Endovascular treatment of abdominal aortic aneurysms: is there a benefit regarding postoperative outcome?

The Impact of Endograft Selection on Outcomes Following Treatment Outside of Instructions for Use (IFU) in Endovascular Abdominal Aortic Aneurysm Repair (EVAR)

Background Endovascular aneurysm repair (EVAR) has become the treatment modality of choice in patients with abdominal aortic aneurysms. This has resulted in endograft utilization within instructions for use (IFU) and in cases with proximal neck anatomy outside of IFU. Purpose To identify whether graft selection influences outcomes following EVAR outside of IFU. Methodology A retrospective analysis was conducted from previously published data for 636 patients, collated from the Endurant Stent Graft Natural Selection Global Post-Market Registry (ENGAGE) and the Global Registry for Endovascular Aortic Treatment (GREAT). Patients were recruited into the ENGAGE registry between 2009 and 2011 and into the GREAT registry between August 2010 and October 2016. In ENGAGE, they received the Medtronic Endurant stent graft (Medtronic Vascular Inc, Dublin, Ireland) for infrarenal AAA repair while patients analyzed in GREAT received the Gore Excluder stent-graft (W. L. Gore & Associates, Flagstaff, Arizona). Analyses were performed to evaluate all-cause mortality, aneurysm-related mortality, endoleak occurrence, and surgical reintervention rates between the two cohorts. Results Of the 636 patients, 225 were from ENGAGE (mean age 73 years) and 411 were from GREAT (mean age 75 years). 17.8% were treated outside of IFU in the ENGAGE registry, while 12.4% were treated outside IFU in the GREAT cohort. Five-year freedom from all-cause mortality was similar in both cohorts (65.6% vs. 63.8%). The rate of type IA endoleak development was lower in the Excluder cohort, although this may have been impacted by the fact that only endoleaks that underwent reintervention were recorded within GREAT analysis (Endurant 10.6% vs. Excluder 7.0%). The reintervention rate was 16% at five years following the Endurant aortic graft while it was 13.3% at five years with the Excluder. Conclusion Treatment outside of IFU, be it with a suprarenal or an infrarenal fixation device, is associated with worse outcomes. This analysis reinforces the importance of the consideration of either fenestrated or open repair in those aneurysms that fail to satisfy IFU while endovascular repair in such a setting should be reserved as a last resort strategy.

[Epidemiology and risk factors for major respiratory complications after aortic surgery]

Introduction

L'incidence des complications respiratoires postopératoires (CRPO) reste très diversement appréciées selon les critères diagnostiques retenues dans les différentes études, ce qui la fait varier de 5 à plus de 50%. Les CRPO majeurs après chirurgie de l'aorte abdominale sont responsables d'une grande morbi-mortalité pouvant aller jusqu’à 36%, d'une durée d'hospitalisation et d'un coût plus importants. Ainsi dans l'optique d'améliorer notre prise en charge périopératoire de la chirurgie de l'aorte, nous avons décidé de mener une étude pour dresser le profil épidémiologique et déterminer les facteurs de risque des complications respiratoires dans notre contexte

Méthodes

Il s'agit d'une étude de cohorte rétrospective du mois de Janvier 2007 au mois de décembre 2011 portant sur l'ensemble des patients opérés pour pathologie aortique au bloc opératoire central de l'hôpital Ibn Sina de Rabat, Maroc.

Résultats

Cent vingt cinq patients ont été inclus dans notre étude, 24 patients ont été opérés pour anévrysme de l'aorte abdominale et 101 patients pour lésion occlusive aortoiliaque. Dans notre série 22 malades soit 17,6% ont présenté une complication respiratoire majeure avec, une reventilation dans 4,8% des cas, une difficulté de sevrage de la ventilation artificielle dans 3,2% des cas, une pneumopathie dans 4% des cas, un syndrome de détresse respiratoire aigue (SDRA) dans 4% des cas et une nécessité de fibroaspiration bronchique dans 1,6% des cas. En analyse univariée: l’âge, la présence d'une BPCO avec dyspnée stade 3 ou 4, la présence d'une anomalie à l'EFR préopératoire, la présence d'un stade avancé (III ou IV) de LOAI et la reprise chirurgicale étaient statistiquement associés à la survenue d'une complication respiratoire postopératoire. En analyse multivariée, seule une anomalie à l'EFR en préopératoire constituait un facteur de risque indépendant de survenue d'une complication respiratoire postopératoire dans notre série avec un Odds Ratio (OR): 11,5; un Intervalle de Confiance (IC) à 95% de (1,6 - 85,2) et un p = 0,016.

