1
|
Besch A, Cotta L, Heckenkamp J, Adili F, Steinbauer M, Behrendt CA. Treatment of Abdominal Aortic Aneurysm in Germany in 2023: A Registry Short Report. Eur J Vasc Endovasc Surg 2025; 69:789-790. [PMID: 39848534 DOI: 10.1016/j.ejvs.2025.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Revised: 12/26/2024] [Accepted: 01/16/2025] [Indexed: 01/25/2025]
Affiliation(s)
- Artur Besch
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Livia Cotta
- German Institute for Vascular Research, Berlin, Germany; German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany
| | - Jörg Heckenkamp
- German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany; Department for Vascular Surgery, Niels-Stensen-Kliniken, Marienhospital Osnabrück, Osnabrück, Germany
| | - Farzin Adili
- German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany; Department of Vascular Medicine and Vascular and Endovascular Surgery, Klinikum Darmstadt, Darmstadt, Germany
| | - Markus Steinbauer
- German Society for Vascular Surgery and Vascular Medicine, Berlin, Germany; Department of Vascular Surgery, Vascular Centre, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; German Institute for Vascular Research, Berlin, Germany.
| |
Collapse
|
2
|
Mylonas SN, Papavlasopoulos V, Moulakakis KG, Kakisis J. Use of Fenestrated/Branched Devices for Rescue of Proximal Endograft Failure After Endovascular Aneurysm Repair: A Systematic Review of the Literature and an Updated Meta-Analysis. J Endovasc Ther 2025:15266028251325430. [PMID: 40079708 DOI: 10.1177/15266028251325430] [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: 03/15/2025]
Abstract
OBJECTIVE To present the current outcomes of fenestrated and branched endovascular aneurysm repair (F/BEVAR) for rescue of proximal endograft failure after endovascular aneurysm repair (EVAR). A systematic review of the currently published literature on F/BEVAR for failed EVAR is undertaken, and the eligible studies are combined into a meta-analysis with the intention of evaluating the safety, efficacy, and the durability of this treatment option. MATERIALS AND METHODS A systematic review of the literature up to September 2024 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (CRD42024590847). Studies were included in the meta-analysis if they reported ≥10 patients and at least one of the major outcomes was stated. Primary endpoint was technical success (efficacy). Secondary endpoints included 30-day/in-hospital mortality and morbidity (safety) and survival and reinterventions rate (durability). Methodological quality and robustness of the results of the eligible articles were assessed according to Joanna Briggs Institute (JBI's) critical appraisal tool. RESULTS A total of 16 studies with overall 1079 patients were included. The pooled estimate for technical success was 94.4% (95% CI 92.5-95.8), whereas for the 30-day/in-hospital mortality 3.9% (95% CI 2.9-5.4). Permanent paraplegia was developed in a pooled rate of 1.6% (95% CI 0.8-3.0), whereas a cerebrovascular event in a pooled rate of 1.5% (95% CI 0.9-2.8). An acute renal function impairment requiring new onset dialysis occurred with a pooled rate of 4.4% (95% CI 3.2-6.1). Postoperative respiratory failure was observed with a pooled estimate of 7.2% (95% CI 5.5-9.4). The pooled estimate for 12-month overall survival was 88% (95% CI 83.4-91.4), and the pooled estimate for 24- and 36-month survival were 79.8% (95% CI 75.6-83.4) and 72.2% (95% CI 66.7-77.2), respectively. Freedom from reintervention was estimated at 83.7% (95% CI 79.9-86.9) for 12 months, 75.8% (95% CI 61.0-86.2) for 24 months and 59.3% (95% CI 36.5-78.7) for 36 months. CONCLUSION This study showed that F/BEVAR is a feasible, safe, and reliable strategy for achieving proper proximal endograft sealing when previous EVAR has failed. The midterm survival of these patients is acceptable, whereas reinterventions are not negligible.Clinical ImpactThis work summarizes the current experience with fenestrated and branched endovascular aneurysm repair for the rescue of failed endovascular aneurysm repair in the most contemporary meta-analysis including 16 studies with a total of 1079 analyzed patients. Feasibility of the method is proven with a technical success of 94.4%, whereas a 30-day/in-hospital mortality of 3.9% was recorded. The compromised survival and freedom from reinterventions rates (72.2% and 59.3% for 36 months, respectively) pose, however, concerns regarding durability of the method.
Collapse
Affiliation(s)
- Spyridon N Mylonas
- Department of Vascular and Endovascular Surgery, General Hospital of Athens "G. GENNIMATAS", Athens, Greece
| | - Vasileios Papavlasopoulos
- Department of Vascular and Endovascular Surgery, General Hospital of Athens "G. GENNIMATAS", Athens, Greece
| | - Konstantinos G Moulakakis
- Faculty of Medicine, Department of Vascular and Endovascular Surgery, University of Athens, "Attikon" Hospital, Athens, Greece
| | - John Kakisis
- Faculty of Medicine, Department of Vascular and Endovascular Surgery, University of Athens, "Attikon" Hospital, Athens, Greece
| |
Collapse
|
3
|
Arslan Ü, Yıldız Z, Pir İ, Aykut Ç. The Justification of Open Surgical Repair for an Abdominal Aortic Aneurysm: A Retrospective Comparison of Outcomes of Endovascular Aneurysm Repair and a Brief Review of the Literature. Life (Basel) 2025; 15:426. [PMID: 40141771 PMCID: PMC11943561 DOI: 10.3390/life15030426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2025] [Revised: 03/05/2025] [Accepted: 03/05/2025] [Indexed: 03/28/2025] Open
Abstract
Background: Abdominal aortic aneurysms (AAAs) are life-threatening conditions that require timely intervention to prevent rupture. Endovascular aneurysm repair (EVAR) is preferred due to faster recovery and lower perioperative risk; however, intraoperative failure and long-term complications highlight the continued significance of open surgical repair (OSR) and the need for improved risk assessment. Methods: This retrospective study analyzed data from 210 patients who underwent EVAR (n = 163) or OSR (n = 47) at a single center. Clinical characteristics, complications, reintervention rates, and 30-day mortality were recorded. EVAR-to-OSR conversion and mortality predictors in AAA treatments were identified. Results: The overall mortality rate was 9.5% (20/210 patients), with 12 patients (7.3%) in the EVAR group and 8 patients (17%) in the OSR group (p = 0.085). Five patients required early and six required late conversion to open surgery. In follow-ups beyond 30 days, the reintervention rate for EVAR was higher (HR: 1.2, 95% CI: 0.4-3.6; p = 0.754). According to the multivariable analysis, rupture (p = 0.045), female sex (p = 0.018), body weight (p = 0.003), and aortic size index (p = 0.019) were significant predictors of mortality, whereas OSR was not (p = 0.212). Conclusions: Treatment optimization requires a balanced approach, integrating both EVAR and OSR based on patient-specific factors. Maintaining expertise in both techniques is essential to ensure the best possible outcomes, and OSR should remain a viable option when clinically indicated.
Collapse
Affiliation(s)
- Ümit Arslan
- Department of Cardiovascular Surgery, Faculty of Medicine, Atatürk University, Erzurum 25030, Turkey; (İ.P.); (Ç.A.)
| | - Ziya Yıldız
- Department of Cardiovascular Surgery, Erzurum City Hospital, Erzurum 25040, Turkey;
| | - İbrahim Pir
- Department of Cardiovascular Surgery, Faculty of Medicine, Atatürk University, Erzurum 25030, Turkey; (İ.P.); (Ç.A.)
| | - Çağrı Aykut
- Department of Cardiovascular Surgery, Faculty of Medicine, Atatürk University, Erzurum 25030, Turkey; (İ.P.); (Ç.A.)
| |
Collapse
|
4
|
Pouncey AL, Loría-Rebolledo LE, Sharples L, Bicknell C, Ryan M, Powell J. Impact of patient sex on selection for abdominal aortic aneurysm repair: a discrete choice experiment. BMJ Open 2025; 15:e091661. [PMID: 40010836 PMCID: PMC11865737 DOI: 10.1136/bmjopen-2024-091661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 01/29/2025] [Indexed: 02/28/2025] Open
Abstract
OBJECTIVES Women with an abdominal aortic aneurysm (AAA) are less likely to receive elective repair than men. This study explored the effect of patient sex and other attributes on vascular surgeons' decision-making for infrarenal AAA repair. DESIGN Discrete choice experiment. SETTING Simulated environment using case scenarios with varying patient attributes. PARTICIPANTS Vascular surgeons. INTERVENTIONS Surgical decision-making. MAIN OUTCOME MEASURES AAA repair versus no repair and endovascular versus open repair. RESULTS 182 surgeons completed 2987 scenarios. When all other attributes were equal, a woman was more likely to be offered an AAA repair (marginal rate of substitution (MRS) 3.86 (95% CI 2.93, 4.79)), while very high anaesthetic risk (MRS -4.33 (95% CI -5.63, -3.03)) and hostile anatomy (MRS -3.28 (95% CI -4.55, -2.01)) were deterrents. Increasing age did not adversely affect the likelihood of offering repair to men but decreased the likelihood for women, which negated women's selection advantage from the age of 83 years. Women were also more likely to be offered endovascular repair (MRS 2.57 (95% CI 1.30, 3.84)). CONCLUSIONS Patient sex alone did not account for real-world disparity observed in selection for surgery. Rather, being a woman was associated with a higher likelihood of being offered AAA repair but also a higher likelihood of being offered less invasive endovascular repair. Increased age decreased the likelihood of surgical selection for women but not men. Preference for less invasive repair, combined with inferior rates of anatomical suitability, and the comparably older age of women at the time of AAA repair selection may account for lower rates of repair for women observed.
Collapse
Affiliation(s)
| | | | - Linda Sharples
- Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Mandy Ryan
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | |
Collapse
|
5
|
Ghoddusi Johari H, Ranjbar K, Kassaee K, Hoseini SM, Shahriarirad R. Evaluation of Aneurysm Cases Undergoing Surgery at a Tertiary Center in Iran: A 22-year Retrospective Study. Health Sci Rep 2025; 8:e70331. [PMID: 39777283 PMCID: PMC11705405 DOI: 10.1002/hsr2.70331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 10/16/2024] [Accepted: 12/19/2024] [Indexed: 01/11/2025] Open
Abstract
Background and Aims An arterial aneurysm is characterized by a localized expansion of a blood vessel relative to its original dimensions. Specifically, an abdominal aortic aneurysm (AAA) is identified as an aortic diameter measuring at least one and a half times the standard diameter at the renal artery level, approximately equivalent to 2.0 cm. In this study, we aim to evaluate the prevalence of AAA, along with the clinical features, trend, and incidence of ruptured AAA among patients undergoing surgery in our center. Methods The database of patients operated in Namazi Hospital from 2000 to 2021 was retrieved and patients undergoing vascular surgeries due to aneurysm were reviewed. All data were analyzed with SPSS version 26.0. Results A total of 599 cases of aneurysm were operated, among which 334 were contributed to the aorta and included in our study. The average age of the participants was 69.6 (SD: 12.1, range 16-93) years and 161 (85.2%) were male. The majority of cases were in the 60 to 80 years age group (n = 205; 62.5%). There was a significant association between the age groups and the AAA rupture (p = 0.003), with the highest occurrence among the above 80 years age group (n = 37, 49.3%). Regarding the location of the aneurysm, 274 were located in the infrarenal and abdominal region, 21 in the thoracoabdominal region, and 12 in the thoracic region. Among the cases in our study, 112 were cases of ruptured aneurysms. Furthermore, the age of patients with ruptured aneurysm were significantly higher compared to non-ruptured patients (71.8 vs. 68.5; p = 0.019). Conclusion We observed an increase in the incidence of AAA surgeries in our center throughout the years, with the population growing towards younger population, while the incidence of rupture increasing towards older age groups.
Collapse
Affiliation(s)
- Hamed Ghoddusi Johari
- Vascular Surgery DepartmentShiraz University of Medical SciencesShirazIran
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical SciencesShirazIran
| | - Keivan Ranjbar
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical SciencesShirazIran
- Division of Vascular Surgery, Cardiovascular CenterTufts Medical CenterBostonMassachusettsUSA
| | - Kimia Kassaee
- School of MedicineIran University of Medical SciencesTehranIran
| | | | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical SciencesShirazIran
| |
Collapse
|
6
|
Ayasa LA, Odeh A, Abuzahra S, Abd Aljalil F, Qozat A. Recurrent peripheral ischemia following endovascular repair of an infrarenal aortic aneurysm: what did we miss? J Surg Case Rep 2025; 2025:rjae823. [PMID: 39790180 PMCID: PMC11716807 DOI: 10.1093/jscr/rjae823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Accepted: 12/14/2024] [Indexed: 01/12/2025] Open
Abstract
We document a case of a 75-year-old patient with a history of hypercholesterolemia and hypertension, who underwent endovascular aortic repair (EVAR) for an infrarenal abdominal aortic aneurysm (AAA) with common iliac artery ectasia. Despite an initially successful procedure, the patient experienced recurrent episodes of acute limb ischemia in his right leg. Subsequent imaging revealed thrombus formation distal to the stent graft, constituting a potential source of embolization, which warranted a reevaluation of the treatment strategy. This case highlights some of the complexities associated with managing AAA patients. In the context of EVAR, it emphasizes the significance of careful patient selection, meticulous endograft implantation, and watchful follow-up while tailoring treatment according to individual patient needs and anatomical considerations.
Collapse
Affiliation(s)
- Laith A Ayasa
- Faculty of Medicine, Al Quds University, Mount of Olives Street 26, Sheikh Jarrah, PO Box 22246, Jerusalem 91513, Palestine
| | - Anas Odeh
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, PO Box 7, Nablus, Palestine
| | - Saad Abuzahra
- Department of Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, PO Box 7, Nablus, Palestine
| | - Fatima Abd Aljalil
- Cleveland Clinic Fairview Hospital, 18101 Lorain Ave, Cleveland, United States
| | - Ahmad Qozat
- Vascular Surgery Department, Bonifatius Hospital, Wilhelmstraße 13, 49808 Lingen, Germany
| |
Collapse
|
7
|
Alsabbagh Y, Erben Y, Vandenberg J, Farres H. New Trends of Personalized Medicine in the Management of Abdominal Aortic Aneurysm: A Review. J Pers Med 2024; 14:1148. [PMID: 39728062 DOI: 10.3390/jpm14121148] [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: 10/25/2024] [Revised: 11/30/2024] [Accepted: 12/06/2024] [Indexed: 12/28/2024] Open
Abstract
Abdominal aortic aneurysm (AAA) is a significant vascular condition characterized by the dilation of the abdominal aorta, presenting a substantial risk of rupture and associated high mortality rates. Current management strategies primarily rely on aneurysm diameter and growth rates to predict rupture risk and determine the timing of surgical intervention. However, this approach has limitations, as ruptures can occur in smaller AAAs below surgical thresholds, and many large AAAs remain stable without intervention. This review highlights the need for more precise and individualized assessment tools that integrate biomechanical parameters such as wall stress, wall strength, and hemodynamic factors. Advancements in imaging modalities like ultrasound elastography, computed tomography (CT) angiography, and magnetic resonance imaging (MRI), combined with artificial intelligence, offer enhanced capabilities to assess biomechanical indices and predict rupture risk more accurately. Incorporating these technologies can lead to personalized medicine approaches, improving decision-making regarding the timing of interventions. Additionally, emerging treatments focusing on targeted delivery of therapeutics to weakened areas of the aortic wall, such as nanoparticle-based drug delivery, stem cell therapy, and gene editing techniques like CRISPR-Cas9, show promise in strengthening the aortic wall and halting aneurysm progression. By validating advanced screening modalities and developing targeted treatments, the future management of AAA aims to reduce unnecessary surgeries, prevent ruptures, and significantly improve patient outcomes.
