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Bianchini Massoni C, Perini P, Rossi G, Carli AG, Catasta A, Nabulsi B, Freyrie A. The role of narrow aortic bifurcation in affecting EVAR treatment and outcomes. Ann Vasc Surg 2024:S0890-5096(24)00240-1. [PMID: 38815912 DOI: 10.1016/j.avsg.2024.03.021] [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: 01/29/2024] [Revised: 03/14/2024] [Accepted: 03/16/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVES The narrow aortic bifurcation is considered a risk factor for endograft thrombosis after aorto-biiliac endovascular aortic repair (EVAR) for aortic or iliac aneurysm. Nowadays, no consensus on the threshold diameter for the definition of narrow aortic bifurcation is reached and other aortic bifurcation features are rarely considered. The aim of the study is to assess the EVAR outcomes using bifurcated endograft according to anatomical characteristics of aortic bifurcation. METHODS The study included patients treated with primary EVAR from 2016 to 2022. A retrospective analysis of single-center prospectively collected database was performed. Patients were classified in standard aortic bifurcation (SAB; aortic bifurcation diameter >20mm), narrow aortic bifurcation (NAB; ≤20mm and >16mm) and extremely narrow aortic bifurcation (eNAB; ≤16mm). The three groups were compared in terms of patient demographics, risk factors, procedure setting (elective or urgent/emergent), type of deployed endograft. In NAB and eNAB groups, severe calcification (SC) and length of stenotic aortic bifurcation >10mm (long-NAB) were assessed from pre-operative imaging. In SAB, NAB and eNAB groups, following outcomes were evaluated: rate of intraoperative iliac endograft stenting (unilateral or kissing stenting), primary patency (PP), freedom from endograft-related reintervention (ffER) and overall survival during follow-up. RESULTS The total number of deployed aorto-biiliac endografts was 365 (mean age: 76.6 years ±7.4; male 89.3%): SAB 298 (81.6%), NAB 57 (15.6%) and eNAB 10 (2.7%) cases. Female gender, COPD and active smokers were more frequent in patients with smaller aortic bifurcation diameter (p=.002, .039 and .010, respectively). In NAB and eNAB groups, SC was reported in 18/67 cases (26.9%) and long-NAB in 15/67 cases (25.4%). Patients with eNAB have more frequent SC of aortic bifurcation (60% vs NAB 21.1%, p=.018) and long-NAB (50% vs NAB 17.5%, p=.023). In SAB, sNAB and eNAB, intraoperative iliac endograft stenting was performed in 34/298 (11.4%), 9/57 (15.8%) and 5/10 (50%), respectively (p=.001). Kissing stenting was performed more frequently in groups with smaller aortic bifurcation diameter (p=.010). Mean follow-up was 30.2 months ±21.5. At 1, 3 and 5 years, PP was 98.5%, 96.6% and 95.6%, respectively. eNAB had lower rate of PP compared to NAB group (p=.030). Long-NAB had lower rate of PP (p=.035). At 1, 3 and 5 years, ffER was 96.8%, 86.7% and 76.7%, respectively, with no differences between three groups (p=.423). At 1, 3 and 5 years, survival was 92.5%, 77.6% and 58.1%, respectively, with no difference between SAB, sNAB and eNAB (p=. 673). CONCLUSIONS Female, COPD patients and active smokers have more frequently smaller aortic bifurcation diameter. eNAB patients have more challenging anatomical characteristics compared with NAB group, requiring higher rate of intraoperative stenting, especially kissing stenting. Mid-term PP seems to be negatively influenced by aortic bifurcation ≤16mm and long-NAB.
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Affiliation(s)
| | - Paolo Perini
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Giulia Rossi
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Anna Giulia Carli
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Alexandra Catasta
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Bilal Nabulsi
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
| | - Antonio Freyrie
- Vascular Surgery, University of Parma, Department of Medicine and Surgery - Parma, Italy
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Taneva GT, Pitoulias AG, Avranas K, Donas KP. Latest evidence on chimney endovascular repair of abdominal aortic aneurysms and the renal artery angulation pitfall. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:119-123. [PMID: 38618696 DOI: 10.23736/s0021-9509.24.12936-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
This article summarizes the key findings in literature up to date on the endovascular treatment of complex abdominal aortic aneurysms (AAAs) employing the chimney technique. Additionally, an unexplored pitfall is described regarding the target vessel angulation. Although balloon-expandable covered stents present more favorable configuration in downward-oriented target vessels, transverse and upward-oriented target vessels may benefit from other endovascular techniques imploring careful case planning and further investigation on the topic.
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Affiliation(s)
- Gergana T Taneva
- Department of Vascular and Endovascular Surgery, Rhein Main Vascular Center, Asklepios Clinics Langen, Langen, Germany -
| | - Apostolos G Pitoulias
- Department of Vascular and Endovascular Surgery, Rhein Main Vascular Center, Asklepios Clinics Langen, Langen, Germany
| | - Konstantinos Avranas
- Department of Vascular and Endovascular Surgery, Rhein Main Vascular Center, Asklepios Clinics Langen, Langen, Germany
| | - Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, Rhein Main Vascular Center, Asklepios Clinics Langen, Langen, Germany
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Leyba K, Hanif H, Millhuff AC, Quazi MA, Sohail AH, Clark RM, Sheikh AB, Rana MA. Racial and sex disparities in inpatient outcomes of patients with ruptured abdominal aortic aneurysms in the United States. J Vasc Surg 2024:S0741-5214(24)00406-3. [PMID: 38431061 DOI: 10.1016/j.jvs.2024.02.029] [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: 12/18/2023] [Revised: 02/07/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Ruptured abdominal aortic aneurysm (AAA) is a medical emergency that requires immediate surgical intervention. The aim of this analysis was to identify the sex- and race-specific disparities that exist in outcomes of patients hospitalized with this condition in the United States using the National Inpatient Sample (NIS) to identify targets for improvement and support of specific patient populations. METHODS In this descriptive, retrospective study, we analyzed the patients admitted with a primary diagnosis of ruptured AAA between January 1, 2016, and December 31, 2020, using the NIS database. We compared demographics, comorbidities, and in-hospital outcomes in AAA patients, and compared these results between different racial groups and sexes. RESULTS A total of 22,395 patients with ruptured AAA were included for analysis. Of these, 16,125 patients (72.0%) were male, and 6270 were female (28.0%). The majority of patients (18,655 [83.3%]) identified as Caucasian, with the remaining patients identifying as African American (1555 [6.9%]), Hispanic (1095 [4.9%]), Asian or Pacific Islander (470 [2.1%]), or Native American (80 [0.5%]). Females had a higher risk of mortality than males (OR, 1.7; 95% confidence interval [CI], 1.45-1.96; P < .001) and were less likely to undergo endovascular aortic repair (OR, 0.70; 95% CI, 0.61-0.81; P < .001) or fenestrated endovascular aortic repair (OR, 0.71; 95% CI, 0.55-0.91; P = .007). Relative to Caucasian race, patients who identified as African American had a lower risk of inpatient mortality (OR, 0.50; 95% CI, 0.37-0.68; P < .001). CONCLUSIONS In this retrospective study of the NIS database from 2016 to 2020, females were less likely to undergo endovascular intervention and more likely to die during their initial hospitalization. African American patients had lower rates in-hospital mortality than Caucasian patients, despite a higher burden of comorbidities. Future studies are needed to elucidate the potential factors affecting racial and sex disparities in ruptured AAA outcomes, including screening practices, rupture risk stratification, and more personalized guidelines for both elective and emergent intervention.
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Affiliation(s)
- Katarina Leyba
- Department of Internal Medicine, University of Colorado, Aurora
| | - Hamza Hanif
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque.
| | - Alexandra C Millhuff
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque
| | - Mohammed A Quazi
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque
| | - Amir H Sohail
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque
| | - Ross M Clark
- Division of Vascular Surgery, Department of Surgery, Albuquerque
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque
| | - Muhammad A Rana
- Division of Vascular Surgery, University of New Mexico School of Medicine, Albuquerque
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Meccanici F, Thijssen CGE, Heijmen RH, Geuzebroek GSC, ter Woorst JF, Gökalp AL, de Bruin JL, Gratama DN, Bekkers JA, van Kimmenade RRJ, Poyck P, Peels K, Post MC, Mokhles MM, Takkenberg JJM, Roos‐Hesselink JW, Verhagen HJM. Male-Female Differences in Acute Type B Aortic Dissection. J Am Heart Assoc 2024; 13:e029258. [PMID: 38156593 PMCID: PMC10863826 DOI: 10.1161/jaha.122.029258] [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: 03/08/2023] [Accepted: 07/31/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Acute type B aortic dissection is a cardiovascular emergency with considerable mortality and morbidity risk. Male-female differences have been observed in cardiovascular disease; however, literature on type B aortic dissection is scarce. METHODS AND RESULTS A retrospective cohort study was conducted including all consecutive patients with acute type B aortic dissection between 2007 and 2017 in 4 tertiary hospitals using patient files and questionnaires for late morbidity. In total, 384 patients were included with a follow-up of 6.1 (range, 0.02-14.8) years, of which 41% (n=156) were female. Women presented at an older age than men (67 [interquartile range (IQR), 57-73] versus 62 [IQR, 52-71]; P=0.015). Prior abdominal aortic aneurysm (6% versus 15%; P=0.009), distally extending dissections (71 versus 85%; P=0.001), and clinical malperfusion (18% versus 32%; P=0.002) were less frequently observed in women. Absolute maximal descending aortic diameters were smaller in women (36 [IQR: 33-40] mm versus 39 [IQR, 36-43] mm; P<0.001), while indexed for body surface area diameters were larger in women (20 [IQR, 18-23] mm/m2 versus 19 [IQR, 17-21] mm/m2). No male-female differences were found in treatment choice; however, indications for invasive treatment were different (P<0.001). Early mortality rate was 9.6% in women and 11.8% in men (P=0.60). The 5-year survival was 83% (95% CI, 77-89) for women and 84% (95% CI, 79-89) for men (P=0.90). No male-female differences were observed in late (re)interventions. CONCLUSIONS No male-female differences were found in management, early or late death, and morbidity in patients presenting with acute type B aortic dissection, despite distinct clinical profiles at presentation. More details on the impact of age and type of intervention are warranted in future studies.
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Affiliation(s)
- Frederike Meccanici
- Department of CardiologyErasmus University Medical CenterRotterdamNetherlands
| | - Carlijn G. E. Thijssen
- Department of CardiologyErasmus University Medical CenterRotterdamNetherlands
- Department of CardiologyRadboud University Medical CenterNijmegenNetherlands
| | - Robin H. Heijmen
- Department of Cardiothoracic SurgerySt. Antonius HospitalNieuwegeinNetherlands
| | | | | | - Arjen L. Gökalp
- Department of Cardiothoracic SurgeryErasmus University Medical CenterRotterdamNetherlands
| | - Jorg L. de Bruin
- Department of Vascular SurgeryErasmus University Medical CenterRotterdamNetherlands
| | - Daantje N. Gratama
- Department of Vascular SurgeryErasmus University Medical CenterRotterdamNetherlands
| | - Jos A. Bekkers
- Department of Cardiothoracic SurgeryErasmus University Medical CenterRotterdamNetherlands
| | - Roland R. J. van Kimmenade
- Department of CardiologyErasmus University Medical CenterRotterdamNetherlands
- Department of CardiologyRadboud University Medical CenterNijmegenNetherlands
| | - Paul Poyck
- Department of Vascular SurgeryRadboud University Medical CenterNijmegenNetherlands
| | - Kathinka Peels
- Department of CardiologyCatharina HospitalEindhovenNetherlands
| | - Marco C. Post
- Department of CardiologySt. Antonius HospitalNieuwegeinNetherlands
- Department of CardiologyUniversity Medical Center UtrechtUtrechtNetherlands
| | - Mostafa M. Mokhles
- Department of Cardiothoracic SurgeryErasmus University Medical CenterRotterdamNetherlands
- Department of Cardiothoracic SurgeryUniversity Medical Center UtrechtUtrechtNetherlands
| | | | | | - Hence J. M. Verhagen
- Department of Vascular SurgeryErasmus University Medical CenterRotterdamNetherlands
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Coca-Martinez M, St-Pierre J, Girsowicz E, Doonan RJ, Obrand DI, Bayne JP, Steinmetz OK, Mackenzie KS, Carli F, Martinez-Palli G, Gill HL. Multimodal Prehabilitation for Patients Undergoing Endovascular Aortic Aneurysm Repair Surgery: A Feasibility Study. J Endovasc Ther 2023:15266028231219674. [PMID: 38158811 DOI: 10.1177/15266028231219674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Elective treatment options for aortic abdominal aneurysms include open repair or the less-invasive endovascular aortic aneurysm repair (EVAR). Recovery from EVAR is generally considered easier and faster than open repair. Despite this, EVAR remains a major procedure, and average return to preoperative quality of life is at least 3 months. The purpose of this study is to determine the safety and feasibility of multimodal prehabilitation, a multidisciplinary preoperative optimization intervention, in patients undergoing EVAR and its impact on perioperative functional capacity and quality of life. METHODS Candidates for EVAR with an infra-renal abdominal aortic aneurysm <7.5cm were invited to participate in a 6-week multimodal prehabilitation program that included (1) supervised and home-based exercise, (2) nutritional support, (3) psychosocial support, and (4) smoking cessation. Functional capacity and quality of life were assessed at baseline, before surgery and 6 weeks postoperatively. Recruitment rate, safety, and compliance were also assessed. RESULTS A total of 24 patients were included, 17 males (70%) and 7 females (30%). No adverse events occurred during the program. Compliance to each component of the program (median [Q1-Q3]) was 66% [67] for supervised training, 100% [67] for home-based training, and 100% [100] for nutrition. The multimodal prehabilitation program elicited a significant increase in functional capacity and quality of life preoperatively. CONCLUSION Multimodal prehabilitation for patients awaiting EVAR is feasible and safe. Multimodal prehabilitation improves both functional capacity and quality of life preoperatively. Further research is needed to assess the impact of multimodal prehabilitation on postoperative quality of life and functional capacity. CLINICAL IMPACT Multimodal prehabilitation is safe and feasible in patients awaiting endovascular aneurysm repair. The importance of this finding is that multimodal prehabilitation can be safely delivered preoperatively in patients awaiting EVAR. Although further research is needed, multimodal prehabilitation seems to improve preoperative functional capacity and quality of life. This could have an impact for the future implementation of prehabilitation interventions in order to increase functional reserve and quality of life preoperatively so that this high-risk population can cope better with the surgical stress and return to their normal life faster postoperatively.
