical and procedural considerations when proposing totally endovascular strategies dedicated to the treatment of patients with AS and AAA.
Collapse
Affiliation(s)
- Massimo Medda
- Clinical and Interventional Cardiology Unit, Cardio-Thoracic Center, IRCCS Ospedale Galeazzi-Sant'Ambrogio, Gruppo San Donato, Via Cristina Belgioioso, 173, Milan, Italy
| | - Francesco Casilli
- Clinical and Interventional Cardiology Unit, Cardio-Thoracic Center, IRCCS Ospedale Galeazzi-Sant'Ambrogio, Gruppo San Donato, Via Cristina Belgioioso, 173, Milan, Italy.
| | - Marta Bande
- Istituto Clinico Sant'Ambrogio, Milan, Italy
- Medical Affairs EMEA, Boston Scientific Corporation, Milan, Italy
| | - Mattia Glauber
- Department of Minimally Invasive Cardiac Surgery, IRCCS Ospedale Galeazzi-Sant'Ambrogio, Gruppo San Donato, Milan, Italy
| | - Maurizio Tespili
- Clinical and Interventional Cardiology Unit, Cardio-Thoracic Center, IRCCS Ospedale Galeazzi-Sant'Ambrogio, Gruppo San Donato, Via Cristina Belgioioso, 173, Milan, Italy
| | - Silvia Cirri
- Department of Anesthesia and Intensive Care, IRCCS Ospedale Galeazzi-Sant'Ambrogio, Gruppo San Donato, Milan, Italy
| | | |
Collapse
|
8
|
Nishibe T, Kano M, Matsumoto R, Ogino H, Koizumi J, Dardik A. Prognostic Value of Nutritional Markers for Long-Term Mortality in Patients Undergoing Endovascular Aortic Repair. Ann Vasc Dis 2023; 16:124-130. [PMID: 37359098 PMCID: PMC10288122 DOI: 10.3400/avd.oa.22-00118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/24/2023] [Indexed: 06/28/2023] Open
Abstract
Objective: The relationship between nutritional status and morbidity and death in a number of diseases and disorders has garnered considerable attension. In patients having endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA), we assessed the prognostic value of nutritional markers of albumin (ALB), body mass index (BMI), and geriatric nutritional risk index (GNRI) for long-term mortality. Materials and Methods: Retrospective data analysis was done on patients who had undergone elective EVAR for AAA more than 5 years earlier. Results: A total of 176 patients underwent EVAR for AAA between March 2012 and April 2016. The optimal cutoff value of ALB, BMI, and GNRI for predicting long-term mortality was calculated as 3.75 g/dL (area under the curve [AUC] 0.64), 21.4 kg/m2 (AUC 0.65), and 101.4 (AUC 0.70), respectively. Low ALB, low BMI, and low GNRI as well as age ≥75 years, chronic obstructive pulmonary disease, chronic kidney disease, and active cancer were independent risk factors for long-term mortality. Conclusion: Malnutrition, which is measured by ALB, BMI, and GNRI, is an independent risk factor for long-term mortality in patients receiving EVAR for AAA. Of the nutritional markers, the GNRI can be the most reliable nutritional indicator to identify a potentially high-risk group of mortality after EVAR.
Collapse
Affiliation(s)
- Toshiya Nishibe
- Department of Medical Management and Informatics, Hokkaido Information University, Ebetsu, Hokkaido, Japan
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Masaki Kano
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Ryumon Matsumoto
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Jun Koizumi
- Department of Radiology, Chiba University School of Medicine, Chiba, Chiba, Japan
| | - Alan Dardik
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
9
|
Siddiq B, Dejong M, Decicco E, Zielke T, D'Andrea M, Aulivola B, Blecha M. Extent of mural thrombus is not associated with increased 5-year mortality following elective AAA repair. Vascular 2023; 31:219-225. [PMID: 35331063 DOI: 10.1177/17085381211063282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mural thrombus in abdominal aortic aneurysm (AAA) has been associated with increased rates of aneurysm growth as well as adverse cardiovascular events. The extent of mural thrombus in thoracoabdominal aortic aneurysms has recently been linked to 1-year mortality following endovascular repair and has been hypothesized as a marker for reduced cardiac reserve. This study investigates whether the extent of mural thrombus in infra-renal AAA is associated with 5-year mortality following elective repair. METHODS Retrospective review of all patients undergoing elective infra-renal AAA repair at a single academic medical center between 2007 and 2016 was performed. The following variables at the time of surgery were investigated for association with 5-year mortality: age, sex, ethnicity, insurance status and co-morbidities, repair type, renal insufficiency, end-stage renal disease on dialysis, history of smoking, coronary artery disease, congestive heart failure, diabetes mellitus, hypertension, stroke, chronic obstructive pulmonary disease, body mass index category, AAA diameter, and ratio of aortic thrombus to total aneurysm diameter. RESULTS Amongst 427 patients undergoing infra-renal AAA repair during the study period, 232 met extensive inclusion criteria. Univariate analysis found mean age (76 vs 72, p < 0.01), age cohort over 72 years (OR = 1.9, p = 0.04), renal insufficiency (OR = 3.1, p < 0.01), ESRD (OR = 6.5, p < 0.01), AAA diameter 6 cm or greater (OR = 2.3, p < 0.01), and mean AAA diameter (61.36 vs 56.99 mm, p < 0.01) all predictive of 5-year mortality. Multivariate analysis revealed renal insufficiency (p < 0.01) and AAA diameter 6 cm or greater (p = 0.03) to be significantly associated with 5-year mortality. The extent of mural thrombus was identical between 5-year survivors and non-survivors. The mean inner to outer AAA diameter was 0.65 in the survivor cohort and 0.64 in the mortality cohort. Inner to outer ratio of < 0.5 was identified in 23% of 5-year survivors and 27% of the mortality group. CONCLUSIONS In our experience, the extent of mural thrombus in AAA does not influence long-term survival after elective repair. AAA repair may provide protection against circulating components of mural thrombus which have the potential to promote atherosclerotic-related adverse events. Patients with renal insufficiency and larger AAA have increased risk of mortality 5 years after elective repair.
Collapse
Affiliation(s)
- Bilal Siddiq
- College of Medicine, 12325University of Tennessee Health Science Center, Memphis, TN, USA
| | - Matthew Dejong
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Emily Decicco
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Tara Zielke
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Melissa D'Andrea
- Department of Surgery, 22165University of Arizona College of Medicine, Tucson, AZ, USA
| | - Bernadette Aulivola
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
| |
Collapse
|
10
|
Shahin Y, Dixon S, Kerr K, Cleveland T, Goode SD. Endovascular aneurysm repair offers a survival advantage and is cost-effective compared with conservative management in patients physiologically unfit for open repair. J Vasc Surg 2023; 77:386-395.e3. [PMID: 36152982 DOI: 10.1016/j.jvs.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively. METHODS A prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment. RESULTS Propensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results. CONCLUSIONS EVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.
Collapse
Affiliation(s)
- Yousef Shahin
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK; SAMRC/WITS Centre for Health Economics and Decision Science-PRICELESS, Johannesburg, South Africa
| | - Karen Kerr
- Department of Anaesthesia, Sheffield Teaching Hospitals, Sheffield, UK
| | - Trevor Cleveland
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK
| | - Stephen D Goode
- Sheffield Vascular Institute, Northern General Hospitals, Sheffield, UK.
| |
Collapse
|
11
|
Sun X, Li S, He Y, Liu Y, Ma T, Zeng R, Liu Z, Chen Y, Zheng Y, Liu X. Effects of cardiac function alterations on the risk of postoperative thrombotic complications in patients receiving endovascular aortic repair. Front Physiol 2023; 13:1114110. [PMID: 36703931 PMCID: PMC9871241 DOI: 10.3389/fphys.2022.1114110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023] Open
Abstract
Introduction: Chronic heart disease (CHD) is a common comorbidity of patients receiving endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA). The explicit relationship between ventricular systolic function and EVAR complication of thrombotic events is unknown. Methods: In this study, we proposed a three-dimensional numerical model coupled with the lumped-elements heart model, which is capable of simulating thrombus formation in diverse systolic functions. The relation of cardiac functions and the predicted risk of thrombus formation in the aorta and/or endograft of 4 patients who underwent EVAR was investigated. Relative risks for thrombus formation were identified using machine-learning algorithms. Results: The computational results demonstrate that thrombus tended to form on the interior side of the aorta arch and iliac branches, and cardiac function can affect blood flow field and affect thrombus formation, which is consistent with the four patients' post-operative imaging follow-up. We also found that RRT, OSI, TAWSS in thrombosis area are lower than whole average. In addition, we found that the thrombus formation has negative correlations with the maximum ventricular contractile force (r = -.281 ± .101) and positive correlations with the minimum ventricular contractile force (r = .238 ± .074), whereas the effect of heart rate (r = -.015 ± .121) on thrombus formation is not significant. Conclusion: In conclusion, changes in ventricular systolic function may alter the risk of thrombotic events after EVAR repair, which could provide insight into the selection of adjuvant therapy strategies for AAA patients with CHD.
Collapse
Affiliation(s)
- Xiaoning Sun
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Siting Li
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuan He
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yuxi Liu
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Tianxiang Ma
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Rong Zeng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Zhili Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yu Chen
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China,Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China,*Correspondence: Yuehong Zheng, ; Xiao Liu,
| | - Xiao Liu
- Key Laboratory of Biomechanics and Mechanobiology, Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, China,*Correspondence: Yuehong Zheng, ; Xiao Liu,
| |
Collapse
|
12
|
Kontopodis N, Galanakis N, Charalambous S, Matsagkas M, Giannoukas AD, Tsetis D, Ioannou CV, Antoniou GA. Editor's Choice - Endovascular Aneurysm Repair in High Risk Patients: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 64:461-474. [PMID: 35872342 DOI: 10.1016/j.ejvs.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/06/2022] [Accepted: 07/10/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To investigate outcomes of endovascular aneurysm repair (EVAR) in high risk patients. METHODS Bibliographic sources (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched using combinations of thesaurus and free text terms. The review protocol was registered in PROSPERO (CRD42021287207) and reported according to PRISMA 2020. Pooled estimates were calculated using odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) applying the Mantel-Haenszel or inverse variance method. EVAR peri-operative mortality in high risk patients over time was examined with mixed effects meta-regression. The GRADE framework was used to rate the certainty of evidence. RESULTS The pooled peri-operative mortality in 18 416 high risk patients who underwent EVAR was 3% (95% CI 2.3 - 4%) and has significantly reduced over time (year of publication p = .003; median study point p = .023). The peri-operative mortality was significantly lower in high risk patients treated with EVAR compared with open repair (OR 0.64; 95% CI 0.45 - 0.92), but no significant difference was found in overall (HR 1.06; 95% CI 0.76 - 1.49) or aneurysm related mortality (HR 0.57; 95% CI 0.21 - 1.55). No significant difference was found in overall mortality between high risk patients treated with EVAR vs. no intervention (HR 0.42; 95% CI 0.14 - 1.26), but the aneurysm related mortality was significantly lower in the former (HR 0.30; 95% CI 0.14 - 0.63). The peri-operative mortality was higher in high risk than normal risk patients treated with EVAR (OR 2.33; 95% CI 1.75 - 3.10), as was the overall mortality (HR 3.50; 95% CI 2.55 - 4.80). The certainty of evidence was very low for EVAR vs. open surgery or no intervention and low for high vs. normal risk patients. CONCLUSION The EVAR peri-operative mortality in high risk patients has improved over time. Even though the aneurysm related mortality of EVAR is lower compared with no intervention, EVAR may confer no overall survival benefit.
