Two decades of abdominal aortic aneurysm repair: have we made any progress?

Socioeconomic and regional variations in repair modality for ruptured abdominal aortic aneurysms

BACKGROUND

Previous studies report that patients of racial/ethnic minorities more frequently present with ruptured abdominal aortic aneurysms (rAAAs) than their counterparts. The distribution of rAAA treatment modality, whether open aneurysm repair (OAR) or endovascular aneurysm repair (EVAR), by race/ethnicity classification remains uncertain. This study aims to investigate disparities, as represented by race/ethnic classification, median income, and insurance status, in the management of rAAA in a national cohort.

METHODS

We conducted a retrospective analysis of patients admitted with rAAA managed with either OAR or EVAR from 2002 to 2020 using the National Inpatient Sample, comparing repair type by race/ethnicity group. Multilevel mixed effects logistic regression models, adjusted for patient- and system-level factors, were used to calculate difference in use of OAR or EVAR dependent on race/ethnicity classification.

RESULTS

We identified 10,788 admissions for rAAA repairs, of which 9506 (88.1%) were White, 605 (5.6%) were Black, 424 (3.9%) were Hispanic, and 253 (2.4%) were Asian/Native American. Asians/Native Americans underwent the highest frequency of OAR as compared with EVAR (61.7% vs 38.3%). In the adjusted model, there was no statistically significant difference in the use of OAR vs EVAR by race/ethnicity classification. In total, primary payer and median income were also not statistically significant predictors of AAA treatment modality.

CONCLUSIONS

Our study found no statistical evidence of disparities with respect to race, insurance, or median income and use of OAR or EVAR for the management of rAAA.

In-hospital mortality risk after endovascular and open aortic aneurysm repairs for ruptured abdominal aortic aneurysms

OBJECTIVE

Observational studies demonstrate reduced mortality after endovascular (EVAR) compared with open aneurysm repair (OAR) for ruptured abdominal aortic aneurysms (rAAAs). We sought to determine national trends in repair type and in-hospital mortality rates for rAAAs.

METHODS

We analyzed patients with rAAAs managed with OAR or EVAR from 2002 to 2020 in the National Inpatient Sample and evaluated annual trends in volume and in-hospital mortality by repair type. Multilevel mixed effects logistic regression model was fit for patient and system-level risk adjustment. We assessed interactions between time, sex, and Elixhauser index with repair type.

RESULTS

We examined 13,376 patients with rAAAs. Of these, 8357 (62.5%) underwent OAR. Patients receiving EVAR were slightly older (73.7 vs 72.5 years; P < .001) with slightly higher mean Elixhauser index (4.0 vs 3.8; P < .001). Unadjusted in-hospital mortality was 37.4% vs 22.4% for OAR and EVAR, respectively. EVAR offered a risk-adjusted survival advantage (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.32-0.46). There was a statistically significant reduction of in-hospital mortality over time in the EVAR group (interaction OR, 0.96; 95% CI, 0.95-0.98). The interaction between Elixhauser index and repair was not statistically significant (interaction OR, 0.95; 95% CI, 0.87-1.05).

CONCLUSIONS

Survival rates for OAR and EVAR improved over time. EVAR persistently provided a substantial survival advantage over OAR in patients with rAAAs over the past 2 decades.

The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge

BACKGROUND

despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment.

METHODS

we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies.

RESULTS

the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention.

CONCLUSIONS

RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.

Infrarenal Abdominal Aortic Aneurysm

Abdominal aortic aneurysms are found in up to 6% of men and 1.7% of women over the age of 65 years and are usually asymptomatic. The natural history of aortic aneurysms is continued dilation leading to rupture, which is associated with an overall 80% mortality. Of the patients with ruptured aneurysms that undergo intervention, half will not survive their hospitalization. Reduction in aneurysm mortality is therefore achieved by prophylactic repair during the asymptomatic period. On a population-based level, this is supported by abdominal aortic aneurysm screening programs. Approximately 60% of abdominal aortic aneurysms are confined to the infrarenal portion of the aorta and are amenable to repair with off-the-shelf endovascular devices. Endovascular techniques have now replaced open surgery as the primary modality for aneurysm repair.

Paradigm shifts in abdominal aortic aneurysm management based on vascular registries

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

Impact of Gradual Adoption of EVAR in Elective Repair of Abdominal Aortic Aneurysm: A Retrospective Cohort Study from 2009 to 2015

INTRODUCTION

The recommendations about the preferred type of elective repair of abdominal aortic aneurysm (AAA) still divides guidelines committees, even nowadays. The aim is to assess outcomes after AAA repair focusing on differences between endovascular aneurysm repair (EVAR) and open surgical repair (OSR).

METHODS

The observational retrospective cohort study of consecutive patients submitted to elective AAA repair at a tertiary center, 2009-2015. Exclusion criteria were as follows: nonelective cases or complex aortic aneurysms. Primary outcomes were postoperative complications, length of hospital stay, survival, freedom from aortic-related mortality, and vascular reintervention. Time trends were assessed along the period under analysis.

RESULTS

From a total of 211 included patients, those submitted to EVAR were older (74 ± 7 vs. 67 ± 9 years; P < 0.001), presented a higher prevalence of hypertension (83.5% vs. 68.5%, P = 0.004), obesity (28.7% vs. 14.3%, P = 0.029), previous cardiac revascularization (30.5% vs. 14.7%, P = 0.005), heart failure (17.2% vs. 5.2%, P = 0.013), and chronic obstructive pulmonary disease (32.8% vs. 13.3%, P = 0.002). Patients were followed during a median of 49 months. EVAR resulted in a significantly shorter length of hospital stay (median 4 and interquartile range 3 vs. 8 (9); P < 0.001), lower 30-day complications (10.6% vs. 22.8%, P = 0.017), lower aortic-related mortality, and similar reintervention after adjustment with a propensity score. Along the time under analysis, EVAR became the predominate type of repair (P = 0.024), the proportion of complications decreased (P = 0.014), and the 30-day mortality (P = 0.035).

CONCLUSIONS

Although EVAR was offered to patients with more comorbidities, better and durable outcomes were achieved after EVAR, favoring its adoption for elective AAA repair.

Sex Disparity in Outcomes of Ruptured Abdominal Aortic Aneurysm Repair Driven by In-hospital Treatment Delays

OBJECTIVE

We sought to assess whether sex-related differences in timely repair of ruptured abdominal aortic aneurysm (rAAA) were associated with excess risk of early mortality in women.

SUMMARY BACKGROUND DATA

rAAA is a surgical emergency and timeliness of intervention affects outcomes. A door-to-intervention time of <90 minutes is recommended.