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Affiliation(s)
- Miquel Coca-Martinez
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
- Department of Anesthesia and Intensive Care, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Jade St-Pierre
- McGill Research Centre for Physical Activity and Health, McGill University, Montreal, QC, Canada
| | - Elie Girsowicz
- Department of Vascular Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Robert J Doonan
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Daniel I Obrand
- McGill Research Centre for Physical Activity and Health, McGill University, Montreal, QC, Canada
| | - Jason P Bayne
- McGill Research Centre for Physical Activity and Health, McGill University, Montreal, QC, Canada
| | - Oren K Steinmetz
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Kent S Mackenzie
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Graciela Martinez-Palli
- Department of Anesthesia and Intensive Care, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Heather L Gill
- Division of Vascular Surgery, Department of Surgery, McGill University, Montreal, QC, Canada
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Elizondo-Benedetto S, Sastriques-Dunlop S, Detering L, Arif B, Heo GS, Sultan D, Luehmann H, Zhang X, Gao X, Harrison K, Thies D, McDonald L, Combadière C, Lin CY, Kang Y, Zheng J, Ippolito J, Laforest R, Gropler RJ, English SJ, Zayed MA, Liu Y. Chemokine Receptor 2 Is A Theranostic Biomarker for Abdominal Aortic Aneurysms. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.11.06.23298031. [PMID: 37986880 PMCID: PMC10659515 DOI: 10.1101/2023.11.06.23298031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Abdominal aortic aneurysm (AAA) is a degenerative vascular disease impacting aging populations with a high mortality upon rupture. There are no effective medical therapies to prevent AAA expansion and rupture. We previously demonstrated the role of the monocyte chemoattractant protein-1 (MCP-1) / C-C chemokine receptor type 2 (CCR2) axis in rodent AAA pathogenesis via positron emission tomography/computed tomography (PET/CT) using CCR2 targeted radiotracer 64 Cu-DOTA-ECL1i. We have since translated this radiotracer into patients with AAA. CCR2 PET showed intense radiotracer uptake along the AAA wall in patients while little signal was observed in healthy volunteers. AAA tissues collected from individuals scanned with 64 Cu-DOTA-ECL1i and underwent open-repair later demonstrated more abundant CCR2+ cells compared to non-diseased aortas. We then used a CCR2 inhibitor (CCR2i) as targeted therapy in our established male and female rat AAA rupture models. We observed that CCR2i completely prevented AAA rupture in male rats and significantly decreased rupture rate in female AAA rats. PET/CT revealed substantial reduction of 64 Cu-DOTA-ECL1i uptake following CCR2i treatment in both rat models. Characterization of AAA tissues demonstrated decreased expression of CCR2+ cells and improved histopathological features. Taken together, our results indicate the potential of CCR2 as a theranostic biomarker for AAA management.
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Epple J, Svidlova Y, Schmitz-Rixen T, Böckler D, Lingwal N, Grundmann RT. Long-Term Outcome of Intact Abdominal Aortic Aneurysm After Endovascular or Open Repair. Vasc Endovascular Surg 2023; 57:829-837. [PMID: 37224305 DOI: 10.1177/15385744231178130] [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] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Endovascular aortic aneurysm repair (EVAR) has been established as a standard treatment option for intact abdominal aortic aneurysm (iAAA) and gained importance due to a lower perioperative mortality than open repair (OAR). However, whether this survival advantage can be maintained or if OAR is beneficial in terms of long-term complications and reinterventions remains questionable. DESIGN In this retrospective cohort study data from patients undergoing elective EVAR or OAR for iAAAs in the years 2010-2016 was analyzed. The patients were followed through 2018. METHODS In the propensity score matched cohorts the perioperative and long-term outcomes of the patients were assessed. We identified 20 683 patients undergoing elective iAAA repair (76.4% EVAR). The propensity matched cohorts included 4886 pairs of patients. RESULTS The perioperative mortality was 1.9% for EVAR and 5.9% for OAR (P = <.001). The perioperative mortality was mainly influenced by patients age (Odds-Ratio (OR):1.073, confidence interval (CI):1.058-1.088, P ≤ .001) and OAR (OR:3.242, CI:2.552-4.119, P ≤ .001). The early survival benefit after endovascular repair persisted for approximately 3 years (estimated survival EVAR 82.3%, OAR 80.9%, P = .021). After that time the estimated survival curves were similar. After 9 years the estimated survival was 51.2% after EVAR as compared to 52.8% after OAR (P = .102). The operation method didn't influence long-term survival significantly (Hazard-Ratio (HR): 1.046, CI: .975-1.122, P = .211). The vascular reintervention rate was 17.4% in the EVAR cohort and 7.1% in the OAR cohort (P ≤ .001). CONCLUSION EVAR has a significantly lower perioperative mortality than OAR, a survival benefit that lasts up to 3 years after intervention. Thereafter, no significant difference in survival was observed between EVAR and OAR. The decision between EVAR or OAR may depend on patient preference, surgeons' experience, and the institutions' ability to handle complications.
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Affiliation(s)
- Jasmin Epple
- Department of Vascular and Endovascular Surgery University Hospital, Frankfurt Am Main, Germany
| | - Yuliya Svidlova
- Department of Vascular and Endovascular Surgery University Hospital, Frankfurt Am Main, Germany
| | - Thomas Schmitz-Rixen
- German Institute for Vascular Healthcare Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital, Heidelberg, Germany
| | - Neelam Lingwal
- Institute for Biostatistics and Mathematical Modeling, Goethe University Frankfurt Am Main, Germany
| | - Reinhart T Grundmann
- German Institute for Vascular Healthcare Research (DIGG) of the German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany
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8
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Ramkumar N, Suckow BD, Columbo JA, Arya S, Sedrakyan A, Mackenzie TA, Brown JR, Goodney PP. Sex differences in outcomes among adults undergoing abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:1212-1220.e5. [PMID: 37442215 DOI: 10.1016/j.jvs.2023.06.105] [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: 10/12/2022] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE Although the differences in short-term outcomes between male and female patients in abdominal aortic aneurysm (AAA) repair have been well studied, it remains unclear if these sex disparities extend to other long-term adverse outcomes after AAA repair, such as reintervention and late rupture. METHODS We performed a retrospective cohort study of 13,007 patients who underwent either endovascular (EVAR) or open AAA repair (OAR) between 2003 and 2015 using data from the Vascular Quality Initiative registries. Eligible patients were linked to fee-for-service Medicare claims to identify late outcomes of rupture and aneurysm-specific reintervention. RESULTS The mean age of our cohort was 76 ± 6.7 years, 22% were female, 94% were White, and 77% underwent EVAR. The 10-year rupture incidence was slightly higher for women at 4.8 per 1000 person-years, vs 3.9 for men, but this difference was not statistically significant after risk adjustment (hazard ratio [HR] = 1.13, 95% confidence interval [CI]: 0.74-1.73). Likewise, we found no sex difference in reintervention rates (5.1 vs 4.8 in women per 1000 person-years) even after risk adjustment (HR = 0.95, 95% CI: 0.83-1.09). Regression models suggest effect modification by repair type for reintervention, where women who underwent index EVAR had a higher risk of reintervention than men (HR = 1.08, 95% CI: 0.93-1.26), whereas women who underwent OAR were at a lower risk of reintervention than men (HR = 0.79, 95% CI: 0.58-1.08); however, neither effect reached statistical significance within each subgroup. In addition, we found that the risk of reintervention for women vs men varied by clinical presentation, where women were less likely to undergo reintervention after an elective or symptomatic AAA repair but were more likely to undergo reintervention after a repair for AAA rupture (HR = 1.70, 95% CI: 1.05-2.75). CONCLUSIONS Male and female patients who underwent AAA repair had similar rates of reintervention and late aneurysm rupture in the 10 years after their procedure. However, our findings suggest that repair type and clinical presentation may affect the role of sex in clinical outcomes and warrant further exploration in these subgroups.
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Affiliation(s)
| | - Bjoern D Suckow
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Jesse A Columbo
- Geisel School of Medicine, Hanover, NH; Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Shipra Arya
- Department of Surgery, Stanford University Medical Center, Stanford, CA
| | | | - Todd A Mackenzie
- Geisel School of Medicine, Hanover, NH; Department of Biomedical Data Science, Geisel School of Medicine, Hanover, NH
| | - Jeremiah R Brown
- Department of Biomedical Data Science, Geisel School of Medicine, Hanover, NH; Department of Epidemiology, Geisel School of Medicine, Hanover, NH
| | - Philip P Goodney
- Geisel School of Medicine, Hanover, NH; Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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9
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George EL, Smith JA, Colvard B, Lee JT, Stern JR. Precocious Rupture of Abdominal Aortic Aneurysms Below Size Criteria for Repair: Risk Factors and Outcomes. Ann Vasc Surg 2023; 97:74-81. [PMID: 37247834 DOI: 10.1016/j.avsg.2023.05.008] [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: 03/27/2023] [Revised: 05/14/2023] [Accepted: 05/15/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Practice guidelines recommend elective repair for abdominal aortic aneurysms (AAAs) ≥ 5.5 cm in men and ≥ 5 cm in women to prevent rupture; however, some rupture at smaller diameters. We identify risk factors for rupture AAA (rAAA) below this threshold and compare outcomes following rAAA repair above/below size criteria. METHODS The Vascular Quality Initiative (2013-2019) was queried for patients undergoing repair for rAAA and stratified based on diameter into small and large cohorts [Small: < 5.5 cm (men), < 5.0 cm (women)]. Univariate analysis was performed, and Kaplan-Meier analysis compared overall survival, aneurysm-related mortality, and reintervention at 12 months. RESULTS Five thousand one hundred sixty two rAAA were identified. Small rAAA patients [n = 588] were more likely to have hypertension (81.3% vs. 77.0%, P < 0.02), diabetes (18.2% vs. 14.9%, P < 0.04), and end-stage renal disease (2.9% vs. 0.9%, P < 0.01) and be on optimal medical therapy (32.1% vs. 26.8%, P < 0.01). Women were more likely to rupture at smaller diameters compared to men (P < 0.01). Small rAAA patients were more likely to undergo endovascular aortic repair (EVAR) (70.2% vs. 56.0%, P < 0.01) and had lower in-hospital mortality (17.7% vs. 27.7%, P < 0.01) and fewer perioperative complications across all categories. At 12 months, small rAAA patients had better overall survival, freedom from aneurysm-related mortality, and freedom from reintervention, largely driven by EVAR approach. CONCLUSIONS More than 11% of patients presenting with ruptured AAA were below the recommended size threshold for repair, and they tended to be younger, non-White, and have hypertension, diabetes, and/or renal failure. Patients with small rAAA experienced lower in-hospital morbidity and mortality and improved 1-year survival, and EVAR was associated with better outcomes than open repair. However, women more frequently rupture at smaller diameters compared to men. Given contemporary elective outcomes for women, a randomized controlled trial for EVAR versus surveillance at a sex-specific size threshold is needed.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA; Veterans Affairs Healthcare System, Surgical Service Line, Section of Vascular Surgery, Palo Alto, CA.
| | - Justin A Smith
- University Hospital Harrington Heart & Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Benjamin Colvard
- University Hospital Harrington Heart & Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Jason T Lee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Jordan R Stern
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
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10
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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.
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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.
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11
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Talvitie M, Åldstedt-Nyrønning L, Stenman M, Roy J, Cohnert T, Hultgren R. Women with large intact abdominal aortic aneurysms remain untreated. J Vasc Surg 2023; 78:657-667.e5. [PMID: 37211143 DOI: 10.1016/j.jvs.2023.05.025] [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: 03/03/2023] [Revised: 04/20/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE A lower elective repair rate among women with abdominal aortic aneurysms (AAAs) has been a consistent finding. Reasons behind this gender gap have not been thoroughly outlined. METHODS This was a retrospective multicenter cohort study (ClinicalTrials.gov: NCT05346289) at three European vascular centers in Sweden, Austria and Norway. Patients in surveillance with AAAs were consecutively identified starting from January 1, 2014, until reaching a total sample size of 200 women and 200 men. All individuals were followed for 7 years through medical records. Final treatment distributions and the proportion of "truly untreated" (surgically untreated despite reaching guideline-directed thresholds: 50 mm for women and 55 mm for men) were determined. In a complementary analysis, a universal 55-mm threshold was used. Gender-specific primary reasons behind untreated statuses were clarified. Eligibility for endovascular repair among the truly untreated was assessed in a structured computed tomography analysis. RESULTS Women and men had similar median diameters at inclusion (46 mm; P = .54) and at treatment decisions (55 mm; P = .36). After 7 years, the repair rate was lower among women (47% vs 57%). More women were truly untreated (26% vs 8%; P < .001) despite similar mean ages as for male counterparts (79.3 years; P = .16). With the 55-mm threshold, 16% women still classified as truly untreated. Similar reasons for nonintervention were captured for women and men (50% due to comorbidities alone, 36% morphology and comorbidity). The endovascular repair imaging analysis revealed no gender differences. Among truly untreated women, ruptures were common (18%), and mortality was high (86%). CONCLUSIONS Surgical AAA management differed between women and men. Women could be underserved in terms of elective repairs: one in every four women was untreated with over-the-threshold AAAs. The lack of obvious gender differences in eligibility analyses could imply unmeasured discrepancies (eg, in disease extent or patient frailty).