Collapse
Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Greece
| | - Nikolaos Galanakis
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece
| | - Stavros Charalambous
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece; Department of Radiology, Division of Interventional Radiology, Nicosia General Hospital, Nicosia, Cyprus
| | - Miltiadis Matsagkas
- Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Vascular Surgery Department, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Tsetis
- Interventiona Radiology Unit, Medical School, University of Crete, Heraklion, Greece
| | - Christos V Ioannou
- Vascular Surgery Department, Medical School, University of Crete, Heraklion, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, United Kingdom.
| |
Collapse
|
13
|
Sunderland K, Jiang J, Zhao F. Disturbed flow's impact on cellular changes indicative of vascular aneurysm initiation, expansion, and rupture: A pathological and methodological review. J Cell Physiol 2022; 237:278-300. [PMID: 34486114 PMCID: PMC8810685 DOI: 10.1002/jcp.30569] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/06/2021] [Accepted: 08/16/2021] [Indexed: 01/03/2023]
Abstract
Aneurysms are malformations within the arterial vasculature brought on by the structural breakdown of the microarchitecture of the vessel wall, with aneurysms posing serious health risks in the event of their rupture. Blood flow within vessels is generally laminar with high, unidirectional wall shear stressors that modulate vascular endothelial cell functionality and regulate vascular smooth muscle cells. However, altered vascular geometry induced by bifurcations, significant curvature, stenosis, or clinical interventions can alter the flow, generating low stressor disturbed flow patterns. Disturbed flow is associated with altered cellular morphology, upregulated expression of proteins modulating inflammation, decreased regulation of vascular permeability, degraded extracellular matrix, and heightened cellular apoptosis. The understanding of the effects disturbed flow has on the cellular cascades which initiate aneurysms and promote their subsequent growth can further elucidate the nature of this complex pathology. This review summarizes the current knowledge about the disturbed flow and its relation to aneurysm pathology, the methods used to investigate these relations, as well as how such knowledge has impacted clinical treatment methodologies. This information can contribute to the understanding of the development, growth, and rupture of aneurysms and help develop novel research and aneurysmal treatment techniques.
Collapse
Affiliation(s)
- Kevin Sunderland
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI 49931
| | - Jingfeng Jiang
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI 49931,Corresponding Authors: Feng Zhao, 101 Bizzell Street, College Station, TX 77843-312, Tel : 979-458-1239, , Jingfeng Jiang, 1400 Townsend Dr., Houghton, MI 49931, Tel: 906-487-1943
| | - Feng Zhao
- Department of Biomedical Engineering, Texas A&M University, College Station, TX 77843,Corresponding Authors: Feng Zhao, 101 Bizzell Street, College Station, TX 77843-312, Tel : 979-458-1239, , Jingfeng Jiang, 1400 Townsend Dr., Houghton, MI 49931, Tel: 906-487-1943
| |
Collapse
|
14
|
Arenas Azofra E, Iglesias CI, González Canga C, Marcos FÁ, Fernández Prendes C, Al-Sibbai AZ, Pérez MA. MIDTERM RESULTS OF ENDOVASCULAR VERSUS OPEN SURGICAL REPAIR FOR INFRARENAL ABDOMINAL AORTIC ANEURYSMS IN LOW SURGICAL RISK PATIENTS. J Vasc Surg 2021; 75:1897-1903. [PMID: 34793922 DOI: 10.1016/j.jvs.2021.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
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).
Collapse
Affiliation(s)
- Ernesto Arenas Azofra
- Department of Angiology and Vascular Surgery. Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain.
| | - Cristóbal Iglesias Iglesias
- Department of Angiology and Vascular Surgery. Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Carmen González Canga
- Department of Angiology and Vascular Surgery. Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Francisco Álvarez Marcos
- Department of Angiology and Vascular Surgery. Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | | | - Amer Zanabili Al-Sibbai
- Department of Angiology and Vascular Surgery. Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Manuel Alonso Pérez
- Department of Angiology and Vascular Surgery. Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| |
Collapse
|
15
|
Nana P, Spanos K, Kouvelos G, Stamoulis K, Rountas C, Arnaoutoglou E, Matsagkas M, Giannoukas AD. Ten-year single center experience in elective standard endovascular abdominal aortic aneurysm repair. INT ANGIOL 2021; 40:240-247. [PMID: 33739077 DOI: 10.23736/s0392-9590.21.04648-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) has become the treatment of choice for abdominal aortic aneurysm (AAA), demonstrating excellent early outcomes. However, EVAR durability has been questioned in the long-term period. The aim of this study was to assess EVAR outcomes in terms of survival and freedom from re-intervention during a long-term period. METHODS All consecutive patients being treated, with elective standard EVAR, in a single tertiary center, were included between 2008 and 2018. Outcomes were defined as survival and freedom from re-intervention and were reported using Kaplan-Meyer lifetables. In subgroup analyses, sex, age (threshold at 65 and 80 years), neck diameter>28mm and type of fixation were also analyzed. Type of re-intervention and endoleak type I (ETIa) were also reported. RESULTS Five hundred and eight patients (94% males, mean age 72±7.3, mean AAA diameter 59±9mm) were included. The median follow-up was 3 years (range 0-10 years). The survival rate was 92.8% (SE 1.5%), 76.5% (SE 3.1%) and 41.6% (SE 6%), at 2, 5 and 10 years of follow-up, respectively. In total, 78 patients died; 8 deaths (8/75, 10%) were aneurysm related. In multivariate regression analysis, age (CI. 1.02-1.14; p=0.006) and ever tobacco use (CI. 1.02-6.12, P=0.045) were associated with the long-term mortality. Freedom from re-intervention was 96% (SE 1.1%), 93% (SE 1.8%), 85.5% (SE 5%) at 2, 5 and 9 years of follow-up. Limb occlusion was a common complication (n/n; 30% of re-intervention), particularly within the first 2 postoperative years. Six patients presented with rupture and were treated with open conversion. EVAR cases with supra-renal fixation graft presented lower rates of ETIa (CI. 76-87.27, P<0.001). CONCLUSIONS Elective standard EVAR is associated with good long-term survival showing low aneurysm-related mortality. Common risk factors such as advanced age and smoking are associated to higher mortality. The procedure presents low re-intervention rates, while limb occlusion is a complication presented within the first 2 postoperative years.
Collapse
Affiliation(s)
- Petroula Nana
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece -
| | - Konstantinos Spanos
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - George Kouvelos
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Konstantinos Stamoulis
- School of Health Sciences, Department of Anesthesiology, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Christos Rountas
- School of Health Sciences, Department of Radiology, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Elena Arnaoutoglou
- School of Health Sciences, Department of Anesthesiology, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Miltiadis Matsagkas
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Athanasios D Giannoukas
- School of Health Sciences, Department of Vascular Surgery, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| |
Collapse
|
16
|
Chang H, Rockman CB, Jacobowitz GR, Ramkhelawon B, Cayne NS, Veith FJ, Patel VI, Garg K. Contemporary outcomes of endovascular abdominal aortic aneurysm repair in patients deemed unfit for open surgical repair. J Vasc Surg 2020; 73:1583-1592.e2. [PMID: 33035595 DOI: 10.1016/j.jvs.2020.08.147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/22/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Endovascular abdominal aortic aneurysm repair (EVAR) has been preferred to open surgical repair (OSR) for the treatment of abdominal aortic aneurysms (AAAs) in high-risk patients. We compared the perioperative and long-term outcomes of EVAR for patients designated as unfit for OSR using a large national dataset. METHODS The Vascular Quality Initiative database was queried for patients who had undergone elective EVAR for AAAs >5 cm from 2013 to 2019. The patients were stratified into two cohorts according to their suitability for OSR (fit vs unfit). The primary outcomes included perioperative (in-hospital) major adverse events, perioperative mortality, and mortality at 1 and 5 years. Patient demographics and postoperative outcomes were analyzed to identify the predictors of perioperative and long-term mortality. RESULTS Of 16,183 EVARs, 1782 patients had been deemed unfit for OSR. The unfit cohort was more likely to be older and female, with a greater proportion of hypertension, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and larger aneurysm diameters. Postoperatively, the unfit cohort was more likely to have experienced cardiopulmonary complications (6.5% vs 3%; P < .001), with greater perioperative mortality (1.7% vs 0.6%; P < .001) and 1- and 5-year mortality (13% and 29% for the unfit vs 5% and 14% for the fit cohorts, respectively; P < .001). A subgroup analysis of the unfit cohort revealed that those deemed unfit because of a hostile abdomen had significantly lower 1- and 5-year mortality (6% and 20%, respectively) compared with those considered unfit because of cardiopulmonary compromise and frailty (14% and 30%, respectively; P = .451). Reintervention-free survival at 1 and 5 years was significantly greater in the fit cohort (93% and 82%, respectively) compared with that for the unfit cohort (85% and 68%, respectively; P < .001). The designation as unfit for OSR was an independent predictor of both perioperative (odds ratio, 1.59; 95% confidence interval [CI], 1.03-2.46; P = .038) and long-term mortality (hazard ratio [HR], 1.92; 95% CI, 1.69-2.17; P < .001). Advanced age (odds ratio, 2.91; 95% CI, 1.28-6.66; P = .011) was the strongest determinant of perioperative mortality, and end-stage renal disease (HR, 2.51; 95% CI, 1.78-3.55; P < .001) was the strongest predictor of long-term mortality. Statin use (HR, 0.77; 95% CI, 0.69-0.87; P < .001) and angiotensin-converting enzyme inhibitor use (HR, 0.83; 95% CI, 0.75-0.93; P < .001) were protective of long-term mortality. CONCLUSIONS Despite low perioperative mortality, the long-term mortality of those designated by operating surgeons as unfit for OSR was rather high for patients undergoing elective EVAR, likely owing to the competing risk of death from medical frailty. An unfit designation because of a hostile abdomen did not confer any additional risks after EVAR. Judicious estimation of the patient's life expectancy is essential when considering the treatment options for this subset of patients deemed unfit for OSR.
