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Shafique H, Quaye K, Cox MW, Long CA, Williams ZF. Endovascular Management of Aortic Stump Blowout by Parallel Grafting and Coil Embolization of Visceral Aorta. Vasc Endovascular Surg 2024; 58:554-558. [PMID: 38166566 DOI: 10.1177/15385744231225890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
Aortic graft and endograft infections remain a significant source of morbidity and mortality after abdominal aortic aneurysm repair. With graft excision and extra-anatomic bypass, an infrarenal aortic stump remains which can have suture line dehiscence and catastrophic stump blowout. Treatment of this is extremely challenging, especially for severely co-morbid patients who cannot undergo major surgery, or in patients with a hostile abdomen. We present a case study of a 74-year-old male found to have an aortoenteric fistula (AEF). This case broadens operative options for this type of patient population by demonstrating an endovascular technique for addressing aortic stump blowout by parallel grafting and coil embolization of the visceral aorta.
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Affiliation(s)
| | - Kofi Quaye
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mitchell W Cox
- Division of Vascular and Endovascular Therapy, Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Zachary F Williams
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Yao J, Zhang Y, Gao B, Zhou M. Associations of Preoperative Nutritional Status and Sarcopenia With Mortality in Patients With Abdominal Aortic Aneurysm After Open and Endovascular Abdominal Aortic Aneurysm Repair: A Retrospective Study. J Cardiothorac Vasc Anesth 2024; 38:1337-1346. [PMID: 38521631 DOI: 10.1053/j.jvca.2024.02.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE The effect of preoperative malnutrition and sarcopenia on outcomes in patients with abdominal aortic aneurysm (AAA) after open surgical repair (OSR) and endovascular abdominal aortic aneurysm repair is undefined. The authors conducted the study to address this issue in this population. DESIGN A retrospective observational study. SETTING A large tertiary hospital. PARTICIPANTS Patients with AAA who underwent OSR and endovascular aneurysm repair (EVAR). INTERVENTIONS Evaluation of nutritional status (Nutritional Risk Screening 2002 [NRS 2002] and the Controlling Nutritional Status [CONUT] scores), muscle size (skeletal muscle index), and postoperative parameters. MEASUREMENTS AND MAIN RESULTS A total of 199 patients were reviewed from January 2020 to December 2022. Patients weew categorized into group A (CONUT <4) and group B (CONUT ≥4) based on whether their CONUT scores were less than 4. The mortality (p = 0.004) and the incidence of Clavien-Dindo class III complications (p = 0.007) in group B were higher than those in group A. CONUT score was an independent risk factor for midterm mortality (hazard ratio 1.329; 95% CI, 1.104-1.697; p = 0.002) and Clavien-Dindo class III complications (odds ratio 1.225; 95% CI, 1.012-1.482; p = 0.037) according to univariate and multivariate analyses, whereas NRS 2002 score and sarcopenia were not. Kaplan-Meier curves showed a lower midterm survival rate in group B (log-rank p < 0.001). CONCLUSION In patients with AAA undergoing OSR or EVAR, a CONUT score ≥4 was associated with increased Clavien-Dindo class III complications and mortality. Preoperative nutritional status should be evaluated and optimized in this high-risk population.
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Affiliation(s)
- Jiashu Yao
- Department of Clinical Nutrition, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yepeng Zhang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Bo Gao
- Department of Clinical Nutrition, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China.
| | - Min Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Goto T, Fujimura H, Shintani T, Shibuya T. Successful chimney endovascular aortic repair with reconstruction of three visceral branches for huge saccular juxtarenal abdominal aortic aneurysm after trans-thoracoabdominal esophagectomy. J Cardiothorac Surg 2024; 19:276. [PMID: 38704597 PMCID: PMC11071143 DOI: 10.1186/s13019-024-02784-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 04/29/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Conventional graft replacement for a juxtarenal abdominal aortic aneurysm (JRAAA) remains challenging for high-risk patients since it often requires the reconstruction of some visceral arteries. CASE PRESENTATION A 76-year-old woman was diagnosed with an 87 × 48 mm saccular JRAAA. Open graft replacement was contraindicated because of frailty and a past history of trans-thoracoabdominal esophagectomy. Chimney endovascular aortic repair (ChEVAR) with three chimney endografts was successfully performed without any endoleaks, and each visceral circulation was kept intact. The patient was discharged uneventfully on postoperative day 8. Significant shrinkage of the aneurysmal sac and preservation of flow through each chimney graft were observed on computed tomography 6 months postoperatively, with no significant increase in serum creatinine levels on laboratory testing. CONCLUSIONS ChEVAR can be a useful surgical option instead of conventional operations, especially for high-risk cases.
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Affiliation(s)
- Takasumi Goto
- Department of Cardiovascular Surgery, Toyonaka Municipal Hospital, 4-14-1, Shibahara, Toyonaka, Osaka, 560-8565, Japan.
| | - Hironobu Fujimura
- Department of Cardiovascular Surgery, Toyonaka Municipal Hospital, 4-14-1, Shibahara, Toyonaka, Osaka, 560-8565, Japan.
| | - Takashi Shintani
- Department of Cardiovascular Surgery, Toyonaka Municipal Hospital, 4-14-1, Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Takashi Shibuya
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan
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Melloni A, Bertoglio L. Regress with Progress: Look for Shrinkage after B/F-EVAR with the Eye of Artificial Intelligence. Eur J Vasc Endovasc Surg 2024; 67:737. [PMID: 38040105 DOI: 10.1016/j.ejvs.2023.11.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/28/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Andrea Melloni
- Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy
| | - Luca Bertoglio
- Division of Vascular Surgery, Department of Experimental and Clinical Sciences, University of Brescia, Brescia, Italy.
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Scott CK, Pizano A, Colon JP, Driessen AL, Miller RT, Timaran CH, Modrall JG, Tsai S, Kirkwood ML, Ramanan B. Impact of chronic kidney disease and end-stage renal disease on outcomes after complex endovascular and open aortic aneurysm repair. J Vasc Surg 2024; 79:1034-1043. [PMID: 38157993 DOI: 10.1016/j.jvs.2023.12.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Chronic kidney disease (CKD) and end-stage renal disease are traditionally associated with worse outcomes after endovascular aortic repair (EVAR) and open aneurysm repair (OAR) of abdominal aortic aneurysms (AAAs). However, there needs to be more data on complex AAA repair involving the aorta's visceral segment. This study stratifies complex AAA repair outcomes by CKD severity and dialysis dependence. METHODS All patients undergoing elective OAR and fenestrated/branched EVAR (F-BEVAR) for complex AAA with preoperative renal function data captured by the Vascular Quality Initiative between January 2003 and September 2020 were analyzed. Patients were stratified by CKD class as follows: normal/mild (CKD 1 and 2), moderate (CKD class 3a), moderate to severe (CKD 3b), severe (CKD class 4 and 5), and dialysis. Only patients with clamp sites above one of the renal arteries were included for complex OAR. For F-BEVAR, patients with proximal landing zones below zone 5 (above celiac artery) were included, and distal landing zones between zones 1 and 5 were excluded. Primary outcomes were perioperative and 1-year mortality. Predictors of mortality were identified by Cox multivariate regression models. RESULTS We identified 7849 elective complex AAA repairs: 4230 (54%) complex OARs and 3619 (46%) F-BEVARs. Most patients were White (89%) and male (74%), with an average age of 72 ± 8 years. The patients who underwent F-BEVAR were older and had more comorbidities. Elective F-BEVAR for complex AAA started in 2012 and increased from 1.4% in 2012 to 58% in 2020 (P < .001). The OAR cohort had more perioperative complications, but less 1-year mortality. The normal/mild CKD cohort had the highest 1-year survival compared with other groups after both complex OAR and F-BEVAR. On Cox regression analysis, when compared with CKD 1-2, worsening CKD stage (CKD 3b: hazard ratio [HR], 2.5; 95% confidence interval [CI], 1.82-3.40; P < .001; CKD 4-5: HR, 1.9; 95% CI, 1.16-3.26; P = .011; and dialysis: HR, 4.4; 95% CI, 2.53-7.72; P < .001) were independently associated with 1-year survival after F-BEVAR. After complex OAR, worsening CKD stage but not dialysis was associated with 1-year mortality compared with CKD 1-2 (CKD 3b: HR, 1.6; 95% CI, 1.13-2.35; P = .009; CKD 4-5: HR, 3.4; 95% CI, 2.03-5.79; P < .001). CONCLUSIONS CKD severity is an essential predictor of perioperative and 1-year mortality after complex AAA repair, irrespective of the treatment modality, which may reflect the natural history of CKD. Consideration should be given to raising the threshold for elective AAA repair in patients with moderate to severe CKD and end-stage renal disease, given the high 1-year mortality rate.
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MESH Headings
- Humans
- Male
- Middle Aged
- Aged
- Aged, 80 and over
- Risk Factors
- Blood Vessel Prosthesis Implantation/adverse effects
- Treatment Outcome
- Endovascular Procedures/adverse effects
- Time Factors
- Kidney Failure, Chronic/complications
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/therapy
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/therapy
- Aortic Aneurysm, Abdominal/complications
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/surgery
- Retrospective Studies
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Affiliation(s)
- Carla K Scott
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Alejandro Pizano
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jesus Porras Colon
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Anna L Driessen
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - R Tyler Miller
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Carlos H Timaran
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - John G Modrall
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Shirling Tsai
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Melissa L Kirkwood
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Bala Ramanan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
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Holden A, Hill AA, Khashram M, Heyligers JMM, Wiersema AM, Hayes PD, Reijnen MMPJ. One-year follow-up after active aortic aneurysm sac treatment with shape memory polymer devices during endovascular aneurysm repair. J Vasc Surg 2024; 79:1090-1100.e4. [PMID: 38185214 DOI: 10.1016/j.jvs.2023.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE To determine the safety and efficacy of treating abdominal aortic aneurysm (AAA) sacs with polyurethane shape memory polymer (SMP) devices during endovascular aneurysm repair (EVAR), using a technique to fully treat the target lumen after endograft placement (aortic flow volume minus the endograft volume). SMP devices self-expand in the sac to form a porous scaffold that supports thrombosis throughout its structure. METHODS Two identical prospective, multicenter, single-arm studies were conducted in New Zealand and the Netherlands. The study population was adult candidates for elective EVAR of an infrarenal AAA (diameter of ≥55 mm in men and ≥50 mm in women). Key exclusion criteria were an inability to adequately seal a common iliac artery aneurysm, patent sac feeding vessels of >4 mm, and a target lumen volume of <20 mL or >135 mL. Target lumen volumes were estimated by subtracting endograft volumes from preprocedural imaging-based flow lumen volumes. SMP devices were delivered immediately after endograft deployment via a 6F sheath jailed in a bowed position in the sac. The primary efficacy end point was technical success, defined as filling the actual target lumen volume with fully expanded SMP at the completion of the procedure. Secondary efficacy outcome measures during follow-up were the change in sac volume and diameter, rate of type II endoleak and type I or III endoleaks, and the rate of open repair and related reinterventions, with data collection at 30 days, 6 months, and 1 year (to date). Baseline sac volumes and diameters for change in sac size analyses were determined from 30-day imaging studies. Baseline and follow-up volumes were normalized by subtraction of the endograft volume. RESULTS Of 34 patients treated with SMP devices and followed per protocol, 33 patients were evaluable at 1 year. Preprocedural aneurysm volume was 181.4 mL (95% confidence interval [CI], 150.7-212.1 mL) and preprocedural aneurysm diameter was 60.8 mm (95% CI, 57.8-63.9 mm). The target lumen volume was 56.3 mL (95% CI, 46.9-65.8 mL). Technical success was 100% and the ratio of SMP fully expanded volume to estimated target lumen volume was 1.4 ± 0.3. Baseline normalized sac volume and diameter were 140.7 mL (95% CI, 126.6-154.9 mL) and 61.0 mm (95% CI, 59.7-62.3 mm). The adjusted mean percentage change in normalized volume at 1 year was -28.8% (95% CI, -35.3 to -22.3%; P < .001). The adjusted mean change in sac diameter at 1 year was -5.9 mm (95% CI, -7.5 to -4.4 mm; P < .001). At 1 year, 81.8% of patients (95% CI, 64.5%-93.0%) achieved a ≥10% decrease in normalized volume and 57.6% of patients (95% CI, 39.2%-74.5%) achieved a ≥5 mm decrease in diameter. No device- or study procedure-related major adverse events occurred through 1 year after the procedure. CONCLUSIONS Treatment of AAA sacs with SMP devices during EVAR resulted in significant sac volume and diameter regression at 1 year with an acceptable safety profile in this prospective study.