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Affiliation(s)
- Mareia Talvitie
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Linn Åldstedt-Nyrønning
- Department of Surgery, Vascular Surgery, St Olavs Hospital, Trondheim, Norway; Department of Circulation and Medical Imaging, NTNU, Trondheim, Norway
| | - Malin Stenman
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Joy Roy
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Tina Cohnert
- Department of Vascular Surgery, Medical University of Graz, Graz, Austria
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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12
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Israni N, Lee J, Bai H, Storch J, Chen J, Cooke PV, Blanchard O, Kim SY, Tadros RO, Lookstein R, Faries PL, Vouyouka AG. Women are Not at Higher Risk for Reintervention or Major Amputation after Lower Extremity Atherectomy for Peripheral Artery Disease. Ann Vasc Surg 2023; 95:95-107. [PMID: 37080286 DOI: 10.1016/j.avsg.2023.04.001] [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: 02/04/2023] [Revised: 03/22/2023] [Accepted: 04/03/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Our objective was to compare short-term and long-term differences in reintervention-free and major amputation-free survival between female and male patients undergoing lower extremity atherectomy for peripheral artery disease. METHODS We analyzed lower extremity atherectomy procedures performed on 294 patients between January 2014 and September 2019. Reintervention was defined as either open bypass or endovascular procedure to the same region following the index operation. Kaplan-Meier (KM) survival analysis was performed to compare reintervention-free and major amputation-free survival between sexes. Multivariate logistic regression analyses were performed to determine the adjusted odds of reintervention and major amputation based on sex. We conducted subgroup analyses by anatomic region (femoropopliteal vs. tibial), indication (claudication vs. chronic limb-threatening ischemia (CLTI)), and balloon type (drug-coated balloon (DCB) versus plain balloon angioplasty (POBA)) across sexes. RESULTS Of the 294 patients, 125 (42.5%) were female. Compared to men, women receiving atherectomy were more likely to be Black (28.0% vs. 16.6%; P = 0.018), a nonsmoker (44.8% vs. 21.3%; P < 0.001), and present with CLTI (55.2% vs. 43.2%; P = 0.042). There were no differences in atherectomy region, lesion type, or balloon type between sexes. KM analysis showed similar 4-year reintervention-free survival (68.8% vs. 75.1%; P = 0.88) and major amputation-free survival (97.6% vs. 97.6%; P = 0.41) between sexes. Women and men had similar reintervention-free survival when grouped by femoropopliteal (67.9% vs. 70.8%; P = 0.69) or tibial (76.2% vs. 83.9%; P = 0.68) atherectomy region. Indication (claudication versus CLTI) did not affect reintervention-free survival in either women (64.5% vs. 69.6%; P = 0.28) or men (68.5% vs. 76.7%; P = 0.84). KM curves for DCB versus POBA were also similar between sexes and showed an early benefit in reintervention rate favoring DCB, which dissipated in both women (65.4% vs. 72.7%; P = 0.61) and men (75.5% vs. 78.4%; P = 0.18) by 3 years. CONCLUSIONS Compared to men, women demonstrate commensurate benefit from atherectomy for lower extremity revascularization. There were no differences seen in long-term reintervention or major amputation between sexes.
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Affiliation(s)
- Nikita Israni
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Jonathan Lee
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Halbert Bai
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jason Storch
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jenny Chen
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter V Cooke
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Olivia Blanchard
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sung Yup Kim
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert Lookstein
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter L Faries
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ageliki G Vouyouka
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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13
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Bradley NA, Walter A, Wilson A, Siddiqui T, Roxburgh CSD, McMillan DC, Guthrie GJK. The prognostic value of preoperative systemic inflammation-based scoring in patients undergoing endovascular repair of abdominal aortic aneurysm. J Vasc Surg 2023; 78:362-369.e2. [PMID: 37086821 DOI: 10.1016/j.jvs.2023.04.018] [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: 02/24/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE Abdominal aortic aneurysm (AAA) is a common condition that is predominantly managed in the United Kingdom by endovascular aneurysm repair (EVAR). Activation of the systemic inflammatory response (SIR) appears to offer prognostic value in patients with vascular disease. The present study examines the relationship between the SIR and survival in patients undergoing standard and complex endovascular aneurysm repair (EVAR and fenestrated/branched [F/B]-EVAR). METHODS Consecutive patients undergoing elective EVAR and F/B-EVAR were retrospectively identified from three tertiary vascular centers over a 5-year period. Neutrophil:lymphocyte ratio and modified Glasgow Prognostic Score were calculated from preoperative blood results and combined into the systemic inflammatory grade (SIG). The primary outcome was all-cause mortality during the follow-up period, which was compared between subgroups of SIGs. RESULTS There were 506 patients included in the final study, with a median follow-up of 68.0 months (interquartile range, 27.3 months), and there were 163 deaths during the follow-up period. Mean survival in the SIG 0 vs SIG 1 vs SIG 2 vs SIG 3 vs SIG 4 subgroups was 80.7 months (95% confidence interval [CI], 76.5-85.0 months) vs 78.7 months (95% CI, 72.7-84.7 months) vs 61.0 months (95% CI, 51.1-70.8 months) vs 65.1 months (95% CI, 45.0-85.2 months) vs 54.9 months (95% CI, 34.4-75.3 months) (P < .05). In the entire cohort, age (P < .001), body mass index (P < .05), high creatinine (P < .05), and SIG (P < .05) were associated with survival on univariate analysis, with retained independent association for age (hazard ratio, 1.72; 95% CI, 1.29-2.31; P < .001) and SIG (hazard ratio, 1.20; 95% CI, 1.02-1.40; P < .05) on multivariate analysis. Increasing SIG (area under the curve, 0.68; 95% CI, 0.58-0.78; P < .01) predicted 1-year mortality. CONCLUSIONS Markers of the SIR such the SIG may be used to identify patients at higher risk of adverse outcome in patients undergoing EVAR and F/B-EVAR for abdominal aortic aneurysms. These findings warrant further investigation in large prospective cohort studies.
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Affiliation(s)
- Nicholas A Bradley
- Academic Unit of Surgery, University of Glasgow, Glasgow, United Kingdom.
| | - Amy Walter
- Department of Vascular Surgery, NHS Tayside, Dundee, United Kingdom
| | - Alasdair Wilson
- Department of Vascular Surgery, NHS Grampian, Aberdeen, United Kingdom
| | - Tamim Siddiqui
- Department of Vascular Surgery, NHS Lanarkshire, Glasgow, United Kingdom
| | | | - Donald C McMillan
- Academic Unit of Surgery, University of Glasgow, Glasgow, United Kingdom
| | - Graeme J K Guthrie
- Academic Unit of Surgery, University of Glasgow, Glasgow, United Kingdom; Department of Vascular Surgery, NHS Tayside, Dundee, United Kingdom
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14
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Özdemir-van Brunschot DMD, Holzhey D, Botsios S. Sex-Related Differences in Proximal Neck Anatomy and Their Consequences in Patients after EVAR: A Matched Cohort Analysis. J Clin Med 2023; 12:4929. [PMID: 37568333 PMCID: PMC10419678 DOI: 10.3390/jcm12154929] [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: 06/18/2023] [Revised: 07/10/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
INTRODUCTION Studies comparing male and female patients with abdominal aortic aneurysms have shown that female patients are generally older and more often experience postoperative complications after endovascular and open repair. There are also indications that female patients have more extensive neck pathologies and that they more often have postoperative complications related to proximal neck pathology. MATERIAL AND METHODS This retrospective study describes all consecutive female patients who underwent EVAR between 1 January 2012 and 31 December 2021. Propensity-score matching was used to obtain a matched control male cohort. Propensity scores were generated with the following anatomic parameters: infrarenal and suprarenal angulation, proximal and distal neck diameter and neck length. 1 Female patient was matched with 3 male patients. RESULTS A total of 160 patients were included, namely 120 male patients and 40 female patients. Due to matching, there were no significant differences regarding infrarenal and suprarenal angulation and proximal and distal neck diameter and length. All-cause and aneurysm-related mortality were comparable (p = 0.19 and p = 0.98). The necessity of neck-related secondary procedures was significantly higher in female patients (p = 0.02). In the multivariate analysis, the female sex was a significant predictor of endoleak type IA within 30 days. However, there was no significant association between intraoperative endoleak type IA and endoleak type IA at the end of follow-up. CONCLUSIONS This study suggests that there was a higher initial incidence of endoleak type IA in female patients, despite thematched preoperative anatomic parameter. Due to the relatively low number of included female patients, conclusions should be drawn carefully.
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Affiliation(s)
- Denise Michelle Danielle Özdemir-van Brunschot
- German Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group, 40472 Düsseldorf, Germany
| | - David Holzhey
- German Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
| | - Spiridon Botsios
- German Faculty of Health, Witten/Herdecke University, 58455 Witten, Germany
- Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital and Catholic Hospital Group, 40472 Düsseldorf, Germany
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15
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Filiberto AC, Leroy V, Ladd Z, Su G, Elder CT, Pruitt EY, Lu G, Hartman J, Zarrinpar A, Garrett TJ, Sharma AK, Upchurch GR. Sex differences in specialized pro-resolving lipid mediators and their receptors in abdominal aortic aneurysms. JVS Vasc Sci 2023; 4:100107. [PMID: 37292185 PMCID: PMC10245328 DOI: 10.1016/j.jvssci.2023.100107] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/08/2023] [Indexed: 06/10/2023] Open
Abstract
Objective In this study, we tested the hypothesis that endogenous expression of specialized pro-resolving lipid mediators (SPMs) that facilitate the resolution of inflammation, specifically Resolvin D1and -D2, as well as Maresin1 (MaR1), can impact abdominal aortic aneurysm (AAA) formation and progression in a sex-specific manner. Methods SPM expression was quantified in aortic tissue from human AAA samples and from a murine in vivo AAA model via liquid chromatography-tandem mass spectrometry. mRNA expression for SPM receptors FPR2, LGR6, and GPR18 were quantified by real-time polymerase chain reaction. A Student t test with nonparametric Mann-Whitney or Wilcoxon test was used for pair-wise comparisons of groups. One-way analysis of variance after post hoc Tukey test was used to determine the differences among multiple comparative groups. Results Human aortic tissue analysis revealed a significant decrease in RvD1 levels in male AAAs compared with controls, whereas FPR2 and LGR6 receptor expressions were downregulated in male AAAs compared with male controls. In vivo studies of elastase-treated mice showed higher levels of RvD2 and MaR1 as well as the SPM precursors, omega-3 fatty acids DHA and EPA, in aortic tissue from males compared with females. FPR2 expression was increased in elastase-treated females compared with males. Conclusions Our findings demonstrate that specific differences in SPMs and their associated G-protein coupled receptors exist between sexes. These results indicate the relevance of SPM-mediated signaling pathways in sex differences impacting the pathogenesis of AAAs.
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Affiliation(s)
| | - Victoria Leroy
- Department of Surgery, University of Florida, Gainesville, FL
| | - Zachary Ladd
- Department of Surgery, University of Florida, Gainesville, FL
| | - Gang Su
- Department of Surgery, University of Florida, Gainesville, FL
| | - Craig T. Elder
- Department of Surgery, University of Florida, Gainesville, FL
| | - Eric Y. Pruitt
- Department of Surgery, University of Florida, Gainesville, FL
| | - Guanyi Lu
- Department of Surgery, University of Florida, Gainesville, FL
| | - Joseph Hartman
- Department of Surgery, University of Florida, Gainesville, FL
| | - Ali Zarrinpar
- Department of Surgery, University of Florida, Gainesville, FL
| | - Timothy J. Garrett
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL
| | - Ashish K. Sharma
- Department of Surgery, University of Florida, Gainesville, FL
- Aortic Disease Center, University of Florida, Gainesville, FL
| | - Gilbert R. Upchurch
- Department of Surgery, University of Florida, Gainesville, FL
- Aortic Disease Center, University of Florida, Gainesville, FL
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16
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DeJong M, Peterson L, Zielke T, Simone A, Penton A, Blecha M. Investigation of Renal Decline and New Onset Dialysis Following Endovascular Aneurysm Repair in the Vascular Quality Initiative. Vasc Endovascular Surg 2023; 57:203-214. [PMID: 36906859 DOI: 10.1177/15385744221141229] [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] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The purpose of this study is to identify variables significantly associated with renal function decline after elective endovascular infra-renal abdominal aortic aneurysm repair and to identify the rate and risks of subsequent progression to dialysis. Specifically, we investigate the long-term impact of supra-renal fixation, female gender, and physiologically stressful perioperative events on renal function following endovascular aneurysm repair (EVAR). METHODS Review of all EVAR cases in the Vascular Quality Initiative between 2003 and 2021 was conducted to investigate variable associations with three primary outcomes: postoperative acute renal insufficiency (ARI); greater than 30% decline in glomerular filtration rate (GFR) in patients beyond 1 year of follow up; and new onset dialysis requirement at any point in follow up. Binary logistic regression analysis was performed for the events of acute renal insufficiency and new onset dialysis requirement. Cox proportional hazard regression was performed regarding long term GFR decline. RESULTS Postoperative ARI occurred in 3.4% (1692/49 772) of patients. Significant (P < .05) association with postoperative ARI was noted for: age (OR 1.014/year, 95% CI 1.008-1.021); female gender (OR 1.44, 95% CI 1.27-1.67); hypertension (OR 1.22, 95% CI 1.04-1.44); chronic obstructive pulmonary disease (OR 1.34, 95% CI 1.20-1.50); anemia (OR 4.24, 95% CI 3.71-4.84); reoperation at index admission (OR 7.86, 95% CI 6.47-9.54); baseline renal insufficiency (OR 2.29, 95% CI 2.03-2.56); larger aneurysm diameter; increased blood loss; and higher volumes of intra-operative crystalloid. Risk factors (P < .05) correlating with a decline of 30% in GFR at any time beyond 1 year were: female gender (HR 1.43, 95% CI 1.24-1.65); body mass index (BMI) less than 20 (HR 1.34, 95% CI 1.03-1.74); hypertension (HR 1.38, 95% CI 1.15-1.64); diabetes (HR 1.34, 95% CI 1.17-1.53); COPD (HR 1.21, 95% CI 1.07-1.37); anemia (HR 1.92, 95% CI 1.52-2.42); baseline renal insufficiency (HR 1.31, 95% CI 1.15-1.49); absence of discharge ace-inhibitor (HR 1.27, 95% CI 1.13-1.42); long term re-intervention (HR 2.43, 95% CI 1.84-3.21) and larger AAA diameter. Patients who experienced long term GRF decline had a significantly higher long-term morality. New onset dialysis following EVAR occurred in .47% (234/49 772) of those meeting inclusion criteria. Higher rate (P < .05) of new onset dialysis was associated with age (OR 1.03/year, 95% CI 1.02-1.05); diabetes (OR 1.376, 95% CI 1.005-1.885); baseline renal insufficiency (OR 6.32, 95% CI4.59-8.72); Reoperation at index admission (OR 2.41, 95% CI 1.03-5.67); postoperative ARI (OR 23.29, 95% CI 16.99-31.91); absence of beta blocker (OR 1.67, 95% CI 1.12-2.49); long term graft encroachment on renal arteries (OR 4.91, 95% CI 1.49-16.14). CONCLUSIONS New onset dialysis following EVAR is a rare event. Perioperative variables influencing renal function following EVAR include blood loss, arterial injury, and reoperation. Supra-renal fixation is not associated with postoperative acute renal insufficiency or new onset dialysis in long term follow up. Renal protective measures are recommended for patients with baseline renal insufficiency undergoing EVAR as acute renal insufficiency following EVAR portends a 20-fold increased risk of new onset dialysis in long term follow up.