Collapse
Affiliation(s)
- Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Caron B Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Bhama Ramkhelawon
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Neal S Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York Presbyterian/Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
| |
Collapse
|
17
|
Sarcopenia Aneurysm Scoring System Predicts Early and Midterm Mortality After Endovascular Repair for Abdominal Aortic Aneurysm. Ann Surg 2020; 276:e247-e254. [PMID: 33002942 DOI: 10.1097/sla.0000000000004230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of the study was to develop a better model of prediction after EVAR using the psoas muscle index (PMI). SUMMARY BACKGROUND DATA The Glasgow Aneurysm Score (GAS), the modified Leiden Score (mLS), the Comorbidity Severity Score (CSS), and the Euro Score (ES) are known prognostic scoring after EVAR. Similarly, sarcopenia measured by PMI has been reported to be an important predictor. This study investigated a new scoring system using PMI predicting short and midterm overall mortality after EVAR. METHODS Three hundred ten patients were retrospectively evaluated. The primary endpoint was all-cause death. One hundred three patients were assigned to the derivation cohort and 207 patients to the validation cohort. RESULTS The all-cause mortality rates were 8.8% at 1 year, 23.5% at 3 years, and 32.8% at 5 years. In a multivariate analysis, age, aneurysm diameter, eGFR, and PMI were associated with all-cause mortality in the derivation cohort. The SAS system was defined as the sum of the following factors: elderly (75 years), large aneurysm (65 mm), low eGFR (30 mL/min/1.73 m), and low PMI (males: 48.2 cm/m, females: 36.8 cm/m). We compared the SAS with the other prognostic scoring for 5-year mortality evaluating the area under the receiver operating characteristic curves in the validation cohort (GAS: 0.731, mLS: 0. 718, CSS: 0. 646, ES: 0.661, and SAS: 0.785, P = 0.013). CONCLUSION We developed the SAS to predict all-cause mortality after elective EVAR and this scoring showed excellent predictive performance.
Collapse
|
18
|
Pandirajan K, Katsogridakis E, Sidloff D, Sayers RD, Bown MJ, Saratzis A. Effects of Left Renal Vein Ligation During Open Abdominal Aortic Aneurysm Repair on Renal Function. Eur J Vasc Endovasc Surg 2020; 60:829-835. [PMID: 32912760 DOI: 10.1016/j.ejvs.2020.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/01/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Left renal vein (LRV) ligation is performed during open abdominal aortic aneurysm (AAA) repair to facilitate proximal anastomosis. Its impact on short, medium, and long term renal function has not been investigated in detail using appropriately validated endpoints. METHODS This was a nested case control study using data from a prospectively maintained AAA institutional dataset (tertiary centre). A total of 76 patients who underwent elective open AAA repair and had LRV ligation (1 January 2012 to 1 January 2018) were individually case matched based on age (within two years), sex, estimated glomerular filtration rate (eGFR), American Society of Anesthesiologist (ASA) score, chronic kidney disease (CKD) stage, and history of diabetes with 76 patients who had open AAA repair without LRV ligation. Renal outcomes were compared between groups, including proportion of patients developing acute kidney injury (AKI) using the Kidney Disease Improving Global Outcomes (KDIGO) criteria, proportion developing major adverse kidney events (MAKE90) at 90 days (comprising mortality and/or decrease in eGFR >25%), and absolute decrease in eGFR at latest follow up. RESULTS A higher proportion of patients developed AKI and MAKE90 in the LRV ligation group (AKI: 11 patients [14.8%] vs. 2 [2.6%], p = .009; MAKE90: 6 [7.9%] vs. 1 [1.3%] p = .053, in the LRV ligation and the non-LRV ligation groups, respectively) - even though the difference in the MAKE90 endpoint was not statistically significant. Changes in eGFR were not statistically different in the LRV ligation group at 90 days (4.0 ± 1.1 mL/min/1.73 m2vs. 4.4 ± 2.1, p = .64) or by the time of latest follow up (median: 28 months; 3.7 ± 1.6 vs. 2.6 ± 2.0, p = .55). CONCLUSION Ligation of the LRV is associated with increased levels of AKI and renal deterioration in the early post-operative phase using validated reporting criteria; however, long term renal function does not seem to be affected.
Collapse
Affiliation(s)
- Kamashi Pandirajan
- Department of Vascular and Endovascular Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Emmanuel Katsogridakis
- Department of Vascular and Endovascular Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - David Sidloff
- Department of Vascular and Endovascular Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Robert D Sayers
- Department of Vascular and Endovascular Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Matthew J Bown
- Department of Vascular and Endovascular Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Athanasios Saratzis
- Department of Vascular and Endovascular Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK; Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
| |
Collapse
|
19
|
Rosenfeld ES, Macsata RA, Nguyen BN, Lala S, Ricotta JJ, Pomy BJ, Lee KB, Sparks AD, Amdur RL, Sidawy AN. Thirty-day outcomes of open abdominal aortic aneurysm repair by proximal clamp level in patients with normal and impaired renal function. J Vasc Surg 2020; 73:1234-1244.e1. [PMID: 32890718 DOI: 10.1016/j.jvs.2020.08.122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/04/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) has often been reserved in contemporary practice for complex aneurysms requiring a suprarenal or supraceliac proximal clamp level. The present study investigated the associated 30-day outcomes of different proximal clamp levels in OSR of complex infrarenal/juxtarenal AAA in patients with normal renal function and those with chronic renal insufficiency (CRI). METHODS All patients undergoing elective OSR of infrarenal and juxtarenal AAA were identified in the American College of Surgeons National Surgical Quality Improvement Program-targeted AAA database from 2012 to 2018. The patients were stratified into two cohorts (normal renal function [estimated glomerular filtration rate, ≥60 mL/min] and CRI [estimated glomerular filtration rate, <60 mL/min and no dialysis]) before further substratification into groups by the proximal clamp level (infrarenal, inter-renal, suprarenal, and supraceliac). The 30-day outcomes, including mortality, renal and pulmonary complications, and major adverse cardiovascular event rates, were compared within each renal function cohort between proximal clamp level groups using the infrarenal clamp group as the reference. Supraceliac clamping was also compared with suprarenal clamping. RESULTS A total of 1284 patients with normal renal function and 524 with CRI were included in the present study. The proximal clamp levels for the 1808 patients were infrarenal for 1080 (59.7%), inter-renal for 337 (18.6%), suprarenal for 279 (15.4%), and supraceliac for 112 (6.2%). In the normal renal function cohort, no difference was found in 30-day mortality with any clamp level. Increased 30-day acute renal failure was only observed in the supraceliac vs infrarenal clamp level comparison (5.9% vs 1.5%; adjusted odds ratio [aOR], 3.97; 95% confidence interval [CI], 1.04-5.18; P = .044). In the CRI cohort, supraceliac clamping was associated with an increased rate of renal composite complications (22.7% vs 5.6%; aOR, 8.81; 95% CI, 3.17-24.46; P < .001) and ischemic colitis (13.6% vs 3.0%; aOR, 4.78; 95% CI, 1.38-16.62; P = .014) compared with infrarenal clamping and greater 30-day mortality (13.6% vs 2.4%; aOR, 6.00; 95% CI, 1.14-31.55; P = .034) and renal composite complications (22.7% vs 10.8%; aOR, 2.87; 95% CI, 1.02-8.13; P = .047) compared with suprarenal clamping. Suprarenal clamping was associated with greater renal dysfunction (10.8% vs 5.6%; aOR, 2.77; 95% CI, 1.08-7.13; P = .035) compared with infrarenal clamping, with no differences in mortality. No differences were found in 30-day mortality or morbidity for inter-renal clamping compared with infrarenal clamping in either cohort. No differences were found in major adverse cardiovascular events with higher clamp levels in either cohort. CONCLUSIONS In elective OSR of infrarenal and juxtarenal AAAs for patients with CRI, this study found a heightened mortality risk with supraceliac clamping and increased renal morbidity with suprarenal clamping, though these effects were not present for patients with normal renal function. Every effort should be made to keep the proximal clamp level as low as possible, especially in patients with CRI.
Collapse
Affiliation(s)
- Ethan S Rosenfeld
- Department of Surgery, The George Washington University, Washington, D.C..
| | - Robyn A Macsata
- Department of Surgery, The George Washington University, Washington, D.C
| | - Bao-Ngoc Nguyen
- Department of Surgery, The George Washington University, Washington, D.C
| | - Salim Lala
- Department of Surgery, The George Washington University, Washington, D.C
| | - John J Ricotta
- Department of Surgery, The George Washington University, Washington, D.C
| | - Benjamin J Pomy
- Department of Surgery, The George Washington University, Washington, D.C
| | - K Benjamin Lee
- Department of Surgery, The George Washington University, Washington, D.C
| | - Andrew D Sparks
- Department of Surgery, The George Washington University, Washington, D.C
| | - Richard L Amdur
- Department of Surgery, The George Washington University, Washington, D.C
| | - Anton N Sidawy
- Department of Surgery, The George Washington University, Washington, D.C
| |
Collapse
|
20
|
Morisaki K, Furuyama T, Yoshiya K, Kurose S, Yoshino S, Nakayama K, Yamashita S, Kawakubo E, Matsumoto T, Mori M. Frailty in patients with abdominal aortic aneurysm predicts prognosis after elective endovascular aneurysm repair. J Vasc Surg 2020; 72:138-143. [DOI: 10.1016/j.jvs.2019.09.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/23/2019] [Indexed: 12/21/2022]
|
21
|
King AH, Schmaier AH, Harth KC, Kumins NH, Wong VL, Zidar DA, Kashyap VS, Cho JS. Elevated neutrophil-lymphocyte ratio predicts mortality following elective endovascular aneurysm repair. J Vasc Surg 2020; 72:129-137. [PMID: 32037083 DOI: 10.1016/j.jvs.2019.10.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 10/06/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The neutrophil-lymphocyte ratio (NLR) is an inexpensive and useful inflammatory marker that incorporates the balance of the innate (neutrophil) and adaptive (lymphocyte) immune responses. Data exist on the association between NLR and mortality in various coronary diseases and in cancer surgery, but there is a paucity of data on the impact of preoperative NLR on vascular surgical outcomes. The aim of this study was to evaluate the relationship between preoperative NLR and elective endovascular aortic aneurysm repair (EVAR) outcome. METHODS A retrospective review of all patients who underwent elective EVAR at a single institution between 2010 and 2018 was conducted (n = 373). Only patients who had a preoperative complete blood count with differential within 30 days of their operation were included. The NLR was computed by dividing the absolute neutrophil count by the absolute lymphocyte count. A receiver operating characteristic curve was used to determine the optimal cutoff value of NLR with the strongest association with mortality. NLR was dichotomized so that patients with NLR above the threshold were at increased risk of mortality compared with those below it. Continuous variables were analyzed using Wilcoxon nonparametric signed-rank test and categorical variables with the Fisher exact test. A comparison of NLR and mortality was completed using Kaplan-Meier survival analysis. Cox regression analysis was used to evaluate factors associated with mortality through 5-year follow-up. RESULTS Overall, 108 patients were included in this study. An NLR ≥ 4.0 was found to be associated with mortality (P < .0001). Thirty-two patients composed the High-NLR (NLR ≥ 4.0) group and the remaining 76 patients formed the Low-NLR (NLR < 4.0) group. Baseline characteristics were similar between groups, except that the High-NLR group was older (77.9 vs 74.4; P = .047). At a mean of 36.4 months follow-up, the overall mortality rate was 32.4%. Although there were no differences in the perioperative period, the Kaplan-Meier estimates of mortality were significantly greater in the High-NLR group at 1, 2, and 5 years postoperatively (P < .0001). The mean preoperative NLR of the deceased was higher (5.94 ± 5.20; median, 4.75; interquartile range, 3.17-7.83) than those who survived (2.87 ± 1.61; median, 2.53; interquartile range, 1.97-3.49) (P < .0001). Secondary interventions and sac enlargement rates were similar between groups. On univariable analysis, NLR (hazard ratio [HR], 1.17; 95% confidence interval [CI], 1.10-1.23; P < .0001), age (HR, 1.06; 95% CI, 1.02-1.11; P = .004), and aneurysm diameter (HR, 1.04; 95% CI, 1.01-1.07; P = .003) were associated with mortality. On multivariable analysis, NLR (HR, 1.19; 95% CI, 1.12-1.27; P < .0001), age (HR, 1.06; 95% CI, 1.01-1.11; P = .026), and aneurysm diameter (HR, 1.04; 95% CI, 1.02-1.07; P = .003) were associated with mortality. CONCLUSIONS Patients with an elevated preoperative NLR, irrespective of other comorbidities, may represent a previously unrecognized subset of patients who are at heightened risk of mortality after elective EVAR. A complete blood count with differential is an inexpensive test that may be used as a prognostic indicator for outcome after EVAR. Further research is warranted to identify clinical, pathological, or anatomical factors associated with an elevated NLR and to determine modifiable factors, which may help improve long-term survival.