METHODS

All rAAA repairs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. Patients were stratified by sex and time-delay cohorts. Univariate and multivariate analyses were performed.

RESULTS

There were 3719 rAAA repairs, of which 797 (21%) were performed in women. Sex did not affect repair type: open versus endovascular (21% females, each). Despite similar presentation delays [median 6 hours (inter quartile range, IQR: 3-16)], admission-to-intervention time was longer for women than men [median 1.5 hours (IQR 1-4] vs 1.2 hours (IQR 1-3), P=0.047]. Overall, 45% of patients had a >90-minute delay from admission to repair, with more women than men experiencing this delay (49% vs 44%, P=0.01). Neither were more likely to undergo transfer for treatment. After risk adjustment, female sex was associated with a 48% increase in 30-day mortality. Sex differences in mortality were no longer observed in patients with intervention delays of ≤90 minutes. In patients with >90-minute delays, a 77% increase in 30-day mortality of women over men was noted.

CONCLUSIONS

Nearly half of rAAA patients have a door-to-intervention time longer than recommended societal guidelines. Sex differences in mortality after rAAA repair seem to be driven by in-hospital treatment delays.

LUCY results show females have equivalent outcomes to males following endovascular abdominal aortic aneurysm repair despite more complex aortic morphology

OBJECTIVE

Females remain underrepresented in studies of endovascular aneurysm repair (EVAR) owing to anatomic ineligibility for EVAR devices. The aim of the LUCY study is to explore the comparative safety and effectiveness of EVAR using a low-profile stent graft (Ovation; Endologix, Inc, Irvine, Calif) in females as well as males.

METHODS

The LUCY registry was a prospective, nonrandomized, multicenter study where patient enrollment was stratified by sex in a two-to-one ratio (male-to-female). Main outcomes were procedural data, 30-day major adverse events, device-related adverse events confirmed with contrast-enhanced computed tomography scans, secondary interventions, and hospital readmissions. Adverse events were adjudicated by a clinical events committee. Patients were followed at their 1-month and 1-year follow-up visits.

RESULTS

A total of 225 patients (76 females, 149 males) were enrolled at 39 U.S. centers. No statistically significant sex differences were observed in demographics or medical history. Females presented with smaller access vessels (6.2 vs 7.7 mm; P < .001), statistically smaller neck diameter (22 mm vs 23 mm; P = .001), similar neck angulation (11% vs 9% angulation >45°; P = .81), and smaller maximum abdominal aortic aneurysm (AAA) diameter (50 mm vs 53 mm; P = .01), however, these factors do not seem to be clinically significant. Technical success was 99%, and the median hospital stay was 1 day. The incidence of MAE through 30 days was 1.3% in females and 2.0% in males. There were no differences between sexes observed among the 30-day perioperative outcomes. The 30-day secondary intervention rate was 0.4%. The all-cause readmission rate through 30 days was 5.3% in females and 6.7% in males. There were no reports of limb occlusion or deaths within the first 30 days. At 1 year, there were no deaths in the female arm but nine deaths (6.0%) were observed in males, two of which were AAA related (1.3%). Through 1 year, there were eight type IA endoleaks (one female, seven males; P = .27) and three cases with limb occlusion (one female, two males). There were no reports of migration, AAA rupture, or surgical conversion through the end of follow-up.

CONCLUSIONS

Despite more complex aortic morphology in females than males, EVAR with a low-profile stent graft was associated with comparable procedural and perioperative outcomes through 1 year between the sexes.

Strain Mapping From Four-Dimensional Ultrasound Reveals Complex Remodeling in Dissecting Murine Abdominal Aortic Aneurysms

Current in vivo abdominal aortic aneurysm (AAA) imaging approaches tend to focus on maximum diameter but do not measure three-dimensional (3D) vascular deformation or strain. Complex vessel geometries, heterogeneous wall compositions, and surrounding structures can all influence aortic strain. Improved understanding of complex aortic kinematics has the potential to increase our ability to predict aneurysm expansion and eventual rupture. Here, we describe a method that combines four-dimensional (4D) ultrasound and direct deformation estimation to compute in vivo 3D Green-Lagrange strain in murine angiotensin II-induced suprarenal dissecting aortic aneurysms, a commonly used small animal model. We compared heterogeneous patterns of the maximum, first-component 3D Green-Lagrange strain with vessel composition from mice with varying AAA morphologies. Intramural thrombus and focal breakage in the medial elastin significantly reduced aortic strain. Interestingly, a dissection that was not detected with high-frequency ultrasound also experienced reduced strain, suggesting medial elastin breakage that was later confirmed via histology. These results suggest that in vivo measurements of 3D strain can provide improved insight into aneurysm disease progression. While further work is needed with both preclinical animal models and human imaging studies, this initial murine study indicates that vessel strain should be considered when developing an improved metric for predicting aneurysm growth and rupture.

Screening women aged 65 years or over for abdominal aortic aneurysm: a modelling study and health economic evaluation

BACKGROUND

Abdominal aortic aneurysm (AAA) screening programmes have been established for men in the UK to reduce deaths from AAA rupture. Whether or not screening should be extended to women is uncertain.

OBJECTIVE

To evaluate the cost-effectiveness of population screening for AAAs in women and compare a range of screening options.

DESIGN

A discrete event simulation (DES) model was developed to provide a clinically realistic model of screening, surveillance, and elective and emergency AAA repair operations. Input parameters specifically for women were employed. The model was run for 10 million women, with parameter uncertainty addressed by probabilistic and deterministic sensitivity analyses.

SETTING

Population screening in the UK.

PARTICIPANTS

Women aged ≥ 65 years, followed up to the age of 95 years.

INTERVENTIONS

Invitation to ultrasound screening, followed by surveillance for small AAAs and elective surgical repair for large AAAs.

MAIN OUTCOME MEASURES

Number of operations undertaken, AAA-related mortality, quality-adjusted life-years (QALYs), NHS costs and cost-effectiveness with annual discounting.

DATA SOURCES

AAA surveillance data, National Vascular Registry, Hospital Episode Statistics, trials of elective and emergency AAA surgery, and the NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP).

REVIEW METHODS

Systematic reviews of AAA prevalence and, for elective operations, suitability for endovascular aneurysm repair, non-intervention rates, operative mortality and literature reviews for other parameters.