Collapse
Affiliation(s)
- Yaman Alsabbagh
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Jonathan Vandenberg
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL 32224, USA
| |
Collapse
|
8
|
Clauss N, Kuntz S, Colvard B, Ohana M, Mertz L, Lejay A, Chakfe N. Intraoperative Staff Radiation Exposure During Aortic Endovascular Procedures. Ann Vasc Surg 2024; 106:16-24. [PMID: 38641000 DOI: 10.1016/j.avsg.2024.01.004] [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: 11/09/2023] [Revised: 12/30/2023] [Accepted: 01/01/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND The risk of radiation exposure in the surgical operating room (OR) and/or catheterization laboratory is now well established. Complex endovascular procedures often require multiple approaches and different positioning of the staff members around the patient, potentially increasing the levels of radiations exposure. Our goal was to evaluate the levels of radiation exposure of the members of the staff during endovascular aortic procedures in order to propose radioprotection optimization. METHODS We included 41 aortic endovascular procedures out of 114 procedures performed between January 12, 2014, and August 31, 2015, including 24 standard endovascular aortic aneurysm repair (EVAR), 7 EVAR with iliac branch (EVARib), 8 complex fenestrated/branched EVAR (F/B EVAR), and 2 thoracic EVAR (TEVAR). Procedures were performed in an OR equipped with a carbon fiber table and a mobile fluoroscopy C-arm. We collected the usual dosimetry data given by the C-arm as well as the patient's peak skin dose (PSD). In all staff members, radiation exposure was measured with thermoluminescent chip dosimeters placed on both temples, on posterior sides of both hands, and on both lower legs. RESULTS PSD levels were low for EVAR because 24 patients had values below the reading threshold. PSD significantly increased with more complex procedures. Main operator (MO) received the higher level of irradiation on whole body, hands, and ankles. Eye lenses irradiation was higher on both assistant operators (AOs). Other members received low levels of irradiation. We found a high ranges of radiation exposure with a high risk of exposure for the AO, mainly for F/B EVAR and EVARib. CONCLUSIONS Even if all personal protections are used, staff positioning is a major point that must be considered. If MO is supposed to be the most exposed to X-rays, specific conditions of positioning of the AO may be at risk of exposure.
Collapse
Affiliation(s)
- Nicolas Clauss
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Salomé Kuntz
- GEPROMED, Strasbourg, France; Department of Vascular Surgery and Kidney Transplantation, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Benjamin Colvard
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH
| | - Mickael Ohana
- Department of Radiology, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Luc Mertz
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Anne Lejay
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France; GEPROMED, Strasbourg, France; Fédération de Médecine Translationelle (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d'Accueil EA3072 "Mitochondrie, Stress Oxydant et Protection Musculaire", Université de Strasbourg, Strasbourg, France
| | - Nabil Chakfe
- Unit of Radiophysic and Radioprotection, Les Hôpitaux Universitaires de Strasbourg, University of Strasbourg, Strasbourg, France; GEPROMED, Strasbourg, France; Fédération de Médecine Translationelle (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d'Accueil EA3072 "Mitochondrie, Stress Oxydant et Protection Musculaire", Université de Strasbourg, Strasbourg, France.
| |
Collapse
|
9
|
Pherwani AD, Johal AS, Cromwell DA, Boyle JR, Szeberin Z, Venermo M, Beiles B, Khashram M, Lattmann T, Altreuther ME, Laxdal E, Behrendt CA, Mani K, Budtz-Lilly J. Editor's Choice - Outcomes Following Intact and Ruptured Aneurysm Repair across Nations: Analysis of International Registry Data from the VASCUNET Collaboration 2014 - 2019. Eur J Vasc Endovasc Surg 2024; 68:162-170. [PMID: 38382695 DOI: 10.1016/j.ejvs.2024.02.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To determine the peri-operative mortality rate for intact and ruptured abdominal aortic aneurysm (AAA) repair in 10 countries and to compare practice and outcomes over a six year period by age, sex, and geographic location. METHODS This VASCUNET study used prospectively collected data from vascular registries in 10 countries on primary repair of intact and ruptured AAAs undertaken between January 2014 and December 2019. The primary outcome was peri-operative death (30 day or in hospital). Logistic regression models were used to estimate the association between peri-operative death, patient characteristics, and type of procedure. Factors associated with the use of endovascular aortic aneurysm repair (EVAR) were also evaluated. RESULTS The analysis included 50 642 intact and 9 453 ruptured AAA repairs. The proportion of EVARs for intact repairs increased from 63.4% in 2014 to 67.3% in 2016 before falling to 62.3% in 2019 (p < .001), but practice varied between countries. EVAR procedures were more common among older patients (p < .001) and men (p < .001). Overall peri-operative mortality after intact AAA repair was 1.4% (95% confidence interval [CI] 1.3 - 1.5%) and did not change over time. Mortality rates were stable within countries. Among ruptured AAA repairs, the proportion of EVARs increased from 23.7% in 2014 to 35.2% in 2019 (p < .001). The average aortic diameter was 7.8 cm for men and 7.0 cm for women (p < .001). The overall peri-operative mortality rate was 31.3% (95% CI 30.4 - 32.2%); the rates were 36.0% (95% CI 34.9 - 37.2%) for open repair and 19.7% (95% CI 18.2 - 21.3%) for EVAR. This difference and shift to EVAR reduced peri-operative mortality from 32.6% (in 2014) to 28.7% (in 2019). CONCLUSION The international practice of intact AAA repair was associated with low mortality rates in registry reported data. There remains variation in the use of EVAR for intact AAAs across countries. Overall peri-operative mortality remains high after ruptured AAA, but an increased use of EVAR has reduced rates over time.
Collapse
Affiliation(s)
- Arun D Pherwani
- Keele University School of Medicine, Department of Vascular Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK.
| | - Amundeep S Johal
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK. http://www.twitter.com/vsqip
| | | | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust and Department of Surgery, University of Cambridge, Cambridge, UK. http://www.twitter.com/Jonnyboyle1
| | - Zoltan Szeberin
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland. http://www.twitter.com/VenerMa
| | - Barry Beiles
- Australasian Vascular Audit, Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - Manar Khashram
- University of Auckland, Waikato Hospital, Hamilton, New Zealand. http://www.twitter.com/ManarKhashram
| | - Thomas Lattmann
- Swissvasc Registry, Clinic for Interventional Radiology and Vascular Surgery, Kantonsspital Winterthur, Winterthur, Switzerland. http://www.twitter.com/LattmannThomas
| | - Martin E Altreuther
- Section of Vascular Surgery, Department of Surgery, St Olavs Hospital, and Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Elin Laxdal
- Department of Vascular Surgery, Landspitalinn University Hospital, Reykjavik, Iceland
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany. http://www.twitter.com/VASCevidence
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden. http://www.twitter.com/KevinMani7
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
10
|
Pouncey AL, Meuli L, Lopez-Espada C, Budtz-Lilly J, Boyle JR, Behrendt CA, Mani K, Pherwani AD. Editor's Choice - Vascular Registries Contributing to VASCUNET Collaborative Abdominal Aortic Aneurysm Outcome Projects: A Scoping Review. Eur J Vasc Endovasc Surg 2024; 68:152-160. [PMID: 38697257 DOI: 10.1016/j.ejvs.2024.04.037] [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: 02/13/2024] [Revised: 04/06/2024] [Accepted: 04/25/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVE Vascular surgery registries report on procedures and outcomes to promote patient safety and drive quality improvement. International registries have contributed significantly to the VASCUNET collaborative abdominal aortic aneurysm (AAA) outcome projects. This scoping review aimed to outline the national registries in vascular surgery that currently participate in the VASCUNET collaborative AAA projects. METHODS A scoping review of all published VASCUNET AAA studies and validation reports between 1997 and 2024 was undertaken. A survey was conducted among representatives of the international vascular registries contributing to VASCUNET collaborative AAA projects. RESULTS Currently, vascular registries from 10 countries (Australia, Denmark, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, Switzerland, and the UK) contribute to the current VASCUNET collaborative AAA project, of which eight have national coverage. In the past, three countries (Germany, Malta, and Italy) have participated in previous VASCUNET AAA projects, and a further three countries (Serbia, Greece, and Portugal) have planned participation in future projects. External validity is high for all current registries, with most reporting rates of > 90%. The majority have internal validation processes to assess data accuracy. VASCUNET mediated validation has also been performed by the consortium for five countries to date (Hungary, Sweden, Denmark, Malta, and Switzerland), for which a high degree of external and internal validity was identified. Most registries have established mechanisms for data linkage with national administrative datasets or insurance claims datasets and contribute to quality improvement through regular reporting to participating centres. CONCLUSION National vascular registries from nations participating in the VASCUNET collaborative AAA projects are largely comprehensive, with high case ascertainment rates and good quality data with internal quality assurance. This provides a template for new registries wishing to join the VASCUNET collaboration and a benchmark for future research.
Collapse
Affiliation(s)
- Anna L Pouncey
- Vascular Department, Division of Surgery and Cancer, Imperial College London, London, UK
| | - Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zurich (USZ), University of Zurich (UZH), Zurich, Switzerland; Copenhagen Aortic Centre, Department of Vascular Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Cristina Lopez-Espada
- Department of Surgery, University Hospital Virgen de las Nieves, University of Granada, Granada, Spain
| | - Jacob Budtz-Lilly
- Division of Vascular Surgery, Department of Cardiovascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular surgery, Uppsala University, Uppsala, Sweden
| | - Arun D Pherwani
- Keele University School of Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK; The National Vascular Registry (NVR), UK.
| |
Collapse
|
11
|
Dumausé M, Mouillard M, Balézeaux Q, Ducasse E, Caradu C, Vincent YM. Creation of a Shared Medical Decision Support Tool for the Management of Abdominal Aortic Aneurysms. Ann Vasc Surg 2024; 105:373-381. [PMID: 38614258 DOI: 10.1016/j.avsg.2024.03.003] [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: 12/04/2023] [Revised: 03/05/2024] [Accepted: 03/08/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Patients with unruptured abdominal aortic aneurysm (AAA) at the surgical threshold may benefit from aneurysmal exclusion either by open surgery or endovascular repair. A patient decision aid (PtDA) could be useful to help patients and their surgeons choose between the 2 techniques. The aim of this study was to develop a shared medical decision support tool, in french language, for the surgical treatment of AAA. METHODS Following the steps recommended by the International Patient Decision Aids Standards, we carried out a qualitative study using semi-structured interviews with patients and vascular surgeons and focus group with patients to identify their main points of interest. After analyzing the interviews using grounded theory with independent double coding, the verbatims were discussed at a steering committee, at the end of which a prototype of the tool was created. RESULTS Four surgeons and 14 patients were interviewed. No new codes emerged from the last 2 interviews. At the end of the steering committee meeting, the information selected for inclusion in the PtDA tool were the definition of an AAA, a description of the 2 surgical techniques (approach, duration of operation), the main complications, the peri-operative mortality rate, and postoperative follow-up (length of hospital stay, monitoring frequency, and risk of re-intervention). It had to be produced on a synthetic paper format, with 6 illustrations and a simple vocabulary. CONCLUSIONS We developed a PtDA tool for use in a sharing decision making process with the patient during consultation with the vascular surgeon and the general practitioner. Further studies are needed to validate the tool and to test it in clinical practice.
Collapse
Affiliation(s)
- Marie Dumausé
- Department of General Medicine, University of Bordeaux - College of Health Sciences, Bordeaux, France.
| | - Marie Mouillard
- Department of General Medicine, University of Bordeaux - College of Health Sciences, Bordeaux, France
| | - Quentin Balézeaux
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Eric Ducasse
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Caroline Caradu
- Department of Vascular Surgery, Bordeaux University Hospital, Bordeaux, France
| | - Yves-Marie Vincent
- Department of General Medicine, University of Bordeaux - College of Health Sciences, Bordeaux, France
| |
Collapse
|
12
|
Menyhei G, Andréka P, Csobay-Novák C, Kolossváry E, Kováts T, Palásthy Z, Szeberin Z. [Vascular Registry is a tool for quality improvement in vascular medicine]. Orv Hetil 2024; 165:950-954. [PMID: 38888970 DOI: 10.1556/650.2024.33074] [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: 04/13/2024] [Accepted: 04/23/2024] [Indexed: 06/20/2024]
Abstract
A 2002 óta működő Érsebészeti Regiszter kezdetben verőérműtétek adatainak
gyűjtéséből és a beavatkozások eredményeinek elemzéséből állt. Nagy előrelépést
jelentett 2006-ban az Európai Érsebész Társaság VASCUNET Munkacsoportjához
történő csatlakozás, mely szervezet azóta globális nemzetközi tudományos
együttműködéssé fejlődött. A hazai regiszter adatainak felhasználásával az
elmúlt 15 évben számos nagy nemzetközi tanulmányt folytattunk le, és ezek
alapján több mint 30 publikáció jelent meg, melyekben aktív szerepet vállaltak a
Magyar Angiológiai és Érsebészeti Társaság Regiszter Bizottságának tagjai is. Az
egyes országok vascularis ellátásának jellemzőit és eredményeit összehasonlító
tanulmányok különösen hasznos következtetések levonását tették lehetővé, ami
hozzájárulhat vascularis ellátórendszerünk fejlődéséhez. Az újonnan létrehozott
Nemzeti Vaszkuláris Regiszter további jelentősége, hogy a tudományos elemző
tevékenység mellett fontos szerepet játszhat az érgyógyászati
minőségfejlesztésben is. Orv Hetil. 2024; 165(24–25): 950–954.