Collapse
Affiliation(s)
- Alexander H King
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Alvin H Schmaier
- Division of Hematology/Oncology, Department of Medicine, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Karem C Harth
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Norman H Kumins
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Virginia L Wong
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - David A Zidar
- Division of Cardiology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Vikram S Kashyap
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jae S Cho
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| |
Collapse
|
22
|
Abdul Jabbar A, Chanda A, White CJ, Jenkins JS. Percutaneous endovascular abdominal aneurysm repair: State‐of‐the art. Catheter Cardiovasc Interv 2019; 95:767-782. [DOI: 10.1002/ccd.28576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/27/2019] [Accepted: 10/25/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Ali Abdul Jabbar
- Interventional CardiologyOchsner Clinic Foundation New Orleans Louisiana
| | - Arijit Chanda
- Interventional CardiologyOchsner Clinic Foundation New Orleans Louisiana
| | | | | |
Collapse
|
23
|
Endovascular Aneurysm Repair May Provide a Survival Advantage in Patients Deemed Physiologically Ineligible for Open Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2019; 61:334-340. [PMID: 31394243 DOI: 10.1016/j.avsg.2019.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/16/2019] [Accepted: 05/24/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity and fitness. It can be used to guide decision making prior to major vascular surgery. The EVAR-2 trial suggested that endovascular aneurysm repair (EVAR) in patients unfit for open repair failed to provide a significant survival advantage over nonsurgical management. The aim of this study is to assess contemporary survival differences between patients with poor CPET measures who underwent EVAR or were not offered surgical intervention. METHODS A prospectively maintained database of CPET results of patients considered for elective infrarenal aortic aneurysm repair were interrogated. Anaerobic threshold (AT) of <11 mL/min/kg was used to indicate poor physical fitness. Hospital electronic records were then reviewed for perioperative, reintervention, and long-term outcomes. RESULTS Between November 2007 and October 2017, 532 aortic aneurysm repairs were undertaken, of which 376 underwent preoperative CPET. Seventy patients were identified as having an AT <11 mL/min/kg. Thirty-seven patients underwent EVAR and 33 were managed nonsurgically. All-cause survival at 1, 3, and 5 years for those patients who underwent EVAR was 97%, 92%, and 81%, respectively. For those not offered surgical intervention survival at the same points was 72%, 48%, and 24% [hazard ratio, HR = 5.13 (1.67-15.82), P = 0.004]. Aneurysm-specific survival at 1, 3, and 5 years for those patients who underwent EVAR was 97%, 94%, and 94%, respectively. Survival at the same time points for those not offered surgical intervention was 90%, 69%, and 39%, respectively [HR = 7.48 (1.37-40.82), P = 0.02]. CONCLUSIONS In this small, retrospective, single-center, nonrandomized cohort, EVAR may provide a survival advantage in patients with poor physical fitness identified via CPET. Randomized studies with current generation EVAR are required to validate the results shown here.
Collapse
|
24
|
Endovascular Abdominal Aortic Aneurysm Repair: Does Anesthesia Type Matter? Ann Vasc Surg 2019; 61:284-290. [PMID: 31344470 DOI: 10.1016/j.avsg.2019.04.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 02/05/2019] [Accepted: 04/16/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Given the various types of anesthesia used for endovascular abdominal aortic aneurysm repair (EVAR), we sought to determine the effect of anesthesia type in the outcomes of elective EVAR in a large multiinstitutional healthcare maintenance organization. METHODS A retrospective chart review was conducted on all elective EVAR conducted from August 2010 to August 2017 in 14 regional hospitals of Kaiser Permanente Southern California. Patients undergoing emergent, nonelective abdominal aortic aneurysm repairs, thoracoabdominal aneurysm repair, requiring conversion to open surgery or general anesthesia were excluded from the study. Basic demographic information, medical risk factors, anesthesia type, operative data, and postoperative morbidity and mortality data were obtained for univariate and multivariate statistical analysis. RESULTS A total of 1,536 patients underwent EVAR, of which 1,206 met inclusion criteria. A total of 788 patients underwent general anesthesia, 164 patients underwent spinal anesthesia, 82 patients underwent epidural anesthesia, and 172 patients underwent local and monitored anesthesia care (AC). There was a significant difference in length of stay and operative time when comparing local/monitored AC to general anesthesia. No significant difference was noted in 30-day morbidity or mortality among the anesthesia groups. CONCLUSIONS Local and regional anesthesia is a safe and effective approach for elective EVAR.
Collapse
|
25
|
Neal D, Beck AW, Eslami M, Schermerhorn ML, Cronenwett JL, Giles KA, Carroccio A, Jazaeri O, Huber TS, Upchurch GR, Scali ST. Validation of a preoperative prediction model for mortality within 1 year after endovascular aortic aneurysm repair of intact aneurysms. J Vasc Surg 2019; 70:449-461.e3. [PMID: 30922759 DOI: 10.1016/j.jvs.2018.10.122] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/25/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Most would agree that at least 1-year survival is necessary after intact abdominal aortic aneurysm (AAA) repair to appropriately justify the cost and risk of the procedure. No validated clinical decision instruments exist to predict survival after endovascular aneurysm repair (EVAR) beyond the perioperative period. The purpose of this analysis was to create a preoperative prediction model for 1-year mortality after EVAR for intact AAA in the Society for Vascular Surgery Vascular Quality Initiative. METHODS All intact EVARs in the Society for Vascular Surgery Vascular Quality Initiative from 2011 to 2015 were randomly divided into training (n = 17,836) and validation (n = 2500) data sets, and 31 preoperative candidate predictors were identified. A logistic regression model for 1-year mortality was created, and bootstrapped stepwise variable elimination was used to reduce this model to a best subset of predictors. Penalized maximum likelihood estimation was used to correct for potential overfitting. The final model was internally validated by bootstrapping the area under the curve (AUC) and the calibration slope and intercept, and its performance when applied to the training and validation data sets was compared. RESULTS After elective and nonelective (symptomatic, intact) EVAR, 1-year mortality was 5.5% (n = 900/16,411) and 11.4% (n = 162/1425), respectively. The mean probability of 1-year mortality was 6.0% (n = 1062) in the training set and 5.7% (n = 143) in the validation cohort (P = .12). Significant preoperative predictors of 1-year mortality included chronic obstructive pulmonary disease, age, preoperative renal insufficiency (creatinine concentration ≥1.8 mg/dL or on hemodialysis), ejection fraction <50%, transfer status, body mass index <24 kg/m2, preoperative beta-blocker exposure, larger AAA diameter, and lower admission hemoglobin level. Preoperative statin use was found to be protective. The bias-corrected AUC was 0.759 (Hosmer-Lemeshow goodness-of-fit P value of 0.36; calibration intercept, -0.003; slope, 0.999). When applied to the validation data set, the model had AUC of 0.724 (95% confidence interval, 0.676-0.768; calibration intercept, 0.0009; slope, 0.970), which was in excellent agreement with the original data set bias-corrected AUC. Notably, ∼27.5% (n = 4902) had four or more risk factors with a predicted 1-year post-EVAR mortality risk of 10% to 22% despite that 33.2% of these patients had AAA diameters below recommended treatment guideline minimum thresholds. CONCLUSIONS This validated preoperative prediction model for 1-year mortality identifies patients less likely to benefit from EVAR. Appropriateness of intact AAA EVAR care delivery can be improved by use of this clinical decision aid to determine which high-risk patients have lower probability of mortality within the first postoperative year relative to their predicted annualized rupture risk.
Collapse
Affiliation(s)
- Dan Neal
- Society for Vascular Surgery Patient Safety Organization, Vascular Quality Initiative, Chicago, Ill
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Mohammed Eslami
- Division of Vascular Surgery and Endovascular Therapy, University of Pittsburgh, Pittsburgh, Pa
| | - Marc L Schermerhorn
- Division of Vascular Surgery and Endovascular Therapy, Beth-Israel Deaconess Medical Center, Boston, Mass
| | - Jack L Cronenwett
- Division of Vascular Surgery and Endovascular Therapy, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Kristina A Giles
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Alfio Carroccio
- Division of Vascular Surgery and Endovascular Therapy, Lenox Hill Hospital, New York, NY
| | - Omid Jazaeri
- Division of Vascular Surgery and Endovascular Therapy, University of Colorado Denver, Aurora, Colo
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Fla.
| |
Collapse
|
26
|
Midorikawa H, Takano T, Ueno K, Takinami G, Kageyama R, Seki H, Kanno M, Satou K. What Did Endovascular Aortic Repair Bring for the Treatment Strategy of Abdominal Aortic Aneurysm? Ann Vasc Dis 2018; 11:484-489. [PMID: 30637003 PMCID: PMC6326053 DOI: 10.3400/avd.oa.18-00099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective: We examined the effects of the introduction of endovascular aortic repair (EVAR) on treatment for abdominal aortic aneurysms (AAAs). Subjects: We compared patients in the following three periods: period I (January 2002–December 2006, 105 patients), period II (January 2007–December 2011, 242 patients, duration of 5 years after the introduction of EVAR), and period III (January 2012–December 2016, 237 patients, duration of 5 years after period II). We used the American Society of Anesthesiologists (ASA) classification for risk assessment. Results: In the Open repair (OR) group, the incidences of ASA class 2 increased and classes 3 and 4 decreased significantly in periods II and III compared with period I. In all periods, there were no in-hospital deaths. Suprarenal aortic cross-clamping was required in 18 patients (19.1%) in period III and 5 patients (6.3) in period I, and the difference was significant (P<0.05). In the EVAR group, no differences in age, sex, or ASA classification class were observed between periods II and III. In period II, one patient died due to aneurysm rupture during surgery. Significant differences were observed when comparing both groups in periods II and III: patients in the EVAR group were older (P<0.01) and the OR group had a higher proportion of ASA class 2 patients and the EVAR group had a higher proportion of ASA class 3 or 4 patients (P<0.01). Among all AAA surgeries, rupture occurred in 25 patients (23.8%) in period I, 18 patients (7.4) in period II, and 16 patients (6.8) in period III. The number of ruptures was significantly lower in periods II and III than in period I (P<0.01). Conclusions: The findings of this study suggest that EVAR should be indicated for high-risk patients and had the good outcome of AAA treatment. (This is a translation of Jpn J Vasc Surg 2018; 27: 27–32.)