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Affiliation(s)
- Andrew Holden
- Department of Interventional Radiology, Auckland City Hospital, Auckland, New Zealand.
| | - Andrew A Hill
- Vascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Manar Khashram
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Jan M M Heyligers
- Department of Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Arno M Wiersema
- Department of Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | | | - Michel M P J Reijnen
- Department of Surgery, Rijnstate, Arnhem, The Netherlands; Multi-Modality Medical Imaging Group, University of Twente, Enschede, The Netherlands
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Squizzato F, Piazza M, Forcella E, Coppadoro S, Grego F, Antonello M. Clinical Impact and Determinants of Fenestration to Target Vessel Misalignment in Fenestrated Endovascular Aortic Repair. Eur J Vasc Endovasc Surg 2024; 67:765-774. [PMID: 37858703 DOI: 10.1016/j.ejvs.2023.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 09/20/2023] [Accepted: 10/12/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE This single centre, retrospective study (2014 - 2022) on juxta-, pararenal, or thoraco-abdominal aortic aneurysms treated by fenestrated endovascular aortic repair (FEVAR) was conducted to investigate the clinical impact and determinants of fenestration to target vessel misalignment in FEVAR. METHODS Pre-operative supracoeliac, pararenal, and infrarenal aortic angles were measured on three dimensional computed tomography angiography (CTA) reconstructions. Two components of misalignment were measured on the first post-operative CTA: horizontal misalignment (angle between the fenestration and the target vessel ostium on perpendicular CTA cuts) and vertical misalignment (vertical distance between the fenestration and the target vessel at its origin). Endpoints were freedom from target vessel instability (TVI) and alignment change over time. RESULTS Of 65 patients treated by FEVAR, 60 (202 target arteries) with juxta-, pararenal (80%), or thoraco-abdominal aortic aneurysm (20%) were included. Mean horizontal misalignment was 9 ± 12° (median 5°; IQR 0 - 16) and mean vertical misalignment was 0.7 ± 1 mm (median 0 mm, IQR 0 - 1). Freedom from TVI was 92% (95% CI 88 - 98) at 36 months. Horizontal misalignment > 15° was significantly associated with TVI (HR 5.19; 95% CI 1.54 - 17.48; p = .008); vertical misalignment did not significantly impact TVI (HR 0.99; 95% CI 0.56 - 1.73; p = .97). By multivariable analysis, pararenal aortic angle (OR 1.01 per increased degree of angulation; 95% CI 1.00 - 1.02; p = .044), bridging distance > 5 mm (OR 1.07; 95% CI 1.02 - 1.11; p = .003), and use of higher profile endografts in tortuous iliac access (OR 7.55; 95% CI 4.55 - 1.11; p = .003) were associated with clinically significant misalignment. Bridging distance > 5 mm (OR 2.00; 95% CI 1.02 - 11.29; p = .044), degree of baseline misalignment (OR 1.04; 95% CI 1.01 - 1.08; p = .036), and persistence of any primary endoleak for > 6 months (OR 5.85; 95% CI 1.23 - 29.1; p = .023) were associated with misalignment increase during follow up. CONCLUSION Horizontal misalignment > 15° is associated with worsened target vessel outcomes. This may occur as a result of excessive iliac access tortuosity, high pararenal aortic angulation, and bridging distance > 5 mm.
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Affiliation(s)
- Francesco Squizzato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Michele Piazza
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Edoardo Forcella
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Sofia Coppadoro
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Franco Grego
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Michele Antonello
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
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Dabravolskaité V, Aweys MM, Venermo M, Hakovirta H, Mufty H, Zimmermann A, Makaloski V, Meuli L. Editor's Choice - External Validation of a Prognostic Model for Survival of Patients With Abdominal Aortic Aneurysms Treated by Endovascular Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:718-725. [PMID: 37995960 DOI: 10.1016/j.ejvs.2023.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/08/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE Current guidelines recommend diameter monitoring of small and asymptomatic abdominal aortic aneurysms (AAAs) due to the low risk of rupture. Elective AAA repair is recommended for diameters ≥ 5.5 cm in men and ≥ 5.0 cm in women. However, data supporting the efficacy of elective treatment for all patients above these thresholds are diverging. For a subgroup of patients, life expectancy might be very short, and elective AAA repair at the current threshold may not be justified. This study aimed to externally validate a predictive model for survival of patients with an asymptomatic AAA treated by endovascular aneurysm repair (EVAR). METHODS This was a multicentre international retrospective observational cohort study. Data were collected from four European aortic centres treating patients between 2001 and 2021. The initial model included age, estimated glomerular filtration rate (eGFR), and chronic obstructive pulmonary disease (COPD) as independent predictors for survival. Model performance was measured by discrimination and calibration. RESULTS The validation cohort included 1 500 patients with a median follow up of 65 months, during which 54.6% of the patients died. The external validation showed slightly decreased discrimination ability and signs of overfitting in model calibration. However, a high risk subgroup of patients with impaired survival rates was identified: octogenarians with eGFR < 60 OR COPD, septuagenarians with eGFR < 30, and septuagenarians with eGFR < 60 and COPD having survival rates of only 55.2% and 15.5% at five and 10 years, respectively. CONCLUSION EVAR is a valuable treatment option for AAA, especially for patients unsuitable for open repair. Nonetheless, not all these patients will benefit from EVAR, and an individualised treatment recommendation should include considerations on life expectancy. This study provides a risk stratification to identify patients who may not benefit from EVAR using the present diameter thresholds.
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Affiliation(s)
- Vaiva Dabravolskaité
- Department of vascular surgery, University of Bern, Inselspital, Bern, Switzerland; Department of vascular surgery, University of Turku, Finland
| | - Mometo M Aweys
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maarit Venermo
- Department of vascular surgery, University of Zurich, Switzerland
| | - Harri Hakovirta
- Department of vascular surgery, University of Turku, Finland
| | - Hozan Mufty
- Department of Vascular Surgery, Leuven University Hospital, Belgium
| | | | - Vladimir Makaloski
- Department of vascular surgery, University of Bern, Inselspital, Bern, Switzerland
| | - Lorenz Meuli
- Department of vascular surgery, University of Zurich, Switzerland.
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Jo EA, Ahn S, Mo H, Jung IM, Kim HK, Ko H, Han A, Min S, Ha J, Min SK. A 20-Year Analysis of Ruptured Abdominal Aortic Aneurysm Outcomes and Associated Factors in Korea. Ann Vasc Surg 2024; 102:152-159. [PMID: 38307230 DOI: 10.1016/j.avsg.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/09/2023] [Accepted: 10/30/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Unlike western countries, which have reported distinct decreases in incidence of ruptured abdominal aortic aneurysm (rAAA) over the last few decades, epidemiologic studies in Korea have not shown significant changes in incidence or mortality of rAAA. The purpose of this study was to analyze the changes in rAAA treatment outcomes and various associated risk factors over the past 2 decades. METHODS A 20-year retrospective multicenter review for rAAA cases from the period of January 2000 to December 2020 was undertaken. Preoperative, intraoperative and postoperative clinical data were extracted for patients diagnosed with rAAA. For analysis, outcomes from the early era, defined as patients treated between January 1, 2000, and December 31, 2010, were compared with outcomes from the late era, defined as patients treated between January 1, 2011, and December 31, 2020. RESULTS The total in-hospital mortality was 34.1% in the early era compared to 44.8% in the late era. Patients in the late era were older than those in the early era (75.2 ± 10.3 years vs. 70.3 ± 8.9 years; P = 0.009). Treatment with rAAA endovascular aneurysm repair increased from 2.3% in early to 13.8% in late era (P = 0.031). In the early era, more patients were operated by experienced surgeons than the late era (78.1% vs. 45.9%; P = 0.002). The emergency room to operating room time did not show improvement over the 20 years. CONCLUSIONS The results indicate that mortality rate of rAAA in Korea has not changed over the last 2 decades. The study suggests the need for national preventive strategies, improved systemic coordination, and potential centralization of vascular services to enhance survival rates for rAAA.