Collapse
Affiliation(s)
- Gábor Menyhei
- 1 Pécsi Tudományegyetem, Általános Orvostudományi Kar, Érsebészeti Klinika Pécs, Ifjúság útja 13., 7624 Magyarország
| | - Péter Andréka
- 2 Gottsegen György Országos Kardiovaszkuláris Intézet Budapest Magyarország
| | - Csaba Csobay-Novák
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Intervenciós Radiológiai Tanszék Budapest Magyarország
| | - Endre Kolossváry
- 4 Dél-budai Centrumkórház Szent Imre Egyetemi Oktatókórház, Belgyógyászat, Angiológiai Profil Budapest Magyarország
| | - Tamás Kováts
- 5 Semmelweis Egyetem, Egészségügyi Menedzserképző Központ Budapest Magyarország
| | - Zsolt Palásthy
- 6 Szegedi Tudományegyetem, Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Érsebészeti Profil Szeged Magyarország
| | - Zoltán Szeberin
- 7 Semmelweis Egyetem, Általános Orvostudományi Kar, Városmajori Szív- és Érgyógyászati Klinika, Érsebészeti és Endovaszkuláris Tanszék Budapest Magyarország
| |
Collapse
|
13
|
Gilmore BF, Scali ST, D’Oria M, Neal D, Schermerhorn ML, Huber TS, Columbo JA, Stone DH. Temporal Trends and Outcomes of Abdominal Aortic Aneurysm Care in the United States. Circ Cardiovasc Qual Outcomes 2024; 17:e010374. [PMID: 38775052 PMCID: PMC11187661 DOI: 10.1161/circoutcomes.123.010374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/08/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR) has had a dynamic impact on abdominal aortic aneurysm (AAA) care, often supplanting open AAA repair (OAR). Accordingly, US AAA management is often highlighted by disparities in patient selection and guideline compliance. The purpose of this analysis was to define secular trends in AAA care. METHODS The Society for Vascular Surgery Vascular Quality Initiative was queried for all EVARs and OARs (2011-2021). End points included procedure utilization, change in mortality, patient risk profile, Society for Vascular Surgery-endorsed diameter compliance, off-label EVAR use, cross-clamp location, blood loss, in-hospital complications, and post-EVAR surveillance missingness. Linear regression was used without risk adjustment for all end points except for mortality and complications, for which logistic regression with risk adjustment was used. RESULTS In all, 66 609 EVARs (elective, 85% [n=55 805] and nonelective, 15% [n=9976]) and 13 818 OARs (elective, 70% [n=9706] and nonelective, 30% [n=4081]) were analyzed. Elective EVAR:OAR ratios were increased (0.2 per year [95% CI, 0.01-0.32]), while nonelective ratios were unchanged. Elective diameter threshold noncompliance decreased for OAR (24%→17%; P=0.01) but not EVAR (mean, 37%). Low-risk patients increasingly underwent elective repairs (EVAR, +0.4%per year [95% CI, 0.2-0.6]; OAR, +0.6 points per year [95% CI, 0.2-1.0]). Off-label EVAR frequency was unchanged (mean, 39%) but intraoperative complications decreased (0.5% per year [95% CI, 0.2-0.9]). OAR complexity increased reflecting greater suprarenal cross-clamp rates (0.4% per year [95% CI, 0.1-0.8]) and blood loss (33 mL/y [95% CI, 19-47]). In-hospital complications decreased for elective (0.7% per year [95% CI, 0.4-0.9]) and nonelective EVAR (1.7% per year [95% CI, 1.1-2.3]) but not OAR (mean, 42%). A 30-day mortality was unchanged for both elective OAR (mean, 4%) and EVAR (mean, 1%). Among nonelective OARs, an increase in both 30-day (0.8% per year [95% CI, 0.1-1.5]) and 1-year mortality (0.8% per year [95% CI, 0.3-1.6]) was observed. Postoperative EVAR surveillance acquisition decreased (67%→49%), while 1-year mortality among patients without imaging was 4-fold greater (9.2% versus imaging, 2.0%; odds ratio, 4.1 [95% CI, 3.8-4.3]; P<0.0001). CONCLUSIONS There has been an increase in EVAR and a corresponding reduction in OAR across the United States, despite established concerns surrounding guideline adherence, reintervention, follow-up, and cost. Although EVAR morbidity has declined, OAR complication rates remain unchanged and unexpectedly high. Opportunities remain for improving AAA care delivery, patient and procedure selection, guideline compliance, and surveillance.
Collapse
Affiliation(s)
- Brian F. Gilmore
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Salvatore T. Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Mario D’Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas S. Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, Florida, USA
| | - Jesse A. Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - David H. Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| |
Collapse
|
14
|
Gormley S, Bernau O, Xu W, Khashram M. Propensity score analysis demonstrates no long term survival benefit from contemporary endovascular aneurysm repair compared to open in Aotearoa New Zealand. ANZ J Surg 2024; 94:819-825. [PMID: 38131414 DOI: 10.1111/ans.18815] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 11/20/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Current guidelines for AAA management are based on landmark trials comparing EVAR and open aneurysm repair (OAR) conducted more than 20 years ago. Important advancements have been made in peri-operative care but the impact of EVAR and OAR on long-term patient survival has not been well reported using contemporary data. The objective of this study was to compare the short and long-term outcomes of OAR and EVAR in the recent era. METHODS This retrospective observational study included all patients undergoing intact AAA repair in NZ from 1st of January 2011 until 31st of December 2019. Data was collected from national administrative and clinical vascular databases and matched using unique identifiers. Time-to-event survival analyses was conducted using cox proportional hazard models to adjust for confounders and propensity score matching were used. RESULTS Two thousand two hundred and ninety-seven patients had an intact AAA repair with a median (IQR) age of 75 (69-80) years; 494 (21.2%) patients were females and 1206 (53%) underwent EVAR. The 30-day mortality for OAR and EVAR was 4.8% and 1.2%. The median (IQR) follow up was 5.2 (2.3-9.2) years. After propensity matching for co-variates, the study cohort consisted of 835 patients in each matched group. Patients undergoing EVAR had a higher overall mortality (HR 1.48 (95% CI: 1.26-1.74) after adjusting for confounders compared to OAR. CONCLUSION Analysis of survival following EVAR and OAR in the current era demonstrates that patients that underwent EVAR had a lower 30-day mortality. However, in the long-term after adjusting for confounders OAR had a better overall survival.
Collapse
Affiliation(s)
- Sinead Gormley
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Oliver Bernau
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - William Xu
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Manar Khashram
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| |
Collapse
|
15
|
Williams T, Jansen S, Golledge J, Beck A, Benson R, Lyons O. Support For a Randomised Trial of Early Endovascular Aortic Aneurysm Repair in Women in New Zealand, Australia, and America. Eur J Vasc Endovasc Surg 2024; 67:848-849. [PMID: 38346556 DOI: 10.1016/j.ejvs.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/13/2024] [Accepted: 02/07/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Thomas Williams
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Shirley Jansen
- Curtin Medical School, Curtin University, Perth, WA, Australia; Heart and Vascular Research Institute, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Jon Golledge
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University, Townsville, Qld, Australia
| | - Adam Beck
- Division of Vascular Surgery and Endovascular Therapy, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ruth Benson
- Department of Surgery, University of Otago, Christchurch, New Zealand
| | - Oliver Lyons
- Department of Surgery, University of Otago, Christchurch, New Zealand.
| |
Collapse
|
16
|
Behrendt CA, Heckenkamp J, Bergsträßer A, Billing A, Böckler D, Bücker A, Cotta L, Donas KP, Grözinger G, Heidecke CD, Hinterseher I, Horn S, Kaltwasser A, Kiefer A, Kirnich-Müller C, Kock L, Kölbel T, Czerny M, Kralewski C, Kurz S, Larena-Avellaneda A, Mutlak H, Oberhuber A, Oikonomou K, Pfeiffer M, Pfister K, Reeps C, Schäfer A, Schmitz-Rixen T, Steinbauer M, Steinbauer C, Strupp D, Stolecki D, Trenner M, Veit C, Verhoeven E, Waydhas C, Weber CF, Adili F. [Recommendations for the specialist further training of nursing personnel on intensive care units in the treatment of abdominal aortic aneurysms: results of a modified Delphi procedure with experts]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:395-405. [PMID: 38498123 PMCID: PMC11031449 DOI: 10.1007/s00104-024-02066-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION The medical development in the previous 15 years and the changes in treatment reality of the comprehensive elective treatment of abdominal aortic aneurysms necessitate a re-evaluation of the quality assurance guidelines of the Federal Joint Committee in Germany (QBAA-RL). In the current version this requires a specialist further training quota for nursing personnel in intensive care wards of 50%. The quota was determined in 2008 based on expert opinions, although a direct empirical evidence base for this does not exist. METHODS Representatives from the fields of patient representation, physicians, nursing personnel and other relevant interface areas were invited to participate in a modified Delphi procedure. Following a comprehensive narrative literature search, a survey and focus group discussions with national and international experts, a total of three anonymized online-based voting rounds were carried out for which previously determined key statements were assessed with a 4‑point Likert scale (totally disagree up to totally agree). In addition, the expert panel had also defined a recommendation for a minimum quota for the specialist training of nursing personnel on intensive care wards in the treatment of abdominal aortic aneurysms, whereby an a priori agreement of 80% of the participants was defined as the consensus limit. RESULTS Overall, 37 experts participated in the discussions and three successive voting rounds (participation rate 89%). The panel confirmed the necessity of a re-evaluation of the guideline recommendations and recommended the introduction of a shift-related minimum quota of 30% of the full-time equivalent of nursing personnel on intensive care wards and the introduction of structured promotional programs for long-term elevation of the quota. CONCLUSION In this national Delphi procedure with medical and nursing experts as well as representatives of patients, the fundamental benefits and needs of professional specialist qualifications in the field of intensive care medicine were confirmed. The corresponding minimum quota for specialist further training of intensive care nursing personnel should generally apply without limitations to specific groups. The expert panel stipulates a shift-related minimum quota for intensive care nursing personnel with specialist training of 30% of the nursing personnel on intensive care wards and the obligatory introduction of structured and transparent promotion programs for the long-term enhancement.
Collapse
Affiliation(s)
- Christian-Alexander Behrendt
- Deutsches Institut für Gefäßmedizinische Gesundheitsforschung gGmbH, Berlin, Deutschland.
- Abt. für Allgemeine und Endovaskuläre Gefäßchirurgie, Asklepios Klinik Wandsbek, Asklepios Medical School, Alphonsstr. 14, 22043, Hamburg, Deutschland.
| | | | | | - Arend Billing
- Kommission Krankenhausökonomie, Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin e. V., Berlin, Deutschland
| | - Dittmar Böckler
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Arno Bücker
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Livia Cotta
- Deutsches Institut für Gefäßmedizinische Gesundheitsforschung gGmbH, Berlin, Deutschland
| | - Konstantinos P Donas
- Rhein Main Vascular Center, Klinik für vaskuläre und endovaskuläre Chirurgie, Asklepios Kliniken Langen, Paulinen Wiesbaden und Seligenstadt, Langen, Deutschland
| | - Gerd Grözinger
- Abt. für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Claus-Dieter Heidecke
- Institut für Qualität und Transparenz im Gesundheitswesen (IQTIG), Berlin, Deutschland
| | - Irene Hinterseher
- Klinik für Gefäßchirurgie, Universitätsklinikum Ruppin-Brandenburg, Medizinische Hochschule Brandenburg, Neuruppin, Deutschland
| | - Silvio Horn
- Gefäßchirurgie, Alexianer St. Josefs Krankenhaus Potsdam, Potsdam, Deutschland
| | - Arnold Kaltwasser
- Sektion Pflegeforschung und Pflegequalität, Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin e. V., Berlin, Deutschland
| | - Andrea Kiefer
- Deutscher Berufsverband für Pflegeberufe (DBfK) Bundesverband e. V., Berlin, Deutschland
| | | | - Lars Kock
- Klinik für Gefäßchirurgie, Immanuel Albertinen Diakonie, Hamburg, Deutschland
| | - Tilo Kölbel
- Klinik für Gefäßmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Martin Czerny
- Abteilung für Herz- und Gefäßchirurgie, Universitätsklinikum Freiburg, Freiburg, Deutschland
- Medizinische Fakultät, Albert Ludwigs Universität Freiburg, Freiburg, Deutschland
| | - Christian Kralewski
- Kompetenz-Centrum Qualitätssicherung (KCQ), Medizinischer Dienst Baden-Württemberg, Tübingen, Deutschland
| | - Stephan Kurz
- Klinik für Herz‑, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum der Charité (DHZC), Berlin, Deutschland
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Deutschland
| | - Axel Larena-Avellaneda
- Abteilung für Gefäß- und endovaskuläre Chirurgie, Asklepios Klinik Altona, Asklepios Medical School, Hamburg, Deutschland
| | - Haitham Mutlak
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, SANA Klinikum Offenbach, Offenbach, Deutschland
| | - Alexander Oberhuber
- Klinik für Vaskuläre und Endovaskuläre Chirurgie, Uniklinik Münster, Münster, Deutschland
| | - Kyriakos Oikonomou
- Abteilung für Gefäß- und Endovaskularchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Manfred Pfeiffer
- Interessenvertretung Patienten-&-Versicherte, Sörgenloch, Deutschland
| | - Karin Pfister
- Universitäres Gefäßzentrum Ostbayern, Abteilung für Gefäßchirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Christian Reeps
- Bereich Gefäß- und Endovaskuläre Chirurgie, Uniklinikum Dresden, Dresden, Deutschland
| | - Andreas Schäfer
- Deutsche Gesellschaft für Pflegewissenschaft e. V., Duisburg, Deutschland
| | | | - Markus Steinbauer
- Klinik für Gefäßchirurgie, Gefäßzentrum, Barmherzige Brüder Regensburg, Regensburg, Deutschland
| | - Claudia Steinbauer
- Katholische Akademie für Berufe im Gesundheits- und Sozialwesen, Regensburg, Deutschland
| | - Daniel Strupp
- Intensivpflege, Asklepios Klinik Wandsbek, Hamburg, Deutschland
| | - Dietmar Stolecki
- Deutsche Gesellschaft für Fachkrankenpflege und Funktionsdienste e. V., Berlin, Deutschland
| | | | | | - Eric Verhoeven
- Klinikum Nürnberg und Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - Christian Waydhas
- Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin e. V., Berlin, Deutschland
- Klinik Für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Christian F Weber
- Abteilung für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Klinik Wandsbek, Hamburg, Deutschland
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Frankfurt, Frankfurt am Main, Deutschland
| | - Farzin Adili
- Klinik für Gefäßmedizin, Gefäßchirurgie und Endovaskuläre Chirurgie, Klinikum Darmstadt, Darmstadt, Deutschland
| |
Collapse
|
17
|
Png CYM, Pendleton AA, Altreuther M, Budtz-Lilly JW, Gunnarsson K, Kan CD, Khashram M, Laine MT, Mani K, Pederson CC, Srivastava SD, Eagleton MJ. Effect of EVAR on International Ruptured AAA Mortality-Sex and Geographic Disparities. J Clin Med 2024; 13:2464. [PMID: 38730993 PMCID: PMC11084331 DOI: 10.3390/jcm13092464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/04/2024] [Accepted: 04/12/2024] [Indexed: 05/13/2024] Open
Abstract
Background: We sought to investigate the differential impact of EVAR (endovascular aneurysm repair) vis-à-vis OSR (open surgical repair) on ruptured AAA (abdominal aortic aneurysm) mortality by sex and geographically. Methods: We performed a retrospective study of administrative data on EVAR from state statistical agencies, vascular registries, and academic publications, as well as ruptured AAA mortality rates from the World Health Organization for 14 14 states across Australasia, East Asia, Europe, and North America. Results: Between 2011-2016, the proportion of treatment of ruptured AAAs by EVAR increased from 26.1 to 43.8 percent among females, and from 25.7 to 41.2 percent among males, and age-adjusted ruptured AAA mortality rates fell from 12.62 to 9.50 per million among females, and from 34.14 to 26.54 per million among males. The association of EVAR with reduced mortality was more than three times larger (2.2 vis-à-vis 0.6 percent of prevalence per 10 percentage point increase in EVAR) among females than males. The association of EVAR with reduced mortality was substantially larger (1.7 vis-à-vis 1.1 percent of prevalence per 10 percentage point increase in EVAR) among East Asian states than European+ states. Conclusions: The increasing adoption of EVAR coincided with a decrease in ruptured AAA mortality. The relationship between EVAR and mortality was more pronounced among females than males, and in East Asian than European+ states. Sex and ethnic heterogeneity should be further investigated.