Collapse
Affiliation(s)
- Hirofumi Midorikawa
- Department of Cardiovascular Surgery, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan
| | - Takashi Takano
- Department of Cardiovascular Surgery, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan
| | - Kyohei Ueno
- Department of Cardiovascular Surgery, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan
| | - Gaku Takinami
- Department of Cardiovascular Surgery, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan
| | - Rie Kageyama
- Department of Cardiovascular Surgery, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan
| | - Haruna Seki
- Department of Cardiovascular Surgery, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan
| | - Megumu Kanno
- Department of Cardiovascular Surgery, Southern TOHOKU General Hospital, Koriyama, Fukushima, Japan
| | - Kouichi Satou
- Department of Cardiovascular Surgery, Sukagawa Hospital, Sukagawa, Fukushima, Japan
| |
Collapse
|
27
|
Lareyre F, Carboni J, Chikande J, Massiot N, Voury-Pons A, Umbdenstock E, Jean-Baptiste E, Hassen-Khodja R, Raffort J. Association of Platelet to Lymphocyte Ratio and Risk of 30-Day Postoperative Complications in Patients Undergoing Abdominal Aortic Surgical Repair. Vasc Endovascular Surg 2018; 53:5-11. [DOI: 10.1177/1538574418789046] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: The predictive value of the platelet to lymphocyte ratio (PLR) has been demonstrated in several cardiovascular diseases. The aim of this study was to investigate the interest of the preoperative PLR as a predictor of 30-day postoperative outcome in patients with abdominal aortic aneurysm (AAA) undergoing open or endovascular surgical repair. Material and Methods: Two hundred twenty-four consecutive patients with infrarenal AAA were retrospectively included and divided into 4 quartiles according to the value of the preoperative PLR: PLR < 91.5 (group I), 91.5 < PLR < 120.8 (group II), 120.8 < PLR < 163.3 (group III), and PLR > 163.3 (group IV). Results: The AAA diameter was similar among the groups (54.9 mm vs 58.6, 57.5, and 58.7 mm; P = .4655). The proportion of symptomatic AAA and the procedural characteristics did not differ. Patients from group I and IV had significantly higher rates of all-cause postoperative complications compared to group II and III (55.4% and 64.3% vs 39.3% and 46.4%, respectively; P = .0478). The all-cause mortality tended to be higher in group I and IV (7.1% and 8.9% vs 0% and 3.6%, respectively; P = .1305). Conclusion: Extreme values of PLR are associated with a higher risk of complications following AAA surgical repair, suggesting its interest as a biomarker to evaluate the surgical risk.
Collapse
Affiliation(s)
- Fabien Lareyre
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
- Université Côte d’Azur, CHU, Inserm U1065, C3M, Nice, France
| | - Joseph Carboni
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
| | - Julien Chikande
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
| | - Nicolas Massiot
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
| | - Audrey Voury-Pons
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
| | | | - Elixène Jean-Baptiste
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
- Université Côte d’Azur, CHU, Inserm U1065, C3M, Nice, France
| | - Réda Hassen-Khodja
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
- Université Côte d’Azur, CHU, Inserm U1065, C3M, Nice, France
| | - Juliette Raffort
- Université Côte d’Azur, CHU, Inserm U1065, C3M, Nice, France
- Clinical Chemistry Laboratory, University Hospital of Nice, Nice, France
| |
Collapse
|
28
|
Beach JM, Rajeswaran J, Parodi FE, Kuramochi Y, Brier C, Blackstone E, Eagleton MJ. Survival affects decision making for fenestrated and branched endovascular aortic repair. J Vasc Surg 2018; 67:722-734.e8. [DOI: 10.1016/j.jvs.2017.07.118] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/15/2017] [Indexed: 11/25/2022]
|
29
|
Adkar SS, Turner MC, Leraas HJ, Gilmore BF, Nag U, Turley RS, Shortell CK, Mureebe L. Low mortality rates after endovascular aortic repair expand use to high-risk patients. J Vasc Surg 2018; 67:424-432.e1. [PMID: 28951155 PMCID: PMC7243615 DOI: 10.1016/j.jvs.2017.06.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/22/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The 2010 endovascular aneurysm repair (EVAR) trial 2 (EVAR 2) reported that patients with comorbidity profiles rendering them unfit for open aneurysm repair who underwent EVAR did not experience a survival advantage compared with those who did not undergo intervention. These patients experienced a 30-day mortality of 7.3%, whereas reports from similar cohorts reported far lower mortality rates. The primary objective of our study was to compare the incidence of 30-day mortality in low- and high-risk patients undergoing EVAR in a contemporary data set, using patient risk stratification criteria from EVAR 2. Secondarily, we sought to identify risk factors associated with a disproportionate contribution to 30-day mortality risk. METHODS Data were obtained from the 2005 to 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data Files (N = 24,813). Patients were included in the high-risk cohort with the presence of renal, respiratory, or cardiac preoperative criteria alone or in combination. Renal impairment criteria were defined as dialysis and creatinine concentration >2.26 mg/dL. Respiratory impairment criteria included history of chronic obstructive pulmonary disease and preoperative ventilator support. Cardiac impairment criteria included history of myocardial infarction, congestive heart failure, angina, and prior coronary intervention. Patient and procedural characteristics and 30-day postoperative outcomes were compared using Pearson χ2 tests for categorical variables and Wilcoxon rank sum tests for continuous variables. RESULTS Among 24,813 patients undergoing EVAR, 12,043 (48%) patients were characterized as high risk (at least one impairment criterion); 12,770 (52%) patients were stratified as low risk. The 30-day mortality rate was 1.9% in the high-risk cohort compared with the 7.3% reported by EVAR 2, and it was higher in the high-risk cohort compared with the low-risk cohort (1.9% vs 0.9%; P < .001). Whereas the presence of each comorbidity increased the odds of 30-day mortality (respiratory odds ratio [OR], 1.62; 95% confidence interval [CI], 1.16-2.26; P = .005; cardiac OR, 1.55; 95% CI, 1.14-2.10; P = .005), the presence of renal criteria disproportionately increased the odds of mortality threefold (OR, 3.42; 95% CI, 2.31-5.09; P < .001). CONCLUSIONS Contemporary 30-day mortality after EVAR in high-risk patients is substantially lower than that reported in the EVAR 2 trial. Whereas low- and high-risk stratification by current comorbidity criteria is appropriate, attention needs to be paid to disproportionate risk contribution from renal disease to mortality compared with cardiac and pulmonary comorbidities. Given the lower mortality risk than previously described, patients stratified as high risk should be thoughtfully considered for definitive EVAR.
Collapse
Affiliation(s)
- Shaunak S Adkar
- Duke University School of Medicine, Duke University Medical Center, Durham, NC.
| | - Megan C Turner
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Harold J Leraas
- Duke University School of Medicine, Duke University Medical Center, Durham, NC
| | - Brian F Gilmore
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Uttara Nag
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ryan S Turley
- Department of Surgery, Duke University Medical Center, Durham, NC; Cardiothoracic Vascular Surgeons, Austin, Tex
| | | | - Leila Mureebe
- Department of Surgery, Duke University Medical Center, Durham, NC
| |
Collapse
|
30
|
Machado R, Teixeira G, Oliveira P, Loureiro L, Pereira C, Almeida R. Is Age a Determinant Factor in EVAR as a Predictor of Outcomes or in the Selection Procedure? Our Experience. Braz J Cardiovasc Surg 2017; 31:132-9. [PMID: 27556312 PMCID: PMC5062736 DOI: 10.5935/1678-9741.20160037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 04/25/2016] [Indexed: 11/26/2022] Open
Abstract
Introduction Endovascular aneurysm repair (EVAR) is the therapy of choice in high risk
patients with abdominal aortic aneurysm. The good results described are
leading to the broadening of clinical indications to younger patients.
However, reintervention rates seem higher and even with successful treatment
sometimes there is growth of the aneurysm sac and rupture, meaning a failure
of the therapeutic goal. This study proposes to analyse the impact of age in
patients' selection and post-EVAR results. Methods The clinical records of consecutive patients undergoing endovascular aneurysm
repair, between 2001 and 2013, were retrospectively reviewed. Patients were
divided according to age groups (<70, 70-80 and >80 years). Gender,
body mass index, aneurysm anatomic features, neck characteristics, iliac
morphology, surgical indication, endograft type, anesthesic risk
classification, length of stay, reinterventions and mortality were analysed
and compared. Results The study included 171 patients, 161 (94.1%) men, and mean age
74.1±8.9 years. The age group under 70 had 32% of the patients. Only
three characteristics were found different among age groups: 1) body mass
index was higher in younger patients, with a considerable trend toward
significance (P=0.06); 2) surgical indication, in the younger group,
surgeon's and the patient's option were more proeminent
(P<0.05); 3) erectile dysfunction was higher in elderly
group (P<0.05). No other clinical and anatomical
characteristics or final outcomes were found statisticaly different among
age groups. Conclusion The absence of statistically differences in mortality and reinterventions
among age groups suggests that age by itself is not a relevant factor in
endovascular aneurysm repair. Indeed, the three characteristics different in
younger (obesity, sexual function and patient's choice) favor endovascular
aneurysm repair.
Collapse
Affiliation(s)
- Rui Machado
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Gabriela Teixeira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Pedro Oliveira
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Luís Loureiro
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Carlos Pereira
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| | - Rui Almeida
- Hospital de Santo António - Centro Hospitalar do Porto, Porto, Portugal
| |
Collapse
|
31
|
Endovascular Repair of Abdominal Aortic Aneurysm in Patients Physically Ineligible for Open Repair. Ann Surg 2017; 266:713-719. [DOI: 10.1097/sla.0000000000002392] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
32
|
Prospective cohort 20 years after endovascular treatment for abdominal aortic aneurysm. J Vasc Surg 2017; 67:1102-1109. [PMID: 29074113 DOI: 10.1016/j.jvs.2017.08.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 08/18/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe the factors associated with survival 20 years after endovascular treatment of an abdominal aortic aneurysm (AAA) in a single center. METHODS Prospective cohort of asymptomatic patients with an infrarenal aortic aneurysm treated with a bifurcated endovascular graft (Talent) between June 1997 and August 2008. Cox proportional hazard multivariable regression was used for analysis of independent risk factors for survival. Kaplan-Meier curves were done with the long-rank test. P < .05 was considered significant. RESULTS We followed 229 patients, 184 without an endoleak and 45 with an endoleak. Ages ranged between 52 and 89 years, and the mean diameter of the aneurysm was 59.51 ± 14.6 mm. Implantation of the endovascular graft was possible in 99% of the patients. The 30-day mortality rate was 3.4%. In the Cox regression, age <73 years (hazard ratio [HR], 0.42; 95% confidence interval [CI], 0.27-0.64), aneurysm size ≤55 mm (HR, 0.62; 95% CI, 0.40-0.95), male sex (HR, 0.17; 95% CI, 0.05-0.52), American Society of Anesthesiologists surgical risk category I and II vs III and IV (HR, 0.51; 95% CI, 0.34-0.75), and aneurysm size reduction ≤3 mm after treatment (HR, 2.23; 95% CI, 1.11-4.51) were significantly correlated with the survival of the patients followed in this long-term case series. CONCLUSIONS This 20-year prospective cohort included patients with an AAA treated with a bifurcated endovascular graft (Talent) at a university hospital in Brazil. This study supports that sex, age, aneurysm size, aneurysm size reduction, and American Society of Anesthesiologists surgical risk category are significantly correlated with patient survival after endovascular treatment of the AAA.