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Affiliation(s)
- Eun-Ah Jo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea; Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Sanghyun Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.
| | - Hyejin Mo
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - In-Mok Jung
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hyo Kee Kim
- Department of Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Hyunmin Ko
- Department of Surgery, Kyung Hee University Medical Center, Seoul, Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sangil Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Lauridsen SV, Bøtker MT, Eldrup N, Juhl-Olsen P. Prehospital point-of-care ultrasound in ruptured abdominal aortic aneurysms-a retrospective cohort study. Acta Anaesthesiol Scand 2024; 68:693-701. [PMID: 38415353 DOI: 10.1111/aas.14393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/14/2024] [Accepted: 02/04/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Patients with ruptured abdominal aortic aneurysm (rAAA) require immediate vascular treatment to survive. The use of prehospital point-of-care ultrasound (POCUS) may support clinical assessment, correct diagnosis, appropriate triage and reduce system delay. The aim was to study the process of care and outcome in patients receiving prehospital POCUS versus patients not receiving prehospital POCUS in patients with rAAA, ruptured iliac aneurysm or impending aortic rupture. METHODS We performed a retrospective cohort study in patients diagnosed with rAAA in the Central Denmark Region treated by a prehospital critical care physician from 1 January 2017 to 31 December 2021. Performance of prehospital POCUS was extracted from the prehospital electronic health records. System delay was defined as the time from the emergency phone call to the emergency medical service dispatch centre until the start of surgery. Data on patients primary hospital admission to a centre with/without vascular treatment expertise, treatments and complications including death were extracted from electronic health records. RESULTS We included 169 patients; prehospital POCUS was performed in 124 patients (73%). Emergency surgical treatment was performed in 71 patients. The overall survival in the POCUS group was 39% versus 16% in the NO POCUS group (hazard ratio (HR) (95% 0.60, 95% CI: 0.41-0.89, p = .011). In the POCUS group 99/124 (80%) were directly admitted to a vascular surgical centre versus 25/45 (56%) in the NO POCUS, RD 24% (95% CI: 8-40)), (p = .002). In the POCUS group, system delay was a median of 142 minutes (interquartile range (IQR) 121-189) and a median of 232 minutes (IQR 166-305) in the NO POCUS group (p = .006). In a multivariable analysis incorporating age, sex, previously known rAAA, and typical clinical symptoms of rAAA, the HR for death was 0.57, 95% CI 0.38-0.86 (p = .008) favouring prehospital POCUS. CONCLUSIONS Prehospital POCUS was associated with reduced time to treatment, higher chance of operability and significantly higher 30-day survival in patients with rAAA, ruptured iliac aneurysm or impending rupture of an AAA in this retrospective study. Residual confounding cannot be excluded. This study supports the clinical relevance of prehospital POCUS of the abdominal aorta.
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Affiliation(s)
- Signe Voigt Lauridsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Research and Development, Prehospital Emergency Medical Service, Central Denmark Region, Aarhus, Denmark
| | - Morten Thingemann Bøtker
- Department of Research and Development, Prehospital Emergency Medical Service, Central Denmark Region, Aarhus, Denmark
- Department of Anaesthesiology, Randers Region Hospital, Randers, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Juhl-Olsen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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11
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Moulakakis KG, Lazaris AM, Georgiadis GS, Kakkos S, Papavasileiou VG, Antonopoulos CN, Papapetrou A, Katsikas V, Klonaris C, Geroulakos G. A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:756-764. [PMID: 38154499 DOI: 10.1016/j.ejvs.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/02/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. METHODS A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital death. RESULTS A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p = .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 - 32.40; p = .010) and in hospital death (OR 9.53, 95% CI 2.79 - 32.58; p < .001). CONCLUSION These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.
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Affiliation(s)
- Konstantinos G Moulakakis
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece.
| | - Andreas M Lazaris
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Stavros Kakkos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | | | - Constantine N Antonopoulos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios Papapetrou
- Hellenic Vascular Registry (HEVAR); Vascular Surgery Clinic, K.A.T. General Hospital, Athens, Greece
| | - Vasilios Katsikas
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Gennimatas General Hospital of Athens, Athens, Greece
| | - Chris Klonaris
- Hellenic Vascular Registry (HEVAR); 2nd Department of Vascular Surgery, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - George Geroulakos
- Hellenic Vascular Registry (HEVAR); Department of Vascular Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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12
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Azuma S, Shimada R, Maeda K, Fukuhara S, Nakamura S. Two-Stage Endovascular Aneurysm Repair with Preemptive Embolization: A Retrospective Study. Ann Vasc Surg 2024; 102:229-235. [PMID: 37940086 DOI: 10.1016/j.avsg.2023.09.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Type II endoleak is the most common complication of endovascular aneurysm repair. Retrograde perfusion from the aneurysmal sac side branch to the aneurysmal sac, including the inferior mesenteric artery and lumbar arteries, is associated with adverse events after endovascular aneurysm repair, such as aneurysm sac enlargement, reintervention, rupture, and abdominal aortic aneurysm-related death. Preemptive embolization of the aneurysmal sac side branch before endovascular aneurysm repair is an effective and safe procedure for preventing type II endoleak and reducing the size of the aneurysmal sac. Since 2019, we have been conducting preemptive embolization of the inferior mesenteric artery and lumbar arteries. Thus, we intended to work on a two-stage endovascular aneurysm repair in which embolization and endovascular aneurysm repair are performed on separate days, owing to concerns about prolonged operative time and increased contrast media use and radiation exposure from performing endovascular aneurysm repair simultaneously. This study aimed to evaluate the effects of a two-stage endovascular aneurysm repair. METHODS This retrospective study included 114 cases of endovascular aneurysm repair (95 men and 19 women) for AAA performed at our hospital between January 2019 and December 2022. Inferior mesenteric artery and lumbar artery embolization were performed simultaneously with endovascular aneurysm repair (simultaneous group) in 49 cases, and two-stage embolization was performed (two-stage group) in 30 cases. The primary endpoints included the occurrence of T2EL during follow-up and the embolization rate of the IMA or LAs. RESULTS Type II endoleak did not occur in the two-stage group (follow-up period: 35 ± 6.2 months), whereas it was observed in 8.2% of patients more than 6 months after EVAR in the simultaneous group (follow-up period: 28 ± 5.5 months). While the total operative time was 340 ± 111.2 min in the simultaneous group, the durations for embolization and endovascular aneurysm repair in the two-stage group were 169 ± 35.5 min and 135.0 ± 26.4 min (total time 304 ± 31.2 min, P = 0.21), respectively, indicating a reduction in the total time required for the 2 techniques. The total amounts of contrast media used in the simultaneous and two-stage groups were 200.0 ± 179.2 mL and 182.0 ± 51.2 mL (P = 0.42), respectively, and the corresponding total radiation doses were 2502.4 ± 690.5 mGy and 2114.6 ± 351.2 mGy (P = 0.28), respectively, showing a decrease in both in the two-stage group. The lumbar artery embolization rates were 74.3% and 87.9% (P < 0.01) in the simultaneous and two-stage groups, respectively, indicating a significant difference. CONCLUSIONS Two-stage endovascular aneurysm repair with preemptive embolization of the inferior mesenteric artery and lumbar arteries may be an effective strategy for reducing type II endoleak occurrence, overall operative time, contrast use, and overall radiation exposure.
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Affiliation(s)
- Shuhei Azuma
- The Department of Cardiovascular Surgery, Kyoto Katsura Hospital, Kyoto City, Kyoto Prefecture, Japan.
| | - Ryo Shimada
- The Department of Cardiovascular Surgery, Kyoto Katsura Hospital, Kyoto City, Kyoto Prefecture, Japan
| | - Kazuto Maeda
- The Department of Cardiovascular Surgery, Kyoto Katsura Hospital, Kyoto City, Kyoto Prefecture, Japan
| | - Shinji Fukuhara
- The Department of Cardiovascular Surgery, Kyoto Katsura Hospital, Kyoto City, Kyoto Prefecture, Japan
| | - Shigeru Nakamura
- The Department of Cardiovascular Surgery, Kyoto Katsura Hospital, Kyoto City, Kyoto Prefecture, Japan
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13
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Budge J, Lenti L, Azhar B, Roy I, Loftus I, Holt P. Quality Assessment of Elective Abdominal Aortic Aneurysm Repair Patient Information on the Internet Using the Modified Ensuring Quality Information for Patients Tool. Eur J Vasc Endovasc Surg 2024; 67:738-745. [PMID: 38185375 DOI: 10.1016/j.ejvs.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 12/07/2023] [Accepted: 01/04/2024] [Indexed: 01/09/2024]
Abstract
OBJECTIVE This study aimed to assess the quality of patient information material regarding elective abdominal aortic aneurysm (AAA) repair on the internet using the Modified Ensuring Quality Information for Patients (MEQIP) tool. METHODS A qualitative assessment of internet based patient information was performed. The 12 most used search terms relating to AAA repair were identified using Google Trends, with the first 10 pages of websites retrieved for each term searched. Duplicates were removed, and information for patients undergoing elective AAA were selected. Further exclusion criteria were marketing material, academic journals, videos, and non-English language sites. The remaining websites were then MEQIP scored independently by two reviewers, producing a final score by consensus. RESULTS A total of 1 297 websites were identified, with 235 (18.1%) eligible for analysis. The median MEQIP score was 18 (interquartile range [IQR] 14, 21) out of a possible 36. The highest score was 33. The 99th percentile MEQIP scoring websites scored > 27, with four of these six sites representing online copies of hospital patient information leaflets, however hospital sites overall had lower median MEQIP scores than most other institution types. MEQIP subdomain median scores were: content, 8 (IQR 6, 11); identification, 3 (IQR 1, 3); and structure, 7 (IQR 6, 9). Of the analysed websites, 77.9% originated from the USA (median score 17) and 12.8% originated in the UK (median score 22). Search engine ranking was related to website institution type but had no correlation with MEQIP. CONCLUSION When assessed by the MEQIP tool, most websites regarding elective AAA repair are of questionable quality. This is in keeping with studies in other surgical and medical fields. Search engine ranking is not a reliable measure of quality of patient information material regarding elective AAA repair. Health practitioners should be aware of this issue as well as the whereabouts of high quality material to which patients can be directed.
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Affiliation(s)
- James Budge
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK; and St George's University of London, London, UK.
| | - Lorenzo Lenti
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK; and St George's University of London, London, UK
| | - Bilal Azhar
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK; and St George's University of London, London, UK
| | - Iain Roy
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK; and St George's University of London, London, UK
| | - Ian Loftus
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK; and St George's University of London, London, UK
| | - Peter Holt
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK; and St George's University of London, London, UK
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14
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Mesnard T, Vacirca A, Baghbani-Oskouei A, Sulzer TAL, Savadi S, Kanamori LR, Tenorio ER, Mirza A, Saqib N, Mendes BC, Huang Y, Oderich GS. Prospective evaluation of upper extremity access and total transfemoral approach during fenestrated and branched endovascular repair. J Vasc Surg 2024; 79:1013-1023.e3. [PMID: 38141739 DOI: 10.1016/j.jvs.2023.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE Total transfemoral (TF) access has been increasingly used during fenestrated-branched endovascular aortic repair (FB-EVAR). However, it is unclear whether the potential decrease in the risk of cerebrovascular events is offset by increased procedural difficulties and other complications. The aim of this study was to compare outcomes of FB-EVAR using a TF vs upper extremity (UE) approach for target artery incorporation. METHODS We analyzed the clinical data of consecutive patients enrolled in a prospective, nonrandomized clinical trial in two centers to investigate the use of FB-EVAR for treatment of complex abdominal aortic aneurysms (CAAA) and thoracoabdominal aortic aneurysms (TAAA) between 2013 and 2022. Patients were classified into TF or UE access group with a subset analysis of patients treated using designs with directional branches. End points were technical success, procedural metrics, 30-day cerebrovascular events defined as stroke or transient ischemic attack, and any major adverse events (MAEs). RESULTS There were 541 patients (70% males; mean age, 74 ± 8 years) treated by FB-EVAR with 2107 renal-mesenteric TAs incorporated. TF was used in175 patients (32%) and UE in 366 patients (68%) including 146 (83%) TF and 314 (86%) UE access patients who had four or more TAs incorporated. The use of a TF approach increased from 8% between 2013 and 2017 to 31% between 2018 and 2020 and 96% between 2021 and 2022. Compared with UE access patients, TF access patients were more likely to have CAAAs (37% vs 24%; P = .002) as opposed to TAAAs. Technical success rate was 96% in both groups (P = .96). The use of the TF approach was associated with reduced fluoroscopy time and procedural time (each P < .05). The 30-day mortality rate was 0.6% for TF and 1.4% for UE (P = .67). There was no early cerebrovascular event in the TF group, but the incidence was 2.7% for UE patients (P = .035). The incidence of MAEs was also lower in the TF group (9% vs 18%; P = .006). Among 237 patients treated using devices with directional branches, there were no significant differences in outcomes except for a reduced procedural time for TF compared with UE access patients (P < .001). CONCLUSIONS TF access was associated with a decreased incidence of early cerebrovascular events and MAEs compared with UE access for target artery incorporation. Procedural time was decreased in TF access patients irrespective of the type of stent graft design.