Collapse
Affiliation(s)
- C. Y. Maximilian Png
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - A. Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Martin Altreuther
- Department of Vascular Surgery, St. Olavs Hospital, 7030 Trondheim, Norway
| | - Jacob W. Budtz-Lilly
- Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Skejby, 8200 Aarhus, Denmark
| | - Kim Gunnarsson
- Department of Surgical Sciences, Uppsala University, 75237 Uppsala, Sweden
| | - Chung-Dann Kan
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 701, Taiwan;
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland 1010, New Zealand
| | - Matti T. Laine
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, 00029 Helsinki, Finland;
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, 75237 Uppsala, Sweden
| | | | - Sunita D. Srivastava
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Matthew J. Eagleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02114, USA
| |
Collapse
|
18
|
Arnaoutakis DJ, Pavlock SM, Neal D, Thayer A, Asirwatham M, Shames ML, Beck AW, Schanzer A, Stone DH, Scali ST. A dedicated risk prediction model of 1-year mortality following endovascular aortic aneurysm repair involving the renal-mesenteric arteries. J Vasc Surg 2024; 79:721-731.e6. [PMID: 38070785 DOI: 10.1016/j.jvs.2023.12.002] [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: 10/17/2023] [Revised: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE Treatment goals of prophylactic endovascular aortic repair of complex aneurysms involving the renal-mesenteric arteries (complex endovascular aortic repair [cEVAR]) include achieving both technical success and long-term survival benefit. Mortality within the first year after cEVAR likely indicates treatment failure owing to associated costs and procedural complexity. Notably, no validated clinical decision aid tools exist that reliably predict mortality after cEVAR. The purpose of this study was to derive and validate a preoperative prediction model of 1-year mortality after elective cEVAR. METHODS All elective cEVARs including fenestrated, branched, and/or chimney procedures for aortic disease extent confined proximally to Ishimaru landing zones 6 to 9 in the Society for Vascular Surgery Vascular Quality Initiative were identified (January 2012 to August 2023). Patients (n = 4053) were randomly divided into training (n = 3039) and validation (n = 1014) datasets. A logistic regression model for 1-year mortality was created and internally validated by bootstrapping the AUC and calibration intercept and slope, and by using the model to predict 1-year mortality in the validation dataset. Independent predictors were assigned an integer score, based on model beta-coefficients, to generate a simplified scoring system to categorize patient risk. RESULTS The overall crude 1-year mortality rate after elective cEVAR was 11.3% (n = 456/4053). Independent preoperative predictors of 1-year mortality included chronic obstructive pulmonary disease, chronic renal insufficiency (creatinine >1.8 mg/dL or dialysis dependence), hemoglobin <12 g/dL, decreasing body mass index, congestive heart failure, increasing age, American Society of Anesthesiologists class ≥IV, current tobacco use, history of peripheral vascular intervention, and increasing extent of aortic disease. The 1-year mortality rate varied from 4% among the 23% of patients classified as low risk to 23% for the 24% classified as high risk. Performance of the model in validation was comparable with performance in the training data. The internally validated scoring system classified patients roughly into quartiles of risk (low, low/medium, medium/high and high), with 52% of patients categorized as medium/high to high risk, which had corresponding 1-year mortality rates of 11% and 23%, respectively. Aneurysm diameter was below Society for Vascular Surgery recommended treatment thresholds (<5.0 cm in females, <5.5 cm in males) in 17% of patients (n = 679/3961), 41% of whom were categorized as medium/high or high risk. This subgroup had significantly increased in-hospital complication rates (18% vs 12%; P = .02) and 1-year mortality (13% vs 5%; P < .0001) compared with patients in the low- or low/medium-risk groups with guideline-compliant aneurysm diameters (≥5.0 cm in females, ≥5.5 cm in males). CONCLUSIONS This validated preoperative prediction model for 1-year mortality after cEVAR incorporates physiological, functional, and anatomical variables. This novel and simplified scoring system can effectively discriminate mortality risk and, when applied prospectively, may facilitate improved preoperative decision-making, complex aneurysm care delivery, and resource allocation.
Collapse
Affiliation(s)
- Dean J Arnaoutakis
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL.
| | - Samantha M Pavlock
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - Angelyn Thayer
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Mark Asirwatham
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Murray L Shames
- Division of Vascular Surgery, University of South Florida College of Medicine, Tampa, FL
| | - Adam W Beck
- Division of Vascular Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Andres Schanzer
- Division of Vascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| |
Collapse
|
19
|
Yunus RA, Saeed S, Levy N, Di Fenza R, Sharkey A, Pobywajlo S, Liang P, Schermerhorn M, Mahmood F, Matyal R, Neves S. A Multidisciplinary Protocolized Approach for Ruptured Abdominal Aortic Aneurysm Management: A Retrospective Before-After Study. J Cardiothorac Vasc Anesth 2024; 38:755-770. [PMID: 38220517 DOI: 10.1053/j.jvca.2023.12.015] [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: 09/07/2023] [Revised: 12/01/2023] [Accepted: 12/11/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES To investigate whether implementation of a multidisciplinary protocol for ruptured abdominal aortic aneurysm (rAAA) management reduces rates of adverse complications. DESIGN A retrospective before-after study. SETTING A tertiary-care academic hospital. PARTICIPANTS Adult patients who underwent open or endovascular rAAA repair; data were stratified into before-protocol implementation (group 1: 2015-2018) and after-protocol implementation (group 2: 2019-2022) groups. INTERVENTION The protocol details the workflow for vascular surgery, anesthesia, emergency department, and operating room staff for a rAAA case; training was accomplished through yearly workshops. MEASUREMENTS AND MAIN RESULTS The primary outcome was in-hospital mortality. Secondary outcomes included all-cause morbidity and other major complications. Differences in postoperative complication rates between groups were assessed using Pearson's χ2 test. Of the 77 patients included undergoing rAAA repair, 41 (53.2%) patients were in group 1, and 36 (46.8%) patients were in group 2. Patients in group 2 had a significantly shorter median time to incision (1.0 v 0.7 hours, p = 0.022) and total procedure time (180.0 v 160.5 minutes, p = 0.039) for both endovascular and open repair. After protocol implementation, patients undergoing endovascular repair exhibited significantly lower rates of mortality (46.2% v 20.0%, p = 0.048), all-cause morbidity (65.4% v 44.0%, p = 0.050), and renal complications (15.4% v 0.0%, p = 0.036); patients undergoing open repair for a rAAA exhibited significantly lower rates of mortality (53.3% v 27.3%, p = 0.018) and bowel ischemia (26.7% v 0.0%, p = 0.035). CONCLUSIONS Implementation of a multidisciplinary protocol for the management of a rAAA may reduce rates of adverse complications and improve the quality of care.
Collapse
Affiliation(s)
- Rayaan A Yunus
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Shirin Saeed
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nadav Levy
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Raffaele Di Fenza
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Aidan Sharkey
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Susan Pobywajlo
- The CardioVascular Institute, Beth Israel Deaconess Medical Center, Boston, MA
| | - Patric Liang
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Marc Schermerhorn
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Sara Neves
- Department of Anesthesia, Critical Care & Pain Medicine Department, Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
20
|
Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 338] [Impact Index Per Article: 338.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
Collapse
|
21
|
Scali S, Wanhainen A, Neal D, Debus S, Mani K, Behrendt CA, D'Oria M, Stone D. Conflicting European and North American Society Abdominal Aortic Aneurysm (AAA) Volume Guidelines Differentially Discriminate Peri-operative Mortality After Elective Open AAA Repair. Eur J Vasc Endovasc Surg 2023; 66:756-764. [PMID: 37573937 DOI: 10.1016/j.ejvs.2023.08.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/14/2023] [Accepted: 08/07/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) guidelines endorse a minimum abdominal aortic aneurysm (AAA) repair volume of 20 open (OAR) and or endovascular (EVAR) AAA repair procedures per year as a proxy for high quality care. In contrast, the Society for Vascular Surgery (SVS) espouses 10 exclusively OARs per year. Given the differences in these volume standards and definitions, debate persists regarding surgeon credentialing and healthcare resource allocation. This analysis aimed to determine which society endorsed volume benchmark better discriminates OAR mortality. METHODS A retrospective national registry based cohort analysis. Patients undergoing elective OAR were compared between centres meeting either ESVS (≥ 20 AAA procedures/year) or SVS (≥ 10 OARs/year) volume thresholds within the Vascular Quality Initiative (2010 - 2020). The primary outcome was in hospital death. Logistic regression was used for risk adjusted comparisons. RESULTS A total of 8 761 OARs were performed at 193 US centres, and the median (IQR) volume was 6.6 (3.3, 9.9) OARs/year. When applying the SVS centre volume definition, the proportion of centres meeting ESVS and SVS minimum case thresholds was 12% (n = 22) and 25% (n = 48), respectively. The absolute mortality difference was 0.3% between centres performing ≥ 20 vs. ≥ 10 OARs/year (2.6% vs. 2.9%; p = .51). There was an incremental association between OAR volume and crude mortality rate; however, this absolute difference between lower and higher thresholds was only 0.2%/procedure (OR 0.98, 95% CI 0.97 - 0.99; p < .001). Moreover, no difference in risk adjusted mortality was detected between volume standards (≥ 10 vs. ≥ 20; p = .78). In sub-analysis, the ESVS ≥ 20 total composite AAA repair volume threshold was not associated with mortality (p = .17); however, increasing the proportion of OAR cases making up the total annual AAA centre volume inversely correlated with mortality (p = .008). CONCLUSION It appears that the SVS endorsed AAA centre volume threshold using exclusively OAR had a modest ability to discriminate peri-operative mortality outcomes and was superior to the current composite ESVS volume guideline in differentiating centre performance. These findings raise questions regarding the clinical validity of using EVAR as a volume proxy for OAR.
Collapse
Affiliation(s)
- Salvatore Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA.
| | - Anders Wanhainen
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, Uppsala, Sweden
| | - Dan Neal
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL, USA
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg - Eppendorf, Hamburg, Germany
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, University of Uppsala, Uppsala, Sweden
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - David Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Centre, Lebanon, NH, USA
| |
Collapse
|
22
|
Torabi N, Shafiee A, Heidari A, Hajizeinali M, Jalali A, Hajizeinali A. Predictors of Five-Year Survival after EVAR: 10-Year Experience of Single-Center Cohort Study. Ann Vasc Surg 2023; 96:115-124. [PMID: 37068627 DOI: 10.1016/j.avsg.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Endovascular abdominal aortic repair (EVAR) is the main therapeutic option for repairing abdominal aortic aneurysms (AAAs). We aimed to determine the long-term outcomes of patients who underwent EVAR at our center. METHODS In this retrospective cohort study, patients who underwent EVAR for intact isolated AAA at Tehran Heart Center between 2007 and 2017 were included. Clinical outcomes and the frequency of mortality were analyzed for follow-up periods. We calculated the 5-year survival rate and its predictors for our patients using Kaplan-Meier estimation. RESULTS We included the data of all patients (154 patients, mean age = 70.7 [± 8.0] years, 96.1% men) who successfully underwent EVAR at our center. The most common risk factors were coronary artery disease (70.1%), hypertension (68.2%), smoking (64.9%), and dyslipidemia (39.6%). There was no mortality during the procedure. The median follow-up was 65.5 months. An average decrease of 9.07 mm (95% confidence interval: 6.9-11.2) occurred in the size of the AAA. During follow-up, 12 patients developed some complications, 49 died, and 7 did not complete the follow-up. The 5-year survival rate was 75% (3.9%). The independent predictors for 5-year survival were age (hazard ratio [HR] = 1.06, P = 0.002) and anemia (HR = 1.91, P = 0.029). Despite not being statistically significant, dyslipidemia (HR = 0.573, P = 0.078) and long intensive care unit/cardiac care unit stays (HR = 1.08, P = 0.070) were borderline mortality predictors. CONCLUSIONS This study depicted an acceptable survival rate for patients who underwent EVAR at our center. Age and anemia, 2 modifiable predictors of 5-year survival, can probably prolong the survival rate of patients, which requires evaluation later.
Collapse
Affiliation(s)
- Nasim Torabi
- Department of Cardiology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Akbar Shafiee
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Heidari
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Mohammadmohsen Hajizeinali
- Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Alimohammad Hajizeinali
- Interventional Cardiology Department, Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
23
|
Yamanaka K, Hamaguchi M, Chomei S, Inoue T, Kono A, Tsujimoto T, Koda Y, Nakai H, Omura A, Inoue T, Yamaguchi M, Sugimoto K, Okada K. Japanese single-center experience of abdominal aortic aneurysm repair over 20 years: should open or endovascular aneurysm repair be performed first? Surg Today 2023; 53:1116-1125. [PMID: 36961608 PMCID: PMC10519864 DOI: 10.1007/s00595-023-02663-3] [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: 02/03/2022] [Accepted: 02/01/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE The present study analyzed the outcomes of our experience with abdominal aortic aneurysm (AAA) repair over 20 years using endovascular aortic repair (EVAR) with commercially available devices or open aortic repair (OAR) and reviewed our surgical strategy for AAA. METHODS From 1999 to 2019, 1077 patients (659 OAR, 418 EVAR) underwent AAA repair. The OAR and EVAR groups were compared retrospectively, and a propensity matching analysis was performed. RESULTS EVAR was first introduced in 2008. Our strategy was changed to an EVAR-first strategy in 2010. Beginning in 2018, this EVAR-first strategy was changed to an OAR-first strategy. After propensity matching, the overall survival in the OAR group was significantly better than that in the EVAR group at 10 years (p = 0.006). Two late deaths due to AAA rupture were identified in the EVAR group, although there were no significant differences between the OAR and EVAR groups with regard to the freedom from AAA-related death at 10 years. The rate of freedom from aortic events at 10 years was significantly higher in the OAR group than in the EVAR group (p < 0.0001). CONCLUSION The rates of freedom from AAA-related death in both the OAR and EVAR groups were favorable, and the rate of freedom from aortic events was significantly lower in the EVAR group than in the OAR group. Close long-term follow-up after EVAR is mandatory.
Collapse
Affiliation(s)
- Katsuhiro Yamanaka
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Mari Hamaguchi
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Shunya Chomei
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Taishi Inoue
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Atsunori Kono
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Takanori Tsujimoto
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Yojiro Koda
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Hidekazu Nakai
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Atsushi Omura
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Takeshi Inoue
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | | | - Koji Sugimoto
- The Department of Radiology, University of Kobe, Kobe, Japan
| | - Kenji Okada
- Division of Cardiovascular Surgery, The Department of Surgery, University of Kobe, Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan.
| |
Collapse
|
24
|
Choksi H, Singla A, Yoon P, Pang T, Vicaretti M, Yao J, Lee T, Yuen L, Laurence J, Lau H, Pleass H. Outcomes of endovascular, open surgical and autotransplantation techniques for renal artery aneurysm repair: a systematic review and meta-analysis. ANZ J Surg 2023; 93:2303-2313. [PMID: 37522385 DOI: 10.1111/ans.18628] [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: 04/25/2023] [Revised: 07/11/2023] [Accepted: 07/16/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Renal artery aneurysms (RAA) can be repaired with endovascular exclusion (EVR), open repair (OR), or ex-vivo repair with renal autotransplantation (ERAT). This systematic review compares repair indications, aneurysm characteristics, and complications following these interventions. METHODS A systematic review of databases including MEDLINE, PUBMED, and EMBASE by two independent reviewers for studies from January 2000-November 2022. All studies evaluating repair indications, RAA morphology, morbidity and mortality following EVR, OR, and ERAT were included. RESULTS A total of 38 studies were included with 1540 EVR, 2377 OR and 109 ERAT subjects. Increasing aneurysm size, or diameters >20 mm, were the most common repair indications across EVR and OR (n = 537; 48%), and ERAT (n = 23; 52%). All ERAT repairs were at or distal to renal artery bifurcations (n = 46). Meta-analyses demonstrated significantly shorter length of stay (LOS) with EVR compared to OR (mean difference -4.06, 95% confidence interval (CI) -5.69 to -2.43, P < 0.001). No significant differences were found in mean aneurysm diameter (P = 0.23), total complications (P = 0.17), and mortality (P = 0.85). Major complications (Clavien-Dindo ≥III) across studies most commonly included acute renal failure (EVR 4.9% vs. OR 7.0%). Nephrectomy was the most common major complication in ERAT (5.5%). CONCLUSIONS Outcomes following EVR and OR of RAAs are comparable. EVR offers a shorter LOS, with no difference in morbidity or mortality. ERAT is currently only utilized for distal RAAs, however carries higher risk of infarction and nephrectomy necessitating specialized expertise or algorithms to assist appropriate selection of repair methods.