Collapse
|
33
|
External validation of a 5-year survival prediction model after elective abdominal aortic aneurysm repair. J Vasc Surg 2017; 67:151-156.e3. [PMID: 28807385 DOI: 10.1016/j.jvs.2017.05.104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/07/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The benefit of prophylactic repair of abdominal aortic aneurysms (AAAs) is based on the risk of rupture exceeding the risk of death from other comorbidities. The purpose of this study was to validate a 5-year survival prediction model for patients undergoing elective repair of asymptomatic AAA <6.5 cm to assist in optimal selection of patients. METHODS All patients undergoing elective repair for asymptomatic AAA <6.5 cm (open or endovascular) from 2002 to 2011 were identified from a single institutional database (validation group). We assessed the ability of a prior published Vascular Study Group of New England (VSGNE) model (derivation group) to predict survival in our cohort. The model was assessed for discrimination (concordance index), calibration (calibration slope and calibration in the large), and goodness of fit (score test). RESULTS The VSGNE derivation group consisted of 2367 patients (70% endovascular). Major factors associated with survival in the derivation group were age, coronary disease, chronic obstructive pulmonary disease, renal function, and antiplatelet and statin medication use. Our validation group consisted of 1038 patients (59% endovascular). The validation group was slightly older (74 vs 72 years; P < .01) and had a higher proportion of men (76% vs 68%; P < .01). In addition, the derivation group had higher rates of advanced cardiac disease, chronic obstructive pulmonary disease, and baseline creatinine concentration (1.2 vs 1.1 mg/dL; P < .01). Despite slight differences in preoperative patient factors, 5-year survival was similar between validation and derivation groups (75% vs 77%; P = .33). The concordance index of the validation group was identical between derivation and validation groups at 0.659 (95% confidence interval, 0.63-0.69). Our validation calibration in the large value was 1.02 (P = .62, closer to 1 indicating better calibration), calibration slope of 0.84 (95% confidence interval, 0.71-0.97), and score test of P = .57 (>.05 indicating goodness of fit). CONCLUSIONS Across different populations of patients, assessment of age and level of cardiac, pulmonary, and renal disease can accurately predict 5-year survival in patients with AAA <6.5 cm undergoing repair. This risk prediction model is a valid method to assess mortality risk in determining potential overall survival benefit from elective AAA repair.
Collapse
|
34
|
Limb graft occlusion following endovascular aortic repair: Incidence, causes, treatment and prevention in a study cohort. Exp Ther Med 2017; 14:1763-1768. [PMID: 28810647 DOI: 10.3892/etm.2017.4658] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 02/24/2017] [Indexed: 11/05/2022] Open
Abstract
The present study investigated the incidence, causes, treatment and prevention of limb graft occlusion following endovascular aortic repair (EVAR). A total of 66 cases of abdominal aortic aneurysm receiving EVAR at our department from January 2005 to December 2013 were enrolled. After EVAR, patients received routine antiplatelet therapy of 75 mg PLAVIX for 6 months and then 100 mg Aspirin for another 6 months by oral administration. According to previous clinical experiences, antiplatelet therapy is able to effectively reduce the incidence of iliac occlusion after EVAR. A total of 61 bifurcated grafts and 5 aortauniilac grafts (127 limbs in total) were used. Physical examination, ankle-brachial-index and computer tomographic angiography were performed at 10 days, at 3, 6 and 12 months and annually thereafter. It was found that 7 limbs in 7 patients (10.6% of patients, 5.5% of limbs) were occluded between 20 days and 12 months (average, 7.8±5.3 months) after EVAR. Acute and severe ischemia was found in 2 cases, claudication was in found 3 cases, asthenia in both legs was found in 1 case and 1 case was asymptomatic. Femoral-femoral bypass, femoral-femoral bypass and stenting, aorto-iliac/femoral bypass, thrombectomy and conservative treatment were performed in 1 patient each and thrombectomy together with stenting was performed in 2 cases. Limb graft occlusion was not rare after EVAR. Treatment of this complication included surgery and endovascular therapy such as bypass, thrombectomy and thrombolysis. In conclusion, aggressive pre-emptive treatment including angioplasty and stenting prevented occlusion in certain cases.
Collapse
|
35
|
Healy GM, Redmond CE, Gray S, Iacob L, Sheehan S, Dowdall JF, Barry M, Cantwell CP, Brophy DP. Midterm Analysis of Survival and Cause of Death Following Endovascular Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2017. [DOI: 10.1177/1538574417703268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To assess rates of complications, secondary interventions, survival, and cause of death following endovascular abdominal aortic aneurysm (AAA) repair over a 10-year period. Materials and Methods: Single-institution retrospective cohort study of all patients undergoing primary endovascular aortic aneurysm repair (EVAR) between July 2006 and June 2015. The population constituted 175 patients with 163 fusiform and 12 saccular AAAs. Of these, 149 (85%) were male, with mean age 75.4 (±7.1) years. Patients were followed up until June 30, 2016. Cause of death was determined from the national death register. Results: Mean follow-up was 34.4 (±24.4) months. The secondary intervention rate was 9.7%, and there were 4 aneurysm ruptures (0.8% annual incidence). Thirty-day mortality was 0.6%. Survival at 1, 3, and 5 years was 93.1%, 84%, and 64.9%, respectively. Forty-eight patients died during follow-up, 3 secondary to rupture, leading to overall and aneurysm-related death rates of 9.7 and 0.6 per 100 person-years. All other deaths were due to nonaneurysm causes, most commonly cardiovascular (n = 15), pulmonary (n = 13), and malignancy (n = 9). Baseline renal impairment ( P < .001), ischemic heart disease ( P < .05), age greater than 75 years ( P < .05), and urgent/emergency EVAR were associated with inferior long-term survival. Type II endoleak negatively influenced fusiform aneurysm sac regression ( P = .02), but there was no association between survival and occurrence of any complication or secondary intervention. Conclusion: The majority of deaths during medium-term follow-up post-EVAR are due to nonaneurysm-related causes. Survival is determined by the following baseline factors: renal impairment, ischemic heart disease, advanced age, and the presence of a symptomatic/ruptured aneurysm.
Collapse
Affiliation(s)
- Gerard M. Healy
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Ciaran E. Redmond
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Sam Gray
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - Lucian Iacob
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Stephen Sheehan
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Joseph F. Dowdall
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Mary Barry
- Department of Vascular Surgery, St. Vincent’s University Hospital, Dublin, Ireland
| | - Colin P. Cantwell
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| | - David P. Brophy
- Department of Radiology, St. Vincent’s University Hospital, Dublin, Ireland
| |
Collapse
|
36
|
Kim W, Gandhi RT, Peña CS, Herrera RE, Schernthaner MB, Tsoukas A, Acuña JM, Katzen BT. Effect of β-blocker on aneurysm sac behavior after endovascular abdominal aortic repair. J Vasc Surg 2017; 65:337-345. [PMID: 28126172 DOI: 10.1016/j.jvs.2016.06.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/25/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study was conducted to determine whether β-blocker (BB) therapy is associated with abdominal aortic aneurysm (AAA) sac regression after endovascular abdominal aortic repair (EVAR). METHODS A total of 198 patients (mean age, 76 years) who underwent EVAR were analyzed (104 in the BB group and 94 in the non-BB group). The primary end point was the incidence of AAA sac regression at 1 and 2 years. RESULTS Hypertension, coronary artery disease, and hyperlipidemia were more common in the BB group. The BB group was also more likely to have been prescribed an aspirin and a statin than the non-BB group. The length of proximal neck was significantly longer in the non-BB group than in the BB group. All study patients were monitored for at least 1 year after EVAR, and 2-year follow-up was available in 104 patients (52.5%). There was no statistically significant difference in the incidence of aneurysm sac regression in either group at 1 year (52.1% in the non-BB group vs 45.2% in the BB group; P = .330) and 2 years (58.5% in the non-BB group vs 64.7% in the BB group; P = .515). The difference of the change of AAA maximum diameter between two groups did not reach statistical significance at 1 year (-6.0 ± 7.0 mm in the non-BB group vs -5.5 ± 8.1 mm in the BB group; P = .644) and 2 years (-9.0 ± 10.5 mm in the non-BB group vs -9.0 ± 10.0 mm in the BB group; P = .977). BB therapy was not associated with increased odds of AAA sac regression. The effect of third-generation BBs on AAA sac regression was not significant. CONCLUSIONS BB therapy had no effect on AAA sac regression. At the present time, there is insufficient evidence to recommend BB therapy for the purpose of AAA sac regression.
Collapse
Affiliation(s)
- Wonho Kim
- Division of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, Fla; Department of Medical and Population Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami, Fla; Division of Cardiology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Republic of Korea
| | - Ripal T Gandhi
- Division of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, Fla
| | - Constantino S Peña
- Division of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, Fla
| | - Raul E Herrera
- Division of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, Fla
| | | | - Athanassios Tsoukas
- Division of Vascular Surgery, Miami Cardiac and Vascular Institute, Miami, Fla
| | - Juan M Acuña
- Department of Medical and Population Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami, Fla
| | - Barry T Katzen
- Division of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, Fla.
| |
Collapse
|
37
|
Kim W, Gandhi RT, Peña CS, Herrera RE, Schernthaner MB, Acuña JM, Becerra VN, Katzen BT. Influence of Statin Therapy on Aneurysm Sac Regression after Endovascular Aortic Repair. J Vasc Interv Radiol 2017; 28:35-43. [DOI: 10.1016/j.jvir.2016.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/05/2016] [Accepted: 09/08/2016] [Indexed: 10/20/2022] Open
|
38
|
Png CYM, Tadros RO, Beckerman WE, Han DK, Tardiff ML, Torres MR, Marin ML, Faries PL. An anatomic risk model to screen post endovascular aneurysm repair patients for aneurysm sac enlargement. J Surg Res 2016; 217:29-35.e1. [PMID: 28095987 DOI: 10.1016/j.jss.2016.12.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 11/30/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Follow-up computed tomography angiography (CTA) scans add considerable postimplantation costs to endovascular aneurysm repairs (EVARs) of abdominal aortic aneurysms (AAAs). By building a risk model, we hope to identify patients at low risk for aneurysm sac enlargement to minimize unnecessary CTAs. METHODS 895 consecutive patients who underwent EVAR for AAA were reviewed, of which 556 met inclusion criteria. A Probit model was created for aneurysm sac enlargement, with preoperative aneurysm morphology, patient demographics, and operative details as variables. RESULTS Our final model included 287 patients and had a sensitivity of 100%, a specificity of 68.9%, and an accuracy of 70.4%. Ninety-nine (35%) of patients were assigned to the high-risk group, whereas 188 (65%) of patients were assigned to the low-risk group. Notably, regarding anatomic variables, our model reported that age, pulmonary comorbidities, aortic neck diameter, iliac artery length, and aneurysms were independent predictors of post-EVAR sac enlargement. With the exception of age, all statistically significant variables were qualitatively supported by prior literature. With regards to secondary outcomes, the high-risk group had significantly higher proportions of AAA-related deaths (5.1% versus 1.1%, P = 0.037) and Type 1 endoleaks (9.1% versus 3.2%, P = 0.033). CONCLUSIONS Our model is a decent predictor of patients at low risk for post AAA EVAR aneurysm sac enlargement and associated complications. With additional validation and refinement, it could be applied to practices to cut down on the overall need for postimplantation CTA.