RESULTS

The prevalence of AAAs (aortic diameter of ≥ 3.0 cm) was estimated as 0.43% in women aged 65 years and 1.15% at age 75 years. The corresponding attendance rates following invitation to screening were estimated as 73% and 62%, respectively. The base-case model adopted the same age at screening (65 years), definition of an AAA (diameter of ≥ 3.0 cm), surveillance intervals (1 year for AAAs with diameter of 3.0-4.4 cm, 3 months for AAAs with diameter of 4.5-5.4 cm) and AAA diameter for consideration of surgery (5.5 cm) as in NAAASP for men. Per woman invited to screening, the estimated gain in QALYs was 0.00110, and the incremental cost was £33.99. This gave an incremental cost-effectiveness ratio (ICER) of £31,000 per QALY gained. The corresponding incremental net monetary benefit at a threshold of £20,000 per QALY gained was -£12.03 (95% uncertainty interval -£27.88 to £22.12). Almost no sensitivity analyses brought the ICER below £20,000 per QALY gained; an exception was doubling the AAA prevalence to 0.86%, which resulted in an ICER of £13,000. Alternative screening options (increasing the screening age to 70 years, lowering the threshold for considering surgery to diameters of 5.0 cm or 4.5 cm, lowering the diameter defining an AAA in women to 2.5 cm and lengthening the surveillance intervals for the smallest AAAs) did not bring the ICER below £20,000 per QALY gained when considered either singly or in combination.

LIMITATIONS

The model for women was not directly validated against empirical data. Some parameters were poorly estimated, potentially lacking relevance or unavailable for women.

CONCLUSION

The accepted criteria for a population-based AAA screening programme in women are not currently met.

FUTURE WORK

A large-scale study is needed of the exact aortic size distribution for women screened at relevant ages. The DES model can be adapted to evaluate screening options in men.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020444 and CRD42016043227.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Morphological suitability for endovascular repair, non-intervention rates, and operative mortality in women and men assessed for intact abdominal aortic aneurysm repair: systematic reviews with meta-analysis

BACKGROUND

Prognosis for women with abdominal aortic aneurysm might be worse than the prognosis for men. We aimed to systematically quantify the differences in outcomes between men and women being assessed for repair of intact abdominal aortic aneurysm using data from study periods after the year 2000.

METHODS

In these systematic reviews and meta-analysis, we identified studies (randomised, cohort, or cross-sectional) by searching MEDLINE, Embase, CENTRAL, and grey literature published between Jan 1, 2005, and Sept 2, 2016, for two systematic reviews and Jan 1, 2009, and Sept 2, 2016, for one systematic review. Studies were included if they were of both men and women, with data presented for each sex separately, with abdominal aortic aneurysms being assessed for aneurysm repair by either endovascular repair (EVAR) or open repair. We conducted three reviews based on whether studies reported the proportion morphologically suitable (within manufacturers' instructions for use) for EVAR (EVAR suitability review), non-intervention rates (non-intervention review), and 30-day mortality (operative mortality review) after intact aneurysm repair. Studies had to include at least 20 women (for the EVAR suitability review), 20 women (for the non-intervention review), and 50 women (for the operative mortality review). Studies were excluded if they were review articles, editorials, letters, or case reports. For the operative review, studies were also excluded if they only provided hazard ratios or only reported in-hospital mortality. We assessed the quality of the studies using the Newcastle-Ottawa scoring system, and contacted authors for the provision of additional data if needed. We combined results across studies by random-effects meta-analysis. This study is registered with PROSPERO, number CRD42016043227.

FINDINGS

Five studies assessed the morphological eligibility for EVAR (1507 men, 400 women). The overall pooled proportion of women eligible (34%) for EVAR was lower than it was in men (54%; odds ratio [OR] 0·44, 95% CI 0·32-0·62). Four single-centre studies reported non-intervention rates (1365 men, 247 women). The overall pooled non-intervention rates were higher in women (34%) than men (19%; OR 2·27, 95% CI 1·21-4·23). The review of 30-day mortality included nine studies (52 018 men, 11 076 women). The overall pooled estimate for EVAR was higher in women (2·3%) than in men (1·4%; OR 1·67, 95% CI 1·38-2·04). The overall estimate for open repair also was higher in women (5·4%) than in men (2·8%; OR 1·76, 95% CI 1·35-2·30).

INTERPRETATION

Compared with men, a smaller proportion of women are eligible for EVAR, a higher proportion of women are not offered intervention, and operative mortality is much higher in women for both EVAR and open repair. The management of abdominal aortic aneurysm in women needs improvement.

FUNDING

National Institute for Health Research (UK).

Phenotype-based selection of bone marrow mesenchymal stem cell-derived smooth muscle cells for elastic matrix regenerative repair in abdominal aortic aneurysms

Chronic proteolytic disruption of elastic fibres within the abdominal aortic wall results in wall vessel expansion to form rupture-prone abdominal aortic aneurysms (AAA). Arresting AAA growth is not possible as adult vascular smooth muscle cells (SMCs) poorly auto-regenerate and repair elastic fibres. Thus, there is a need to identify alternate cell sources capable of robust elastic matrix assembly to overcome elastolysis in the AAA wall. Previously, we demonstrated the superior elastogenic properties of rat bone marrow mesenchymal stem cell (BM-MSC)-derived SMCs (BM-SMCs) relative to aneurysmal and healthy rat aortic SMCs. In the present study, we investigate how phenotypic coordinates of the derived BM-SMCs, in turn dependent on conditions of BM-MSC differentiation, impact their elastic matrix synthesis abilities. More specifically, we investigated how glucose content, serum levels and the presence of transforming growth factor (TGF)-β1 supplements alone or together with platelet-derived growth factor (PDGF-BB) in the differentiation medium influence phenotype of, and elastogenesis by derived rat BM-SMCs. BM-SMCs generated in low-glucose and 10% v/v serum conditions in the presence of TGF-β1 with or without PDGF-BB exhibited a mature phenotype characterized by contractility and migrative tendencies similar to healthy rat aortic SMCs, and yet capable of robust tropoelastin (precursor) synthesis and assembly of a fibrous, highly crosslinked elastic matrix. Thus, we have identified metrics and conditions for selecting BM-SMCs with superior elastogenesis for in situ elastic matrix regeneration. Future studies will focus on characterizing these specific BM-SMC subtypes for their pro-elastogenic and anti-proteolytic effects on aneurysmal SMCs to confirm their preferred use for therapy aimed at AAA tissue regenerative repair. Copyright © 2016 John Wiley & Sons, Ltd.