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Affiliation(s)
- Thomas Mesnard
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Andrea Vacirca
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aidin Baghbani-Oskouei
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Titia A L Sulzer
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Safa Savadi
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Lucas Ruiter Kanamori
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Emanuel R Tenorio
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Aleem Mirza
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Naveed Saqib
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Bernardo C Mendes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Ying Huang
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX
| | - Gustavo S Oderich
- Department of Cardiothoracic & Vascular Surgery, Advanced Aortic Research Program at the University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX.
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15
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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16
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DeHaven C, Zil-E-Ali A, Lavanga E, Flohr TR, Krause K, Rossip M, Aziz F. Octogenarians fare better under local anesthesia for elective endovascular aortic aneurysm repair. J Vasc Surg 2024; 79:1079-1089. [PMID: 38141740 DOI: 10.1016/j.jvs.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE With an aging patient population, an increasing number of octogenarians are undergoing elective endovascular abdominal aortic aneurysm repair (EVAR) in the United States. Multiple studies have shown that, for the general population, use of local anesthetic (LA) for EVAR is associated with improved short-term and long-term outcomes as compared with performing these operations under general anesthesia (GA). Therefore, this study aimed to study the association of LA for elective EVARs with perioperative outcomes, among octogenarians. METHODS The Vascular Quality Initiative database (2003-2021) was used to conduct this study. Octogenarians (Aged ≥80 years) were selected and sorted into two study groups: LA (Group I) and GA (Group II). Our primary outcomes were length of stay and mortality. Secondary outcomes included operative time, estimated blood loss, return to operating room, cardiopulmonary complications, and discharge location. RESULTS Of the 16,398 selected patients, 1197 patients (7.3%) were included in Group I, and 15,201 patients (92.7%) were in Group II. Procedural time was significantly shorter for the LA group (114.6 vs 134.6; P < .001), as was estimated blood loss (152 vs 222 cc; P < .001). Length of stay was significantly shorter (1.8 vs 2.6 days; P < .001), and patients were more likely to be discharged home (LA 88.8% vs GA 86.9%; P = .036) in the LA group. Group I also experienced fewer pulmonary complications; only 0.17% experienced pneumonia and 0.42% required ventilator support compared with 0.64% and 1.02% in Group II, respectively. This finding corresponded to fewer days in the intensive care unit for Group I (0.41 vs 0.69 days; P < .001). No significant difference was seen in 30-day mortality cardiac, renal, or access site-related complications. Return to operating room was also equivocal between the two groups. Multivariate regression analysis confirmed GA was associated with a significantly longer length of stay and significantly higher rates of non-home discharge (adjusted odds ratio [AOR], 1.59; P < .001 and AOR, 1.40; P = .025, respectively). When stratified by the New York Heart Association classification system, classes I, II, III, and IV (1.55; P < .001; 1.26; P = .029; 2.03; P < .001; 4.07; P < .001, respectively) were associated with significantly longer hospital stays. CONCLUSIONS The use of LA for EVARs in octogenarians is associated with shorter lengths of stay, fewer respiratory complications, and home discharge. These patients also experienced shorter procedure times and less blood loss. There was no statistically significant difference in 30-day mortality, return to operating room, or access-related complications. LA for octogenarians undergoing EVAR should be considered more frequently to shorten hospital stays and decrease complication rates.
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Affiliation(s)
- Christopher DeHaven
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Penn State University College of Medicine, Hershey, PA.
| | - Elizabeth Lavanga
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Tanya R Flohr
- Division of Vascular Surgery, Penn State University College of Medicine, Hershey, PA
| | - Kayla Krause
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Maxwell Rossip
- Department of Medical Education, Penn State University, College of Medicine, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State University College of Medicine, Hershey, PA
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17
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Sterpetti AV, Di Marzo L, Bozzani A. A New Way to Look at Screening for Aortic Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:861-862. [PMID: 38253172 DOI: 10.1016/j.ejvs.2023.08.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 01/24/2024]
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18
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Jessula S, Cote C, Khoury M, DeCarlo C, Bellomo TR, Grant-Gorveatt A, Herman C, Smith M, Dua A, Eagleton M, Casey P, Zacharias N. Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results. Ann Vasc Surg 2024; 102:64-73. [PMID: 38301848 DOI: 10.1016/j.avsg.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/03/2023] [Accepted: 11/09/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality. METHODS The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality. RESULTS Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25). CONCLUSIONS LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.
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Affiliation(s)
- Samuel Jessula
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS.
| | - Claudia Cote
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Mitri Khoury
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Tiffany R Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexa Grant-Gorveatt
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Christine Herman
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Matthew Smith
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Patrick Casey
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, Halifax, NS
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Goyal A, Fatima L, Mushtaq F, Tariq MD, Kamran A, Sohail AH, Chunawala Z, Sulaiman SA, Shrestha AB, Sheikh AB, Belur AD. Comparison between the outcomes of transfemoral access and transfemoral access with adjunct upper extremity access in patients undergoing endovascular aortic repair: A pilot systematic review and meta-analysis. Catheter Cardiovasc Interv 2024; 103:982-994. [PMID: 38584518 DOI: 10.1002/ccd.31048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/18/2024] [Accepted: 03/31/2024] [Indexed: 04/09/2024]
Abstract
Endovascular aortic repair is an emerging novel intervention for the management of abdominal aortic aneurysms. It is crucial to compare the effectiveness of different access sites, such as transfemoral access (TFA) and upper extremity access (UEA). An electronic literature search was conducted using PubMed, EMBASE, and Google Scholar databases. The primary endpoint was the incidence of stroke/transient ischemic attack (TIA), while the secondary endpoints included technical success, access-site complications, mortality, myocardial infarction (MI), spinal cord ischemia, among others. Forest plots were constructed for the pooled analysis of data using the random-effects model in Review Manager, version 5.4. Statistical significance was set at p < 0.05. Our findings in 9403 study participants (6228 in the TFA group and 3175 in the UEA group) indicate that TFA is associated with a lower risk of stroke/TIA [RR: 0.55; 95% CI: 0.40-0.75; p = 0.0002], MI [RR: 0.51; 95% CI: 0.38-0.69; p < 0.0001], spinal cord ischemia [RR: 0.41; 95% CI: 0.32-0.53, p < 0.00001], and shortens fluoroscopy time [SMD: -0.62; 95% CI: -1.00 to -0.24; p = 0.001]. Moreover, TFA required less contrast agent [SMD: -0.33; 95% CI: -0.61 to -0.06; p = 0.02], contributing to its appeal. However, no significant differences emerged in technical success [p = 0.23], 30-day mortality [p = 0.48], ICU stay duration [p = 0.09], or overall hospital stay length [p = 0.22]. Patients with TFA had a lower risk of stroke, MI, and spinal cord ischemia, shorter fluoroscopy time, and lower use of contrast agents. Future large-scale randomized controlled trials are warranted to confirm and strengthen these findings.
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Affiliation(s)
- Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Laveeza Fatima
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Fiza Mushtaq
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Muhammad Daoud Tariq
- Department of Internal Medicine, Foundation University Medical College, Islamabad, Pakistan
| | - Aemen Kamran
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Amir Humza Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - Zainali Chunawala
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Samia Aziz Sulaiman
- Department of Internal Medicine, School of Medicine, University of Jordan, Amman, Jordan
| | | | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
| | - Agastya D Belur
- Department of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
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20
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Manunga J, Stanberry LI, Skeik N, Hanif H, Rana MA. Use of physician-modified inverted limb in conjunction with Zenith fenestrated stent graft to rescue failed previous endovascular and open repair. J Vasc Surg 2024; 79:1101-1109. [PMID: 38103807 DOI: 10.1016/j.jvs.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE To evaluate outcomes and performance of inverted limbs (ILs) when used in conjunction with Zenith fenestrated stent grafts (Zfens) to treat patients with short distance between the lowest renal artery (RA) and aortic or graft bifurcation (A/GB). METHODS This study was a multicenter, retrospective review of prospectively maintained database of patients with complex aortic aneurysms, failed endovascular aneurysm repair (EVAR), or open surgical repair (OSR) with short distance between LRA and A/GB treated using a combination of Zfen and an IL between 2013 and 2023. Endpoints included technical success, aneurysm sac regression, long-term device integrity, and target vessel patency. We defined technical success as implantation of the device with no endoleak, conversion to an aorto-uni-iliac or OSR. RESULTS During this time, 52 patients underwent endovascular rescue of failed repair. Twenty (38.5%) of them required relining of the failed repairs using IL due to lowest RA to A/GB length restrictions. Two patients had undergone rescue with a fenestrated cuff alone but developed type III endoleaks. One patient with no previous implant had a short distance between the lowest RA and aortic bifurcation to accommodate the bifurcated distal device, and two patients had failed OSR or anastomotic pseudoaneurysms. The majority (94%) were men with a mean age of 76.8 ± 6.1 years. The mean aortic neck diameter and aneurysm size were 32 ± 4 cm and 7.2 ± 1.3 cm, respectively. The median time laps between initial repair and failure was 36 months (interquartile range [IQR], 24-54 months). Sixteen patients (80%) were classified as American Society of Anesthesiologists class III, whereas four were class IV. Seventy-eight vessels were targeted and successfully incorporated. Technical success was 100%, and median estimated blood loss was 100 mL (IQR, 100-200 mL). Mean fluoroscopy time and dose were 61 ± 18 minutes and 2754 ± 1062 mGy, respectively. Average hospital length of stay was 2.75 ± 2.15 days. Postoperative complication occurred in one patient who required lower extremity fasciotomy for compartment syndrome. At a median follow-up of 50 months (IQR, 18-58 months), there were no device migration, components separation, aneurysmal related mortality, and type I or type III endoleak. Aneurysm sac regression (95%) or stabilization (5%) was observed in all patients, including in four patients (25%) with type II endoleak. CONCLUSIONS The use of IL in conjunction with Zfen to treat patients with short distance between the lowest RA and A/GB is safe, effective, and has excellent long-term results. The technique expands the indication of Zfen, especially in patients with failed previous EVAR.