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Affiliation(s)
- Matthew DeJong
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Laelle Peterson
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Tara Zielke
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Avital Simone
- Stritch School of Medicine, 12248Loyola University Chicago, Maywood, IL, USA
| | - Ashley Penton
- Department of Surgery, 25815Loyola University Medical Center, Maywood, IL, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
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17
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Rastogi V, Romijn ASC, Yadavalli SD, Marcaccio CL, Jongkind V, Zettervall SL, Quiroga E, Saillant NN, Verhagen HJM, Schermerhorn ML. Males and females have similar mortality after thoracic endovascular aortic repair for blunt thoracic aortic injury. J Vasc Surg 2023; 77:997-1005. [PMID: 36565777 DOI: 10.1016/j.jvs.2022.12.026] [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: 10/29/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Prior literature has demonstrated worse outcomes for female patients after abdominal aortic aneurysm repair. Also, prior studies in the context of thoracic endovascular aneurysm repair (TEVAR) for thoracic aortic aneurysms have reported conflicting results regarding sex-related outcomes. Because the influence of sex on the outcomes after TEVAR for blunt thoracic aortic injuries (BTAIs) remains understudied, we evaluated the association between sex and outcomes after TEVAR for BTAI. METHODS We identified patients who had undergone TEVAR for BTAIs in the Vascular Quality Initiative registry from 2013 to 2022 and included those who had undergone TEVAR within zones 2 to 5 of the thoracic aorta. Patients with missing information regarding the aortic injury grade (Society for Vascular Surgery aortic injury grading system) were excluded. We performed multivariable logistic regression and Cox regression to determine the influence of sex on the perioperative outcomes and long-term mortality, respectively. RESULTS We identified 1311 patients, of whom 27% were female. The female patients were significantly older (female, 47 years [interquartile range (IQR), 30-63 years]; male, 38 years [IQR, 28-55 years]; P < .001) with higher rates of comorbidities. Although the female patients had had higher Glasgow coma scale scores (median, 15 [IQR, 11-15]; vs 14 [IQR, 8-15]; P = .028), no differences were found in the aortic injury grade or other coexisting traumatic injuries between the sexes. Apart from the longer procedure duration for the female patients (median, 79 minutes [IQR, 52-119 minutes]; vs 69 minutes [IQR, 48-106 minutes]; P = .008), the procedural characteristics were comparable. After adjustment, no significant association was found between female sex and perioperative mortality (7.1% vs 8.1%; odds ratio, 0.76; 95% confidence interval [CI], 0.43-1.3; P = .34). The male and female patients had had comparable rates of postoperative complications (26% vs 29%; odds ratio, 0.89; 95% CI: 0.52-1.5]; P = .26) including access-related complications (0.5% vs 0.8%; P=.83). However, females had a significantly higher risk for reintervention during the index admission (odds ratio, 2.5; 95% CI, 1.1-5.5; P = .024). No significant difference was found between the male and female patients with respect to 5-year mortality (hazard ratio, 0.87; 95% CI, 0.57-1.35; P = .50). CONCLUSIONS Unlike the sex-based outcome disparities observed after thoracic aortic aneurysm repair, we found no significant association between sex and perioperative outcomes or long-term mortality after TEVAR for BTAIs. This contrast in the sex-related outcomes after other vascular pathologies might be explained by differences in the pathology, demographics, and anatomic factors in these patients.
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Affiliation(s)
- Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anne-Sophie C Romijn
- Division of Trauma and Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vincent Jongkind
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Noelle N Saillant
- Division of Trauma and Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hence J M Verhagen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Tan X, Jung G, Herrmann E, Derwich W, Grundmann R, Schmitz-Rixen T, Gray D. Sex difference in early mortality after abdominal aortic aneurysm repair. J Vasc Surg 2023; 77:1658-1668.e2. [PMID: 36773666 DOI: 10.1016/j.jvs.2023.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVE Although female patients have a lower prevalence of abdominal aortic aneurysm (AAA), they seem to have a worse treatment outcome compared with male patients. Both maximum aneurysm diameter and aortic size index (ASI) are important indicators of the risk of AAA rupture, among which ASI has been shown capable of equalizing sex-related anatomical differences. Our study aimed to investigate whether sex is an independent risk factor for early postoperative mortality and how the diameter or ASI affects the association between sex and mortality. METHODS We performed a retrospective analysis of patients who enrolled in the AAA registry of the German Society of Vascular Surgery from 2013 to 2019. The patients were treated by either open surgical repair (OSR) or endovascular aneurysm repair (EVAR). The association between sex and 30-day mortality was investigated using logistic regression analysis. The interaction and mediating effects of maximum aneurysm diameter and ASI were investigated to verify their roles in the effect of sex on mortality. The relationships between the diameter (or ASI) and the risk of 30-day mortality in different sexes were demonstrated by the restricted cubic spline. RESULTS Overall, 23,275 cases were included in our analysis, with 20,130 male (86.5%) and 3139 female (13.5%) patients. Female patients had a smaller maximum aneurysm diameter (OSR, 55.23 ± 10.29 mm vs 58.05 ± 11.28 mm [P < .001]; EVAR, 54.06 ± 9.08 mm vs 56.11 ± 9.38 mm [P < .001]), but a higher ASI (OSR, 3.16 ± 0.71 vs 2.92 ± 0.69 [P < .001]; EVAR, 3.05 ± 0.66 vs 2.80 ± 0.59 [P < .001]) compared with male patients. The 30-day mortality rate was higher for female patients in both OSR (6.6% vs 4.2%; P = .002) and EVAR groups (1.8% vs 0.8%; P < .001). Logistic regression confirmed a significantly higher risk of 30-day mortality for female patients compared with male patients (odds ratio, 1.55; 95% confidence interval, 1.21-1.99; P = .001). No interaction was found between sex and diameter or ASI, but there were mediating effects for diameter and ASI in the effect of sex on 30-day mortality. For female patients, the risk of 30-day mortality linearly increased with the increase of diameter (PNonlinear = .089) or ASI (PNonlinear = .888), whereas the risk for male patients was U-shaped (for diameter, PNonlinear < .001; for ASI, PNonlinear = .020). CONCLUSIONS Sex is an independent risk factor for 30-day mortality after AAA repair. Both diameter and ASI are mediating factors for the effect of sex on 30-day mortality. The relationship between diameter or ASI and the risk of 30-day mortality is different for male and female patients.
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Affiliation(s)
- Xinji Tan
- Department of Vascular and Endovascular Surgery, University Hospital of Goethe University Frankfurt, Frankfurt, Germany
| | - Georg Jung
- Department of Vascular Surgery, Luzern, Switzerland
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Frankfurt, Germany
| | - Wojciech Derwich
- Department of Vascular and Endovascular Surgery, University Hospital of Goethe University Frankfurt, Frankfurt, Germany
| | - Reinhart Grundmann
- Department of Vascular Medicine, University Heart Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Schmitz-Rixen
- Department of Vascular and Endovascular Surgery, University Hospital of Goethe University Frankfurt, Frankfurt, Germany
| | - Daphne Gray
- Department of Vascular and Endovascular Surgery, University Hospital of Goethe University Frankfurt, Frankfurt, Germany.
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Forbes SM, Mahmood DN, Rocha R, Tan KT, Ouzounian M, Chung JCY, Lindsay TF. Females experience elevated early morbidity and mortality but similar mid-term survival compared to males after branched/fenestrated endovascular aortic aneurysm repair. J Vasc Surg 2022; 77:1349-1358.e5. [PMID: 36581014 DOI: 10.1016/j.jvs.2022.12.031] [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: 08/19/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The objective of this study was to identify sex-related differences in outcomes following branched and/or fenestrated endovascular aortic repair (B/FEVAR) for thoracoabdominal (TAAA) and juxtarenal (JRAA) aortic aneurysms. METHODS Chart review completed on 242 B/FEVAR patients (57 female; 23.5%) between 2007 and 2020 at a single center. Median follow-up time was 3.3 years (interquartile range [IQR], 1.6-5.3 years). RESULTS No statistically significant differences in age (females, 75.9 ± 5.4 years vs males, 74.7 ± 7.2 years; P = .162) or aneurysm size (64.9 ± 6.8 vs 65.8 ± 9.4 mm; P = .41) at presentation were observed between sexes. Females presented with fewer JRAAs (45.6% vs 73%; P < .001) and received more Crawford extent II (26.3% vs 10.8%; P =.004) TAAA coverage. Increased incidence of moderate/severe target vessel stenosis (29.8% vs 14%; P = .022) was observed in female patients. Intraoperatively, females had higher procedure times (530 [IQR, 425-625] vs 420 [IQR, 350-510] minutes; P < .001), fluoroscopy times (124.1 ± 49 vs 107.3 ± 43.5 minutes; P = .017), and contrast usage (200 [IQR, 150-270] vs 175 [IQR, 130-225] mL; P = .005). Unplanned intraoperative maneuvers (45.6% vs 28.1%; P = .043), graft delivery issues (24.6% vs 4.9%; P < .001), and additional intraoperative complications (61.4% vs 35.7%; P < .001) were also increased in females. Postoperatively, females had a longer intensive care unit (3 [IQR, 1-5] vs 1 [IQR, 1-3] days; P = .002) and hospital stay (8 [IQR, 5-13] vs 5 [IQR, 3-9] days; P < .001) and experienced increased rates of spinal cord ischemia (15.8% vs 3.8%; P = .001) and bowel ischemia (10.5% vs 2.7%; P = .013). In-hospital mortality (12.3% vs 2.7%; P = .004) was higher in female patients but mid-term (6-year) survival was 60.2% for all patients (95% confidence interval, 53.0%-68.5%) and was similar between sexes (hazard ratio, 0.95; P = .83), which were the primary endpoints. No sex differences in mid-term follow-up reintervention, endoleak, and rupture rates were observed. CONCLUSIONS Females experienced significantly higher B/FEVAR intraoperative times, complications, and in-hospital morbidity and mortality compared with males but similar mid-term outcomes. Anatomic and atherosclerotic differences may have contributed to the observed in-hospital differences.
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Affiliation(s)
- Samantha M Forbes
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniyal N Mahmood
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kongteng Tan Tan
- Division of Interventional Radiology, Toronto General Hospital, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C-Y Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas F Lindsay
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Isernia G, Simonte G, Gallitto E, Bertoglio L, Fargion A, Melissano G, Chiesa R, Lenti M, Pratesi C, Faggioli G, Gargiulo M. Sex Influence on Fenestrated and Branched Endovascular Aortic Aneurysm Repair: Outcomes From a National Multicenter Registry. J Endovasc Ther 2022:15266028221137498. [DOI: 10.1177/15266028221137498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction: Women are generally underrepresented in trials focusing on aortic aneurysm. Nevertheless, sex-related differences have recently emerged from several studies and registries. The aim of this research was to assess whether sex-related anatomical disparities existed in fenestrated and branched aortic repair candidates and whether these discrepancies could influence endovascular repair outcomes. Methods: Data from all consecutive patients treated during the 2008–2019 period within the Italian Multicenter fenestrated or branched endovascular aortic repair (F/BEVAR) Registry were included in the present study. Propensity matching was performed using a logistic regression model adjusted for demographic data and comorbidities to obtain comparable male and female samples. The selection model led to a final study population of 176 patients (88 women and 88 men) among the total initial cohort of 596. Study endpoints were technical and clinical success, overall survival, aneurysm-related death, and reintervention rates evaluated at 30 days and during follow-up. Results: Twenty-eight patients (15.9%) received urgent/emergent repair. In most of the cases (71.6%), women received treatment for extensive thoracoabdominal pathology (Crawford type I, II, or III aneurysm rather than type IV or juxta-pararenal) versus 46.6% of men (p=0.001). Female patients presented with more challenging iliac accesses with at least one side considered hostile in 27.3% of the cases (vs 13.6% in male patients, p=0.039). Finally, women had significantly smaller visceral vessels. Women had significantly worse operative outcomes, with an 86.2% technical success rate versus 96.6% in the male population (p=0.016). No differences were recorded in terms of 30-day reinterventions between men and women. The 5-year estimate of freedom from late reintervention, according to Kaplan-Meier analysis, was 85.6% in men versus 81.6% in women (p=ns). No aneurysm-related death was recorded during follow-up (median observational time, 23 months [interquartile range, 7–45 months]). Conclusion: Women presented a significantly higher incidence of thoracoabdominal aneurysms, smaller visceral vessels, and more complex iliofemoral accesses, resulting in a significantly lower technical success after F/BEVAR. Further studies assessing sex-related differences are needed to properly determine the impact on outcomes and stratify procedural risks. Clinical Impact Women are generally underrepresented in trials focusing on aortic aneurysms. Aiming to assess whether sex may affect outcomes after a complex endovascular aortic repair, a propensity score selection was applied to a total population of 596 patients receiving F/BEVAR aortic repair with the Cook platform, matching each treated female patient with a corresponding male patient. Women presented more frequently a thoracoabdominal aneurysm extent, smaller visceral vessels, and complex iliofemoral accesses, resulting in significantly worse operative outcomes, with an 86.2% technical success versus 96.6% (p=0.016). No differences were recorded in terms of short-term and mid-term reinterventions. According to these results, careful and critical assessment should be posed in case of female patients receiving complex aortic repair, especially regarding preoperative anatomical evaluation and clinical selection with appropriate surgical risk stratification.