Collapse
Affiliation(s)
- Harsham Choksi
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Discipline of Surgery, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Animesh Singla
- Discipline of Surgery, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Peter Yoon
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Tony Pang
- Westmead Clinical School, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
- Surgical Innovations Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mauro Vicaretti
- Discipline of Surgery, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jinna Yao
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Taina Lee
- Discipline of Surgery, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Lawrence Yuen
- Discipline of Surgery, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jerome Laurence
- Discipline of Surgery, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Howard Lau
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Henry Pleass
- Discipline of Surgery, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
25
|
Mao J, Behrendt CA, Falster MO, Varcoe RL, Zheng X, Peters F, Beiles B, Schermerhorn ML, Jorm L, Beck AW, Sedrakyan A. Long-term Mortality and Reintervention After Endovascular and Open Abdominal Aortic Aneurysm Repairs in Australia, Germany, and the United States. Ann Surg 2023; 278:e626-e633. [PMID: 36538620 PMCID: PMC10225011 DOI: 10.1097/sla.0000000000005768] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To examine long-term outcomes after endovascular (EVAR) and open repairs (OAR) for intact abdominal aortic aneurysms in Australia, Germany, and the United States, using a unified study design. BACKGROUND Similarities and differences in long-term outcomes after EVAR versus OAR across countries remained unclear, given differences in designs across existing studies. METHODS We identified patients aged >65 years undergoing intact abdominal aortic aneurysm repairs during 2010-2017/2018. We compared long-term patient mortality and reintervention after EVAR and OAR using Kaplan-Meier analyses and Cox regressions. Propensity score matching was performed within each country to adjust for differences in baseline patient characteristics between procedure groups. RESULTS We included 3311, 4909, and 145363 patients from Australia, Germany, and the United States, respectively. The median patient age was 76 to 77 years, and most patients were males (77%-84%). Patient mortality was lower after EVAR than OAR within the first 60 days and became similar at 3-year follow-up (Australia 14.7% vs 16.5%, Germany 18.2% vs 19.7%, United States: 24.4% vs 24.4%). At the end of follow-up, patient mortality after EVAR was higher than OAR in Australia [ hazard ratio (HR) 95% CI: 1.21 (0.96-1.54)] but similar to OAR in Germany [HR 95% CI: 0.92 (0.80-1.07)] and the United States [HR 95% CI: 1.02 (0.99-1.05)]. The risk of reintervention after EVAR was more than twice that after OAR in Australia [HR 95% CI: 2.60 (1.09-6.15)], Germany [HR 95% CI: 4.79 (2.56-8.98)], and the United States [HR 95% CI: 2.67 (2.38-3.00)]. The difference in reintervention risk appeared early in German and United States patients. CONCLUSIONS This multinational study demonstrated important similarities in long-term outcomes after EVAR versus OAR across 3 countries. Variation in long-term mortality and reintervention comparisons indicates possible differences in patient profiles, surveillance, and best medical therapy across countries.
Collapse
Affiliation(s)
- Jialin Mao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Christian-Alexander Behrendt
- Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Asklepios Medical School Hamburg, Asklepios Clinic Wandsbek, Department of Vascular and Endovascular Surgery, Hamburg, Germany
| | - Michael O. Falster
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Ramon L. Varcoe
- Department of Surgery, Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Xinyan Zheng
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Frederik Peters
- Research Group GermanVasc, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Barry Beiles
- Australian and New Zealand Society for Vascular Surgery, Melbourne, Australia
| | - Marc L. Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Louisa Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Adam W. Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Art Sedrakyan
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
26
|
Troisi N, Bertagna G, Torri L, Canovaro F, D’Oria M, Adami D, Berchiolli R. The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge. J Clin Med 2023; 12:5530. [PMID: 37685601 PMCID: PMC10488063 DOI: 10.3390/jcm12175530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Lorenzo Torri
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Francesco Canovaro
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Mario D’Oria
- Vascular Surgery Unit, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy;
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| |
Collapse
|
27
|
Hofmann AG, Leinweber ME, Assadian A, Falkensammer J, Taher F. The Effect of Age on Peri-Operative Outcomes after FEVAR. J Clin Med 2023; 12:jcm12113858. [PMID: 37298053 DOI: 10.3390/jcm12113858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 05/28/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION Fenestrated endovascular aortic repair (FEVAR) has become a popular custom-made treatment option for juxtarenal and pararenal aneurysms. It has been previously investigated whether octogenarians as a distinct subgroup are at increased risk for adverse outcomes after FEVAR. With diverging results and an inconclusive understanding of age as a risk factor in general, an analysis of the historical data of a single center was conducted to add to the available body of evidence and further investigate the effect of age as a continuous risk factor. METHODS A retrospective data analysis of a prospectively maintained single-center database of all patients who underwent FEVAR at a single department of vascular surgery was performed. The main endpoint was post-operative survival. In addition to association analyses, potential confounders such as co-morbidities, complication rates, or aneurysm diameter were examined. In terms of sensitivity analyses, logistic regression models were created for the dependent variables of interest. RESULTS During the observation period from April 2013 to November 2020, 40 patients over the age of 80 and 191 patients under the age of 80 were treated by FEVAR. The 30-day survival showed no significant difference between the groups (95.1% in octogenarians and 94.3% in patients under 80 years of age). The sensitivity analyses conducted also showed no difference between the two groups, and complication and technical success rates were comparable. The aneurysm diameter was 67 ± 13 mm in the study group and 61 ± 15 mm in those under 80 years of age. Additionally, the sensitivity analyses showed that age as a continuous variable exhibits no effect on the outcomes of interest. DISCUSSION In the present study, age was not associated with adverse peri-operative outcomes after FEVAR, including mortality, lower technical success rates, complications, or length of hospital stay. Essentially, the most highly associated factor with hospital and ICU length of stay was time spent in surgery. However, octogenarians had a significantly larger aortic diameter at the time of treatment, which might indicate the potential introduction of bias by pre-interventional patient selection. Nevertheless, the usefulness of research on octogenarians as a distinct subgroup might be questionable regarding the scalability of results, and future studies might focus on age as a continuous risk factor instead.
Collapse
Affiliation(s)
- Amun Georg Hofmann
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Montleartstrasse 37, Pavillon 30B, 1160 Vienna, Austria
| | - Maria Elisabeth Leinweber
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Montleartstrasse 37, Pavillon 30B, 1160 Vienna, Austria
| | - Afshin Assadian
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Montleartstrasse 37, Pavillon 30B, 1160 Vienna, Austria
| | - Juergen Falkensammer
- Department of Vascular Surgery, Barmherzige Brueder Hospital, 4020 Linz, Austria
| | - Fadi Taher
- Department of Vascular and Endovascular Surgery, Klinik Ottakring, Montleartstrasse 37, Pavillon 30B, 1160 Vienna, Austria
| |
Collapse
|
28
|
Veličković VM, Carradice D, Boyle JR, Hamady M, Cleveland T, Neequaye S, Ignjatović A, Bogdanović D, Savovic J, Siebert U. Umbrella review and meta-analysis of reconstructed individual patient data of mortality following conventional endovascular and open surgical repair of infrarenal abdominal aortic aneurysm. Expert Rev Cardiovasc Ther 2023; 21:347-356. [PMID: 37128666 DOI: 10.1080/14779072.2023.2207009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 04/21/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVES This umbrella review aims to quality assess published meta-analyses, conduct a de-novo meta-analysis of the available randomized control trials (RCTs), and test the hypothesis that there is a long-term difference in mortality between OSR and EVAR. METHODS A systematic search was conducted in MEDLINE and EMBASE's bibliographic databases (June 2022). Data were extracted using standardized extraction forms. The methodological quality of publications was assessed using the ROBIS tool. Data were analyzed with 'one-stage' and 'two-stage' approaches. RESULTS According to two-stage analysis, EVAR has significantly favorable mortality for up to four years (increasing evidence). Subsequently, until the longest available time period, there is no difference between EVAR and OSR; all the results are statistically non-significant.In one stage analysis, the Cox model demonstrated a non-significant (weak evidence) hazard ratio of 1.03 (95% confidence interval [CI]: 0.94-1.12) in favor of OSR. The best-fitting parametric model (generalized gamma), leads to an hazard ratio of 0.97 (95% CI: 0.93-1.01) in favor of EVAR, with the results approaching significance (weak evidence). CONCLUSION The results of this umbrella systematic review and meta-analysis failed to demonstrate any difference in long-term mortality following planned EVAR, compared with OSR of infrarenal AAA.
Collapse
Affiliation(s)
- Vladica M Veličković
- Evidence Synthesis Department, Biomath Models, London, UK
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL, University for Health Sciences and Technology, Hall i.T, Austria
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Hull York Medical School & Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Jonathan R Boyle
- Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, UK
| | - Mohamad Hamady
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Trevor Cleveland
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Neequaye
- Department of Interventional Radiology, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Aleksandra Ignjatović
- Evidence Synthesis Department, Biomath Models, London, UK
- Faculty of Medicine, University of Niš, Niš, Serbia
| | | | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- and Weston NHS Foundation Trust, NIHR Applied Research Collaboration West (ARC West) at University Hospitals Bristol, Bristol, UK
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL, University for Health Sciences and Technology, Hall i.T, Austria
- Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
- Center for Health Decision Science, Departments of Epidemiology and Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
29
|
Kwan JY, Tang SH, Davies H, Sood M, Sucharitkul PP, Wallace T, Scott DJA, Coughlin PA, Bailey MA. Analyzing Sex Differences in Intensity of Cardiovascular Disease Prevention Medications in Patients With Abdominal Aortic Aneurysms-A Single-Center Cross-Sectional Study. Ann Vasc Surg 2023; 90:67-76. [PMID: 36460174 DOI: 10.1016/j.avsg.2022.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/08/2022] [Accepted: 10/22/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Patients with abdominal aortic aneurysm (AAA) are at a significant risk of cardiovascular events, similar to that of patients who have already experienced a major cardiac event. The European Society for Vascular Society AAA guidelines suggest that antiplatelet therapy and lipid-lowering therapy (LLT) should be considered in all patients with AAA. This study explores the overall prevalence and intensity of antithrombotic therapy and LLT, and lipid profile monitoring in a single center AAA surveillance cohort alongside any sex differences. METHODS This was a retrospective, single center, cross-sectional study of 614 patients enrolled in the AAA surveillance program of a tertiary vascular surgery unit. All patients undergoing at least 1 surveillance scan from January 1, 2018, to December 31, 2020, were assessed. Electronic hospital records linked to real-time primary care records were interrogated for data on demographics, comorbidities, antiplatelet and LLT prescriptions, and serum cholesterol laboratory results. An analysis of covariance test was used to account for the effects of confounding comorbidities. RESULTS Twenty-one percent of patients were not on antithrombotic therapy, and 20% of patients were not on LLT which reflects a group of patients receiving sub-optimal clinical care. In total, 47% of the cohort were on low/moderate intensity statin therapy which reflects a group of patients where care can be improved upon. Female sex was independently associated with a reduced likelihood of being prescribed LLT (P = 0.008, eta squared (ηp2) = 0.012, small effect size) but not antithrombotic therapy (P = 0.202). Fewer women underwent low-density lipoprotein cholesterol (LDL-C) monitoring (mean difference 9%, P = 0.040) and achieved the European Society of Cardiology-European Atherosclerosis Society- LDL-C target of <1.4 mmol/L (mean difference 9%, P = 0.040). CONCLUSIONS Overall, there is room for improvement in these aspects of cardiovascular risk prevention for both sexes. Sex differences in the prescription of LLT, the prevalence of lipid profile monitoring, and likelihood of achieving LDL-C targets exist among patients with AAA, with a lower prevalence in women.
Collapse
Affiliation(s)
- Jing Yi Kwan
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK; The Leeds Institute of Cardiovascular & Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - Steve Hm Tang
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Henry Davies
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK; The Leeds Institute of Cardiovascular & Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - Mehak Sood
- The Leeds Institute for Medical Education, School of Medicine, University of Leeds, Leeds, UK
| | - Penelope Pj Sucharitkul
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK; The Leeds Institute for Medical Education, School of Medicine, University of Leeds, Leeds, UK
| | - Tom Wallace
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Julian A Scott
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Patrick A Coughlin
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Marc A Bailey
- The Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK; The Leeds Institute of Cardiovascular & Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK.
| |
Collapse
|
30
|
Mathlouthi A, Abdelkarim A, Elsayed N, Ramakrishnan G, Naazie I, Malas MB. Novel Risk Score Calculator for Perioperative Mortality after EVAR with Incorporation of Anatomical Factors. Ann Vasc Surg 2023:S0890-5096(23)00120-6. [PMID: 36863488 DOI: 10.1016/j.avsg.2023.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 02/07/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Hostile proximal aortic neck anatomy has been associated with an increased risk of perioperative mortality after endovascular aneurysm repair (EVAR). However, all available mortality risk prediction models after EVAR lack neck anatomic associations. The aim of this study is to develop a preoperative prediction model for perioperative mortality after EVAR incorporating important anatomic factors. METHODS Data were obtained from the Vascular Quality Initiative database on all patients who underwent elective EVAR between January 2015 and December 2018. A stepwise multivariable logistic regression analysis was implemented to identify independent predictors and develop a risk calculator for perioperative mortality after EVAR. Internal validation was done using bootstrap of 1,000 reps. RESULTS A total of 25,133 patients were included, of whom 1.1% (N = 271) died within 30 days or before discharge. Significant preoperative predictors of perioperative mortality were age (odds ratio [OR], 1.053; 95% confidence interval [CI], 1.050-1.056; P < 0.001), female sex (OR, 1.46; 95% CI, 1.38-1.54; P < 0.001), chronic kidney disease (OR, 1.65; 95% CI, 1.57-1.73; P < 0.001), chronic obstructive pulmonary disease (OR, 1.86; 95% CI, 1.77-1.94; P < 0.001), congestive heart failure (OR, 2.02; 95% CI, 1.91-2.13, P < 0.001), aneurysm diameter ≥ 6.5 cm (OR, 2.35; 95% CI, 2.24-2.47, P < 0.001), proximal neck length < 10 mm (OR, 1.96; 95% CI, 1.81-2.12; P < 0.001), proximal neck diameter ≥ 30 mm (OR, 1.41; 95% CI, 1.32-1.5; P < 0.001), infrarenal neck angulation ≥ 60° (OR, 1.27; 95% CI, 1.18-1.26; P < 0.001), and suprarenal neck angulation ≥ 60° (OR, 1.26; 95% CI, 1.16-1.37; P < 0.001). Significant protective factors included aspirin use (OR, 0.89; 95% CI, 0.85-0.93; P < 0.001) and statin intake (OR, 0.77; 95% CI, 0.73-0.81; P < 0.001). These predictors were incorporated to build an interactive risk calculator of perioperative mortality after EVAR (C-statistic = 0.749). CONCLUSIONS This study provides a prediction model for mortality following EVAR that incorporates aortic neck features. The risk calculator can be used to weigh risk/benefit ratio when counseling patients preoperatively. Prospective use of this risk calculator may show its benefit in long-term prediction of adverse outcomes.