Collapse
Affiliation(s)
- Chien Yi M Png
- Department of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rami O Tadros
- Department of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - William E Beckerman
- Department of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daniel K Han
- Department of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Melissa L Tardiff
- Department of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marielle R Torres
- Department of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael L Marin
- Department of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Peter L Faries
- Department of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| |
Collapse
|
39
|
Sevilla N, Clara A, Diaz-Duran C, Ruiz-Carmona C, Ibañez S. Survival After Endovascular Abdominal Aortic Aneurysm Repair in a Population with a Low Incidence of Coronary Artery Disease. World J Surg 2016; 40:1272-8. [PMID: 26711643 DOI: 10.1007/s00268-015-3377-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) is a prophylactic procedure, so the decision to operate should consider, as recent guidelines suggest, the life expectancy of the patient. Several models for predicting life span have been already designed, but little is known about how intervened patients evolve in Southern European Countries, where the incidence of coronary artery disease, the main cause of death among these subjects, is low. METHODS We conducted a retrospective analysis of 176 consecutive patients who underwent elective EVAR at the Vascular Surgery Department of the Hospital del Mar (Barcelona, Spain) during 2000-2014. Cox regressions were performed to identify preoperative factors associated with long-term survival after EVAR, and a risk model was developed. RESULTS Three- and five-year survival rates were 73.9 and 53.9 %, respectively. During the follow-up, 72 deaths (40.9 %) were registered, cancer being the most frequent cause (41.7 %). Preoperative variables negatively associated with long-term survival were serum creatinine ≥ 150 µmol/L (HR 2.5; 95 % CI 1.4-4.2), chronic obstructive pulmonary disease (HR 1.9; 95 % CI 1.2-3.1), atrial fibrillation (HR 2.0; 95 % CI 1.2-3.4), and prior cancer history (HR 1.9; 95 % CI 1.2-3.1). Distal pulses present in both lower limbs were marginally associated with survival (HR 0.65; 95 % CI 0.4-1.07). The survival predictive model showed a good discrimination capacity (C statistic = 0.703; 95 % CI 0.641-0.765). CONCLUSIONS Long-term survival of patients submitted to EVAR in our setting was worse than expected and markedly related to cancer. Our study suggests that predictive models for long-term survival after EVAR may be influenced by regional characteristics of the intervened population. This effect should be taken in consideration in the decision-making process of these patients.
Collapse
Affiliation(s)
- Nerea Sevilla
- Angiology and Vascular Surgery Department, Hospital del Mar, Universitat Autònoma de Barcelona - Universitat Pompeu Fabra, Passeig Marítim 25-29, 080003, Barcelona, Spain
| | - Albert Clara
- Angiology and Vascular Surgery Department, Hospital del Mar, Universitat Autònoma de Barcelona - Universitat Pompeu Fabra, Passeig Marítim 25-29, 080003, Barcelona, Spain.
| | - Carles Diaz-Duran
- Angiology and Vascular Surgery Department, Hospital del Mar, Universitat Autònoma de Barcelona - Universitat Pompeu Fabra, Passeig Marítim 25-29, 080003, Barcelona, Spain
| | - Carlos Ruiz-Carmona
- Angiology and Vascular Surgery Department, Hospital del Mar, Universitat Autònoma de Barcelona - Universitat Pompeu Fabra, Passeig Marítim 25-29, 080003, Barcelona, Spain
| | - Sara Ibañez
- Angiology and Vascular Surgery Department, Hospital del Mar, Universitat Autònoma de Barcelona - Universitat Pompeu Fabra, Passeig Marítim 25-29, 080003, Barcelona, Spain
| |
Collapse
|
40
|
Tillman BW, Chun Y, Cho SK, Chen Y, Liang N, Maul T, Demetris A, Gu X, Wagner WR, Tevar AD. Dual chamber stent prevents organ malperfusion in a model of donation after cardiac death. Surgery 2016; 160:892-901. [PMID: 27524434 DOI: 10.1016/j.surg.2016.06.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/16/2016] [Accepted: 06/24/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The paradigm for donation after cardiac death subjects donor organs to ischemic injury. A dual-chamber organ perfusion stent would maintain organ perfusion without affecting natural cardiac death. A center lumen allows uninterrupted cardiac blood flow, while an external chamber delivers oxygenated blood to the visceral vessels. METHODS A prototype organ perfusion stent was constructed from commercial stents. In a porcine model, the organ perfusion stent was deployed, followed by a simulated agonal period. Oxygenated blood perfused the external stent chamber. Organ perfusion was compared between controls (n = 3) and organ perfusion stent (n = 6). Finally, a custom, nitinol, dual chamber organ perfusion stent was fabricated using a retrievable "petal and stem" design. RESULTS Endovascular organ perfusion stent deployment achieved visceral isolation without adverse impact on cardiac parameters. Visceral oxygen delivery was 4.8-fold greater compared with controls. During the agonal period, organs in organ perfusion stent-treated animals appeared well perfused in contrast with the malperfused controls. A custom nitinol and polyurethane organ perfusion stent was recaptured easily with simple sheath advancement. CONCLUSION An organ perfusion stent maintained organ perfusion during the agonal phase in a porcine model of donation after cardiac death organ donation without adversely affecting cardiac function. Ultimately, the custom retrievable design of this study may help resolve the critical shortage of donor organs for transplant.
Collapse
Affiliation(s)
- Bryan W Tillman
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Youngjae Chun
- Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Sung Kwon Cho
- Mechanical Engineering & Materials Science, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Yanfei Chen
- Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Nathan Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Timothy Maul
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anthony Demetris
- Division of Transplantation Pathology, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Xinzhu Gu
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - William R Wagner
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Amit D Tevar
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
41
|
Siracuse JJ, Schermerhorn ML, Meltzer AJ, Eslami MH, Kalish JA, Rybin D, Doros G, Farber A. Comparison of outcomes after endovascular and open repair of abdominal aortic aneurysms in low-risk patients. Br J Surg 2016; 103:989-94. [DOI: 10.1002/bjs.10139] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/22/2015] [Accepted: 01/06/2016] [Indexed: 11/11/2022]
Abstract
Abstract
Background
In randomized trials endovascular aortic aneurysm repair (EVAR) has been shown to have superior perioperative outcomes compared with open aneurysm repair (OAR). However, outcomes in patients at low risk of complications are unclear and many surgeons still prefer OAR in this cohort. The objective was to analyse perioperative and longer-term outcomes of OAR and EVAR in this low-risk group of patients.
Methods
All elective infrarenal EVARs and OARs in the Vascular Study Group of New England database were reviewed from 2003 to 2014. The Medicare scoring system was used to identity patients at low risk of perioperative complications and death. Perioperative and longer-term outcomes were analysed in this cohort. A Kaplan–Meier plot was constructed for evaluation of longer-term survival. Further propensity matching and multivariable analysis were performed to analyse additional differences between the two groups.
Results
Some 1070 patients who underwent EVAR and 476 who had OAR were identified. Mean(s.d.) age was 67·3(5·7) and 65·1(6·3) years respectively (P < 0·001). EVAR was associated with a lower overall perioperative complication rate (4·2 versus 26·5 per cent; P < 0·001). There was no difference in 30-day mortality (0·4 versus 0·6 per cent; P = 0·446). Overall survival at 3 years was similar after EVAR and OAR (92·5 versus 92·1 per cent respectively; P = 0·592). In multivariable analyses there was no difference in freedom from reintervention (odds ratio 1·69, 95 per cent c.i. 0·73 to 3·90; P = 0·220) or survival (hazard ratio 0·85, 0·61 to 1·20; P = 0·353).
Conclusion
In patients predicted to be at low risk of perioperative death following aneurysm repair, EVAR resulted in fewer perioperative complications than OAR. However, perioperative mortality, reinterventions and survival rates in the longer term appeared similar between endovascular and open repair.
Collapse
Affiliation(s)
- J J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Massachusetts, USA
| | - M L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - A J Meltzer
- Division of Vascular and Endovascular Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, USA
| | - M H Eslami
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Massachusetts, USA
| | - J A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Massachusetts, USA
| | - D Rybin
- Department of Biostatistics, Boston University, School of Medicine, Massachusetts, USA
| | - G Doros
- Department of Biostatistics, Boston University, School of Medicine, Massachusetts, USA
| | - A Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Massachusetts, USA
| | | |
Collapse
|
42
|
Mousa AY, Bozzay J, Broce M, Yacoub M, Stone PA, Najundappa A, Bates MC, AbuRahma AF. Novel Risk Score Model for Prediction of Survival Following Elective Endovascular Abdominal Aortic Aneurysm Repair. Vasc Endovascular Surg 2016; 50:261-9. [PMID: 27114446 DOI: 10.1177/1538574416638760] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study was to identify significant predictors of long-term mortality after elective endovascular abdominal aortic aneurysm repair (EVAR). METHODS We included all cases with elective EVAR based on a national data set from the Society for Vascular Surgery Patient Safety Organization. Clinical and anatomic variables were analyzed with a Kaplan-Meier and Cox-regression model to determine predictors of mortality and develop a score equation to categorize patients into low, medium, and high long-term mortality risk. RESULTS A total of 5678 patients with EVAR were included with an average age of 73.6 ± 8.2 years. The majority were male (81.6%) with a history of smoking (86.1%). There were 3 deaths within 30 days (0.1%). Several factors were associated with poor survival: unstable angina (hazard ratio [HR], 2.8; P = .008), dialysis (HR, 3.7; P < .001), estimated glomerular filtration rate (eGFR) <30 (HR, 1.7; P = .044), eGFR 30 to 59 (HR, 1.4; P = .002), age >80 (HR, 3.2; P < .001), age 75 to 79 (HR, 2.2; P < .001), chronic obstructive pulmonary disease on oxygen (HR, 3.3; P < .001), aortic diameter >5.8 cm (HR, 1.2; P = .043), and high risk for surgery (HR, 1.4; P = .043). Preoperative aspirin use and body mass index 25 to 35 were both found to be protective (HR, 0.78; P = .017 and HR, 0.8; P = .024, respectively). With our scoring model, 5- and 10-year survival rates for patients with low, medium, and high risk were 89.2%, 80.7%, and 64.1% and 77.2%, 60.1%, and 40.1%, respectively (P < .001). CONCLUSION Ten-year survival following EVAR in patients with a high-risk score utilizing the model provided was 40.1%. Patients with multiple comorbidities at risk for decreased long-term survival can be identified with our model, which is more applicable for high-volume contemporary institutions.