Conclusion

Au terme de notre étude, il nous parait donc nécessaire pour diminuer l'incidence des CRPO majeurs dans notre population, d'agir sur les facteurs que nous jugeons modifiables tel l'amélioration de l’état respiratoire basal moyennant une préparation respiratoire préopératoire, s'intégrant dans un véritable programme de réhabilitation et associant une rééducation à l'effort, une kinésithérapie incitative ainsi qu'une optimisation des thérapeutiques habituelles.

Effects of study design and trends for EVAR versus OSR

Purpose:

To investigate if study design factors such as randomization, multi-center versus single center evidence, institutional surgical volume, and patient selection affect the outcomes for endovascular repair (EVAR) versus open surgical repair (OSR). Finally, we investigate trends over time in EVAR versus OSR outcomes.

Methods:

Search strategies for comparative studies were performed individually for: OVID’s MEDLINE, EMBASE, CINAHL, HAPI, and Evidence Based Medicine (EBM) Reviews (including Cochrane DSR, ACP Journal Club, DARE and CCTR), limited to 1990 and November 2006.

Results:

Identified literature: 84 comparative studies pertaining to 57,645 patients. These include 4 randomized controlled trials (RCTs), plus 2 RCTs with long-term follow-up. The other 78 comparative studies were nonrandomized with 75 reporting perioperative outcomes, of which 16 were multi-center, and 59 single-center studies. Of the single-center studies 31 were low-volume and 28 were high-volume centers. In addition, 5 studies had all patients anatomically eligible for EVAR, and 8 studies included high-risk patients only. Finally, 25 long term observational studies reported outcomes up to 3 years.

Outcomes:

Lower perioperative mortality and rates of complications for EVAR versus OSR varied across study designs and patient populations. EVAR adverse outcomes have decreased in recent times.

Conclusion:

EVAR highlights the problem of performing meta-analysis when the experience evolves over time.

Anesthésie et réanimation pour chirurgie réglée de l'anévrisme de l'aorte abdominale

OBJECTIVES

Patient scheduled for infrarenal abdominal aortic aneurysm surgery carries a high risk of cardiac or respiratory comorbidity. To outline the perioperative management for these patients.

METHODS

Review of the literature using MesH Terms "abdominal aortic aneurysm", "anesthesia", "analgesia" "critical care" and/or "surgery" in Medline database.

RESULTS

Cardiac preoperative evaluation and management have recently been reviewed. Intermediate and high-risk patients should undergo non-invasive cardiac testing to decide between a preoperative medical strategy (using betablocker+/-statin and aspirin) and an interventional strategy (coronary angioplasty or cardiac surgery). Perioperative myocardial ischaemia should also be investigated by clinical, electrocardiographic and biologic monitoring such as plasmatic troponin Ic dosage. Specific score could also assess the respiratory failure risk preoperatively. Epidural analgesia decreases this risk. There is no evidence that a pharmacological treatment decreases the incidence of acute renal failure after aortic surgery. Endovascular repair is actually recommended for older, higher-risk patients or patients with a hostile abdomen or other technical factors that may complicate standard open repair.

Postoperative care of vascular surgery patients

Vascular surgery continues to carry one of the highest postoperative morbidity and mortality rates. A detailed understanding of postoperative central nervous, myocardial, respiratory, and renal pathophysiology potentially helps to improve outcome. Current economic constraints, combined with changing intraoperative management, prompt inquiry into whether these patients can safely be managed outside of an intensive care unit setting. This article reviews whether efforts to less invasively manage these patients intraoperatively improves postoperative outcome remains under investigation, and what is known about the effects on postoperative outcome of regional anesthesia for carotid endarterectomy and endovascular treatment of aortic vascular disease.

Critical care of the vascular surgery patient

Providing effective critical care to vascular surgical patients is challenging to the intensivist. These patients often have multiple significant concurrent diseases that need to be adequately managed. A selective policy for identifying patients that need ICU is recommended. Early and smooth restoration to their preoperative physiological homeostasis is crucial. Optimal pain relief, return to normothermia, and adequate intravascular volume replacement are thus key interventions. Epidurals provide excellent analgesia. Vigilant monitoring and decisive therapy of the wide range of complications that may occur in the postoperative is of paramount importance. The level of monitoring should be an extension of that done intraoperatively. Hemorrhage and thrombosis are dreaded sequelae; cardiac morbidity and mortality is significant. Respiratory complications may necessitate prolonged postoperative mechanical ventilation. Careful clinical evaluation is necessary to detect the various neurological complications that may occur. Renal and gastrointestinal complications are potentially lethal. Graft sepsis may occur later. The development of new techniques, such as endovascular repairs of aneurysms, may minimize the need for ICU.