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Affiliation(s)
- Jesse Manunga
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN; Minneapolis Heat Institute Foundation, Minneapolis, MN.
| | | | - Nedaa Skeik
- Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN; Minneapolis Heat Institute Foundation, Minneapolis, MN
| | - Hamza Hanif
- Division of Vascular Surgery, University of New Mexico, Albuquerque, NM
| | - Muhammad Ali Rana
- Division of Vascular Surgery, University of New Mexico, Albuquerque, NM
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21
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Kachroo P. Commentary: Roadmap to improved success with high-risk thoracoabdominal aortic aneurysm patients. J Thorac Cardiovasc Surg 2024; 167:1703-1704. [PMID: 36283890 DOI: 10.1016/j.jtcvs.2022.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Puja Kachroo
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
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22
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Leone N, Bartolotti LAM, Capitain AN, Migliari M, Silingardi R, Czerny M, Rylski B, Gennai S. Comparison of bare and nonbare stent grafts during thoracic endovascular aneurysm repair of the aortic arch. J Vasc Surg 2024; 79:997-1004.e1. [PMID: 38142945 DOI: 10.1016/j.jvs.2023.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE We compared the outcomes of patients treated with nonbare stents (NBS) and proximal bare stents (PBS) endografts with a proximal landing zone in the aortic arch during thoracic endovascular aortic repair (TEVAR). METHODS We conducted a retrospective cohort, observational, multicenter study that included 361 consecutive TEVAR procedures undertaken between November 2005 and December 2021. TEVAR patients with both BS and NBS Relay stent graft configurations with proximal landing in zones 1, 2, or 3 were enrolled. Preoperative anamnestic and morphological data, clinical outcomes, and aortic modifications 30 days after surgery and at the latest follow-up available were collected. The primary outcome was freedom from proximal endoleak (type IA) comparing the two configurations. Total and detailed endoleak rates, clinical and technical success, intraoperative additional maneuvers, major adverse events, and reinterventions were secondary outcomes. RESULTS The median follow-up was 4.9 (interquartile range, 2.0-8.1) years. No statistically significant difference between NBS and PBS patients concerning 30-day major adverse events, retrograde aortic dissection, disabling stroke, or late type IA endoleak (10.8% vs 7.8%; P = .597). Aneurysmal disease (P = .026), PLZ diameter of >34 mm (P = .026), aortic tortuosity index of >1.4 (P = .008), type III aortic arch (P = .068), and PLZ thrombus (P = .014) identified as risk factors by univariate Cox regression analysis. PLZ thrombus was the only type IA endoleak risk factor at multivariate Cox regression (P = .016). CONCLUSIONS We found no statistically significant difference in freedom from type IA endoleak, retrograde dissection, or disabling stroke observed between the NBS and the BS configuration of the Relay endograft. Proximal landing zone thrombotic apposition was a prominent risk factor for type IA endoleak after TEVAR.
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Affiliation(s)
- Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Luigi A M Bartolotti
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - André N Capitain
- Clinic for Cardiovascular Surgery, University Heart Centre, Freiburg, Germany
| | - Mattia Migliari
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy; Clinic for Cardiovascular Surgery, University Heart Centre, Freiburg, Germany
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Martin Czerny
- Clinic for Cardiovascular Surgery, University Heart Centre, Freiburg, Germany
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, University Heart Centre, Freiburg, Germany
| | - Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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23
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Morell-Hofert D, Gruber L, Gruber H, Glodny B, Gruber I, Loizides A. Contrast-Enhanced Ultrasound after Endovascular Aortic Repair: Supplement and Potential Substitute for CT in Early- and Long-Term Follow-Up. Ann Vasc Surg 2024; 102:9-16. [PMID: 38301847 DOI: 10.1016/j.avsg.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 09/03/2023] [Accepted: 11/17/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Endoleaks are the most common complication after endovascular aneurysm repair (EVAR). Computed tomography angiography (CTA) is presently the golden standard for lifelong surveillance after EVAR. Several studies and meta-analyses have shown contrast-enhanced ultrasound (CEUS) to be a good alternative. The main goal of our study was to further validate the inclusion of CEUS in follow-up examination protocols for the systematic surveillance after EVAR. METHODS A retrospective analysis of patients who had received CEUS as part of their routine surveillance after EVAR at our center was conducted. Detection rate and classification of endoleak types were compared between available postinterventional CTA/magnetic resonance angiography and follow-up CEUS examinations. Last preinterventional CTAs before EVAR served as baselines with focus on potential cofactors such as age, body mass index, maximum aortic aneurysm diameters, endoleak orientation, and distance-to-surface influencing detection rates and classification. RESULTS In total, 101 patients were included in the analysis. Forty-four endoleaks (43.5% of cases) were detected by either initial CEUS or CTA, mostly type II (37.6% of the included patients). Initial CEUS showed an endoleak sensitivity of 91.2%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 84.6%. No covariate with an influence on the correct classification could be identified either for CEUS or CT. CONCLUSIONS CEUS should be considered a valid complementary method to CTA in the lifelong surveillance after EVAR. As type II endoleaks seem to be a common early-term, sometimes spontaneously resolving complication that can potentially be missed by CTA, we suggest combined follow-up protocols including CEUS in the early on postinterventional assessment.
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Affiliation(s)
| | - Leonhard Gruber
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria.
| | - Hannes Gruber
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Ingrid Gruber
- Department of Vascular Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
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24
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Ali TZ, Zil-E-Ali A, Lavanga E, Aziz F. Race-Based Variation in the Utilization of Epidural Analgesia in Addition to General Anesthesia for Open Abdominal Aortic Aneurysm Repair in the United States. Ann Vasc Surg 2024; 102:101-109. [PMID: 38307225 DOI: 10.1016/j.avsg.2023.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/20/2023] [Accepted: 11/25/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Epidural analgesia (EA) is recommended along with general anesthesia (GA) for patients undergoing open abdominal aortic aneurysm repair (AAA) and is known to be associated with improved postoperative outcomes. This study evaluates inequities in using this superior analgesic approach and further assesses the disparities at patient and hospital levels. METHODS A retrospective analysis was performed using the Vascular Quality Initiative database of adult patients undergoing elective open AAA repair between 2003 and 2022. Patients were grouped and analyzed based on anesthesia utilization, that is, EA + GA (Group I) and GA only (Group II). Study groups were further stratified by race, and outcomes were studied. Univariate and multivariate analyses were performed to study the impact of race on the utilization of EA with GA. A subgroup analysis was also carried out to learn the EA analgesia utilization in hospitals performing open AAA with the least to most non-White patients. RESULTS A total of 8,940 patients were included in the study, of which EA + GA (Group I) comprised n = 4,247 (47.5%) patients, and GA (Group II) had n = 4,693 (52.5%) patients. Based on multivariate regression analysis, the odds ratio of non-White patients receiving both EA and GA for open AAA repair compared to White patients was 0.76 (95% confidence interval: 0.53-0.72, P < 0.001). Of the patients who received both EA + GA, non-White race was associated with increased length of intensive care unit stay and a longer total length of hospital stay compared to White patients. Hospitals with the lowest quintile of minorities had the highest utilization of EA + GA for all patients compared to the highest quintile. CONCLUSIONS Non-White patients are less likely to receive the EA + GA than White patients while undergoing elective open AAA repair, demonstrating a potential disparity. Also, this disparity persists at the hospital level, with hospitals with most non-White patients having the least EA utilization, pointing toward system-wide disparities.
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Affiliation(s)
- Tarik Z Ali
- Division of Vascular Surgery, Heart & Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Ahsan Zil-E-Ali
- Division of Vascular Surgery, Heart & Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA.
| | - Elizabeth Lavanga
- Office of Medical Education, Penn State University College of Medicine, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Heart & Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA
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25
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Columbo JA, Scali ST, Jacobs BN, Scully RE, Suckow BD, Huber TS, Neal D, Stone DH. Size thresholds for repair of abdominal aortic aneurysms warrant reconsideration. J Vasc Surg 2024; 79:1069-1078.e8. [PMID: 38262565 PMCID: PMC11032259 DOI: 10.1016/j.jvs.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/10/2024] [Accepted: 01/17/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND The historical size threshold for abdominal aortic aneurysm (AAA) repair is widely accepted to be 5.5 cm for men and 5.0 cm for women. However, contemporary AAA rupture risks may be lower than historical benchmarks, which has implications for when AAAs should be repaired. Our objective was to use contemporary AAA rupture rates to inform optimal size thresholds for AAA repair. METHODS We used a Markov chain analysis to estimate life expectancy for patients with AAA. The primary outcome was AAA-related mortality. We estimated survival using Social Security Administration life tables and published contemporary AAA rupture estimates. For those undergoing repair, we modified survival estimates using data from the Vascular Quality Initiative and Medicare on complications, late rupture, and open conversion. We used this model to estimate the AAA repair size threshold that minimizes AAA-related mortality for 60-year-old average-health men and women. We performed a sensitivity analysis of poor-health patients and 70- and 80-year-old base cases. RESULTS The annual risk of all-cause mortality under surveillance for a 60-year-old woman presenting with a 5.0 cm AAA using repair thresholds of 5.5 cm, 6.0 cm, 6.5 cm, and 7.0 cm was 1.7%, 2.3%, 2.7%, and 2.8%, respectively. The corresponding risk for a man was 2.3%, 2.9%, 3.3%, and 3.4% for the same repair thresholds, respectively. For a 60-year-old average-health woman, an AAA repair size of 6.1 cm was the optimal threshold to minimize AAA-related mortality. Life expectancy varied by <2 months for repair at sizes from 5.7 cm to 7.1 cm. For a 60-year-old average-health man, an AAA repair size of 6.9 cm was the optimal threshold to minimize AAA-related mortality. Life expectancy varied by <2 months for repair at sizes from 6.0 cm to 7.4 cm. Women in poor health, at various age strata, had optimal AAA repair size thresholds that were >6.5 cm, whereas men in poor health, at all ages, had optimal repair size thresholds that were >8.0 cm. CONCLUSIONS The optimal threshold for AAA repair is more nuanced than a discrete size. Specifically, there appears to be a range of AAA sizes for which repair is reasonable to minmized AAA-related mortality. Notably, they all are greater than current guideline recommendations. These findings would suggest that contemporary AAA size thresholds for repair should be reconsidered.