Open versus endovascular abdominal aortic aneurysm repair in Medicare beneficiaries

Abdominal aortic aneurysms are relatively common and often life-threatening, with especially high mortality after aneurysm rupture. The introduction of endovascular aneurysm repair, a minimally invasive alternative to traditional open repair, led to decreased mortality and morbidity in randomized controlled trials, but these trials were conducted in highly selected patients and providers and were underpowered to detect differences in rare adverse events throughout follow-up. With observational studies of Medicare beneficiaries, we demonstrate that the randomized trial results are generalizable to the majority of patients undergoing abdominal aortic aneurysm repair in the United States. Additionally, with a larger cohort, comparative analyses evaluating rare, previously unstudied late outcomes such as laparotomy-related complications, late reinterventions, mortality with reinterventions, and late rupture could be conducted. Furthermore, trends in management over time and relationships between surgeon and hospital volume and outcomes can be studied. The goal of this review was to summarize the existing literature regarding abdominal aortic aneurysms among Medicare beneficiaries and to evaluate the benefits and limitations of administrative claims data in comparative effectiveness research.

The putative role of autophagy in the pathogenesis of abdominal aortic aneurysms

Abdominal aortic aneurysms (AAA) are a significant cause of worldwide mortality and morbidity. While the histopathological characteristics of AAA are well documented, the cellular and molecular mechanisms involved in the pathogenesis of AAA are not entirely understood. Autophagy is a highly conserved basal cellular process in eukaryotic cells that involves the turnover of organelles and proteins. It is also activated as an adaptive response to stressful conditions to promote cell survival. While autophagy typically promotes pro-survival processes, it can sometimes lead to cellular demise. Preclinical studies have revealed autophagy to be a protective mechanism in certain vascular diseases with several autophagy-related genes reported to be markedly upregulated in human aneurysmal tissue. The role autophagy plays in the pathogenesis of AAA, however, remains poorly defined. In this review, we discuss the putative role of autophagy in AAA by reviewing several in vitro and in vivo studies that address the functional significance of autophagy in cells that are involved in the pathophysiology of AAA, amongst which are macrophages, smooth muscle and endothelial cells.

Endovascular Abdominal Aneurysm Repair in Women: What are the Differences Between the Genders?

INTRODUCTION:

Abdominal aortic aneurysm has a lower incidence in the female population, but a higher complication rate. It was been hypothesized that some anatomical differences of abdominal aortic aneurysm in women could be responsible for that. We proposed to analyze our data to understand the differences in the clinical and anatomical characteristics and the outcomes of patients undergoing endovascular aneurysm repair, according to gender.

METHODS:

A retrospective analysis of patients undergoing endovascular aneurysm repair between 2001-2013 was performed. Patients were divided according gender and evaluated regarding age, atherosclerotic risk factors, aneurysm anatomic features, endograft type, anesthesic risk classification, length of stay, reinterventions and mortality. Two statistical studies were performed, first comparing women and men (Group A) and a second one comparing women and men, adjusted by age (Group B).

RESULTS:

Of the 171 patients, only 5.8% (n=10) were females. Women were older (P<0.05) and the number of women with no atherosclerotic risk factor was significantly higher. The comparison adjusted by age revealed women with statistically less smoking history, less cerebrovascular disease and ischemic heart disease. Women had a trend to more complex anatomy, with more iliac intern artery aneurysms, larger aneurysm diameter and neck angulations statistically more elevated. No other variables were statistically different between age groups, neither reintervention nor mortality rates.

CONCLUSION:

Our study showed a clear difference in the clinical characteristics of women. The female population was statistically older, and when compared with men adjusted by age, had less atherosclerotic risk factors and less target organ disease. Women showed a more complex anatomy but with the same outcomes.

Influence of Gender on Abdominal Aortic Aneurysm Repair in the Community

BACKGROUND

Women have been shown to experience inferior outcomes following intact and ruptured abdominal aortic aneurysm (AAA) treatment in endovascular aneurysm repair (EVAR) and open surgical repair (OSR) groups. The goal of our study was to compare gender-specific presentation, management, and early outcomes after AAA repair using a statewide registry.

METHODS

We utilized the Washington State's Vascular Interventional Surgical Care and Outcomes Assessment Program registry data collected in 19 hospitals from July 2010 to September 2013. Demographics, presentation, procedural data, and outcomes in elective and emergent AAA repair groups were analyzed.

RESULTS

We identified 1,231 patients (19.6% women) who underwent intact (86.4%) or ruptured AAA (13.6%) repairs. Nine thousand seventy-two (79.0%) patients had EVAR and 259 (21.0%) had OSR. Men and women were of equivalent age and had similar comorbidities, except that women had less coronary artery disease (P < 0.01) and were more likely to suffer from chronic obstructive pulmonary disease (P = 0.05). Women had smaller aneurysm diameters (5.8 ± 1.1 vs. 6.2 ± 1.8 cm, P < 0.01) at the time of presentation and men had slightly higher incidence of rupture at larger aneurysm size. Men were more likely to undergo EVAR, with significant differences in elective (82.1% vs. 74.1%, P = 0.01), but not ruptured repair. Women had significantly higher mortality rates following elective EVAR (3.1% vs. 0.6%, P = 0.01), but not after ruptured or elective open repair. Following elective EVAR, women were less likely to be discharged to home after longer hospital stays (3 vs. 2 days, P < 0.01).

CONCLUSIONS

Despite presentation at a similar age, with a smaller aneurysm diameter, and similar medical comorbidities, women experience substantially worse hospital outcomes primarily driven by elective endovascular procedures. Utilization of endovascular techniques in women still remains lower compared with men. Improvement of elective outcomes in women will likely depend on technical advancements in repair techniques and management strategies that may differ between genders.

Endoluminal Repair of Ruptured Abdominal Aortic Aneurysms Under Local Anesthesia: Initial Experience

Open surgical repair is the standard treatment for a ruptured infrarenal abdominal aortic aneurysm (rAAA). This approach is associated with mortality rates of up to 70%, with significant surgery-related morbidity among survivors. In selected patients, endoluminal repair (ER) of an rAAA under local anesthesia may allow emergent aneurysm repair with reduced perioperative stress, ideally resulting in improved outcomes. The authors report their initial experience using a commercially available bifurcated endoluminal stent-graft to treat patients with rAAA under local anesthesia. Five of 8 patients (63%) with rAAA in a 1-year interval (June 2000–May 2001) were treated with ER. Criteria for ER were the following: (1) suitable aortic anatomy based on preoperative computed tomography (CT) imaging and (2) a hemodynamic state not requiring immediate aortic control. Mean size of ER rAAAs was 8 cm. Four of 5 patients underwent ER under local anesthesia. All 5 ER patients survived the initial surgery, and 4 patients survived to discharge. The expired patient was a Jehovah’s Witness who had a successful ER but was profoundly anemic postoperatively and refused transfusion. On postoperative CT imaging, no endoleaks were noted and no AAA enlargement had occurred. In a selected but significant subset of rAAA patients, emergent repair using a commercially available bifurcated endograft under local anesthesia is feasible, and clinical outcomes are acceptable. These promising initial results suggest that a further evaluation of the role of endoluminal repair in the treatment of ruptured infrarenal AAAs is warranted.