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Affiliation(s)
- Giacomo Isernia
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Gioele Simonte
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Enrico Gallitto
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant’Orsola-Malpighi Hospital, Bologna, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Aaron Fargion
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Germano Melissano
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Lenti
- Unit of Vascular and Endovascular Surgery, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Carlo Pratesi
- Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Careggi University Teaching Hospital, University of Florence, Florence, Italy
| | - Gianluca Faggioli
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant’Orsola-Malpighi Hospital, Bologna, Italy
| | - Mauro Gargiulo
- Vascular Surgery, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant’Orsola-Malpighi Hospital, Bologna, Italy
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Marcaccio CL, O'Donnell TFX, Dansey KD, Patel PB, Hughes K, Lo RC, Zettervall SL, Schermerhorn ML. Disparities in reporting and representation by sex, race, and ethnicity in endovascular aortic device trials. J Vasc Surg 2022; 76:1244-1252.e2. [PMID: 35623599 PMCID: PMC9613501 DOI: 10.1016/j.jvs.2022.05.003] [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: 03/04/2022] [Accepted: 05/15/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Vulnerable populations, including women and racial and ethnic minorities, have been historically underrepresented in clinical trials. We, therefore, studied the demographics of patients enrolled in pivotal endovascular aortic device trials in the United States. METHODS We queried the Food and Drug Administration (FDA) medical devices database for all FDA-approved endografts for the treatment of aortic aneurysms, transections, and dissections from September 1999 to November 2021. These included abdominal endovascular aortic repair (EVAR), thoracic EVAR (TEVAR), fenestrated EVAR (FEVAR) devices, and dissection stents. Multiple cases of approval for expanded indications were included separately. The primary outcomes included the proportion of trials reporting participant sex, race, and ethnicity and the proportion of enrolled participants across sex, racial, and ethnic groups. RESULTS The FDA provided 29 approvals from 29 trials of 24 devices: 15 EVAR devices (52%), 12 TEVAR devices (41%), 1 FEVAR device (3.4%), and 1 dissection stent (3.4%). These trials had included 4046 patients. Of the 29 trials, all had reported on the sex of the participants, and the median female enrollment was 21% (interquartile range [IQR], 11%-34%). The EVAR trials had the lowest female enrollment (11%; IQR, 8.7%-13%) compared with 41% (IQR, 27%-45%) in the TEVAR trials, 21% in the FEVAR trial, and 34% in the dissection stent trial (P < .01 for the difference). Only 52% of the trials had reported the three most common racial groups (White, Black, Asian), and only 48% had reported Hispanic ethnicity. The TEVAR trials were the most likely to report all three racial groups and Hispanic ethnicity (92% and 75%, respectively), while the EVAR trials had the lowest reporting rates (13% and 20%, respectively). Where reported, the median enrollment of racial and ethnic groups across the trials was as follows: Black patients, 9.8% (FEVAR, 0%; EVAR, 1.9%; TEVAR, 12%; dissection stent, 25%; P = .01); Asian patients, 2.4% (EVAR, 0.6%; FEVAR, 2.4%; TEVAR, 2.5%; dissection stent, 11%; P = .24); and Hispanic patients, 3.8% (EVAR, 1.3%; FEVAR, 2.4%; TEVAR, 3.9%; dissection stent, 4.1%; P = .75). CONCLUSIONS Racial and ethnic minority groups were underrepresented and underreported in pivotal aortic device trials that led to FDA approval. Female patients were also underrepresented in these aortic trials, especially for EVAR. These data suggest the need for standardization of reporting practices and minimum thresholds for minority and female participation in pivotal trials to promote equitable representation.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kirsten D Dansey
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Priya B Patel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kakra Hughes
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Ruby C Lo
- Division of Vascular Surgery, Department of Surgery, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI
| | - Sara L Zettervall
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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22
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Harnarayan P, Budhooram S, Harnanan D, Ramdass MJ, Islam S, Naraynsingh V. Gender Influence on Abdominal Aortic Aneurysm Surgery in a Caribbean Population. Int J Angiol 2022; 32:26-33. [PMID: 36727148 PMCID: PMC9886443 DOI: 10.1055/s-0042-1750017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Female patients with abdominal aortic aneurysms (AAAs) are usually less common and older than their male counterparts. We report on AAA disease in a Caribbean nation with respect to gender and review their outcomes relative to the male population. Data were collected prospectively and analyzed retrospectively for patients with AAAs who underwent surgery from 2001 to 2018. Sixty patients were diagnosed with AAA with 44 going on to have surgical repair of which 35 were males, aged 61 to 89 (mean age 73.4 years). Nine women ages 44 to 74 years (mean age 60.8 years) had surgical intervention, three being between 40 and 49 years. The size of aneurysms in these patients ranged from 4.3 to 11.0 cm in diameter (average 6.95 cm), female patients having an average diameter of 6.7 cm. Of the 44 patients, 43 underwent open and one endovascular repair. Thirty-three were elective cases and 11 were ruptured with 32 aorto-aortic and 13 aorto-iliac repairs. There were nine fatalities, three elective and six ruptured, with only one being female. Women had similar outcomes to men in all age groups with young patients having good results. Female AAA patients are usually older, undergo less surgical procedures especially if endovascular, and have worse outcomes than their male counterparts. Our study showed that the females were younger but had similar outcomes to the male patients. The female Caribbean patients may present at much younger ages than in continental populations and this may be due to genetic, ethnic, or lifestyle factors.
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Affiliation(s)
- Patrick Harnarayan
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies,Address for correspondence Patrick Harnarayan, MBBS, FRCS, FACS Department of Clinical Surgical Sciences, University of the West IndiesSt. Augustine, Trinidad and TobagoWest Indies
| | - Steve Budhooram
- Department of Vascular Surgery, The Surgi-Med Clinic, San Fernando, Trinidad and Tobago, West Indies
| | - Dave Harnanan
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies
| | - Michael J. Ramdass
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies
| | - Shariful Islam
- Department of Surgery, San Fernando General and Teaching Hospitals, San Fernando, Trinidad and Tobago, West Indies
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies
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23
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Corsi T, Ciaramella MA, Palte NK, Carlson JP, Rahimi SA, Beckerman WE. Female Sex Is Associated With Reintervention and Mortality Following Elective Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg 2022; 76:1494-1501.e1. [PMID: 35705120 DOI: 10.1016/j.jvs.2022.05.011] [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: 02/25/2022] [Revised: 04/15/2022] [Accepted: 05/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE While sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes are increasingly reported, but contributing factors remain without consensus. We investigated disparities in sex-specific outcomes following elective EVAR at our institution and evaluated factors that may predispose females to increased morbidity and mortality. METHODS A retrospective chart review of all patients undergoing elective EVAR from 2011 to 2020 at a suburban tertiary care center was performed. The primary outcomes were five-year survival and freedom from reintervention. Fisher's exact test, t-tests, and Kaplan-Meier analysis using the rank-log test investigated associations between sex and outcomes. A multivariable Cox proportional hazard model controlling for age and common comorbidities evaluated the effect of sex on survival and freedom from reintervention. RESULTS Two hundred and seventy-three patients underwent elective EVAR during the study period, including 68 (25%) females and 205 (75%) males. Females were older on average than males (76 years vs. 73 years, p= <0.01) and were more likely to have chronic obstructive pulmonary disease (COPD; 38% versus 23%, p=0.01), require home oxygen therapy (9% versus 2%, p=0.04) or dialysis preoperatively (4% versus 0%, p=0.02). Distribution of other common vascular comorbidities was similar between the sexes. Thirty-day readmission was greater in females than males (18% versus 8%, p=0.02). Females had significantly lower survival at five years (48% ± 7.9% versus 65% ± 4.3%, p<0.01) and significantly lower one-year (89% ± 4.1% for females vs. 94% ± 1.7% for males, p=0.01) and five-year freedom from reintervention (69% ± 8.9% versus 84% ± 3.3%, p=0.02). On multivariable analysis, female sex (hazard ratio [HR]: 1.8, 95% confidence interval [CI]: 1.1-2.9), congestive heart failure (HR: 2.2, 95% CI: 1.2-3.9) and age (HR: 1.1, 95% CI: 1.0-1.1) were associated with 5-year mortality. Female sex remained as the only variable with a statistically significant association with five-year reintervention (HR: 2.4, 95% CI: 1.1-4.9). CONCLUSIONS Female sex was associated with decreased five-year survival and increased one and five-year reintervention following elective EVAR. Data from our institution suggests factors beyond patient age and baseline health risk likely contribute to greater surgical morbidity and mortality for females following elective EVAR.
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Affiliation(s)
- Taylor Corsi
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | | | - Nadia K Palte
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - John P Carlson
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - Saum A Rahimi
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - William E Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ.
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Gontarz B, Majeed R, Staff I, DeMartino R, Jain A, Aitcheson E, Shah P, Divinagracia T, Gallagher J, Healy L, Ayach M, Gifford E. Female sex is associated with worse outcomes following complex fenestrated or branched endovascular aortic repair. Ann Vasc Surg 2022; 87:113-123. [PMID: 35339593 DOI: 10.1016/j.avsg.2022.03.010] [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: 01/23/2022] [Revised: 03/09/2022] [Accepted: 03/11/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Sex-related discrepancies after standard endovascular aneurysm repair (EVAR) are noted to disproportionally affect females. A growing body of literature suggests similar disparities may extend to complex fenestrated or branched endovascular aneurysm repair (FBEVAR). However, recent examination of complex FBEVAR by a consortium of high-volume centers noted equivalent mortality among sexes. Whether similar results extend to non-trial data is unknown. METHODS We examined all juxta-renal through type IV thoraco-abdominal aneurysms (sealing zones 6-8) who underwent elective FBEVAR within the Vascular Quality Initiative (VQI) database from January 2012 to December 2020. Urgent, symptomatic, ruptured, and staged cases were excluded, as were parallel stent grafts. Demographics, comorbid conditions, and technical factors were compared between sexes. Univariate analysis with Wilcoxon ranked sum tests and Chi-square tests of proportion were performed, followed by multivariate logistic regression for failure of target vessel technical success, reintervention, complications, and in-hospital mortality. RESULTS Our analysis included 1521 patients, 1180 males (77.6%) and 341 females (22.4%). There were noted differences in pre-operative demographics, medical optimization, and technical aspects of the procedure. However, no difference was noted in proximal or distal sealing stents, number of fenestrations, or immediate endoleaks. On multi variate logistic regression, female sex was an independent predictor of failure of target vessel technical success (OR 3.339, 95% CI: 2.173-5.132, p<.001), reintervention (OR 2.192, 95% CI: 1.304-3.683, p=.003), complications (OR 1.747, 95% CI: 1.282-2.381, p<.001), and in-hospital mortality (OR 2.836, 95% CI: 1.510-5.328, p=.001). CONCLUSION Females suffer worse outcomes after FBEVAR despite similar extent of disease, number of fenestrations, and incidence of immediate endoleak. Notable discrepancies were higher rates of COPD and lower rates of pre-operative aspirin, statin, and beta blocker therapy in females. Controlling for pre-operative demographics, female sex remained an independent predictor of worse outcomes. These discrepancies warrant further examination and should impact case planning for female patients undergoing complex aortic aneurysm repair.
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Affiliation(s)
- Brendan Gontarz
- Department of Surgery, University of Connecticut Health Center, Farmington, CT
| | - Rashad Majeed
- Department of Surgery, University of Connecticut Health Center, Farmington, CT; Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Ilene Staff
- Department of Clinical Research, Hartford Hospital, Hartford, CT
| | | | - Akhilesh Jain
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - Parth Shah
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | | | - James Gallagher
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Laura Healy
- Department of Surgery, University of Connecticut Health Center, Farmington, CT; Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Mouhanad Ayach
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT
| | - Edward Gifford
- Division of Vascular Surgery, Hartford Hospital, Hartford, CT.