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Affiliation(s)
- Jesse A Columbo
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery, Veteran's Affairs Medical Center, White River Junction, VT.
| | - Salvatore T Scali
- University of Florida School of Medicine, Gainesville, FL; Section of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL; Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Benjamin N Jacobs
- University of Florida School of Medicine, Gainesville, FL; Section of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL; Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Rebecca E Scully
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery, Veteran's Affairs Medical Center, White River Junction, VT
| | - Bjoern D Suckow
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery, Veteran's Affairs Medical Center, White River Junction, VT
| | - Thomas S Huber
- University of Florida School of Medicine, Gainesville, FL; Section of Vascular Surgery, Department of Surgery, University of Florida, Gainesville, FL; Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Dan Neal
- University of Florida School of Medicine, Gainesville, FL; Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - David H Stone
- Geisel School of Medicine at Dartmouth, Hanover, NH; Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Surgery, Veteran's Affairs Medical Center, White River Junction, VT
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26
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Migliari M, Leone N, Veraldi GF, Simonte G, Silingardi R, Resch T, Gennai S. Comparison of bridging stent grafts in branched endovascular aortic repair. J Vasc Surg 2024; 79:1026-1033. [PMID: 38154606 DOI: 10.1016/j.jvs.2023.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Endovascular treatment of thoracoabdominal aortic aneurysms has become common, with satisfactory results. Nevertheless, long-term durability remains an issue mainly because of target visceral vessel (TVV) instability. Currently, no covered stent has been approved as a bridging stent graft (BSG), demanding continuous research on this topic. METHODS This was a multicenter observational retrospective cohort study comparing the midterm results of the Bard Covera Plus and Gore VBX as BSGs during branched endovascular aneurysm repair. The primary outcome was the comparison of the target vessel instability between the two groups. Primary patency, freedom from branch-related type I and III endoleaks and reintervention, and technical and clinical success were considered secondary outcomes. Logistic regression analysis was used to assess the association between selected baseline factors and TVV instability. TVV instability during follow-up was then evaluated using the Kaplan-Meier cumulative function. RESULTS Three hundred forty-five TVVs in 106 patients were considered suitable for the analysis. Two hundred twenty vessels were stented with the Covera stent graft (64%) and 125 with VBX (36%). Two hundred ninety-nine TVVs received a single BSG, 45 two BSGs, and only 1 three BSGs. Bare metal stent relining was required in 36% of TVVs, mostly in the Covera group (89 [41%] vs 36 [29%]) (P = .030). The primary technical success rate was 96% (331/345), and the assisted primary technical success rate was 99% (342/345). The TVV instability rate within 30 days was 2% (one Covera and five VBX; P = .015). Three BSG occlusions (one Covera and two VBX) and three type Ic endoleaks (three VBX) were detected. The median follow-up was 13.9 months (range, 5.8-25.5 months). Sixteen TVV instabilities were detected during the follow-up. Twelve BSG occlusions (six Covera and six VBX), three type Ic endoleaks (one Covera and two VBX), and one type IIIc endoleak (VBX). The overall target vessel instability rate was 5% (16/342). TVV instability was associated with the use of Gore VBX in the univariable logistic regression (odds ratio, 3.0; 95% confidence interval, 1.1-8.0; P = .027). Aneurysm rupture and aneurysm diameter were also associated with TVV instability in the univariable analysis (P = .002 and P = .008, respectively). The only factor predisposing to TVV instability in the multivariable logistic regression analysis was the use of Gore VBX as a BSG (odds ratio, 2.9; 95% confidence interval, 1.0-8.0; P = .043). Kaplan-Meier analysis showed a significantly higher risk of TVV instability in the VBX group (P < .001). CONCLUSIONS Overall midterm outcomes in this cohort were satisfactory. Patency rates were similar between the two stents. Nevertheless, VBX seems to be associated with worse TVV instability. These results may be correlated with a higher incidence of type Ic endoleaks, which require an extensive learning curve for correct stent selection and deployment.
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Affiliation(s)
- Mattia Migliari
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola Leone
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy.
| | - Gian Franco Veraldi
- Unit of Vascular Surgery, Integrated University Hospital of Verona, Verona, Italy
| | - Gioele Simonte
- Unit of Vascular Surgery, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Roberto Silingardi
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Timothy Resch
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stefano Gennai
- Department of Vascular Surgery, Ospedale Civile di Baggiovara, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Nana P, Spanos K, Apostolidis G, Haulon S, Kölbel T. Systematic review and meta-analysis of fenestrated or branched devices after previous open surgical aortic aneurysm repair. J Vasc Surg 2024; 79:1251-1261.e4. [PMID: 37757916 DOI: 10.1016/j.jvs.2023.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Despite open surgical repair (OSR) of abdominal aortic aneurysms being considered as a durable solution, disease progression and para-anastomotic aneurysms may require further repair, and fenestrated and branched endovascular aneurysm repair (F/BEVAR) may be applied to address these pathologies. The aim of this systematic review was to assess technical success, mortality, and morbidity (acute kidney injury, spinal cord ischemia) at 30 days, and mortality and reintervention rates during the available follow-up, in patients managed with F/BEVAR after previous OSR. METHODS The PRISMA statement was followed, and the study was pre-registered to the PROSPERO (CRD42022363214). The English literature was searched, via Ovid, using MEDLINE, EMBASE, and CENTRAL databases, through November 30, 2022. Observational studies and case series with ≥5 patients (2000-2022), reporting on F/BEVAR outcomes after OSR, were considered eligible. The Newcastle-Ottawa Scale and GRADE were used to assess the risk of bias and quality of evidence. The primary outcome was technical success, mortality, and morbidity at 30 days. Data on the outcomes of interest were synthesized using proportional meta-analysis. RESULTS The initial search yielded 1694 articles. Eight retrospective studies (476 patients) were considered eligible. In 78.3% of cases, disease progression set the indication for reintervention. Technical success was estimated at 96% (95% confidence interval [CI], 89%-98%; I2 = 0%; 95% prediction interval [PI], 79%-99%). Thirty-day mortality was 2% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-28%). The estimated spinal cord ischemia and acute kidney injury rates were 3% (95% CI, 1%-9%; I2 = 0%; 95% PI, 0%-30%) and 6% (95% CI, 2%-15%; I2 = 0%; 95% PI, 1%-40%), respectively. During follow-up, overall mortality was 5% (95% CI, 2%-12%; I2 = 34%; 95% PI, 0%-45%) and aorta-related mortality was 1% (95% CI, 0%-2%; I2 = 0%; 95% PI, 0%-3%). The rate of reinterventions was 16% (95% CI, 9%-26%; I2 = 22%; 95% PI, 3%-50%). CONCLUSIONS According to the available literature, F/BEVAR after OSR may be performed with high technical success and low mortality and morbidity during the perioperative period. Follow-up aortic-related mortality was 1%, whereas the reintervention rates were within the standard range following F/BEVAR.
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Affiliation(s)
- Petroula Nana
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany.
| | - Konstantinos Spanos
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany; Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - George Apostolidis
- Vascular Surgery Department, Larissa University Hospital, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Stéphan Haulon
- Aortic Center, Marie Lannelongue Hospital, Groupe Hospitalier Paris Saint Joseph, Paris Saclay University, Paris, France
| | - Tilo Kölbel
- German Aortic Center Hamburg, Department of Vascular Medicine, University Heart & Vascular Center, Hamburg, Germany
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Zettervall SL, Schanzer A. Surveillance after EVAR Should Continue to Be a Priority. Eur J Vasc Endovasc Surg 2024; 67:701-702. [PMID: 38754944 DOI: 10.1016/j.ejvs.2024.01.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 05/18/2024]
Affiliation(s)
- Sara L Zettervall
- University of Washington, Division of Vascular Surgery, Seattle, WA, USA.
| | - Andres Schanzer
- UMass Chan Medical School, Division of Vascular Surgery, Worcester, MA, USA. https://twitter.com/AndresSchanzer
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Mandigers TJ, Trimarchi S. A A A, AAA, Stayin' Alive, Stayin' Alive: Useful for Everyone? Eur J Vasc Endovasc Surg 2024; 67:726-727. [PMID: 38040108 DOI: 10.1016/j.ejvs.2023.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Tim J Mandigers
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands; Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Santi Trimarchi
- Section of Vascular Surgery, Cardio Thoracic Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy.
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D'Oria M, Manoranjithan S, Scoville C, Vogel TR, Cheung S, Calvagna C, Lepidi S, Bath J. Systematic review of risk factors and outcomes of post-implantation syndrome following endovascular aortic repair. J Vasc Surg 2024; 79:1240-1250.e4. [PMID: 38122858 DOI: 10.1016/j.jvs.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/08/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE Post implantation syndrome (PIS) is an early systemic inflammatory response following endovascular aortic repair (EVAR). The response is variable in patients and the clinical significance of PIS upon outcomes is unknown. This study aims to evaluate the incidence, risk factors, and prognostic implication of PIS. METHODS Systematic literature review and analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines of PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Eligible English-language studies regarding PIS after infrarenal EVAR were included, after removing duplicates. RESULTS After screening, 31 studies were included. A total of 2847 patients were reviewed, with mean age of 70.7 years, of which 2012 (90.4%) were male, with a pooled mean follow-up of 26.1 months. PIS was reported in 25.3% of cases, with mean aneurysm diameter of 56.4 cm. Polytetrafluoroethylene (PTFE) grafts were utilized in 794 patients (27.9%) with polyester in 1839 (64.6%). White blood cell count, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 levels were all significantly elevated postoperatively. Thirty-day outcomes included type I endoleak rate of 0.8%, type II endoleak rate of 1.7%, reintervention rate of 0.35%, and mortality rate of 0.25%. Subgroup pooled analysis of patients with PIS (n = 309) vs No-PIS (n = 691) revealed that polyester (n = 642), rather than PTFE (n = 234) grafts, were associated with a higher rate of PIS (94.8% vs 3.7%; P = .0001), White blood cell count was higher in the PIS group both preoperatively (7.61 vs 6.76 × 109/L; P = .04) and postoperatively (15.0 vs 9.8 × 109/L; P = .0007) and IL-6 levels were higher in the PIS group postoperatively (98.6 vs 25.2 pg/mL; P = .02). Aneurysm diameter and amount of chronic or new thrombus within the aneurysm sac was not identified as a risk factor for PIS. Pooled outcomes of patients with PIS vs No-PIS demonstrated a significantly higher rate of 30-day mortality (0.6% vs 0%; P = .03) and major adverse cardiac events (5.8% vs 0.43%; P < .0001) without any differences seen in reintervention or 30-day type I or type II endoleaks. CONCLUSIONS This systematic review suggests that polyester grafts are strongly associated with PIS compared with PTFE. Interestingly, this report is suggestive of an association between 30-day mortality and major adverse cardiac events and PIS. Given these clinical sequelae, consideration for use of PTFE over polyester grafts to reduce the incidence of PIS may be a simple step to improve overall outcome. Further, exploration of the relationship between inflammatory mediators associated with PIS and mortality and cardiac complications may engender deeper understanding of risks, leading to eventual mitigation of harm for patients experiencing PIS.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardio-Thoraco-Vascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | | | - Caryn Scoville
- Health Sciences Library, University of Missouri, Columbia, MO
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Steven Cheung
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Cristiano Calvagna
- Division of Vascular and Endovascular Surgery, Cardio-Thoraco-Vascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardio-Thoraco-Vascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri, Columbia, MO.