Abdominal Aortic Aneurysm Repair in Octogenarians versus Younger Patients in a Tertiary Referral Center

Operative survival is as high as 96% for elective abdominal aortic aneursym (AAA) repair but as low as 10% for emergency repair. Our primary aim was to compare elective AAA repair in octogenarians with nonoperative management. Our secondary aim was to compare octogenarians with their younger counterparts.

From 1998 to 2003, 180 patients with AAA were treated operatively or nonoperatively. Factors determining treatment included American Society of Anesthesiologists grade ≥ 4, inoperable malignancy, New York Heart Association class III, forced expiratory volume in 1 second < 35%, creatinine > 6.0 mg/dL, and patient and family choice. A parallel-group observational study was performed to assess age and treatment effects on outcome.

Seventy (39%) patients were repaired electively, 68 (38%) were managed nonoperatively, and 42 (23%) underwent emergency repair. Fifty-nine (33%) were octogenarians.

The octogenarian 5-year survival rate was 20% following emergency repair, 42% if treated nonoperatively, and 83% following elective repair. Younger cohort rates were 55% (emergency), 44% (nonoperative), and 76% (elective).

The octogenarian mean expansion rate was 0.26 cm/yr in those treated nonoperatively and 1.04 cm/yr in confirmed rupture. Rupture rate was related to expansion rate (95% confidence interval [CI] 0.06–0.59, r = .35, p = .01). The rates in the younger subgroup were 0.32 cm/yr and 1.14 cm/yr (95% CI −0.021–0.672}, r = .37, p = .03).

The octogenarian survival rate was highest following elective repair. Rupture was closely correlated with aneurysm expansion. Screening should reduce the incidence of octogenarian rupture of AAA and identify those patients most suitable for nonoperative management.

Correlations of perioperative coagulopathy, fluid infusion and blood transfusions with survival prognosis in endovascular aortic repair for ruptured abdominal aortic aneurysm

BACKGROUND

Factors associated with survival prognosis among patients who undergo endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysms (rAAA) have not been sufficiently investigated. In the present study, we examined correlations between perioperative coagulopathy and 24-h and 30-day postoperative survival. Relationships between coagulopathy and the content of blood transfusions, volumes of crystalloid infusion and survival.

METHODS

This was a retrospective study of the medical records of all patients who underwent EVAR for rAAA at Chiba-Nishi General Hospital during the period from October 2013 to December 2015. Major coagulopathy was defined using the international normalized ratio or activated partial thromboplastin time (APTT) ratio of at least 1.5, or platelet count less than 50 × 10/l. We quantified the amounts of blood transfusions and crystalloid infusions administered from arrival to the hospital to admission to ICU following operations.

RESULTS

Coagulopathy among patients with rAAA was found to progress even after they had presented at the hospital. No statistically significant correlation between preoperative coagulopathy and mortality was found, although a significantly greater degree of postoperative coagulopathy was seen among patients who died both within 24-h and 30 days postoperatively. Among patients with postoperative coagulopathy, lesser quantities of fresh frozen plasma (FFP) compared with red cell concentrate (RCC) were used during the period from hospital arrival to postoperative ICU entry. In both groups of patients who did not survive after 24-h and 30 days, FFP was used less than RCC. Large transfusions of crystalloids administered during the periods from hospital arrival to surgery and from hospital arrival to the end of surgery were associated with postoperative incidence of major coagulopathy, death within 24-h, and death within 30 days.

CONCLUSION

Coagulopathy progressed during care in the emergency outpatient clinic and operations. Postoperative coagulopathy was associated with poorer outcomes. Smaller FFP/RCC ratios and larger volumes of crystalloid infusion were associated with development of coagulopathy and poorer prognosis of survival.

TRIAL REGISTRATION

This study is retrospectively registered in UMIN Clinical Trials Registry (Registration 19 April 2016, registered number is R000025334 UMIN000021978).

Endovascular Aortic Aneurysm and Dissection Repair (EVAR) in Iran: Descriptive Midterm Follow-up Results

Background:

Endovascular repair of aorta in comparison to open surgery has a low early operative mortality rate, but its long-term results are uncertain.

Objectives:

The current study describes for the first time our initial four-year experience of elective endovascular aortic repair (EVAR) at Tehran heart center, the first and a major referral heart center in Iran, as a pioneer of EVAR in Iran.

Patients and Methods:

A total of 51 patients (46 men) who had the diagnosis of either an abdominal aortic aneurysm (AAA) (n = 36), thoracic aortic aneurysm (TAA) (n = 7), or thoracic aortic dissection (TAD) (n = 8) who had undergone EVAR by Medtronic stent grafts by our team between December 2006 and June 2009 were reviewed.

Results:

The rate of in-hospital aneurysm-related deaths in the group with AAA stood at 2.8% (one case), while there was no in-hospital mortality in the other groups. All patients were followed up for 13-18 months. The cumulative death rate in follow-up was nine cases from the total 51 cases (18%), out of which six cases were in the AAA group (four patients due to non-cardiac causes and two patients due to aneurysm-related causes), one case in the TAA group (following a severe hemoptysis), and two cases in the TAD group (following an expansion of dissection from re-entrance). The major event-free survival rate was 80.7% for endovascular repair of AAA, 85.7% for endovascular repair of TAA, and 65.6% for endovascular repair of TAD.

Conclusion:

The endovascular stent-graft repair of the abdominal and thoracic aortic aneurysm and aortic dissection had high technical success rates in tandem with low-rate early mortality and morbidity, short hospital stay, and acceptable mid-term free symptom survival among Iranian patients.

Effects of long-term chloroquine administration on the natural history of aortic aneurysms in mice

Autophagy regulates cellular homeostasis and integrates the cellular pro-survival machinery. We investigated the role of autophagy in the natural history of murine abdominal aortic aneurysms (AAA). ApoE(-/-) mice were implanted with saline- or angiotensin II (Ang-II)-filled miniosmotic pumps then treated with either the autophagy inhibitor chloroquine (CQ; 50 mg·(kg body mass)(-1)·day(-1), by intraperitoneal injection) or saline. Ang-II-elicited aneurysmal expansion of the suprarenal aorta coupled with thrombus formation were apparent 8 weeks later. CQ had no impact on the incidence (50% for Ang-II compared with 46.2% for Ang-II + CQ; P = NS) and categorical distribution of aneurysms. The markedly reduced survival rate observed with Ang-II (57.1% for Ang-II compared with 100% for saline; P < 0.05) was unaffected by CQ (61.5% for Ang-II + CQ; P = NS compared with Ang-II). CQ did not affect the mean maximum suprarenal aortic diameter (1.91 ± 0.19 mm for Ang-II compared with 1.97 ± 0.21 mm for Ang-II + CQ; P = NS). Elastin fragmentation, collagen accumulation, and smooth muscle attrition, which were higher in Ang-II-treated mice, were unaffected by CQ treatment. Long-term CQ administration does not affect the natural history and prognosis of experimental AAA, suggesting that global loss of autophagy is unlikely to be a causal factor in the development of aortic aneurysms. Manipulation of autophagy as a mechanism to reduce AAA may need re-evaluation.