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25
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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26
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Levin SR, Farber A, Goodney PP, Schermerhorn ML, Eslami MH, Patel VI, Garg K, McGinigle KL, Siracuse JJ. The U.S. Preventive Services Task Force Abdominal Aortic Aneurysm Screening Guidelines Negligibly Impacted Repair Rates in Male Never-Smokers and Female Smokers. Ann Vasc Surg 2021; 82:87-95. [PMID: 34936889 DOI: 10.1016/j.avsg.2021.11.020] [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: 10/28/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE In 2014, in addition to male smokers aged 65-75, the U.S. Preventive Services Task Force (USPSTF) recommended abdominal aortic aneurysm (AAA) screening for male never-smokers aged 65-75 with cardiovascular risk factors (Grade C). The USPSTF evolved from a negative to neutral position on screening for female smokers aged 65-75 (Grade I). We sought to determine whether 2014 guidelines resulted in more AAA repairs in these populations. METHODS We queried the Vascular Quality Initiative national database (2013-2018) for elective endovascular aortic repairs and open aortic repairs. We implemented difference-in-differences (DID) analysis, a causal inference technique that adjusts for secular time trends, to isolate changes in repair numbers due to the 2014 USPSTF guidelines. Our DID models compared changes in repair numbers in patient groups targeted by the USPSTF updates (intervention group) to those in unaffected, older patient groups (control), before and after 2014. The first model compared changes in repair numbers between male never-smokers aged 65-75 (intervention group) and 76-85 (control). The second model compared repair numbers between female smokers aged 65-75 (intervention group) and 76-85 (control). RESULTS There was no significant change in male never-smokers (n=1,295) aged 65-75 (42%) vs. 76-85 (58%) undergoing AAA repairs after guideline updates, averaged over 4.5 years (+2.4 percentage points; 95% Confidence Interval [CI] -.56-5.26). However, when their primary insurer was Medicare, male never-smokers aged 65-75 compared with 76-85 underwent significantly more repairs over 4.5 years (+3.69 percentage points; 95% CI.16-7.22; representing a 10.4% relative increase from baseline in the proportion of male never-smokers on Medicare undergoing AAA repair). Comparing female smokers (n=2,312) aged 65-75 (54%) vs. 76-85 (46%), there was no significant change in repairs over 4.5 years (-.66 percentage points; 95% CI -4.57-3.26). CONCLUSIONS The USPSTF 2014 AAA guidelines were associated with modestly increased repairs in male never-smokers aged 65-75 only on Medicare. There was no impact among female smokers. Higher-grade recommendations and improved guideline adherence may be requisites for change.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | - Philip P Goodney
- Division of Vascular and Endovascular Surgery, Dartmouth-Hitchcock Medical Center, Hanover, NH
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Virendra I Patel
- Section of Vascular Surgery and Endovascular Interventions, NYP-Columbia University Irving Medical Center, New York, NY
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, NYU Langone Health, New York, NY
| | - Katharine L McGinigle
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
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Nana P, Dakis K, Brodis A, Spanos K, Kouvelos G, Eckstein HH, Giannoukas A. A systematic review and meta-analysis on early mortality after abdominal aortic aneurysm repair in females in urgent and elective setting. J Vasc Surg 2021; 75:1082-1088.e6. [PMID: 34740807 DOI: 10.1016/j.jvs.2021.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/24/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Females represent a group of patients with higher mortality after abdominal aortic aneurysm (AAA), endovascular (EVAR) or open (OSR), repair. This systematic review aimed to evaluate the 30-day mortality after AAA repair in females, comparing both EVAR and OSR, in elective and urgent settings. METHODS The protocol of the review was registered to the PROSPERO (CRD42021242686). A search of the English literature was conducted, using PubMed, EMBASE and CENTRAL databases, from inception to March 5, 2021, using the Systematic Reviews and Meta-Analysis guidelines (PRISMA). Only studies reporting on 30-day mortality of AAA repair, in urgent and elective setting, comparing EVAR and OSR, in female population were eligible. Patients were stratified according to the need for elective or urgent repair. Symptomatic and ruptured cases were included into the urgent group. Individual studies were assessed for risk of bias using the ROBINS-I tool. The GRADE approach was used to evaluate the quality of evidence. The primary outcome was 30-day mortality after AAA repair in the female population, comparing EVAR and OSR. The outcomes were summarized as odds ratio along with their 95% confidence intervals (CI), through a paired meta-analysis. RESULTS Eight studies reported data on 30-day mortality following AAA repair. A total of 56,982 females (22,995 EVAR vs. 33,987 OSR) were included. A significantly reduced total 30-day mortality rate was recorded among females that underwent EVAR compared to OSR (OR, 0.25; 95% CI, 0.23-0.27; P<.001, Ι2=86%). Also a reduced 30-day mortality was found in females that underwent elective EVAR compared to OSR (OR, 0.37; 95% CI, 0.33-0.41; P< .001, Ι2=48%). Despite that OSR was more frequently offered in the urgent setting (OR, 0.21; 95% CI, 0.19-0.23; P< .001, Ι2=84%), EVAR was associated with a reduced 30-day mortality (OR, 0.48; 95% CI, 0.40-0.57; P<.001, Ι2=0%). CONCLUSIONS In females, EVAR is associated with lower 30-day mortality in both elective and urgent AAA repair, although it appears as less likely to be offered in the setting of urgent AAA repair.
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Affiliation(s)
- Petroula Nana
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Konstantinos Dakis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Alexandros Brodis
- Department of Neurosurgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Technical University of Munich TUM, Germany
| | - Athanasios Giannoukas
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Blecha M, Malach L, Dickens B, Decicco E, D'Andrea M, DeJong M, Bechara CF. Predictors of Decline in Renal Function 5 Years after EVAR. Vasc Endovascular Surg 2021; 56:166-172. [PMID: 34694174 DOI: 10.1177/15385744211054283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION While there exists copious short-term data regarding renal function following infra-renal endovascular abdominal aortic aneurysm repair (EVAR), long-term analysis is sparse. This is a single institution retrospective review of predictors of renal function decline 5 years after elective EVAR. METHODS All EVAR between 2007 and 2015 were queried. Patients in whom renal function was documented 5 years postoperatively were included in analysis. Exclusion criteria were ruptured aneurysm, mortality before 56 months, lack of follow-up, ESRD status, and concomitant renal intervention. The primary outcome investigated was a 20% or greater drop in glomerular filtration rate (GFR) 5 years postoperatively. The following variables at the time of surgery were investigated as potential predictors: age, gender, hypertension, hyperlipidemia, diabetes, CAD or prior MI, COPD, prior stroke, baseline eGFR under 60 mL/min/1.73 m2, supra-renal fixation, infra-renal fixation, neck diameter, neck length, and number of contrast CT. RESULTS 354 EVAR were identified of which 143 met inclusion criteria (211 excluded). Univariate analysis revealed female gender (OR 2.7), hypertension (OR 9.4), baseline renal insufficiency (OR 3.8), larger neck diameter, and supra-renal fixation (OR 2.32) all predictive (P < .05) of GFR drop at 5 years. Multivariate binary logistic regression analysis found female gender (multivariate OR 3.9, P = .023) and baseline renal insufficiency (multivariate OR 3.0, P = .029) as significant predictors of greater than 20% GFR drop at 5 years. Only 2 patients of the 143 progressed to dialysis requirement at 5 years. CONCLUSIONS Females and patients with baseline renal insufficiency are more vulnerable to significant decline in renal function 5 years following EVAR. Consistent with analogous literature, supra-renal fixation appears moderately deleterious toward renal function with no clinical significance in those with baseline normal renal function. The potential benefit of avoidance of supra-renal fixation in female patients with baseline renal insufficiency is worth further investigation in a more robust multi-center study.
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Affiliation(s)
- Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
| | - Lillian Malach
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Brooke Dickens
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Emily Decicco
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Melissa D'Andrea
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Matthew DeJong
- 12248Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Carlos F Bechara
- Division of Vascular Surgery and Endovascular Therapy, 23356Loyola University Health System, Maywood, IL, USA
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How Does Female Sex Affect Complex Endovascular Aortic Repair? A Single Centre Cohort Study. Eur J Vasc Endovasc Surg 2021; 62:849-856. [PMID: 34686454 DOI: 10.1016/j.ejvs.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 08/03/2021] [Accepted: 08/26/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE There is growing evidence of a female patient disadvantage in complex endovascular aortic repair using fenestrated and branched endografts (FB-EVAR) primarily related to peri-procedural events including ischaemic and access vessel complications. This study aimed to determine the impact of sex differences on treatment patterns, and in hospital outcomes in a single centre cohort. METHODS This was a retrospective cross sectional single centre cohort study of all consecutive FB-EVAR procedures provided to patients with asymptomatic pararenal and thoraco-abdominal aortic aneurysm (TAAA) between 1 January 2010 and 28 February 2021. Adjusted multivariable logistic regression models were developed using backward (Wald) elimination of variables to determine the independent impact of female sex on short term outcomes. RESULTS In total, 445 patients (24.3% females, median age 73.0 years, IQR 66, 78) were included. Female patients had a smaller aneurysm diameter, less frequent coronary artery disease (29.6% vs. 44.8%, p = .007) and history of myocardial infarction (2.8% vs. 15.4%, p < .001) when compared with males. Females were more frequently treated for TAAA than males (49.1% vs. 25.2%, p < .001). The median length of post-procedural hospital stay was 10 days in females and 9 in males. In adjusted analyses, female sex was independently associated with higher mortality (odds ratio [OR] 10.135, 95% CI 2.264 - 45.369), post-procedural complications (OR 2.500, 95% CI 1.329 - 4.702), spinal cord ischaemia (OR 4.488, 95% CI 1.610 - 12.509), sepsis (OR 4.940, 95% CI 1.379 - 17.702), and acute respiratory insufficiency (OR 3.283, 95% CI 1.015 - 10.622) after pararenal aortic aneurysm repair during the hospital stay. CONCLUSION In this analysis of consecutively treated patients, female sex was associated with increased in hospital mortality, peri-procedural complications, and spinal cord ischaemia after elective complex endovascular repair of pararenal aortic aneurysm, while no differences were revealed in the TAAA subgroup. These results suggest that sex related patient selection and peri-procedural management should be studied in future research.
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Patel PB, De Guerre LEVM, Marcaccio CL, Dansey KD, Li C, Lo R, Patel VI, Schermerhorn ML. Sex-specific criteria for repair should be utilized in patients undergoing aortic aneurysm repair. J Vasc Surg 2021; 75:515-525. [PMID: 34506899 DOI: 10.1016/j.jvs.2021.08.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 08/09/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Female patients are more likely to undergo repair of intact and ruptured abdominal aortic aneurysm (AAA) at smaller aortic diameter compared with male patients. By adjusting for inherent anatomic differences between sexes, aortic size index (ASI) and aortic height index (AHI) may provide an additional method for guiding treatment. We therefore analyzed sex-specific criteria for AAA repair using aortic diameter, ASI, and AHI. METHODS We identified all patients who underwent AAA repair between 2003 and 2019 in the Vascular Quality Initiative database. The Dubois and Dubois formula was used to calculate body surface area; aortic diameter was divided by body surface area to calculate ASI. Aortic diameter was divided by height to calculate AHI. Cumulative distribution curves were used to plot the proportion of patients who underwent repair of ruptured aneurysm according to aortic diameter, ASI, and AHI. Multivariable logistic regression modeling was used to identify the association of female sex with perioperative mortality and any major postoperative complication. RESULTS We identified 55,647 patients, of whom 12,664 were female (20%). For both intact and rupture repair, female patients were older, less likely to undergo endovascular aneurysm repair, and more likely to have comorbid conditions. Female patients underwent repair at smaller median aortic diameter compared with male patients for intact (5.4 vs 5.5 cm; P < .001) and rupture repair (6.7 vs 7.7 cm; P < .001). However, ASI was higher in female patients for both intact (3.1 vs 2.7 cm/m2; P < .001) and rupture repair (3.8 vs 3.7 cm/m2; P < .001), whereas AHI was higher in female patients for intact repair (3.3 vs 3.1 cm/m; P < .001) but lower for rupture repair (4.1 vs 4.3 cm/m; P < .001). When analyzing the cumulative distribution of rupture repair in male patients, 12% of rupture repairs were performed at an aortic diameter below 5.5 cm. To achieve the same proportion of rupture repair in female patients, the repair diameter was only 4.9 cm. However, when ASI and AHI were used, female and male patients both reached 12% of rupture repair at an ASI of 2.7 cm/m2 and an AHI of 3.0 cm/m. CONCLUSION Our study provides data to strongly support the sex-specific 5.0-cm aortic diameter threshold suggested for repair in female patients by the Society for Vascular Surgery. The high percentage of patients undergoing rupture repair below 5.5 cm in male patients and 5.0 cm in female patients highlights the need to better identify patients at risk of rupture at smaller aortic diameters.
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Affiliation(s)
- Priya B Patel
- The Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Livia E V M De Guerre
- The Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; The Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Christina L Marcaccio
- The Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Kirsten D Dansey
- The Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Chun Li
- The Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Ruby Lo
- Department of Vascular and Endovascular Surgery, Rhode Island Hospital, Brown University, Providence, RI
| | - Virendra I Patel
- Division of Vascular Surgery and Endovascular Interventions, New York Presbyterian/Columbia University Medical Center, New York, NY
| | - Marc L Schermerhorn
- The Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Tumer NB, Askin G, Akkaya BB, Civelek I, Unal EU, Iscan HZ. Outcomes after EVAR in females are similar to males. BMC Cardiovasc Disord 2021; 21:301. [PMID: 34130661 PMCID: PMC8207773 DOI: 10.1186/s12872-021-02114-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/07/2021] [Indexed: 01/15/2023] Open
Abstract
Introduction Women are less likely to develop infrarenal abdominal aortic aneurysm; however, when they do, it is almost always associated with challenging anatomy, more rapid aneurysmal growth rate and earlier rupture. Women generally have poorer outcomes following open aneurysm repair; and in this respect, the present study aims to evaluate if it is so after endovascular repair.
Methods A retrospective analysis of our database was performed for patients underwent endovascular aneurysm repair (EVAR) between January 2013–March 2020. 249 elective EVAR patients were evaluated. Patients were categorized according to gender and 26 patients (10.4%) were female. Demographics and pre-peri-postoperative findings were compared. Propensity score matching (ratio 1:1) was performed to reduce selection bias.
Results In the overall unmatched cohort, female population had more diabetes mellitus (p = 0.016) and hypertension (p = 0.005). However, coronary artery disease (p = 0.005) and coronary artery bypass grafting (p = 0.006) were more in male gender. Non-IFU implantation was higher in female group (38.5% vs. 11.5%, p = 0.025). After propensity matching, even though it was not statistically significant, early mortality for female gender was higher when compared to male gender (7.7% and 0%, respectively, p = 0.490). In the follow-up period, no difference in all-cause mortality, secondary interventions or complications have been observed between the genders. Conclusion Challenging anatomy and subsequently treated patients outside IFU may be the reasons for higher morbidity and mortality in women. However, despite these factors female and male patients revealed equivalent early and late results.