Collapse
Affiliation(s)
| | | | | | | | - Isaac Naazie
- University of California San Diego, La Jolla, CA
| | | |
Collapse
|
31
|
Beverly A, Ong G, Kimber C, Sandercock J, Dorée C, Welton NJ, Wicks P, Estcourt LJ. Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2023; 2:CD013649. [PMID: 36800489 PMCID: PMC9936832 DOI: 10.1002/14651858.cd013649.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
BACKGROUND Vascular surgery may be followed by internal bleeding due to inadequate surgical haemostasis, abnormal clotting, or surgical complications. Bleeding ranges from minor, with no transfusion requirement, to massive, requiring multiple blood product transfusions. There are a number of drugs, given systemically or applied locally, which may reduce the need for blood transfusion. OBJECTIVES To assess the effectiveness and safety of anti-fibrinolytic and haemostatic drugs and agents in reducing bleeding and the need for blood transfusion in people undergoing major vascular surgery or vascular procedures with a risk of moderate or severe (> 500 mL) blood loss. SEARCH METHODS We searched: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL, and Transfusion Evidence Library. We also searched the WHO ICTRP and ClinicalTrials.gov trial registries for ongoing and unpublished trials. Searches used a combination of MeSH and free text terms from database inception to 31 March 2022, without restriction on language or publication status. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adults of drug treatments to reduce bleeding due to major vascular surgery or vascular procedures with a risk of moderate or severe blood loss, which used placebo, usual care or another drug regimen as control. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were units of red cells transfused and all-cause mortality. Our secondary outcomes included risk of receiving an allogeneic blood product, risk of reoperation or repeat procedure due to bleeding, risk of a thromboembolic event, risk of a serious adverse event and length of hospital stay. We used GRADE to assess certainty of evidence. MAIN RESULTS We included 22 RCTs with 3393 participants analysed, of which one RCT with 69 participants was reported only in abstract form, with no usable data. Seven RCTs evaluated systemic drug treatments (three aprotinin, two desmopressin, two tranexamic acid) and 15 RCTs evaluated topical drug treatments (drug-containing bioabsorbable dressings or glues), including fibrin, thrombin, collagen, gelatin, synthetic sealants and one investigational new agent. Most trials were conducted in high-income countries and the majority of the trials only included participants undergoing elective surgery. We also identified two ongoing RCTs. We were unable to perform the planned network meta-analysis due to the sparse reporting of outcomes relevant to this review. Systemic drug treatments We identified seven trials of three systemic drugs: aprotinin, desmopressin and tranexamic acid, all with placebo controls. The trials of aprotinin and desmopressin were small with very low-certainty evidence for all of our outcomes. Tranexamic acid versus placebo was the systemic drug comparison with the largest number of participants (2 trials; 1460 participants), both at low risk of bias. The largest of these included a total of 9535 individuals undergoing a number of different higher risk surgeries and reported limited information on the vascular subgroup (1399 participants). Neither trial reported the number of units of red cells transfused per participant up to 30 days. Three outcomes were associated with very low-certainty evidence due to the very wide confidence intervals (CIs) resulting from small study sizes and low number of events. These were: all-cause mortality up to 30 days; number of participants requiring an allogeneic blood transfusion up to 30 days; and risk of requiring a repeat procedure or operation due to bleeding. Tranexamic acid may have no effect on the risk of thromboembolic events up to 30 days (risk ratio (RR) 1.10, 95% CI 0.88 to 1.36; 1 trial, 1360 participants; low-certainty evidence due to imprecision). There is one large ongoing trial (8320 participants) comparing tranexamic acid versus placebo in people undergoing non-cardiac surgery who are at high risk of requiring a red cell transfusion. This aims to complete recruitment in April 2023. This trial has primary outcomes of proportion of participants transfused with red blood cells and incidence of venous thromboembolism (DVT or PE). Topical drug treatments Most trials of topical drug treatments were at high risk of bias due to their open-label design (compared with usual care, or liquids were compared with sponges). All of the trials were small, most were very small, and few reported clinically relevant outcomes in the postoperative period. Fibrin sealant versus usual care was the topical drug comparison with the largest number of participants (5 trials, 784 participants). The five trials that compared fibrin sealant with usual care were all at high risk of bias, due to the open-label trial design with no measures put in place to minimise reporting bias. All of the trials were funded by pharmaceutical companies. None of the five trials reported the number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. The other three outcomes were associated with very low-certainty evidence with wide confidence intervals due to small sample sizes and the low number of events, these were: all-cause mortality up to 30 days; risk of requiring a repeat procedure due to bleeding; and risk of thromboembolic disease up to 30 days. We identified one large trial (500 participants) comparing fibrin sealant versus usual care in participants undergoing abdominal aortic aneurysm repair, which has not yet started recruitment. This trial lists death due to arterial disease and reintervention rates as primary outcomes. AUTHORS' CONCLUSIONS Because of a lack of data, we are uncertain whether any systemic or topical treatments used to reduce bleeding due to major vascular surgery have an effect on: all-cause mortality up to 30 days; risk of requiring a repeat procedure or operation due to bleeding; number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. There may be no effect of tranexamic acid on the risk of thromboembolic events up to 30 days, this is important as there has been concern that this risk may be increased. Trials with sample size targets of thousands of participants and clinically relevant outcomes are needed, and we look forward to seeing the results of the ongoing trials in the future.
Collapse
Affiliation(s)
- Anair Beverly
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Giok Ong
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Wicks
- Cardiac Anaesthesia and Intensive Care, University Hospital Southampton, Southampton, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| |
Collapse
|
32
|
Fan EY, Buckner MA, LiCausi J, Crawford A, Boitano LT, Malka KT, Schanzer A, Simons JP. Characterizing the frequency and indications for repair of abdominal aortic aneurysms with diameters smaller than recommended by societal guidelines. J Vasc Surg 2023; 77:1637-1648.e3. [PMID: 36773667 DOI: 10.1016/j.jvs.2023.01.201] [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: 10/31/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVE While the Society for Vascular Surgery recommends repair of abdominal aortic aneurysms (AAA) at ≥5.5 cm in men and ≥5.0 cm in women, AAA repair below these thresholds has been well documented. There are clear indications for repair other than these strict size criteria, but the expected proportion of such repairs in one's practice has not been studied. We sought to characterize the indications for repairs of aneurysms below diameter recommendations at a single academic center. Using the assumption that this real-world experience would approximate that of other practices, we then used national data to extrapolate these findings. METHODS A single-center retrospective review was conducted of all elective open (oAAA) and endovascular (EVAR) AAA repairs (2010-20) to assess the incidence of and indications for repair of aneurysms below diameter recommendations (defined as <5.5cm in men and <5.0cm in women). Reasons for these repairs were defined as: 1) iliac aneurysm, 2) saccular morphology, 3) rapid expansion, 4) patient anxiety, 5) distal embolization, 6) other, and 7) no documented reason. The Vascular Quality Initiative (VQI) was queried for all asymptomatic oAAA and EVAR (2010-20) and repairs below diameter recommendations were identified. Findings from the single-center analysis were applied to the VQI cohort to extrapolate estimates of reasons for repairs done nationally. In-hospital mortality and major adverse cardiac events (MACE) were compared between those below size recommendations and those meeting size recommendations. RESULTS Of 456 elective AAA repairs at our center, 147 (32%) were below size recommendations. This was more common for EVAR (35% vs 28%). Reasons were: not documented (41%), iliac aneurysm (23%), saccular (10%), rapid expansion (10%), patient anxiety (7%), other (6%), and distal embolism (3%). Of 44,820 elective AAA repairs in VQI, 17,057 (38%) were below size recommendations (40% EVAR, 26% oAAA). Patients who were repaired below size recommendations had lower in-hospital death (oAAA: 2.4% vs 4.6% p<0.0001; EVAR: 0.3% vs 0.8% p<0.0001). When single-center findings were applied to the VQI dataset, an estimated 10,064 repairs were performed nationally for acceptable indications other than size criteria. Conversely, there may have been 6993 repairs (with an associated 35 deaths) performed without documented indication. CONCLUSION Repairs for AAA below recommended diameter guidelines account for approximately one third of all elective AAA procedures in both VQI and our single-center experience. Assuming our practice is typical, nearly 60% of repairs below size recommendations meet criteria for other clear reasons. The remaining 40% lack a documented reason, meaning 13% of all elective AAA repairs were done for aneurysms below size recommendations without an acceptable indication. As awareness of overuse/underuse is heightened, these data help estimate the expected proportion of repairs for less common pathologies. They also provide a potential baseline data point for efforts at reducing overuse.
Collapse
Affiliation(s)
- Emily Y Fan
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | | | - Joseph LiCausi
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Allison Crawford
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Kimberly T Malka
- Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland, ME
| | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA.
| |
Collapse
|
33
|
Die Regierungskommission für eine moderne und bedarfsgerechte Krankenhausversorgung und das Bauchaortenaneurysma – Haben wir eine inhaltliche Diskussion um Mindestmengen und Qualitätsindikatoren verpasst? GEFÄSSCHIRURGIE 2023. [DOI: 10.1007/s00772-023-00975-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
34
|
Modarai B, Haulon S, Ainsbury E, Böckler D, Vano-Carruana E, Dawson J, Farber M, Van Herzeele I, Hertault A, van Herwaarden J, Patel A, Wanhainen A, Weiss S, Esvs Guidelines Committee, Bastos Gonçalves F, Björck M, Chakfé N, de Borst GJ, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kakkos SK, Koncar IB, Kolh P, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Document Reviewers, Bacher K, Brountzos E, Fanelli F, Fidalgo Domingos LA, Gargiulo M, Mani K, Mastracci TM, Maurel B, Morgan RA, Schneider P. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Radiation Safety. Eur J Vasc Endovasc Surg 2023; 65:171-222. [PMID: 36130680 DOI: 10.1016/j.ejvs.2022.09.005] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/15/2022] [Indexed: 01/24/2023]
|
35
|
Santosa F, Beckerath OV, Cremer S, Katoh M, Juntermanns B, Kröger K, Gäbel G. Increased aortic repair in Germany correlates with reduction of death caused by aortic aneurysms but not aortic dissections. Vascular 2023; 31:18-25. [PMID: 35119319 DOI: 10.1177/17085381211054263] [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 We asked if there is a significant correlation between the increasing trend in aortic repair (AR) and decreasing aortic aneurysm (AA) and aortic dissection (AD) mortality? Therefore, we retrospectively analyzed all aortic repairs in patients with AA and AD and its correlation with disease-specific death rates and hospitalizations for ruptured AA and AD in Germany. METHODS We retrieved the number of cases hospitalized for AA and AD as well as the procedures in these cases from the Federal Bureau of Statistics (DRG statistics) and death rates from the national mortality statistic published by the Federal Statistical Office in Germany for the years 2006-2017. RESULTS From 2006 to 2017, the total number of hospitalized cases admitted with principal diagnosis of AA increased by 25.8% and that of AD by 56.7%. That of cases with the principal diagnosis of ruptured AA (rAA) remained unchanged (-2.5%) and that with rAD increased by 54.6%. The number of (open and endovascular) procedures in cases hospitalized for AA increased by 39.4% and for AD by 126.4%. The age-adjusted death rates in Germany for AA decreased from 4.0 to 2.9 per 100,000 inhabitants and that for AD increased from 1.0 to 1.4. The decrease in death attributed to AA cases can be described by linear regression as y = -0.0003*y + 6.7076 (p < 0.0001). Accepting this association between increased elective procedures and reduced AA mortality, each/all 1000 procedures save 0.3 lives per 100,000 inhabitants. CONCLUSION Despite increasing numbers of AR for AA and AD, only the mortality rate for all AAs decreased, while we did not observe a decrease in overall mortality of AD in Germany.
Collapse
Affiliation(s)
- Frans Santosa
- Medical Faculty Universitas Pembangunan Nasional Veteran Jakarta, Depok, Indonesia
| | - Olga von Beckerath
- Department of Vascular Medicine, HELIOS Klinikum Krefeld, Krefeld, Germany
| | - Svenja Cremer
- Department of Vascular Medicine, HELIOS Klinikum Krefeld, Krefeld, Germany
| | - Marcus Katoh
- Department of Radiology, HELIOS Klinikum Krefeld, Krefeld, Germany
| | | | - Knut Kröger
- Department of Vascular Medicine, HELIOS Klinikum Krefeld, Krefeld, Germany
| | - Gabor Gäbel
- Department of Vascular Medicine, HELIOS Klinikum Krefeld, Krefeld, Germany
| |
Collapse
|
36
|
Wang L, Wang Y, Ma T, Yuan J, Wang H, Ren Y, Zhang J. Brucella Infectious Aneurysm: A Retrospective Study of 14 Cases and Review of the Literature - Case Report and Literature Review. Infect Drug Resist 2023; 16:87-104. [PMID: 36636379 PMCID: PMC9830056 DOI: 10.2147/idr.s393060] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/16/2022] [Indexed: 01/07/2023] Open
Abstract
Objective To analyze the clinical characteristics and treatment process of 14 patients with aneurysm due to brucellosis, summarize the morbidity characteristics, and improve the knowledge and diagnosis of the disease. Methods The clinical data of patients with aneurysms who were diagnosed to have brucellosis through Rose Bengal Test (RBT), Serum Agglutination Test (SAT), blood culture, and computed tomography angiography from January 2012 to November 2022 in Bethune Hospital, Shanxi Province, China, were retrospectively analyzed, and their clinical characteristics and disease regression findings were summarized. Results Of the 14 patients, 13 were men, and 1 was a woman; the youngest patient was 48-year-old, and the oldest patient was of 74 years. All had a history of smoking. The sites of lesion occurrence included the abdominal aorta (5 patients), abdominal aorta +iliac artery (5 patients), iliac artery (2 patients), thoracic aorta and brachial artery were less common (1 case each). Symptoms in the patients mostly began with abdominal pain, which was accompanied by fever, nausea, and vomiting. Six patients had a clear history of livestock exposure. Fourteen patients showed elevated D-dimer and C-reactive protein levels and decreased hemoglobin and albumin levels. Thirteen of the 14 cases were treated surgically, there were no complications of surgery, and 3 patients were readmitted with recurrence of brucellosis, it is related to the treatment that did not reach the early stage, combination, full dose and full course of treatment, with a mean recurrence time of 8 months. In the telephone follow-up, the patient's recovery proceeded well. Conclusion The present study revealed that the recurrence in male gender, advanced age, smoking and irregular treatment is higher. On the contrast, early intervention, a combination of adequate course of anti-infection treatment and timely surgery can improve the prognosis.
Collapse
Affiliation(s)
- Lin Wang
- Department of Infection, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, People’s Republic of China
| | - Yan Wang
- Department of Infection, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, People’s Republic of China,Correspondence: Yan Wang, Department of Infection, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, People’s Republic of China, Tel +8613513635015, Email
| | - Tongqiang Ma
- Department of Vascular Surgery, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, People’s Republic of China
| | - Jianwei Yuan
- Department of Infection, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, People’s Republic of China
| | - Hongxia Wang
- Department of Infection, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, People’s Republic of China
| | - Yuan Ren
- School of Public Health, Shanxi Medical University, Taiyuan, People’s Republic of China
| | - Jianwei Zhang
- Department of Infection, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, People’s Republic of China
| |
Collapse
|
37
|
Debus ES, von Kodolitsch Y, Behrendt CA, Kölbel T, Sachweh A, Preuß M. [Vascular surgery in old people]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:10-16. [PMID: 36459217 DOI: 10.1007/s00104-022-01770-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 12/05/2022]
Abstract
The age pyramid in Germany is upside down. According to the Federal Statistical Office this development will continue in the coming years, which presents a challenge for surgeons to surgically treat increasingly more and increasingly older people. Particularly in vascular surgery, which is a surgery of old people, this fact represents a special challenge. The frailty of old people is, among other things, due to a series of comorbidities, which must be taken into consideration within the framework of surgical treatment. They can have an important influence on the perioperative planning, the operation, the postoperative treatment and the outcome of the patient. This treatment planning becomes more and more challenging, because due to the progress in endovascular surgery there will soon be no limits to what is feasible; however, the question arises whether the feasible is also reasonable? Within the scope of this article the authors try to give answers to the treatment of old patients in vascular surgery and to find strategies for planning and to establish an individualized optimal treatment.