Endovascular balloon occlusion is associated with reduced intraoperative mortality of unstable patients with ruptured abdominal aortic aneurysm but fails to improve other outcomes

BACKGROUND

Proximal aortic control by endovascular balloon occlusion (EBO) is an alternative to conventional aortic cross-clamping (CAC) in hemodynamically unstable patients presenting with a ruptured abdominal aortic aneurysm (rAAA). The aim of this study was to evaluate the potential clinical benefit of EBO over CAC.

METHODS

Data from 72 patients with rAAA treated at our institution from 2001 to 2013 were retrospectively analyzed. All patients were hemodynamically unstable (mean arterial blood pressure at admission <65 mm Hg or associated unconsciousness, cardiac arrest, or emergency endotracheal intubation). Clinical end points of hemodynamic restoration, mortality rate, and major postoperative complications were assessed for CAC (group 1) and EBO (group 2).

RESULTS

At admission, 72 patients were unstable. CAC was performed in 40 and EBO in 32. Intraoperative mortality was 43% in group 1 vs 19% in group 2 (P = .031). In group 1, the approach for CAC (thoracotomy [n = 23] vs laparotomy [n = 17]) did not influence intraoperative mortality (43% vs 41%). There was no significant difference in 30-day (75% vs 62%) and in-hospital (77% vs 69%) mortality rates between groups. After EBO, the treatment-open vs endovascular repair-did not influence the intraoperative mortality rate (31% vs 43%; P = .5). Eight surgical complications were secondary to CAC (1 vena cava injury, 3 left renal vein injuries, 1 left renal artery injury, 1 pancreaticoduodenal vein injury, and 2 splenectomies), but no EBO-related complication was noted (P = .04). Differences in colon ischemia (15% vs 28%) and renal failure (12% vs 9%) were not statistically significant. Abdominal compartment syndrome occurred in four patients in group 2 and in no patients in group 1.

CONCLUSIONS

Compared with CAC, EBO is a feasible and valuable strategy and is associated with reduced intraoperative mortality of unstable rAAA patients, but not in-hospital mortality, in this retrospective study.

Rupture signs on computed tomography, treatment, and outcome of abdominal aortic aneurysms

OBJECTIVES

Abdominal aortic aneurysm (AAA) rupture has a high mortality rate. Although the diagnosis of a ruptured AAA is usually straightforward, detection of impending rupture signs can be more challenging. Early diagnosis of impending AAA rupture can be lifesaving. Furthermore, differentiating between impending and complete rupture has important repercussions on patient management and prognosis. The purpose of this article is to classify and illustrate the entire spectrum of AAA rupture signs and to review current treatment options for ruptured AAAs.

METHODS

Using medical illustrations supplemented with computed tomography (CT), this essay showcases the various signs of impending rupture and ruptured AAAs. Endovascular aneurysm repair (EVAR) and open surgical repair are also discussed as treatment options for ruptured AAAs.

RESULTS

CT imaging findings of ruptured AAAs can be categorised according to location: intramural, luminal, and extraluminal. Intramural signs generally indicate impending AAA rupture, whereas luminal and extraluminal signs imply complete rupture. EVAR has emerged as an alternative and possibly less morbid method to treat ruptured AAAs.

CONCLUSIONS

AAA rupture occurs at the end of a continuum of growth and wall weakening. This review describes the CT imaging findings that may help identify impending rupture prior to complete rupture.

TEACHING POINTS

• AAA rupture occurs at the end of a continuum of growth and wall weakening. • Intramural imaging findings indicate impending AAA rupture. • Luminal and extraluminal imaging findings imply complete AAA rupture. • Some imaging findings are not specific to AAA ruptures and can be seen in other pathologies. • EVAR has emerged as an alternative and possibly less morbid method of treating ruptured AAAs.

Comparative effectiveness of endovascular versus open repair of ruptured abdominal aortic aneurysm in the Medicare population

OBJECTIVE

Endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) is increasingly used for emergent treatment of ruptured AAA (rAAA). We sought to compare the perioperative and long-term mortality, procedure-related complications, and rates of reintervention of EVAR vs open aortic repair of rAAA in Medicare beneficiaries.

METHODS

We examined perioperative and long-term mortality and complications after EVAR or open aortic repair performed for rAAA in all traditional Medicare beneficiaries discharged from a United States hospital from 2001 to 2008. Patients were matched by propensity score on baseline demographics, coexisting conditions, admission source, and hospital volume of rAAA repair. Sensitivity analyses were performed to evaluate the effect of bias that might have resulted from unmeasured confounders.

RESULTS

Of 10,998 patients with repaired rAAA, 1126 underwent EVAR and 9872 underwent open repair. Propensity score matching yielded 1099 patient pairs. The average age was 78 years, and 72.4% were male. Perioperative mortality was 33.8% for EVAR and 47.7% for open repair (P < .001), and this difference persisted for >4 years. At 36 months, EVAR patients had higher rates of AAA-related reinterventions than open repair patients (endovascular reintervention, 10.9% vs 1.5%; P < .001), whereas open patients had more laparotomy-related complications (incisional hernia repair, 1.8% vs 6.2%; P < .001; all surgical complications, 4.4% vs 9.1%; P < .001). Use of EVAR for rAAA increased from 6% of cases in 2001 to 31% in 2008, whereas during the same interval, overall 30-day mortality for admission for rAAA, regardless of treatment, decreased from 55.8% to 50.9%.

CONCLUSIONS

EVAR for rAAA is associated with lower perioperative and long-term mortality in Medicare beneficiaries. Increasing adoption of EVAR for rAAA is associated with an overall decrease in mortality of patients hospitalized for rAAA during the last decade.