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Affiliation(s)
- Naim Boran Tumer
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey.
| | - Goktan Askin
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | | | - Isa Civelek
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ertekin Utku Unal
- Department of Cardiovascular Surgery, Hitit University Erol Olcok Training and Research Hospital, Çorum, Turkey
| | - Hakki Zafer Iscan
- Department of Cardiovascular Surgery, Ankara City Hospital, Ankara, Turkey
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Barry IP, Turley LP, Thomas AR, Mwipatayi MT, Mwipatayi BP. The Impact of Endograft Selection on Mid-Term Outcomes in Female Patients Following Endovascular Aortic Aneurysm Repair (EVAR) for Abdominal Aortic Aneurysm (AAA). Cureus 2021; 13:e14584. [PMID: 33889469 PMCID: PMC8057124 DOI: 10.7759/cureus.14584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Abdominal aortic aneurysms (AAA) are far more common in male than female gender, although they appear to have a more aggressive pathophysiology in females. Given the lower incidence of AAA in females, it has been difficult to assess the impact of graft selection for endovascular aortic aneurysm repair (EVAR) in this cohort. Purpose To identify whether graft selection influences outcomes following AAA endoluminal repair in female patients. Methodology A retrospective analysis of published data for 711 female patients was conducted, collating data from three cohorts - Endurant Stent Graft Natural Selection Global post-market registry (ENGAGE), Global Registry for Endovascular Aortic Treatment (GREAT) and U.S. Zenith multicenter trial in combination with the Zenith female registry. Patients were recruited into the ENGAGE registry between 2009 and 2011, the GREAT registry between August 2010 and October 2016, and into the Zenith registry between 2000 and 2003. Patients from ENGAGE received the Medtronic Endurant stent graft for infrarenal AAA repair, patients analysed in GREAT received the Gore Excluder stent graft and the Zenith group received the Cook Zenith stent graft. Analyses were performed to evaluate all-cause mortality, aorta-related mortality, endoleak occurrence and surgical reintervention rates between the three cohorts. Results Of the 711 females, 133 were from ENGAGE (mean age 76 years), 538 were from GREAT (mean age 75 years) and 40 were from Zenith (mean age 74 years). The rates of co-morbidities between the three groups were broadly similar except for atherosclerotic disease which was more commonly observed in those treated with the GORE Excluder. The rate of endoleaks was lower when the Excluder stent was utilised as compared to the other two stents (Excluder 6.7% vs. Zenith 12.5% vs. Endurant 35.3%) even considering the limited follow-up of the Zenith group to two years as compared to five years for both ENGAGE and GREAT. All-cause mortality was similar in all three groups across the period examined while aorta-related mortality was uncommon. Reintervention rate was 15% at two years following the utilisation of the Zenith aortic graft while the rate of intervention at five years was broadly similar between ENGAGE and GREAT. Conclusion The newer generation, lower profile aortic endografts appear to have provided a safe and successful tool in the management of AAA in female patients, despite more complex aortic anatomy with shorter infrarenal neck length and larger aortic neck angulation.
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Affiliation(s)
- Ian P Barry
- Vascular Surgery, Royal Perth Hospital, Perth, AUS
| | - Luke P Turley
- Surgery, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Angel R Thomas
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, AUS
| | | | - Bibombe P Mwipatayi
- Vascular Surgery, Royal Perth Hospital, Perth, AUS.,Surgery, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, AUS
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Edman NI, Schanzer A, Crawford A, Oderich GS, Farber MA, Schneider DB, Timaran CH, Beck AW, Eagleton M, Sweet MP. Sex-related outcomes after fenestrated-branched endovascular aneurysm repair for thoracoabdominal aortic aneurysms in the U.S. Fenestrated and Branched Aortic Research Consortium. J Vasc Surg 2021; 74:861-870. [PMID: 33775747 DOI: 10.1016/j.jvs.2021.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/28/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Fenestrated-branched endovascular aneurysm repair (FBEVAR) has expanded the treatment of patients with thoracoabdominal aortic aneurysms (TAAAs). Previous studies have demonstrated that women are less likely to be treated with standard infrarenal endovascular aneurysm repair because of anatomic ineligibility and experience greater mortality after both infrarenal and thoracic aortic aneurysm repair. The purpose of the present study was to describe the sex-related outcomes after FBEVAR for treatment of TAAAs. METHODS The data from 886 patients with extent I to IV TAAAs (excluding pararenal or juxtarenal aneurysms), enrolled in eight prospective, physician-sponsored, investigational device exemption studies from 2013 to 2019, were analyzed. All data were collected prospectively, audited and adjudicated by clinical events committees and/or data safety monitoring boards, and subject to Food and Drug Administration oversight. All the patients had been treated with Cook-manufactured patient-specific FBEVAR devices or the Cook t-Branch off-the-shelf device (Cook Medical, Brisbane, Australia). RESULTS Of the 886 patients who underwent FBEVAR, 288 (33%) were women. The women had more extensive aneurysms and a greater prevalence of diabetes (33% vs 26%; P = .043) but a lower prevalence of coronary artery disease (33% vs 52%; P < .0001) and previous infrarenal endovascular aneurysm repair (7.6% vs 16%; P < .001). The women had required a longer operative time from incision to surgery end (5.0 ± 1.8 hours vs 4.6 ± 1.7 hours; P < .001), experienced lower technical success (93% vs 98%; P = .002), and were less likely to be discharged to home (72% vs 83%; P = .009). Despite the smaller access vessels, the women did not have an increased incidence of access site complications. Also, the 30-day outcomes were broadly similar between the sexes. At 1 year, no differences were found between the women and men in freedom from type I or III endoleak (91.4% vs 92.0%; P = .64), freedom from reintervention (81.7% vs 85.3%; P = .10), target vessel instability (87.5% vs 89.2%; P = .31), and survival (89.6% vs 91.7%; P = .26). The women had a greater incidence of postoperative sac expansion (12% vs 6.5%; P = .006). Multivariable modeling adjusted for age, aneurysm extent, aneurysm size, urgent procedure, and renal function showed that patient sex was not an independent predictor of survival (hazard ratio, 0.83; 95% confidence interval, 0.50-1.37; P = .46). CONCLUSIONS Women undergoing FBEVAR demonstrated metrics of increased complexity and had a lower level of technical success, especially those with extensive aneurysms. Compared with the men, the women had similar 30-day mortality and 1-year outcomes, with the exception of an increased incidence of sac expansion. These data have demonstrated that FBEVAR is safe and effective for women and men but that further efforts to improve outcome parity are indicated.
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Affiliation(s)
- Natasha I Edman
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Wash; Medical Scientist Training Program, University of Washington, Seattle, Wash
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts, Worcester, Mass
| | - Allison Crawford
- Division of Vascular Surgery, University of Massachusetts, Worcester, Mass
| | - Gustavo S Oderich
- Advanced Endovascular Aortic Program, Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Tex
| | - Mark A Farber
- Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Darren B Schneider
- Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Carlos H Timaran
- Clinical Heart and Vascular Center, University of Texas Southwestern, Dallas, Tex
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Matthew P Sweet
- Division of Vascular Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Wash.
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Dansey KD, Varkevisser RRB, Swerdlow NJ, Li C, de Guerre LEVM, Liang P, Marcaccio C, O'Donnell TFX, Carroll BJ, Schermerhorn ML. Epidemiology of endovascular and open repair for abdominal aortic aneurysms in the United States from 2004 to 2015 and implications for screening. J Vasc Surg 2021; 74:414-424. [PMID: 33592293 DOI: 10.1016/j.jvs.2021.01.044] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Contemporary national trends in the repair of ruptured abdominal aortic aneurysms (AAAs) and intact AAAs are relatively unknown. Furthermore, screening is only covered by insurance for patients aged 65 to 75 years with a family history of AAAs and for men with a positive smoking history. It is unclear what proportion of patients who present with a ruptured AAA would have been candidates for screening. METHODS Using the National Inpatient Sample from 2004 to 2015, we identified ruptured and intact AAA admissions and repairs using the International Classification of Diseases codes. We generated the screening-eligible cohort using previously identified proportions of male smokers (87%) and all patients with a family history of AAAs (10%) and applied these proportions to patients aged 65 to 75 years. We accounted for those who could have had a previous AAA diagnosis (17%), either from screening or an incidental detection in patients aged >75 years who had presented with AAA rupture. The primary outcomes were treatment and in-hospital mortality between patients meeting the criteria for screening vs those who did not. RESULTS We evaluated 65,125 admissions for ruptured AAAs and 461,191 repairs for intact AAAs. Overall, an estimated 45,037 admitted patients (68%) and 25,777 patients who had undergone repair for ruptured AAAs (59%) did not meet the criteria for screening. Of the patients who did not qualify, 27,653 (63%) were aged >75 years, 10,603 (24%) were aged <65 years, and 16,103 (36%) were women. Endovascular AAA repair (EVAR) increased for ruptured AAAs from 10% in 2004 to 55% in 2015 (P < .001), with operative mortality of 35%. EVAR increased for intact AAAs from 45% in 2004 to 83% in 2015 (P < .001), with operative mortality of 2.0%. CONCLUSIONS Most patients who had undergone repair for ruptured AAAs did not qualify for screening. EVAR was the primary treatment of both ruptured and intact AAAs with relatively low in-hospital mortality. Therefore, expansion of the screening criteria to include selected women and a wider age range should be considered.
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Affiliation(s)
- Kirsten D Dansey
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston
| | - Rens R B Varkevisser
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston
| | | | - Patric Liang
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston
| | - Christina Marcaccio
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston
| | - Brett J Carroll
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston.
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Abstract
Abdominal aortic aneurysm (AAA) disease remains a major source of morbidity in developed countries and can progress to life-threatening rupture if left untreated, with exceedingly high mortality. The goal of AAA management is to identify and electively repair AAAs before rupture. AAA disease burden and outcomes have improved over time with declining tobacco use and advancements in care across patients' disease course. The introduction of endovascular AAA repair, in particular, has allowed for elective AAA repair in patients previously considered too high risk for open surgery and has contributed to lower rates of AAA rupture over time. However, these improved outcomes are not universally experienced, and disparities continue to exist in the detection, treatment, and outcomes of AAA by sex, race, and ethnicity. Mitigating these disparities requires enhanced, focused efforts at preventing disease, promoting health, and delivering appropriate care among an increasingly diverse patient population.
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Affiliation(s)
- Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis Street, Suite 5B, Boston, MA 02215
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, 110 Francis Street, Suite 5B, Boston, MA 02215.
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Luo S, Zhu Y, Xie E, Ding H, Yang F, Chen L, Liu J, Liu Y, Xue L, Fan R, Luo J, Chen J. Influence of Sex on Outcomes After Thoracic Endovascular Repair for Type B Aortic Dissection. Angiology 2021; 72:556-564. [PMID: 33504166 DOI: 10.1177/0003319720987956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
We aimed to investigate whether sex differences influence the clinical outcomes of patients who undergo thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD). We retrospectively analyzed a prospectively maintained single-center cohort of patients with TBAD who underwent TEVAR between January 2010 and June 2017. We evaluated the in-hospital and long-term mortality and composite end point. Of the 913 patients, 793 (86.8%) were male and 120 (13.1%) were female. Compared to male patients, the female patients were older, more likely to have diabetes mellitus, but less likely to smoke or have hypertension. The proximal landing zone in 0 and 1 was higher in male patients (P = .023), who were more likely to require an aortic arch bypass. Endoleak, delirium, and ICU stay after stent-graft implantation were also more frequent in men. Sex factor was not associated with in-hospital or long-term mortality or the composite end point in the multivariable regression analyses and Cox regression model. The mean estimated survival time was similar between males and females (2462.9 ± 141.2 vs 2804.1 ± 117.4 days, P = .167) in the propensity score-matched cohort. Despite distinct characteristics between sex, there was no sex-related difference in long-term clinical outcomes after TEVAR for TBAD.
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Affiliation(s)
- Songyuan Luo
- Department of Cardiovascular, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Yi Zhu
- Department of Cardiology, 477093Guangzhou Panyu Central Hospital, Guangzhou, People's Republic of China
| | - Enmin Xie
- Department of Cardiovascular, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Huanyu Ding
- Department of Cardiovascular, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Fan Yang
- Department of Emergency and Critical Care Medicine, 89346Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Lyufan Chen
- Department of Cardiovascular, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jitao Liu
- Department of Cardiovascular, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Yuan Liu
- Department of Cardiovascular, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Ling Xue
- Department of Cardiovascular, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Ruixin Fan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - JianFang Luo
- Department of Cardiovascular, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jiyan Chen
- Department of Cardiovascular, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, 569066Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
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Malayala SV, Raza A, Vanaparthy R. Gender-Based Differences in Abdominal Aortic Aneurysm Rupture: A Retrospective Study. J Clin Med Res 2020; 12:794-802. [PMID: 33447313 PMCID: PMC7781278 DOI: 10.14740/jocmr4376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/31/2020] [Indexed: 12/04/2022] Open
Abstract
Background Annually, 5% of sudden deaths are due to abdominal aortic aneurysm (AAA) rupture. There is evidence suggesting that AAA ruptures have worse outcomes in females than males and the aneurysms rupture at a smaller size in females than in males. The United States Preventive Services Task Force (USPSTF) recommends a one-time ultrasound screening for males aged 65 - 75 years who ever smoked. There is insufficient evidence to screen females aged 65 - 75 years who ever smoked though there is evidence suggesting that AAAs rupture at a smaller size and have worse outcomes in females. The objective of this study is to compare the characteristics, mortality and morbidity of ruptured AAAs in females and males. Methods This is a retrospective review of 117 patients from two teaching institutions over a period of 6 years. A total of 39 parameters were compared between males and females including demographic variables, comorbidities like hypertension, dyslipidemia, cardiovascular diseases; previous history of AAA; medications, characteristics of aneurysm, type of surgery and its outcome; postoperative complications and long-term survival. Results The overall incidence of AAA rupture was higher in males (68%) than in females (32%). Females die from AAA rupture at a later age. There was a significant difference in the size of AAA rupture between females (mean = 7.4 cm, standard deviation (SD) = 2.0) and males (mean = 8.2 cm, SD = 1.8; P = 0.04). The probability to undergo surgery for ruptured AAA was significantly lower for females as compared to males (P = 0.03). Females had higher overall mortality (P = 0.001), postoperative mortality (P = 0.02), higher length of intensive care unit (ICU) stay, incidence of postoperative complications, use of vasopressors and use of ventilator. Conclusions Using a similar threshold of size of AAA for elective surgery for both males and females might not be appropriate. Further population-based studies are needed to warrant AAA screening for high-risk females owing to the higher morbidity and mortality.