Collapse
Affiliation(s)
- E S Debus
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Y von Kodolitsch
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland
| | - Ch-A Behrendt
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland
| | - T Kölbel
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland
| | - A Sachweh
- Universitäres Herz- und Gefäßzentrum, UKE Hamburg-Eppendorf, Hamburg, Deutschland
| | - M Preuß
- Klinik und Poliklinik für Gefäßmedizin (Gefäßchirurgie - Angiologie - Endovaskuläre Therapie), Universitären Herzzentrum Hamburg-Eppendorf, Deutsches Aortenzentrum des Universitären Herzzentrums Hamburg, Gebäude O70, Martinistraße 52, 20246, Hamburg, Deutschland
| |
Collapse
|
38
|
Duan L, Xin W, Li S, Zhao L, Xin S. The treatment choices of abdominal aortic aneurysm patients in China in the era of value-based healthcare. Front Cardiovasc Med 2022; 9:961830. [DOI: 10.3389/fcvm.2022.961830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/09/2022] [Indexed: 11/30/2022] Open
Abstract
BackgroundEndovascular aneurysm repair (EVAR) is often seen as the first choice treatment for patients with abdominal aortic aneurysm (AAA), particularly high-risk patients, yet the long-term survival rate and improvement in quality of life are still unclear. In order to seek the value of EVAR to the entire healthcare field, we conducted a retrospective study to evaluate whether the improvement EVAR can truly bring to the quality of medical care in the era of value-based healthcare.MethodsWe included AAA patients who underwent surgical treatment in the Department of Vascular Surgery, First Hospital of China Medical University, from January 1, 2004, to December 31, 2019 and evaluated surgery procedure data, short-term and long-term mortality, complications, prognoses, and medical costs.ResultsWe analyzed 507 patients with AAA who underwent open repair (n = 232) or EVAR (n = 275) over a 15-year period. The operative time, blood loss, blood transfusion rate, and postoperative length of hospital stay of the EVAR group is significantly lower than which of the open repair group. Meanwhile, neither short-term nor long-term mortality rates shows significant differences between the two groups. On the other hand, the complication rate of the EVAR group was significantly higher than that of the open repair group. Lastly, the total cost of EVAR was significantly higher than that of open repair.ConclusionExisting evidence suggests that EVAR improves neither short-term nor long-term survival rate compared with open surgery. In contrast, the complication rate and the reintervention rate in the EVAR group were higher than those in the open surgery group. Moreover, the cost of EVAR and that paid by medical insurance were higher than those for open surgery. For patients with a long-life expectancy, in order to ensure that patients receive appropriate and effective care, surgeons should choose a suitable method that considers both the quality of medical care as well as the expense accordingly.
Collapse
|
39
|
Sedrakyan A, Marinac-Dabic D, Campbell B, Aryal S, Baird CE, Goodney P, Cronenwett JL, Beck AW, Paxton EW, Hu J, Brindis R, Baskin K, Cowley T, Levy J, Liebeskind DS, Poulose BK, Rardin CR, Resnic FS, Tcheng J, Fisher B, Viviano C, Devlin V, Sheldon M, Eldrup-Jorgensen J, Berlin JA, Drozda J, Matheny ME, Dhruva SS, Feeney T, Mitchell K, Pappas G. Advancing the Real-World Evidence for Medical Devices through Coordinated Registry Networks. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2022; 4:e000123. [PMID: 36393894 PMCID: PMC9660584 DOI: 10.1136/bmjsit-2021-000123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/31/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives Generating and using real-world evidence (RWE) is a pragmatic solution for evaluating health technologies. RWE is recognized by regulators, health technology assessors, clinicians, and manufacturers as a valid source of information to support their decision-making. Well-designed registries can provide RWE and become more powerful when linked with electronic health records and administrative databases in coordinated registry networks (CRNs). Our objective was to create a framework of maturity of CRNs and registries, so guiding their development and the prioritization of funding. Design setting and participants We invited 52 stakeholders from diverse backgrounds including patient advocacy groups, academic, clinical, industry and regulatory experts to participate on a Delphi survey. Of those invited, 42 participated in the survey to provide feedback on the maturity framework for CRNs and registries. An expert panel reviewed the responses to refine the framework until the target consensus of 80% was reached. Two rounds of the Delphi were distributed via Qualtrics online platform from July to August 2020 and from October to November 2020. Main outcome measures Consensus on the maturity framework for CRNs and registries consisted of seven domains (unique device identification, efficient data collection, data quality, product life cycle approach, governance and sustainability, quality improvement, and patient-reported outcomes), each presented with five levels of maturity. Results Of 52 invited experts, 41 (79.9%) responded to round 1; all 41 responded to round 2; and consensus was reached for most domains. The expert panel resolved the disagreements and final consensus estimates ranged from 80.5% to 92.7% for seven domains. Conclusions We have developed a robust framework to assess the maturity of any CRN (or registry) to provide reliable RWE. This framework will promote harmonization of approaches to RWE generation across different disciplines and health systems. The domains and their levels may evolve over time as new solutions become available.
Collapse
Affiliation(s)
- Art Sedrakyan
- Department of Population Health Sciences; Medical Devices Epidemiology Network (MDEpiNet) Coordinating Center, Weill Cornell Medical College, New York, New York, USA
| | - Danica Marinac-Dabic
- Center for Devices and Radiological Health (CDRH), US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Bruce Campbell
- Vascular Surgery, University of Exeter Medical School, Exter, UK
| | - Suvekshya Aryal
- Department of Population Health Sciences; Medical Devices Epidemiology Network (MDEpiNet) Coordinating Center, Weill Cornell Medical College, New York, New York, USA
| | - Courtney E Baird
- Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Philip Goodney
- Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jack L Cronenwett
- Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama, Birmingham, Alabama, USA
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, Harbor City, California, USA
| | - Jim Hu
- Department of Urology, Weill Cornell Medical College, New York, New York, USA
| | - Ralph Brindis
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Kevin Baskin
- Vascular and Interventional Radiology, Conemaugh Memorial Medical Center, Johnstown, Pennsylvania, USA
| | | | - Jeffery Levy
- Robotic Surgery, Institute of Surgical Excellence, Philadelphia, Pennsylvania, USA
| | - David S Liebeskind
- Department of Neurology, Stroke Center, University of California Los Angeles, Los Angeles, California, USA
| | - Benjamin K Poulose
- Center for Abdominal Core Health, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Charles R Rardin
- Department of Obstetrics and Gyencology, Women and Infants Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Frederic S Resnic
- Department of Cardiology, Comparative Effective Research Institute, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - James Tcheng
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Benjamin Fisher
- Center for Devices and Radiological Health (CDRH), US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Charles Viviano
- Center for Devices and Radiological Health (CDRH), US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Vincent Devlin
- Center for Devices and Radiological Health (CDRH), US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Murray Sheldon
- Center for Devices and Radiological Health (CDRH), US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jens Eldrup-Jorgensen
- Vascular Surgery, Maine Medical Center, Portland, Maine, USA
- Surgery, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Jesse A Berlin
- Global Epidemiology, Johnson and Johnson Limited, New Brunswick, New Jersey, USA
| | - Joseph Drozda
- Outcomes Research, Mercy Health, St. Louis, Missouri, USA
| | - Michael E Matheny
- Department of Biomedical Informatics and Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sanket S Dhruva
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Timothy Feeney
- Department of Surgery, Boston University, Boston, Massachusetts, USA
| | | | - Gregory Pappas
- Center for Biologicals Evaluation and Research (CBER), US Food and Drug Administration, Silver Spring, Maryland, USA
| |
Collapse
|
40
|
The Impact of an Abdominal Aortic Aneurysm Appropriateness Dashboard on Clinical Practice. J Vasc Surg 2022; 77:778-784. [DOI: 10.1016/j.jvs.2022.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/18/2022] [Accepted: 10/25/2022] [Indexed: 11/22/2022]
|
41
|
Center Volume and Failure to Rescue after Open or Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. J Vasc Surg 2022; 76:1565-1576.e4. [PMID: 35872329 DOI: 10.1016/j.jvs.2022.05.022] [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: 11/20/2021] [Revised: 04/26/2022] [Accepted: 05/05/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND The correlation between center volume and elective abdominal aortic aneurysm(AAA) repair outcomes is well established; however, these effects for either endovascular(EVAR) or open(OAR) repair of ruptured AAA(rAAA) remains unclear. Notably, the capacity to either avert or manage complications associated with postoperative mortality is an important cause of outcome disparities following elective procedures; however, there is a paucity of data surrounding non-elective presentations. Therefore, the purpose of this analysis was to describe the association between annual center volume, complications, and failure to rescue(FtR) after EVAR and OAR of rAAA. METHODS All consecutive endovascular and open rAAA repairs from 2010-2020 in the Vascular Quality Initiative were examined. Annual center volume(procedures/year per center) was grouped into quartiles: EVAR-Q1[<14](3.4%), Q2[14-23](12.8%), Q3[24-37](24.7%), Q4[>38](59.1%); OAR-Q1[<3](5.4%), Q2[4-6](12.8%), Q3[7-10](22.7%), Q4[>10](59.1%). The primary end-point was FtR, defined as in-hospital death after experiencing one of six major complications(cardiac, renal, respiratory, stroke, bleeding, colonic ischemia). Risk-adjusted analyses for inter-group comparisons was completed using multivariable logistic regression. RESULTS The unadjusted in-hospital death rate was 16.5% and 28.9% for EVAR and OAR, respectively. Complications occurred in 45% of EVAR(n=1,439/3,188) and 70% of OAR(n=1,366/1,961) patients with corresponding FtR rates of 14%(EVAR) and 26%(OAR). For OAR, Q4-centers had a 43% lower FtR risk(OR 0.57, 95%CI 0.4-0.9;p=.017) compared to Q1 centers. Centers performing >5 OARs/year had a 43% lower risk(OR 0.57, 95%CI 0.4-0.7;p<.001) of FtR and this decreased 4% for each additional 5 procedures performed annually(95%CI .93-.991;p=.013). However, there was no significant relationship between center volume and FtR after EVAR. The risk of FtR was strongly associated with a greater number of complications for both procedures(OR multiplied by 6.5 for EVAR and 1.5 for OAR for each additional complication;p<.0001). Among OAR patients with a single recorded complication, return to the operating room for bleeding had highest risk of in-hospital mortality(OR 4.1, 95%CI 1.1-4.8;p=.034), while no specific type of complication increased FtR risk after EVAR. CONCLUSIONS FtR occurs commonly after EVAR and OAR of rAAA within VQI centers. Importantly, increasing center volume was associated with reduced FtR risk after OAR but not EVAR. Complication pattern and frequency predicted FTR after either repair strategy. For stable patients, especially those deemed anatomically ineligible for EVAR, these findings emphasize the need to improve coordination of regional referral networks that centralize rAAAs to high-volume centers. Moreover, hospitals that treat rAAA should invest resources that develop protocols targeting specific complications to mitigate risk of preventable postoperative death.
Collapse
|
42
|
Boudreau H, Blakeslee-Carter J, Novak Z, Sutzko DC, Spangler EL, Passman MA, Scali ST, McFarland GE, Pearce BJ, Beck AW. Association of Statin and Antiplatelet Use with Survival in Patients with AAA with and without Concomitant Atherosclerotic Occlusive Disease. Ann Vasc Surg 2022; 83:70-79. [PMID: 35108555 PMCID: PMC9634438 DOI: 10.1016/j.avsg.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Statin therapy has been associated with improved clinical outcomes in patients undergoing treatment for vascular disease. Current guidelines do not address statin therapy in isolated abdominal aortic aneurysm (AAA) in the absence of other atherosclerotic cardiovascular disease (ASCVD). This study aims to elucidate effects of statin therapy, either as monotherapy or combined with antiplatelet agents, on the long-term mortality of patients with and without ASCVD who undergo elective AAA repair. METHODS A retrospective review was performed on all AAA patients treated electively with endovascular (EVAR) and open aortic repair (OAR) in the Society for Vascular Surgery Vascular Quality Initiative from 2003-2020. Long-term mortality was evaluated based on the presence of statin and antiplatelet medication use at discharge stratified by those with and without a history of ASCVD. Unadjusted survival was estimated by Kaplan Meier methodology. Cox proportional hazards modeling was used to determine mortality risk after adjusting for key factors. RESULTS A total of 47,012 AAA repairs were selected for analysis: 80.7% EVAR (N = 40,153) and 19.3% OAR (N = 6,859). EVAR patients on combined statin/antiplatelet (AP) therapy had significantly better survival irrespective of whether they had known ASCVD. In the presence of ASCVD, EVAR patients on statin alone had improved survival compared to those not on a statin (10.9 ± 0.5 vs. 10.5 ± 0.4 years, Log Rank < 0.001), with survival being even greater among those receiving combined statin/AP therapy (12.2 ± 0.2 vs. 10.5 ± 0.4 years, Log Rank < 0.001). In the absence of ASCVD, EVAR patients on statin alone also had better mean survival compared to patients not on a statin (8.7 ± 0.5 vs. 8.4 ± 0.4 years, Log Rank<.001), with higher survival among statin/AP therapy patients (9.4 ± 0.2 years vs. 8.7 ± 0.5 years, Log Rank < 0.001). Comparison of adjusted survival via Cox multivariable regression demonstrated a protective effect of statins (HR = 0.737, P = 0.04, vs. no medication) and combined statin/AP therapy (HR = 0.659, P = 0.001, vs no medication) in patients with ASCVD history. A similar protective effect (statin: HR 0.826, P = 0.05. Combination statin/AP: HR 0.726, P < 0.001, vs. no medication) was identified in patients without ASCVD history. Within the OAR cohort, statin therapy was not associated with improved survival among patients without ASCVD; however, combined statin/AP therapy had a protective effect for patients with a known ASCVD diagnosis. Based on KM analysis, OAR patients with ASCVD on combined statin/AP therapy had significantly higher mean survival compared to isolated statin therapy (12.7 ± 0.2 vs. 10.3 ± 0.65 years) and no medical therapy (10.5 ± 0.8 years, Log Rank < 0.001). In KM analysis, OAR patients without known ASCVD indications (N = 3591) had no significant survival differences based on the presence of combined statin/AP therapy (8.4 ± .07 vs. 8.5 ± .11 years, Log Rank = 0 638). CONCLUSION Isolated statin therapy and combined statin/AP therapy showed significant survival benefit in all EVAR and OAR patients with ASCVD indications, as well as among EVAR patients without a known ASCVD diagnosis. OAR patients without ASCVD did not have a significant survival benefit from statin therapy, but low numbers in this group may have confounded the findings. Combined statin/AP therapy appears to have significant post-repair survival benefits even in isolated AAA without ASCVD, as demonstrated in post-EVAR patients in this study. Expansion of statin use recommendations within aneurysm treatment guidelines may be warranted.