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Leinweber ME, Geisbuesch P, Balzer K, Schmandra T, Karl T, Popp S, Hoffmann J, Schmitz-Rixen T, Jung G, Oikonomou K, Storck M, Balzer K, Kugelmann U, Schneider C, Engelhardt M, Petzold M, Weis-Mueller B, Wortmann M, Popp S, Grotemeyer D, Wenk H, Shayesteh-Kheslat R, Torsello G, Böckler D, Meisenbacher K, Hoffmann J, Schelzig H, Roopa Y, Strohschneider T, Noppeney T, Reichert V, Lorenz U, Pfister K, Damirchi S, Stojanovic T, Oberhuber A, Lobenstein B, Sagban TA, Pfeiffer T, Koller J, Sprenger C, Kruschwitz T, Schmedt CG, Marquardt F, Schmandra T, Bail D. Sex disparities in popliteal artery aneurysms. J Vasc Surg 2024; 79:1179-1186.e1. [PMID: 38145634 DOI: 10.1016/j.jvs.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/16/2023] [Accepted: 12/18/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVE Only 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe's largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented. METHODS POPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form. RESULTS Of the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions. CONCLUSIONS Women have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.
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Affiliation(s)
| | - Phillip Geisbuesch
- Department of Vascular and Endovascular Surgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Kai Balzer
- Department of Vascular and Endovascular Surgery, St. Marien-Hospital, GFO-Kliniken, Bonn, Germany
| | - Thomas Schmandra
- Department of Vascular Surgery, Sana Klinikum Offenbach, Offenbach, Germany
| | - Thomas Karl
- Department of Vascular and Endovascular Surgery, Klinikum am Plattenwald, SLK-Kliniken Heilbronn GmbH, Bad Friedrichshall, Germany
| | - Sebastian Popp
- Department of Vascular Surgery, RoMed Klinik Wasserburg am Inn, Wasserburg am Inn, Germany
| | - Johannes Hoffmann
- Department of Vascular Surgery and Phlebology, Contilia Herz und Gefaeßzentrum, Essen, Germany
| | | | - Georg Jung
- Department of Vascular and Endovascular Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
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Bastos Gonçalves F, Wanhainen A. The One Size Fits All EVAR Follow Up Has Proven Unsuccessful and Is a Thing of the Past. Eur J Vasc Endovasc Surg 2024; 67:703-704. [PMID: 38521189 DOI: 10.1016/j.ejvs.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/14/2024] [Accepted: 03/18/2024] [Indexed: 03/25/2024]
Affiliation(s)
- Frederico Bastos Gonçalves
- Hospital de Santa Marta, Unidade Local de Saúde São José, Centro Clínico Académico de Lisboa, Lisbon, Portugal; NOVA Medical School | Faculdade de Ciências Médicas, NMS|FCM, Universidade Nova de Lisboa, Lisbon, Portugal; Hospital CUF Tejo, Lisbon, Portugal.
| | - Anders Wanhainen
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgical and Peri-operative Sciences, Surgery, Umeå University, Umeå, Sweden
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Rastogi V, Sulzer TAL, de Bruin JL, Oliveira-Pinto J, Alberga AJ, Hoeks SE, Bastos Goncalves F, Ten Raa S, Josee van Rijn M, Akkersdijk GP, Fioole B, Verhagen HJM. Aneurysm Sac Dynamics and its Prognostic Significance Following Fenestrated and Branched Endovascular Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2024; 67:728-736. [PMID: 37995962 DOI: 10.1016/j.ejvs.2023.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 10/14/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE This study aimed to assess aneurysm sac dynamics and its prognostic significance following fenestrated and branched endovascular aneurysm repair (F/BEVAR). METHODS Patients undergoing F/BEVAR for degenerative complex aortic aneurysm from 2008 to 2020 at two large vascular centres with two imaging examinations (30 day and one year) were included. Patients were categorised as regression and non-regression, determined by the proportional volume change (> 5%) at one year compared with 30 days. All cause mortality and freedom from graft related events were assessed using Kaplan-Meier methods. Factors associated with non-regression at one year and aneurysm sac volume over time were examined for FEVAR and BEVAR independently using multivariable logistic regression and linear mixed effects modelling. RESULTS One hundred and sixty-five patients were included: 122 FEVAR, of whom 34% did not regress at one year imaging (20% stable, 14% expansion); and 43 BEVAR, of whom 53% failed to regress (26% stable, 28% expansion). Following F/BEVAR, after risk adjusted analysis, non-regression was associated with higher risk of all cause mortality within five years (hazard ratio [HR] 2.56, 95% confidence interval [CI] 1.09 - 5.37; p = .032) and higher risk of graft related events within five years (HR 2.44, 95% CI 1.10 - 5.26; p = .029). Following multivariable logistic regression, previous aortic repair (odds ratio [OR] 2.56, 95% CI 1.11 - 5.96; p = .029) and larger baseline aneurysm diameter (OR/mm 1.04, 95% CI 1.00 - 1.09; p = .037) were associated with non-regression at one year, whereas smoking history was inversely associated with non-regression (OR 0.21, 95% CI 0.04 - 0.96; p = .045). Overall following FEVAR, aneurysm sac volume decreased significantly up to two years (baseline vs. two year, 267 [95% CI 250 - 285] cm3vs. 223 [95% CI 197 - 248] cm3), remaining unchanged thereafter. Overall following BEVAR, aneurysm sac volume remained stable over time. CONCLUSION Like infrarenal EVAR, non-regression at one year imaging is associated with higher five year all cause mortality and graft related events risks after F/BEVAR. Following FEVAR for juxtarenal aortic aneurysm, aneurysm sacs generally displayed regression (66% at one year), whereas after BEVAR for thoraco-abdominal aortic aneurysm, aneurysm sacs displayed a concerning proportion of growth at one year (28%), potentially suggesting a persistent risk of rupture and consequently requiring intensified surveillance following BEVAR. Future studies will have to elucidate how to improve sac regression following complex EVAR, and whether the high expansion risk after BEVAR is due to advanced disease extent.
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Affiliation(s)
- Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.
| | - Titia A L Sulzer
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jorg L de Bruin
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - José Oliveira-Pinto
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Angiology and Vascular Surgery, Centro Hospitalar São João, Porto, Portugal
| | - Anna J Alberga
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Sanne E Hoeks
- Department of Anaesthetics, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Frederico Bastos Goncalves
- NOVA Medical School - Faculdade de Ciências Médicas (NMS|FCM), Universidade Nova de Lisboa, Lisbon, Portugal; Hospital CUF Tejo, Lisbon, Portugal
| | - Sander Ten Raa
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Marie Josee van Rijn
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - George P Akkersdijk
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Bram Fioole
- Department of Vascular Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Mathisen SR, Berge ST. A Single Centre Long Term Follow Up of the Nellix Endovascular Aneurysm Sealing System. Eur J Vasc Endovasc Surg 2024; 67:747-753. [PMID: 37951384 DOI: 10.1016/j.ejvs.2023.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/20/2023] [Accepted: 11/08/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE To evaluate the clinical performance at long term follow up of endovascular aneurysm sealing (EVAS, Endologix Inc. Nellix, Irvine, CA, USA) in the treatment of abdominal aortic aneurysm (AAA). METHODS Observational, prospective, single centre study of primary AAA interventions with EVAS (n = 117) from November 2013 to November 2016. Endpoints were primary technical success, Nellix device failure, freedom from open surgical conversion (OSC), freedom from secondary intervention, sac rupture, total mortality, and aneurysm related mortality at long term follow up. RESULTS The median age was 75 years (interquartile range [IQR] 70, 81 years) and 83% were male. The median AAA diameter was 58 mm (IQR 54, 60 mm). The median length of follow up was 6.2 years (IQR 5.6, 6.8 years). Primary technical success was 100%. Median time to Nellix failure was 5.6 years (IQR 3.3, 7.4 years). Freedom from Nellix failure at five and seven years was 54% (95% confidence interval [CI] 54.2 - 63.8%) and 36% (95% CI 22.3 - 49.7%), respectively. Freedom from OSC at five and seven years was 63% (95% CI 53.2 - 72.8%) and 59% (95% CI 47 - 71%), respectively. The secondary intervention rate was 11.4/100 person years. Freedom from secondary intervention at five and seven years was 52% (95% CI 42.2 - 61.8%) and 51% (95% CI 41.2 - 60.8%), respectively. The cumulative mortality rate at five and seven years was 36% and 54%, respectively. Secondary sac rupture occurred in 9.4% (11/117) with a rate of 2/100 person years. Aneurysm related mortality was 12% (14/117) with a rate of 2.5/100 person years. The median survival was four years (IQR 3, 5.6 years). Thirty day mortality for acute OSC was 67% (n = 3) and 17.1% (6/35) for elective OSC. CONCLUSION Long term follow up showed an increased failure rate. Diligent surveillance after endovascular AAA treatment is mandatory, especially when promising new devices are put into clinical use.
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Affiliation(s)
- Sven R Mathisen
- Department of Vascular Surgery, Innlandet Hospital Trust, Hamar, Norway.
| | - Simen T Berge
- Department of Vascular Surgery, Innlandet Hospital Trust, Hamar, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
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Wu S, Cheng G, Lu W, Xu Y. Postoperative serum mir-28-5p level has predictive value for the prognosis after endovascular abdominal aortic aneurysm repair. J Cardiothorac Surg 2024; 19:267. [PMID: 38664759 PMCID: PMC11044549 DOI: 10.1186/s13019-024-02758-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/30/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND We explored the clinical significance of miR-28-5p pre- and post-endovascular abdominal aortic aneurysm repair (EVAR) in abdominal aortic aneurysm (AAA) patients. METHODS Subjects included AAA patients receiving EVAR and non-AAA people without statistical differences from AAA patient in comorbidities/Framingham risk score. Fasting elbow venous blood (4 mL) was collected in the morning of the day of EVAR surgery and in the morning of 3 months post-EVAR. Pre-/post-EVAR serum miR-28-5p expression, AAA maximum diameter alterations, CD3+/CD4+/CD8+/TC/TG pre-/post-EVAR, and the correlations between miR-28-5p and AAA maximum diameter were investigated. Prediction of miR-28-5p on post-EVAR mortality, prognosis, and independent factors of post-EVAR death were analyzed using receiver operating characteristic curve (ROC)/Kaplan-Meier curve/univariable and multivariable Cox regression. According to the cut-off value of ROC curve for postoperative miR-28-5p was the cut-off value, and the patients were classified into the miR-28-5p high- and low-expression groups. The survival or death of both groups were compared after 48-month follow-up. RESULTS Serum miR-28-5p levels in AAA patients dropped post-EVAR. AAA patients showed notable differences in CD3+/CD4+/CD8+/TC/TG levels pre-/post-EVAR. The miR-28-5p low-expression group exhibited higher CD3+/CD4+ and lower CD8+/TC/TG levels. We observed a positive correlation between post-EVAR miR-28-5p and AAA maximum diameter and between the pre-/post-EVAR miR-28-5p fold change and the AAA maximum diameter change. Postoperative miR-28-5p demonstrated good predictive value for postoperative death. Hypertension, Framingham risk score, TC, TG, and miR-28-5p were independent influencing factors of post-EVAR death. CONCLUSION EVAR decreased serum miR-28-5p expression in AAA patients. Post-operative miR-28-5p level and pre-/post-operative fold change level are positively-correlated with AAA diameter.