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Affiliation(s)
| | - Ambreen Raza
- Department of Medicine, Bristol Hospital, Farmington, CT, USA
| | - Rachana Vanaparthy
- Department of Pulmonology, Oregon Health and Science University, Portland, OR, USA
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O'Donnell TFX, Deery SE, Boitano LT, Schermerhorn ML, Siracuse JJ, Clouse WD, Malas MB, Takayama H, Patel VI. The long-term implications of access complications during endovascular aneurysm repair. J Vasc Surg 2020; 73:1253-1260. [PMID: 32889076 DOI: 10.1016/j.jvs.2020.08.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 08/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Access issues are one of the most common complications of endovascular aneurysm repair (EVAR). However, contemporary rates as well as risk factors for complications and the subsequent impact of access complications on mortality are poorly described. METHODS We studied all EVAR for intact abdominal aortic aneurysms without prior aortic surgery in the Vascular Quality Initiative between 2011 and 2018. We studied factors associated with access complications (thrombosis, embolus, wound infection, hematoma, and conversion to cutdown), as well as the interaction with female sex and the impact on survival using multilevel logistic regression and propensity weighting. Multiple imputation was used for missing data. RESULTS There were 33,951 EVAR during the study period (91% elective, 9% symptomatic); most cases (70%) involved an attempt at percutaneous access on at least one side, with 30% bilateral cutdowns and 0.1% iliac conduits. There were 1553 patients (4.6%) who experienced at least one access complication. Access complications were almost twice as common in female patients (7.5% vs 3.9%; P < .001). The factors associated with access complications included female sex (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.0-3.6; P < .001), age (OR, 1.05 per 5 years; 95% CI, 1.02-1.1; P < .01), aortouni-iliac device (OR, 1.6; 95% CI, 1.1-2.3; P < .01), smoking (OR, 1.4; 95% CI, 1.1-1.7; P < .01), body mass index of less than 16 (OR, 1.8; 95% CI, 1.3-2.5; P = .001), dual antiplatelet therapy (1.3; 95% CI, 1.02-1.6 P = .03), prior infrainguinal bypass (OR, 1.8; 95% CI, 1.3-2.7; P < .01), and beta blocker use (OR, 1.2; 95% CI, 1.03-1.4; P = .02). Conversion from percutaneous access to open cutdown was associated with higher rates of complications than planned open cutdown (8.6% vs 2.9%; P < .001). In propensity-weighted analysis, percutaneous access was associated with significantly lower odds of access complications in women (OR, 0.6; 95% CI, 0.4-0.96; P = .03). Patients who experienced an access complication had more than four times the odds of perioperative death (OR, 4.2; 95% CI, 2.5-7.1; P < .001), and a 60% higher risk of long-term mortality (hazard ratio, 1.6; 95% CI, 1.2-2.1; P = .001). In addition to death, patients with access site complications had higher rates of other major complications, including reoperation during the index hospitalization (19% vs 1.2%; P < .001), myocardial infarction (3.5% vs 0.7%; P < .001), stroke (0.8% vs 0.2%; P < .001), acute kidney injury (12% vs 3%; P < .001), and reintubation (5.7% vs 0.8%). CONCLUSIONS Although access complications are infrequent in the current era, they are associated with both perioperative and long-term morbidity and mortality. Female patients in particular are at high risk of access complications, but may benefit from percutaneous access.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Hospital, Baltimore, Md
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, Mass
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, Va
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California, San Diego, Calif
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Irving Medical Center, Columbia University Vagelos College of Physicians & Surgeons, New York, NY.
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39
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Nikol S, Mathias K, Olinic DM, Blinc A, Espinola-Klein C. Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review. VASA 2020; 49:1-36. [PMID: 32856993 DOI: 10.1024/0301-1526/a000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.
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Affiliation(s)
- Sigrid Nikol
- Department of Angiology, ASKLEPIOS Klinik St. Georg, Hamburg, Germany.,University of Münster, Germany
| | - Klaus Mathias
- World Federation for Interventional Stroke Treatment (WIST), Hamburg, Germany
| | - Dan Mircea Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy and Interventional Cardiology Department, Emergency Hospital, Cluj-Napoca, Romania
| | - Aleš Blinc
- Department of Vascular Diseases, University Medical Centre Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Slovenia
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40
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Gao Z, Xiong J, Chen Z, Deng X, Xu Z, Sun A, Fan Y. Gender differences of morphological and hemodynamic characteristics of abdominal aortic aneurysm. Biol Sex Differ 2020; 11:41. [PMID: 32693818 PMCID: PMC7372899 DOI: 10.1186/s13293-020-00318-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Gender difference in cardiovascular diseases (CVDs) is an important topic in the field of cardiovascular medicine. In this study, we focused on the mortality difference of abdominal aortic aneurysms (AAA), which is higher for female than that of male. The aim of this study was to verify whether morphological and hemodynamic factors play their roles in this phenomenon. METHODS Patient-specific AAA models of 11 females and 23 males with similar age and body mass index (BMI) have been reconstructed based on clinical computed tomography (CT) data. Firstly, the morphological parameters (diameters, curvature, intraluminal thrombus volume, etc.) of AAA models and lumbar vertebrae models were collected and analyzed. Then, based on statistical results of morphological parameters, uniformed male and female AAA models were reconstructed, and hemodynamic simulations were conducted respectively. In post-processing, the hemodynamic performances induced by gender-different morphological geometries were analyzed and compared. RESULTS The comparison of morphological parameters revealed that the average curvature of lumbar vertebrae and AAA centerline of female AAA models were obviously higher than that of the male. The amount of intraluminal thrombus in female AAA models was relatively lower than that of the male. According to the hemodynamic simulation, the uniform female AAA model has higher peak pressure, lower oscillatory shear stress index (OSI), and lower relative residence time (RRT) than that of the male model, all of which put female AAA to a relatively higher risk hemodynamic situation. CONCLUSIONS The morphological and hemodynamic features of AAA have very obvious gender differences that would induce higher risk of rupture for female AAA biomechanically. These findings would help to explore the mechanism of gender differences in AAA and draw attention to gender-specific consideration for AAA treatment. More morphological and hemodynamic indictors are suggested to be involved in the future guidelines.
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Affiliation(s)
- Zujie Gao
- School of Biological Science and Medical Engineering, Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beihang University, Beijing, 100083 China
| | - Jiang Xiong
- Department of Vascular and Endovascular Surgery, The Chinese PLA General Hospital, Beijing, 100853 China
| | - Zengsheng Chen
- School of Biological Science and Medical Engineering, Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beihang University, Beijing, 100083 China
| | - Xiaoyan Deng
- School of Biological Science and Medical Engineering, Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beihang University, Beijing, 100083 China
| | - Zaipin Xu
- College of Animal Science, Guizhou University, Guiyang, 550025 China
| | - Anqiang Sun
- School of Biological Science and Medical Engineering, Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beihang University, Beijing, 100083 China
| | - Yubo Fan
- School of Biological Science and Medical Engineering, Beijing Advanced Innovation Center for Biomedical Engineering, Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, Beihang University, Beijing, 100083 China
- Key Laboratory of Rehabilitation Aids Technology and System of the Ministry of Civil Affairs, National Research Center for Rehabilitation Technical Aids, No. 1 Ronghuazhong Road, Beijing BDA, Beijing, 100176 China
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41
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Liao JL, Wang SK, Maijub JG, Gupta AK, Sawchuk AP, Motaganahalli RL, Murphy MP, Fajardo AC. Perioperative and Long-term Results of Zenith Fenestrated Aortic Repair in Women. Ann Vasc Surg 2020; 68:44-49. [PMID: 32479879 DOI: 10.1016/j.avsg.2020.05.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 03/13/2020] [Accepted: 05/02/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Inferior perioperative outcomes for women receiving major vascular surgery are well established in the literature in multiple arterial distributions. Therefore, this study was completed to determine the perioperative and durability results associated with women undergoing complex aortic reconstruction using the Zenith Fenestrated platform (ZFEN; Cook Medical, Bloomington, IN). METHODS A retrospective review of a fenestrated endovascular aortic repair (FEVAR) database capturing all ZFENs performed at our institution between October 2012 and March 2019 was completed. Preoperative, intraoperative, perioperative, and follow-up outcomes were tabulated for females and compared with their male counterparts. RESULTS Within our study period, 136 total ZFEN procedures were performed; of which, 20 devices (14.7%) were implanted in women. Intraoperatively, we observed a higher rate of estimated blood loss (660.0 mL vs. 311.6 mL, P < 0.01) and resultant need for transfusion (1.4 vs. 0.3 units, P < 0.01) in women despite a similar frequency of brachial (5.0% vs. 7.8%, P > 0.99) and femoral artery cutdowns (55.0% vs. 49.1%, P = 0.81). Operative (295.7 min vs. 215.7 mins, P < 0.01) and fluoroscopy (84.3 vs. 58.7 min, P < 0.01) times were also significantly higher in females than those in their male counterparts. In the perioperative (30-day) period, we observed significantly longer length of stay (5.6 days vs. 3.3 days, P = 0.03) and continued need for transfusion (50% vs. 9.5%, P < 0.01) in women. Statistical trends favoring men were also noted with respect to all-cause mortality, reintervention, visceral stent thrombosis, renal failure, acute kidney injury, and respiratory failure. After a mean follow-up of nearly 2 years, we found no differences in late all-cause or aneurysm-related mortality, major adverse cardiovascular events, or need for reinterventions. CONCLUSIONS The implantation of ZFEN in females is significantly more difficult than that in their male counterparts and may result in increased perioperative, but not necessarily long-term, complications.
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Affiliation(s)
- Jane L Liao
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - S Keisin Wang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
| | - John G Maijub
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Alok K Gupta
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Alan P Sawchuk
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael P Murphy
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Andres C Fajardo
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
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42
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Abdominal aortic aneurysm screening guidelines: United States Preventative Services Task Force and Society for Vascular Surgery. J Vasc Surg 2020; 71:1457-1458. [DOI: 10.1016/j.jvs.2020.01.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/29/2020] [Indexed: 01/11/2023]
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43
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Mwipatayi BP, Anwari T, Wong J, Verhoeven E, Dubenec S, Heyligers JM, Milner R, Mascoli C, Gargiulo M, Shutze WP. Sex-Related Outcomes After Endovascular Aneurysm Repair Within the Global Registry for Endovascular Aortic Treatment. Ann Vasc Surg 2020; 67:242-253.e4. [PMID: 32194136 DOI: 10.1016/j.avsg.2020.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 02/02/2020] [Accepted: 02/04/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Abdominal aortic aneurysms (AAAs) are more common in men. However, women have been shown to have more short- and long-term adverse outcomes after endovascular aneurysm repair. This disparity is thought to be multifactorial, including anatomical differences, hormonal differences, older age of presentation, and a greater degree of preoperative comorbidities. METHODS A retrospective analysis that included data for 3,758 patients from the Global Registry for Endovascular Aortic Treatment (GREAT) was conducted. Patients were recruited into GREAT between August 2010 and October 2016 and received the Gore Excluder stent graft for infrarenal AAAs repair. Cox multivariate regression analyses were performed to analyze any reintervention and device-related intervention rates. RESULTS Of the 3,758 patients, 3,220 were male (mean age 73 years) and 538 were female (mean age 75 years). Women had higher prevalence rates of chronic obstructive pulmonary disease (P < 0.0001) and renal insufficiency (P = 0.03), whereas men had higher rates of cardiovascular comorbidities. The AAAs in women were smaller in diameter with shorter and more angulated necks. Women did not experience a significantly higher rate of endoleaks but did exhibit higher reintervention rates, including reintervention for device-related issues. In terms of mortality, aorta-related mortality was most prevalent within the first 30 days after procedure in both sexes. CONCLUSIONS Women were treated at an older age and had a more hostile aneurysmal anatomy. Although the mortality rates were lower in women, they had significantly higher rates of reintervention, and thus higher morbidity rates after endovascular aneurysm repair.
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Affiliation(s)
- Bibombe P Mwipatayi
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia; Faculty of Medicine, School of Surgery, Dentistry and Health Sciences, University of Western Australia, Perth, Australia.
| | - Tahmina Anwari
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Jackie Wong
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Eric Verhoeven
- Department of Vascular and Endovascular Surgery, Paracelsus, Medical University, Nuremberg, Germany
| | - Steven Dubenec
- Department of Vascular Surgery, Royal Prince Alfred, Sydney, Australia
| | - Jan M Heyligers
- Department of Vascular Surgery, University Medical Center Utrecht, Heidelberglaan, the Netherlands
| | - Ross Milner
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University, Atlanta, GA
| | - Chiara Mascoli
- Department of Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - Mauro Gargiulo
- Department of Vascular Surgery, University of Bologna, DIMES, Bologna, Italy
| | - William P Shutze
- Division of Vascular Surgery, The Heart Hospital Baylor, Plano, TX
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