Endovascular versus open repair of ruptured abdominal aortic aneurysms

Although major improvement has occurred to make elective repair of abdominal aortic aneurysms a safe procedure, the incidence of ruptured abdominal aortic aneurysms and mortality rates are still disappointing. Endovascular abdominal aortic aneurysm repair has produced quantum changes in aneurysm treatment. The successful application of the endovascular approach for the treatment of abdominal aortic aneurysms in the elective setting has prompted a strong interest regarding its possible use in dealing with the long-standing challenge of a ruptured abdominal aortic aneurysm. Since the first report, several centers have reported results and a wide spectrum of opinion regarding its application, with special consideration to logistical and practical barriers for appropriate utilization. The purpose of this article is to review all the available literature on the endovascular repair of ruptured abdominal aortic aneurysms and to analyze the most recent trends in their management, with special consideration given to comparing results of conventional and endovascular approaches.

Transradial approach for the endovascular treatment of type I endoleak after aortic aneurysm repair: a case report

Background

Endovascular repair of aortic aneurysms (EVAR) is obtained through the positioning of an aortic stent-graft, which excludes the aneurysmatic dilation. Type I endoleak is the most common complication, and it is caused by an incompetent proximal or distal attachment site, causing the separation between the stent-graft and the native arterial wall, and in turn creating direct communication between the aneurysm sac and the systemic arterial circulation. Endoleak occurrence is associated with high intrasac pressures, and requires a quick repair to prevent abdominal aortic aneurysm rupture.

Case presentation

We report the first case of a 80-year-old man undergoing percutaneous closure of a peri-graft endoleak (type I) by transcatheter embolization through radial arterial access.

Conclusion

The transradial approach has been shown to be a safe and effective alternative to the traditional transfemoral approach. A decrease in vascular complications and improved patient comfort are the primary benefits of this technique in patients with previous EVAR.

Construct domain analysis of patient health-related quality of life: physical and mental trajectory profiles following open versus endovascular repair of abdominal aortic aneurysm

Purpose

Many clinical trials comparing the outcomes of open surgical repair (OSR) versus endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) have been conducted, with varying results. Surprisingly, few outcomes studies have closely examined perceived physical and mental health-related quality of life (HRQOL) factors through a validated survey tool. The purpose of this prospective observational study was to describe the trajectory of HRQOL measures, from baseline to 1 year after surgery, in patients undergoing OSR or EVAR for AAA, and to explore for differences in physical and mental composite scores and their construct domains (subscales) using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36^®) tool.

Patients and methods

Over an 18-month period, a small sample of patients undergoing elective AAA repair in a community hospital setting were prospectively enrolled. Fifteen patients undergoing OSR and twenty patients undergoing EVAR were studied. Physical and mental HRQOL parameters were assessed using the SF-36.

Results

No significant differences in demographic and clinical variables were found between the OSR and EVAR groups. In the multivariable linear models with repeated measures, both groups showed a significant decline in physical health composite scores 30 days after the surgical procedure (P < 0.01). However, although the OSR group showed a statistically significant decline in three of the four physical health domains, the EVAR group declined in only one physical health domain. Only the OSR group showed a significant decline in three of the four mental health domains at 30 days; however, the decline of these domains was not reflected in the group’s mental health composite scores. By 90 days after surgery, both groups were not significantly different from their baseline in physical or mental health composite scores, or in any of their respective physical health domains.

Conclusion

In this small sample of patients undergoing AAA repair, EVAR resulted in less physical and emotional decline than OSR in the early postoperative period. However, patients in both groups may return to near baseline status at 90 days.

Is the abdominal aortic aneurysm rupture rate decreasing?

Decreased smoking has likely had the most significant impact on reducing the prevalence of AAAs. In a review of public data in England and Wales, Anjum and colleagues illustrated a reduction of AAA rupture from 1997 to2009 across all ages attributed to a concurrent decrease in prevalence of smoking. This trend has also been noted in a meta-analysis from Sweeting and colleagues and attributed to a reduction in the prevalence of smoking since the mid-1970s along with an enhanced awareness of cardiovascular risk factor reduction and selective aneurysm screening. Along with an effort to reduce AAA progression and rupture, tools to predict patient-specific risk of AAA rupture are evolving with refined models that incorporate both aneurysm wall stress and wall strength likely to provide the most promising approach. Although the role of statins, ACE inhibitors, beta-blockers, and aspirin in preventing or slowing aneurysmal rupture remains unresolved, their proven benefit in reducing long-term cardiovascular mortality suggests that these medications should be considered in any patient with a small AAA. Currently, randomized trials do not show any survival benefit for open or endovascular repair for small aneurysms in the range of 4.0 to 5.4 cm. AAA repair, whether through an endovascular or open approach, is not without potential complication. Even at centers of excellence, the 30-day mortality rate for conventional AAA surgery is 3% to 5%, with rates of major morbidityranging from 15% to 40%. The Society for Vascular Surgery guidelines recommends surveillance for patients with a fusiform AAA of 4.0 to 5.4 cm. The risk of AAA rupture appears to be decreasing through heightened public awareness, advanced technology for AAA detection, screening and surveillance, improved understanding of biomechanics and natural progression in AAA rupture, along with the availability of a wide range of medical therapies for risk factor reduction and minimally invasive options for AAA repair.

Ascending aorta aneurysm and blood group A among Iranian patients

BACKGROUND

Ascending aortic aneurysm is a life threatening conditions leading to surgery in many cases. Demonstrating risk factors for this disease is essential for development of screening strategies for high-risk populations. Blood group although described as a potential risk factor for abdominal aortic aneurysm, has not been addressed in patients with aneurysm of the ascending aorta.

OBJECTIVES

Our study aimed to demonstrate the prevalence of ABO blood groups among one of the largest Iranian population with diagnosed aneurysm of the ascending aorta.

METHODS

A retrospective study was conducted in Tehran Heart Center in Tehran, Iran reviewing profile of 24,433 patients admitted to the cardiac surgery ward between January 2005 and February 2012 to extract data of 96 patients with confirmed diagnosis of ascending aortic aneurysm (AAA). Frequency of blood groups was determined and risk factors and AAA-related complications and mortality were compared between different blood groups.

RESULTS

Of ninety six patients with AAA, 38 patients (39.58%) had blood group A, followed by 16 patients with blood group B (16.66%), 12 blood group AB (12.5%), and 30 patients (30.25%) with blood group O. Cerebrovascular accident (CVA), peripheral vascular disease (PVD), and AAA-related mortality were more frequent in patients with blood group A. However, it did not reveal statistically significant difference (p>0.05).

CONCLUSION

Our study showed that risk factors for developing vascular disease are more prevalent in patients with blood group A and this blood group is associated with higher complication and mortality in AAA.

Changes in abdominal aortic aneurysm rupture and short-term mortality, 1995-2008: a retrospective observational study

OBJECTIVE

To examine the modern epidemiology of abdominal aortic aneurysm (AAA) rupture and short-term AAA-related mortality after the introduction of endovascular aneurysm repair (EVAR).