Collapse
Affiliation(s)
- Albeir Y Mousa
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Joseph Bozzay
- Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Mike Broce
- Center for Health Services and Outcomes Research, Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Michael Yacoub
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Patrick A Stone
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Aravinda Najundappa
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Mark C Bates
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| | - Ali F AbuRahma
- Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Vascular Center of Excellence, Charleston Area Medical Center, Charleston, WV, USA
| |
Collapse
|
43
|
Kolh P, De Hert S, De Rango P. The Concept of Risk Assessment and Being Unfit for Surgery. Eur J Vasc Endovasc Surg 2016; 51:857-66. [PMID: 27053098 DOI: 10.1016/j.ejvs.2016.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 02/03/2016] [Indexed: 02/06/2023]
Abstract
The concept of risk assessment and the identification of surgical unfitness for vascular intervention is a particularly controversial issue today as the minimally invasive surgical population has increased not only in volume but also in complexity (comorbidity profile) and age, requiring an improved pre-operative selection and definition of high risk. A practical step by step (three steps, two points for each) approach for surgical risk assessment is suggested in this review. As a general rule, the identification of a "high risk" patient for vascular surgery follows a step by step process where the risk is clearly defined, quantified (when too "high"?), and thereby stratified based on the procedure, the patient, and the hospital, with the aid of predictive risk scores. However, there is no standardized, updated, and objective definition for surgical unfitness today. The major gap in the current literature on the definition of high risk in vascular patients explains the lack of sound validated predictive systems and limited generalizability of risk scores in vascular surgery. In addition, the concept of fitness is an evolving tool and many traditional high risk criteria and definitions are no longer valid. Given the preventive purpose of most vascular procedures performed in elderly asymptomatic patients, the decision to pursue or withhold surgery requires realistic estimates not only regarding individual peri-operative mortality, but also life expectancy, healthcare priorities, and the patient's primary goals, such as prolongation of life versus maintenance of independence or symptom relief. The overall "frailty" and geriatric risk burden, such as cognitive, functional, social, and nutritional status, are variables that should be also included in the analyses for stratification of surgical risk in elderly vascular patients.
Collapse
Affiliation(s)
- P Kolh
- Cardiovascular Surgery Department, University Hospital (CHU, ULg) of Liège, Belgium.
| | - S De Hert
- Department of Anesthesiology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - P De Rango
- Unit of Vascular Surgery, Hospital S.M. Misericordia, Perugia, Italy
| |
Collapse
|
44
|
Machado R, Teixeira G, Loureiro L, Oliveira P, Almeida R. A idade e o tratamento endovascular do aneurisma da aorta abdominal. Estado da arte. ANGIOLOGIA E CIRURGIA VASCULAR 2016. [DOI: 10.1016/j.ancv.2015.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|
45
|
Georgakarakos E, Ioannou CV, Georgiadis GS, Storck M, Trellopoulos G, Koutsias S, Lazarides MK. The ovation abdominal stent graft for the treatment of abdominal aortic aneurysms: current evidence and future perspectives. Expert Rev Med Devices 2016; 13:253-62. [DOI: 10.1586/17434440.2016.1147949] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
46
|
Hale AL, Twomey K, Ewing JA, Langan EM, Cull DL, Gray BH. Impact of sarcopenia on long-term mortality following endovascular aneurysm repair. Vasc Med 2016; 21:217-22. [DOI: 10.1177/1358863x15624025] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Sarcopenia, also known as a reduction of skeletal muscle mass, is a patient-specific risk factor for vascular and cancer patients. However, there are no data on abdominal aortic aneurysm (AAA) patients treated with endovascular aneurysm repair (EVAR) who have sarcopenia. To determine the impact of sarcopenia on mortality following EVAR, we retrospectively reviewed 200 patients treated with EVAR by estimating muscle mass on abdominal computed tomography (CT) scans. Mortality was analyzed according to its presence ( n=25) or absence ( n=175). Sarcopenia was more common in women than men (32.0% vs 9.7%; p=0.005). Patients with sarcopenia had an increased risk of mortality compared to those without (76% vs 48%; p=0.016). Of note, the overall mortality rate was 51% with a median follow up of 8.4 years (interquartile range, 5.3–11.7). In conclusion, the presence of sarcopenia on a CT scan is an important predictor of long-term mortality in patients treated for AAA with EVAR. Pending further study, these data suggest that sarcopenia may aid in pre-procedural long-term survival assessment of patients undergoing EVAR.
Collapse
Affiliation(s)
- Allyson L Hale
- Department of Surgery, Vascular Medicine Division, Greenville Health System, Greenville, SC, USA
| | - Kayla Twomey
- Department of Surgery, Vascular Medicine Division, Greenville Health System, Greenville, SC, USA
| | - Joseph A Ewing
- Department of Surgery, Vascular Medicine Division, Greenville Health System, Greenville, SC, USA
| | - Eugene M Langan
- Department of Surgery, Vascular Medicine Division, Greenville Health System, Greenville, SC, USA
| | - David L Cull
- Department of Surgery, Vascular Medicine Division, Greenville Health System, Greenville, SC, USA
| | - Bruce H Gray
- Department of Surgery, Vascular Medicine Division, Greenville Health System, Greenville, SC, USA
| |
Collapse
|
47
|
Koudoumas D, Iyer V, Curl RG. Simultaneous percutaneous transcatheter aortic valve replacement and endovascular abdominal aortic aneurysm repair in a high risk patient with hostile aortic neck, a case report. J Cardiothorac Surg 2015; 10:184. [PMID: 26654723 PMCID: PMC4676848 DOI: 10.1186/s13019-015-0392-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 12/08/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) can be a potential life threatening condition if left untreated. Total endovascular techniques to approach aortic aneurysms have extended management options and enabled patients who are unfit for open surgery to undergo repair. Transcatheter aortic valve replacement is increasingly used to treat patients with severe symptomatic aortic stenosis, who once were considered high risk for traditional open aortic valve replacement. RESULTS Herein we report the complete simultaneous treatment of an infrarenal AAA with hostile neck and severe aortic stenosis in a patient deemed high risk for surgical repair. CONCLUSION Advances in catheter based endovascular technology have enabled physicians to approach patients with AAA and valvular pathology even with multiple comorbidities that otherwise would be poor surgical candidates, even in the presence of challenging anatomic considerations and various comorbidities.
Collapse
Affiliation(s)
- Dimitrios Koudoumas
- SUNY at Buffalo, Department of Vascular Surgery, Buffalo General Medical Center, Gates Vascular Institute, 100 High Street, B-7, Buffalo, NY, 14203, USA.
| | - Vijay Iyer
- SUNY at Buffalo, Department of Interventional Cardiology, Buffalo General Medical Center, Gates Vascular Institute, Buffalo, NY, USA.
| | - Richard G Curl
- SUNY at Buffalo, Department of Vascular Surgery, Buffalo General Medical Center, Gates Vascular Institute, 100 High Street, B-7, Buffalo, NY, 14203, USA.
| |
Collapse
|
48
|
Khashram M, Williman JA, Hider PN, Jones GT, Roake JA. Systematic Review and Meta-analysis of Factors Influencing Survival Following Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2015; 51:203-15. [PMID: 26602162 DOI: 10.1016/j.ejvs.2015.09.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 09/09/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Predicting long-term survival following repair is essential to clinical decision making when offering abdominal aortic aneurysm (AAA) treatment. A systematic review and a meta-analysis of pre-operative non-modifiable prognostic risk factors influencing patient survival following elective open AAA repair (OAR) and endovascular aneurysm repair (EVAR) was performed. METHODS MEDLINE, Embase and Cochrane electronic databases were searched to identify all relevant articles reporting risk factors influencing long-term survival (≥1 year) following OAR and EVAR, published up to April 2015. Studies with <100 patients and those involving primarily ruptured AAA, complex repairs (supra celiac/renal clamp), and high risk patients were excluded. Primary risk factors were increasing age, sex, American Society of Anaesthesiologist (ASA) score, and comorbidities such as ischaemic heart disease (IHD), cardiac failure, hypertension, chronic obstructive pulmonary disease (COPD), renal impairment, cerebrovascular disease, peripheral vascular disease (PVD), and diabetes. Estimated risks were expressed as hazard ratio (HR). RESULTS A total of 5,749 study titles/abstracts were retrieved and 304 studies were thought to be relevant. The systematic review included 51 articles and the meta-analysis 45. End stage renal disease and COPD requiring supplementary oxygen had the worst long-term survival, HR 3.15 (95% CI 2.45-4.04) and HR 3.05 (95% CI 1.93-4.80) respectively. An increase in age was associated with HR of 1.05 (95% CI 1.04-1.06) for every one year increase and females had a worse survival than men HR 1.15 (95% CI 1.07-1.27). An increase in ASA score and the presence of IHD, cardiac failure, hypertension, COPD, renal impairment, cerebrovascular disease, PVD, and diabetes were also factors associated with poor long-term survival. CONCLUSION The result of this meta-analysis summarises and quantifies unmodifiable risk factors that influence late survival following AAA repair from the best available published evidence. The presence of these factors might assist in clinical decision making during discussion with patients regarding repair.
Collapse
Affiliation(s)
- M Khashram
- Department of Surgery, University of Otago, Christchurch, New Zealand; Department of Vascular Endovascular & Transplant Surgery Christchurch Hospital, New Zealand.
| | - J A Williman
- Department of Population Health, University of Otago, Christchurch, New Zealand
| | - P N Hider
- Department of Population Health, University of Otago, Christchurch, New Zealand
| | - G T Jones
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, New Zealand
| | - J A Roake
- Department of Surgery, University of Otago, Christchurch, New Zealand; Department of Vascular Endovascular & Transplant Surgery Christchurch Hospital, New Zealand
| |
Collapse
|
49
|
Comparison of Efficacy of Endovascular Aneurysm Repair Versus Open Surgical Repair in Middle/High-Risk Patients With Abdominal Aortic Aneurysm. Am J Ther 2015; 23:e37-43. [PMID: 26295612 DOI: 10.1097/mjt.0000000000000289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To explore the efficacy of endovascular aneurysm repair (EVAR) compared with traditional open surgical repair (OSR) in the treatment of middle/high-risk patients with abdominal aortic aneurysm (AAA). With a retrospective method, we analyzed the clinical data of 57 patients with middle/high-risk AAA admitted to Linyi People's Hospital Affiliated to Shandong University from January 2010 to January 2014. Twenty-eight of the 57 patients received EVAR and 29 others received OSR. Statistical analysis was conducted by the design of spreadsheet according to preoperative, intraoperative, perioperative, and postoperative follow-up relevant information. Our study showed that the difference in baseline characteristics of different therapies in middle/high-risk AAA patients was not statistically significant in preoperative period (P > 0.05). In intraoperative period, the efficacy of middle/high-risk AAA patients in EVAR group was significantly superior to OSR group in terms of blood loss, blood transfusion, and general anesthesia rate (all P < 0.01). In perioperative period, the ICU observation time and the average fasting time of middle/high-risk AAA patients in EVAR group were remarkably lower than OSR group (all P < 0.01), but the average hospital stay and the operation cost of middle/high-risk AAA patients in EVAR group were notably higher than OSR group. In postoperative follow-up period, OSR group was identified with a lower incidence of surgery-related complications than EVAR group (P < 0.05), but EVAR group was demonstrated with a higher survival rate than OSR group (P < 0.05); after 12 months of follow-up, SF-36 scale scores in OSR group were higher than EVAR group (P < 0.05). In conclusion, EVAR may have a better short-term effect, whereas OSR may have a better long-term effect in the treatment of middle/high-risk AAA patients.
Collapse
|