Collapse
Affiliation(s)
- Hunter Boudreau
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Juliet Blakeslee-Carter
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL.
| |
Collapse
|
43
|
Kimura Y, Ohtsu H, Yonemoto N, Azuma N, Sase K. Endovascular versus open repair in patients with abdominal aortic aneurysm: a claims-based data analysis in Japan. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2022; 4:e000131. [PMID: 35989874 PMCID: PMC9345055 DOI: 10.1136/bmjsit-2022-000131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 07/05/2022] [Indexed: 11/03/2022] Open
Abstract
ObjectivesEndovascular aortic repair (EVAR) evolved through competition with open aortic repair (OAR) as a safe and effective treatment option for appropriately selected patients with abdominal aortic aneurysm (AAA). Although endoleaks are the most common reason for post-EVAR reintervention, compliance with lifelong regular follow-up imaging remains a challenge.DesignRetrospective data analysis.SettingThe Japan Medical Data Center (JMDC), a claims database with anonymous data linkage across hospitals, consists of corporate employees and their families of ≤75 years of age.ParticipantsThe analysis included participants in the JMDC who underwent EVAR or OAR for intact (iAAA) or ruptured (rAAA) AAA. Patients with less than 6 months of records before the aortic repair were excluded.Main outcome measuresOverall survival and reintervention rates.ResultsWe identified 986 cases (837 iAAA and 149 rAAA) from JMDC with first aortic repairs between January 2015 and December 2020. The number of patients, median age (years (IQR)), follow-up (months) and post-procedure CT scan (times per year) were as follows: iAAA (OAR: n=593, 62.0 (57.0–67.0), 26.0, 1.6, EVAR: n=244, 65.0 (31.0–69.0), 17.0, 2.2), rAAA (OAR: n=110, 59.0 (53.0–59.0), 16.0, 2.1, EVAR: n=39, 62.0 (31.0–67.0), 18.0, 2.4). Reintervention rate was significantly higher among EVAR than OAR in rAAA (15.4% vs 8.2%, p=0.04). In iAAA, there were no group difference after 5 years (7.8% vs 11.0%, p=0.28), even though EVAR had initial advantage. There were no differences in mortality rate between EVAR and OAR for either rAAA or iAAA.ConclusionsClaims-based analysis in Japan showed no statistically significant difference in 5-year survival rates of the OAR and EVAR groups. However, the reintervention rate of EVAR in rAAA was significantly higher, suggesting the need for regular post-EVAR follow-up with imaging. Therefore, international collaborations for long-term outcome studies with real-world data are warranted.
Collapse
Affiliation(s)
- Yuki Kimura
- Clinical Pharmacology and Regulatory Science, Juntendo University School of Medicine Graduate School of Medicine, Bunkyo-ku, Japan
| | - Hiroshi Ohtsu
- Clinical Pharmacology and Regulatory Science, Juntendo University School of Medicine Graduate School of Medicine, Bunkyo-ku, Japan
- Leading Center for the Development and Research of Cancer Medicine, Juntendo University, Bunkyo-ku, Japan
- Institute for Medical Regulatory Science, Organization for University Research Initatives, Waseda University, Wakamatsu-cho, Shinjuku-ku, Japan
| | - Naohiro Yonemoto
- Department of Public Health, Juntendo University School of Medicine Graduate School of Medicine, Bunkyo-ku, Japan
- National Institute of Mental Health, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Midorigaoka higashi Asahikawa, Japan
| | - Kazuhiro Sase
- Clinical Pharmacology and Regulatory Science, Juntendo University School of Medicine Graduate School of Medicine, Bunkyo-ku, Japan
- Institute for Medical Regulatory Science, Organization for University Research Initatives, Waseda University, Wakamatsu-cho, Shinjuku-ku, Japan
| |
Collapse
|
44
|
Borzsák S, Szentiványi A, Süvegh A, Fontanini DM, Vecsey-Nagy M, Banga P, Szeberin Z, Sótonyi P, Csobay-Novák C. Complex Aortic Interventions Can Be Safely Introduced to the Clinical Practice by Physicians Skilled in Basic Endovascular Techniques. LIFE (BASEL, SWITZERLAND) 2022; 12:life12060902. [PMID: 35743933 PMCID: PMC9225306 DOI: 10.3390/life12060902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 11/16/2022]
Abstract
Our purpose was to evaluate the risk associated with the learning curve of starting a complex aortic programme in an Eastern European country. A retrospective study was conducted involving the initial 20 patients (16 males, mean age: 65 ± 11 years) undergoing fenestrated/branched endovascular aortic repair in a single centre. Demographic, anatomical, procedural, and postoperative variables were collected. Our elective patient cohort consisted of 9 pararenal aneurysms (45%) and 11 thoracoabdominal aortic aneurysms (55%), with the latter including 4 chronic dissection cases (20%). A total of 71 branch vessels were incorporated (3.5 ± 0.9 per patient). The per vessel technical success rate was 100%. In-hospital mortality was 5% (1/20). At an average follow-up of 14 ± 22 months, the primary clinical success rate was 45% (9/20) and the secondary clinical success was achieved in 75% of cases (15/20). All-cause mortality at 14 months was 20% (4/20; aortic related: 1/20, 5%). Four bridging stent occlusions were found (5.6%). Mortality and reintervention rates were comparable to the initial results of high-volume centres, while the complexity of our cases and the per vessel technical success rate was comparable to the values reported as late experience. The morbidity of the learning curve could be decreased if operators are skilled in basic endovascular procedures.
Collapse
Affiliation(s)
- Sarolta Borzsák
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (Z.S.); (P.S.)
| | - András Szentiványi
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
| | - András Süvegh
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
| | - Daniele Mariastefano Fontanini
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (Z.S.); (P.S.)
| | - Milán Vecsey-Nagy
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
| | - Péter Banga
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (Z.S.); (P.S.)
- Department of Vascular and Endovascular Surgery, Semmelweis University, 1122 Budapest, Hungary
| | - Zoltán Szeberin
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (Z.S.); (P.S.)
- Department of Vascular and Endovascular Surgery, Semmelweis University, 1122 Budapest, Hungary
| | - Péter Sótonyi
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (Z.S.); (P.S.)
- Department of Vascular and Endovascular Surgery, Semmelweis University, 1122 Budapest, Hungary
| | - Csaba Csobay-Novák
- Department of Interventional Radiology, Semmelweis University, 1122 Budapest, Hungary; (S.B.); (A.S.); (A.S.); (D.M.F.); (M.V.-N.)
- Semmelweis Aortic Center, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (P.B.); (Z.S.); (P.S.)
- Correspondence: ; Tel.: +361-458-6870
| |
Collapse
|
45
|
Mannitol Use is Renal Protective in Patients with Chronic Kidney Disease Requiring Suprarenal Aortic Clamping. Ann Vasc Surg 2022; 85:77-86. [PMID: 35452789 DOI: 10.1016/j.avsg.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Objective: Mannitol is often administered during open juxtarenal or suprarenal aortic surgery to prevent ischemic injury to the kidneys. Prior evidence evaluating the benefits of intraoperative mannitol in reducing ischemia/reperfusion injury is conflicting and largely based on small, retrospective series. The aim of this study was to evaluate the effect of mannitol in preventing postoperative hemodialysis in patients undergoing open abdominal aortic aneurysm (AAA) repair where proximal control involved temporary renal ischemia. METHODS Methods: The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. Patients were included in the current analysis if the proximal aortic clamp was placed above at least one renal artery. Chronic kidney disease (CKD) was defined as Cr >1.8mg/dL. Primary endpoints were 30-day major morbidity (myocardial infarction, respiratory complications, lower extremity or intestinal ischemia, and the need for temporary or permanent hemodialysis) and mortality. Comparisons were made between the mannitol and non-mannitol cohorts and stratified by the presence of pre-existing CKD. RESULTS Results: During the study period, 4,156 patients underwent elective open AAA repair requiring clamp placement above one (32.7%) or both (67.3%) renal arteries; 182 patients (4.4%) had pre-existing CKD. Overall, 69.8% of patients received mannitol during their surgery. Mannitol was more frequently used in cases involving clamp placement above both renal arteries (70.3%) than one renal artery (61.5%). While prolonged ischemia time (greater than 40 minutes) was associated with higher risk of post-operative dialysis in patients without CKD, it was not significant in patients with baseline CKD. On univariate analysis, mannitol use in patients with CKD was associated with lower risk of post-operative dialysis (p=0.005). This remained significant on multivariate analysis (p=0.008). Mannitol use did not appear to confer renal protective effects in patients without baseline CKD. CONCLUSIONS Conclusion: Mannitol use was associated with a decreased risk of need for post-operative hemodialysis in patients with CKD undergoing suprarenal aortic clamping for open aneurysm repair. In appropriately selected patients, particularly those with underlying renal insufficiency, mannitol may confer a renal protective effect in open repair of pararenal AAA requiring suprarenal clamping.
Collapse
|
46
|
Alberga AJ, Karthaus EG, Wilschut JA, de Bruin JL, Akkersdijk GP, Geelkerken RH, Hamming JF, Wever JJ, Verhagen HJM. Treatment Outcome Trends for Non-Ruptured Abdominal Aortic Aneurysms: A Nationwide Prospective Cohort Study. Eur J Vasc Endovasc Surg 2022; 63:275-283. [PMID: 35027275 DOI: 10.1016/j.ejvs.2021.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/19/2021] [Accepted: 08/15/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The Dutch Surgical Aneurysm Audit (DSAA) initiative was established in 2013 to monitor and improve nationwide outcomes of aortic aneurysm surgery. The objective of this study was to examine whether outcomes of surgery for intact abdominal aortic aneurysms (iAAA) have improved over time. METHODS Patients who underwent primary repair of an iAAA by standard endovascular (EVAR) or open surgical repair (OSR) between 2014 and 2019 were selected from the DSAA for inclusion. The primary outcome was peri-operative mortality trend per year, stratified by OSR and EVAR. Secondary outcomes were trends per year in major complications, textbook outcome (TbO), and characteristics of treated patients. The trends per year were evaluated and reported in odds ratios per year. RESULTS In this study, 11 624 patients (74.8%) underwent EVAR and 3 908 patients (25.2%) underwent OSR. For EVAR, after adjustment for confounding factors, there was no improvement in peri-operative mortality (aOR [adjusted odds ratio] 1.06, 95% CI 0.94 - 1.20), while major complications decreased (2014: 10.1%, 2019: 7.0%; aOR 0.91, 95% CI 0.88 - 0.95) and the TbO rate increased (2014: 68.1%, 2019: 80.9%; aOR 1.13, 95% CI 1.10 - 1.16). For OSR, the peri-operative mortality decreased (2014: 6.1%, 2019: 4.6%; aOR 0.89, 95% CI 0.82 - 0.98), as well as major complications (2014: 28.6%, 2019: 23.3%; aOR 0.95, 95% CI 0.91 - 0.99). Furthermore, the proportion of TbO increased (2014: 49.1%, 2019: 58.3%; aOR 1.05, 95% CI 1.01 - 1.10). In both the EVAR and OSR group, the proportion of patients with cardiac comorbidity increased. CONCLUSION Since the establishment of this nationwide quality improvement initiative (DSAA), all outcomes of iAAA repair following EVAR and OSR have improved, except for peri-operative mortality following EVAR which remained unchanged.
Collapse
Affiliation(s)
- Anna J Alberga
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.
| | - Eleonora G Karthaus
- Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Janneke A Wilschut
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Robert H Geelkerken
- Department of Surgery, Hospital Medisch Spectrum Twente, Enschede, The Netherlands; Multi-Modality Medical Imaging group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jan J Wever
- Department of Vascular Surgery, Haga Teaching Hospital, The Hague, The Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | | |
Collapse
|
47
|
Kessler V, Klopf J, Eilenberg W, Neumayer C, Brostjan C. AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis. Biomedicines 2022; 10:94. [PMID: 35052774 PMCID: PMC8773452 DOI: 10.3390/biomedicines10010094] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 01/27/2023] Open
Abstract
Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.
Collapse
Affiliation(s)
| | | | | | | | - Christine Brostjan
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna General Hospital, 1090 Vienna, Austria; (V.K.); (J.K.); (W.E.); (C.N.)
| |
Collapse
|
48
|
Imene B, Nasser-Eddine B, Khaoula B, Slimane L. Fuzzy inference analysis of the arterial hypertension effect on aneurysm. VASCULAR INVESTIGATION AND THERAPY 2022. [DOI: 10.4103/2589-9686.348228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
49
|
Scali ST, Suckow BD, Goodney PP, de Guerre LE, Schermerhorn ML, Huber TS, Upchurch GR, Neal D, Columbo JA, Kang J, Powell RJ, Stone DH. A Significant Proportion of Current EVAR Practice Fails to Meet SVS Clinical Practice Guideline Recommended AAA Diameter Treatment Thresholds in the Vascular Quality Initiative. J Vasc Surg 2022; 75:1234-1241.e1. [DOI: 10.1016/j.jvs.2021.08.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/18/2021] [Indexed: 11/28/2022]
|
50
|
Alberga AJ, von Meijenfeldt GCI, Rastogi V, de Bruin JL, Wever JJ, van Herwaarden JA, Hamming JF, Hazenberg CEVB, van Schaik J, Mees BME, van der Laan MJ, Zeebregts CJ, Schurink GWH, Verhagen HJM. Association of Hospital Volume with Perioperative Mortality of Endovascular Repair of Complex Aortic Aneurysms: A Nationwide Cohort Study. Ann Surg 2021; 277:00000658-900000000-93144. [PMID: 34913891 DOI: 10.1097/sla.0000000000005337] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We evaluate nationwide perioperative outcomes of complex EVAR and assess the volume-outcome association of complex EVAR. SUMMARY OF BACKGROUND DATA Endovascular treatment with fenestrated (FEVAR) or branched (BEVAR) endografts is progressively used for excluding complex aortic aneurysms (complex AAs). It is unclear if a volume-outcome association exists in endovascular treatment of complex AAs (complex EVAR). METHODS All patients prospectively registered in the Dutch Surgical Aneurysm Audit who underwent complex EVAR (FEVAR or BEVAR) between January 2016 and January 2020 were included. The effect of annual hospital volume on perioperative mortality was examined using multivariable logistic regression analyses. Patients were stratified into quartiles based on annual hospital volume to determine hospital volume categories. RESULTS We included 694 patients (539 FEVAR patients, 155 BEVAR patients). Perioperative mortality following FEVAR was 4.5% and 5.2% following BEVAR. Postoperative complication rates were 30.1% and 48.7%, respectively. The first quartile hospitals performed <9 procedures/yr; second, third, and fourth quartile hospitals performed 9-12, 13-22, and ≥23 procedures/yr. The highest volume hospitals treated the significantly more complex patients. Perioperative mortality of complex EVAR was 9.1% in hospitals with a volume of < 9, and 2.5% in hospitals with a volume of ≥13 (P = 0.008). After adjustment for confounders, an annual volume of ≥13 was associated with less perioperative mortality compared to hospitals with a volume of < 9. CONCLUSIONS Data from this nationwide mandatory quality registry shows a significant effect of hospital volume on perioperative mortality following complex EVAR, with high volume complex EVAR centers demonstrating lower mortality rates.
Collapse
Affiliation(s)
- Anna J Alberga
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands Department of Surgery (Division of Vascular Surgery), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands Department of Vascular Surgery, Haga Teaching Hospital, The Hague, the Netherlands Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|