BACKGROUND

Previous epidemiologic studies have demonstrated stable rates of AAA repair, repair mortality, and AAA rupture. Recently, EVAR has been introduced as a less invasive treatment method, and its use has expanded to more than 75% of elective AAA repairs.

METHODS

We identified Medicare beneficiaries undergoing AAA repair and those hospitalized with a ruptured AAA during the period 1995 to 2008 and calculated standardized annual rates of AAA-related deaths due to either elective repair or rupture.

RESULTS

A total of 338,278 patients underwent intact AAA repair during the study period. There were 69,653 patients with AAA rupture, of whom 47,524 underwent repair. Intact repair rates increased substantially in those older than 80 years (57.7-92.3 per 100,000, P < 0.001) but decreased in those 65 to 74 years old (81.8-68.9, P < 0.001). A decline in ruptures with and without repair was seen in all age groups. By 2008, 77% of all intact repairs and 31% of all rupture repairs were performed with EVAR (P < 0.001). Operative mortality declined during the study period for both intact (4.9%-2.4%, P < 0.001) and ruptured (44.1%-36.3%, P < 0.001) AAA repair. Short-term AAA-related deaths decreased by more than half (26.1-12.1 per 100,000, P < 0.001), with the greatest decline occurring in those older than 80 years (53.7-27.3, P < 0.001).

CONCLUSIONS

A recent decline in AAA rupture and short-term AAA-related mortality is demonstrated and likely related in part to the introduction and expansion of EVAR. This is due to decreased deaths from ruptures (with and without repair) and decreased mortality with intact repairs, particularly in patients older than 80 years.

Nationwide trends in abdominal aortic aneurysm repair and use of endovascular repair in the emergency setting

PURPOSE

To analyze nationwide trends in abdominal aortic aneurysm (AAA) repair and the use of endovascular abdominal aortic aneurysm repair (EVAR) in the emergency setting.

MATERIALS AND METHODS

Data were obtained from the Nationwide Inpatient Sample (NIS) using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes for open and endovascular repairs from 2001-2009. Trends in outcome parameters and hospital charges were compared.

RESULTS

The number of emergency EVAR procedures increased from 382 in 2001 to 1,247 in 2009 (P < .001). During the study period, length of hospital stay associated with total number of EVAR procedures decreased from 3.8 days to 3.4 days (P < .05), and the in-hospital mortality decreased from 2.4% to 2% (P = .32). From 2001-2009, mean hospital charges associated with EVAR increased from $50,630 to $91,401 (74% increase), whereas charges associated with open repairs increased from $54,578 to $128,925 (136% increase). The proportion of patients needing rehabilitation or nursing home placement after EVAR increased from 5.8% to 7.7% (P < .01), and need for home health increased from 6.9% to 10.5% (P < .01).

CONCLUSIONS

There was a significant increase in the number of emergency EVAR procedures during the study period; however, the overall in-hospital mortality associated with EVAR remained unchanged, and the length of hospital stay showed a decreasing trend. The total hospital charges for EVAR were lower than the charges for open abdominal aneurysm repair throughout the study period; the difference in charges between the procedures showed a significant increasing trend with time.

Early and mid-term results of a prospective observational study comparing emergency endovascular aneurysm repair with open surgery in both ruptured and unruptured acute abdominal aortic aneurysms

The aim of the paper is to prospectively describe early and mid-term outcomes for emergency endovascular aneurysm repair (eEVAR) versus open surgery in acute abdominal aortic aneurysms (aAAAs), both unruptured (symptomatic) and ruptured. We enrolled all consecutive patients treated for aAAA at our center between April 2002 and April 2008. The main outcome parameters were 30-day, 6- and 12-month mortality (all-cause and aneurysm-related). Two hundred forty patients were enrolled in the study. In the unruptured aAAA group ( n = 111), 47 (42%) underwent eEVAR. The 30-day, 6- and 12-month mortality rates were 6, 13 and 15% in the eEVAR group versus 11% (NS), 13% (NS) and 16% (NS) in the open group, respectively. In the ruptured aAAA group ( n = 129), 25 (19%) underwent eEVAR (mortality rates: 20, 28 and 36%, respectively) compared with 104 (81%) patients who underwent open surgery (mortality rates: 45% ( P = 0.021), 60% ( P = 0.004) and 63% ( P = 0.014), respectively). In conclusion, the present study showed a reduced 30-day, 6- and 12-month mortality of eEVAR compared with open surgery in all patients with aAAA, mainly due to a lower mortality in the ruptured aAAA group. Late aneurysm-related mortality occurred only in the eEVAR group.

Open repair of infra renal abdominal aortic aneurysms: a single center experience from the developing world

INTRODUCTION

In the absence of endovascular aneurysm repair due to financial constraints, Abdominal Aortic Aneurysm (AAA) in Sri Lanka is managed exclusively by open surgery. We report our experience with open AAA repair with emphasis on peri-operative morbidity and mortality.

METHODS

Seventy nine consecutive open AAA repairs were carried out between April 2004 and March 2010. A multiple regression model was used to identify predictors of significant peri-operative morbidity and mortality.

RESULTS

Mean age of the study cohort was 68 years. There were 63 (80%) males and 16 (20%) females. Mean aneurysm diameter was 6.4 (3.5-9.70) cm. Twenty seven (34%) underwent emergency surgical repair (group-1) while 52 (66%) had elective repair (group-2). The peri-operative mortality was 10/27 (37%) in group-1, 4/52 (7.6%) in group-2, (p = 0.0035). Significant post-operative morbidity was seen in 5/17 (29%) in group-1 and 7/48 (15%) in group-2, (p = 0.27). Aneurysm diameter >7 cm (p = 0.001), emergency repair (p = 0.004), history of smoking (p = 0.002), aortic cross-clamp time >60 minutes (p = 0.044), and need for post-operative ventilwation >24 hours (p = 0.024) were found to be independent predictors of peri-operative mortality or significant morbidity.

CONCLUSION

Open aneurysm repair still has a strong place especially in the limited resource setting, with acceptable outcomes.

Ruptured AAA: open surgical management

Ruptured abdominal aorta aneurysm (rAAA) is the 13th leading cause of death in the United States. Despite many advances in the field of vascular surgery, the improvement in mortality rates of rAAA have been very modest. Although endovascular repair has surpassed open repair for elective AAA repair in the United States, open rAAA repair remains the most common therapy for this devastating vascular emergency. In this article, we discuss open surgical management for rAAA. We also describe a fast-track algorithm we have developed at the University of Massachusetts where open and endovascular repairs play equally important roles in management of rAAA.