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Affiliation(s)
- Senyan Wu
- Department of Vascular Surgery, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, 100 Minjiang Avenue, Kecheng District, Quzhou, Zhejiang, 324000, China
| | - Guobing Cheng
- Department of Vascular Surgery, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, 100 Minjiang Avenue, Kecheng District, Quzhou, Zhejiang, 324000, China.
| | - Wei Lu
- Department of Vascular Surgery, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, 100 Minjiang Avenue, Kecheng District, Quzhou, Zhejiang, 324000, China
| | - Youyao Xu
- Department of Vascular Surgery, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, 100 Minjiang Avenue, Kecheng District, Quzhou, Zhejiang, 324000, China
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Bresler AM, Panthofer A, Kuramochi Y, Olson SL, Eagleton M, Schneider DB, Lyden SP, Blackwelder WC, Uhl CF, Bischoff MS, Matsumura JS, Böckler D. Image-based assessment of aortoiliac aneurysm anatomical characteristics in patients from the global iliac branch study. Langenbecks Arch Surg 2024; 409:135. [PMID: 38649506 PMCID: PMC11035386 DOI: 10.1007/s00423-024-03326-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Endovascular repair is the preferred treatment for aortoiliac aneurysm, with preservation of at least one internal iliac artery recommended. This study aimed to assess pre-endovascular repair anatomical characteristics of aortoiliac aneurysm in patients from the Global Iliac Branch Study (GIBS, NCT05607277) to enhance selection criteria for iliac branch devices (IBD) and improve long-term outcomes. METHODS Pre-treatment CT scans of 297 GIBS patients undergoing endovascular aneurysm repair were analyzed. Measurements included total iliac artery length, common iliac artery length, tortuosity index, common iliac artery splay angle, internal iliac artery stenosis, calcification score, and diameters in the device's landing zone. Statistical tests assessed differences in anatomical measurements and IBD-mediated internal iliac artery preservation. RESULTS Left total iliac artery length was shorter than right (6.7 mm, P = .0019); right common iliac artery less tortuous (P = .0145). Males exhibited greater tortuosity in the left total iliac artery (P = .0475) and larger diameter in left internal iliac artery's landing zone (P = .0453). Preservation was more common on right (158 unilateral, 34 bilateral) than left (105 unilateral, 34 bilateral). There were 192 right-sided and 139 left-sided IBDs, with 318 IBDs in males and 13 in females. CONCLUSION This study provides comprehensive pre-treatment iliac anatomy analysis in patients undergoing endovascular repair with IBDs, highlighting differences between sides and sexes. These findings could refine patient selection for IBD placement, potentially enhancing outcomes in aortoiliac aneurysm treatment. However, the limited number of females in the study underscores the need for further research to generalize findings across genders.
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Affiliation(s)
- Alina-Marilena Bresler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
| | - Annalise Panthofer
- Department of Surgery, Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Yuki Kuramochi
- Vascular Surgery Department, Heart Vascular Thoracic Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sydney L Olson
- Department of Surgery, Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Matthew Eagleton
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Darren B Schneider
- Department of Surgery, Division of Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sean P Lyden
- Vascular Surgery Department, Heart Vascular Thoracic Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - William C Blackwelder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christian F Uhl
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Jon S Matsumura
- Department of Surgery, Division of Vascular Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Surgery, Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
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van den Berg R, den Hartog FPJ, Bali C, Matsagkas M, Bevis PM, Earnshaw JJ, Debus ES, Honig S, Berrevoet F, Detry O, Stabilini C, Muysoms F, Tanis PJ. Protocol for an independent patient data meta-analysis of prophylactic mesh placement for incisional hernia prevention after abdominal aortic aneurysm surgery: a collaborative European Hernia Society project (I-PREVENT-AAA). BMJ Open 2024; 14:e081046. [PMID: 38626979 PMCID: PMC11029178 DOI: 10.1136/bmjopen-2023-081046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/05/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Incisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention to prevent IHs. Randomised controlled trials (RCTs) have demonstrated that prophylactic mesh reinforcement after abdominal surgery, in general, is effective and safe. In patients with abdominal aortic aneurysm (AAA), prophylactic mesh reinforcement after open repair has not yet been recommended in official guidelines, because of relatively small sample sizes in individual trials. Furthermore, the identification of subgroups that benefit most from prophylactic mesh placement requires larger patient numbers. Our primary aim is to evaluate the efficacy and effectiveness of the use of a prophylactic mesh after open AAA surgery to prevent IH by performing an individual patient data meta-analysis (IPDMA). Secondary aims include the evaluation of postoperative complications, pain and quality of life, and the identification of potential subgroups that benefit most from prophylactic mesh reinforcement. METHODS AND ANALYSIS We will conduct a systematic review to identify RCTs that study prophylactic mesh placement after open AAA surgery. Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase, Web of Science Core Collection and Google Scholar will be searched from the date of inception onwards. RCTs must directly compare primary sutured closure with mesh closure in adult patients who undergo open AAA surgery. Lead authors of eligible studies will be asked to share individual participant data (IPD). The risk of bias (ROB) for each included study will be assessed using the Cochrane ROB tool. An IPDMA will be performed to evaluate the efficacy, with the IH rate as the primary outcome. Any signs of heterogeneity will be evaluated by Forest plots. Time-to-event analyses are performed using Cox regression analysis to evaluate risk factors. ETHICS AND DISSEMINATION No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publications in peer-reviewed journals and summaries posted online. PROSPERO REGISTRATION NUMBER CRD42022347881.
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Affiliation(s)
- Rudolf van den Berg
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Medicine, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Floris P J den Hartog
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Christina Bali
- Department of Surgery, University Hospital of Ioannina, Ioannina, Greece
| | | | - Paul M Bevis
- Department of Vascular Surgery, North Bristol NHS Trust, Westbury on Trym, UK
| | - Jonothan J Earnshaw
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Eike S Debus
- Department of Vascular Medicine, University Medical Center Hamburg-Eppendorf University Heart & Vascular Center, Eppendorf, Hamburg, Germany
| | - Susanne Honig
- Department of Vascular Surgery, Hospital Robert Schuman Kirchberg Hospital, Luxembourg City, Luxembourg
| | - Frederik Berrevoet
- Department of General and Hepatobiliary Surgery and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, Division of Abdominal Wall Surgery, CHU Liege, University of Liege, Liege, Belgium
| | - Cesare Stabilini
- Department of Surgical Sciences, University of Genoa, Genoa, Italy
| | - Filip Muysoms
- Department of Surgery, AZ Maria Middelares Hospital, Ghent, Belgium
| | - Pieter J Tanis
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Wang H, Wang W, Wang W, Liu D. Surgeon-modified fenestrated endovascular grafts and thoracoscope-assisted fixation for treatment of thoraco-abdominal aortic aneurysms. J Cardiothorac Surg 2024; 19:199. [PMID: 38600502 PMCID: PMC11008025 DOI: 10.1186/s13019-024-02686-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 03/24/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Total endovascular technique with fenestrated endovascular graft might be hampered for the late dilatation of proximal landing zone, which may cause endografts migration. We describe a successful urgent hybrid procedure for extent III thoracoabdominal aortic aneurysm with aortic intramural hematoma. CASE PRESENTATION A 55-year-old female with thoracoabdominal aortic aneurysm was considered at high surgical risk and unfit for open repair due to multiple comorbidities. Therefore, a hybrid procedure of surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted Transaortic epicardial fixation of endograft was finally chosen and performed in the endovascular operating room. A 3-port technique was performed through a left video-assisted thoracoscopic approach. After the first tampering stent-graft was deployed, a double-needle suture was penetrated both the aortic wall and stent-graft to fixate it in the proximal descending aorta. Then the second endograft, which had been fenestrated on table, was introduced and oriented extracorporeally by rotating superior mesenteric artery and left renal artery fenestration radiopaque markers and deployed with perfect apposition between the fenestrations and target visceral artery. Each vessel was sequentially stented using Viabahn self-expandable stent to finish target vessel stenting. An Ankura cuff stent was deployed in the distal abdominal aortic artery. CONCLUSION Surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted fixation may be an innovative and viable alternative for selected high-risk patients with extent III thoracoabdominal aortic aneurysm. A longer follow-up is needed to ascertain the success of this approach.
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Affiliation(s)
- Hong Wang
- Department of Cardiac Surgery and Respiratory, Lanzhou University Second Hospital, Lanzhou, China
| | - Wei Wang
- Department of Cardiac Surgery and Respiratory, Lanzhou University Second Hospital, Lanzhou, China
| | - Weifan Wang
- Department of Cardiac Surgery and Respiratory, Lanzhou University Second Hospital, Lanzhou, China
| | - Debin Liu
- Department of Cardiac Surgery and Respiratory, Lanzhou University Second Hospital, Lanzhou, China.
- Department of Cardiac Surgery, Hainan General Hospital, Hainan Hospital Affiliated to Hainan Medical University, No. 19, Xiuhua Road, Xiuying District, Haikou, Hainan, China.
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Akai T, Kaneko T, Furuya T. Endovascular repair of an abdominal aortic aneurysm with external iliac artery occlusion using VBX as the contralateral leg via axillary delivery: A case report. Medicine (Baltimore) 2024; 103:e37731. [PMID: 38579061 PMCID: PMC10994543 DOI: 10.1097/md.0000000000037731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/06/2024] [Indexed: 04/07/2024] Open
Abstract
RATIONALE A hostile iliac access route is an important consideration when enforcing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA). Herein, we report a case of AAA with unilateral external iliac artery occlusion, for which bifurcated EVAR was successfully performed using a single femoral and brachial artery access. PATIENT CONCERNS A 76-year-old man who had undergone surgery for lung cancer 4.5 years prior was diagnosed AAA by computed tomography (CT). DIAGNOSIS Two and a half years before presentation, CT revealed an infrarenal 48 mm AAA, which had enlarged to 57 mm by 2 months preoperatively. CT identified occlusion from the right external iliac artery to the right common femoral artery, with no observed ischemic symptoms in his right leg. The right external iliac artery, occluded and atrophied, had a 1 to 2 mm diameter. INTERVENTION Surgery was commenced with the selection of a Zenith endovascular graft (Cook Medical) with an extended body length. Two Gore Viabahn VBX balloon expandable endoprosthesis (VBX; W.L. Gore & Associate) were delivered from the right axilla as the contralateral leg. OUTCOMES CT scan on the 2nd day after surgery revealed no endoleaks. LESSONS While the long-term results remain uncertain, this method may serve as an option for EVAR in patients with unilateral external iliac artery occlusion.
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Affiliation(s)
- Takafumi Akai
- Department of Vascular Surgery, Asahi General Hospital, Chiba, Japan
| | - Takanori Kaneko
- Department of Vascular Surgery, Asahi General Hospital, Chiba, Japan
| | - Takatoshi Furuya
- Department of Vascular Surgery, Asahi General Hospital, Chiba, Japan
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Lareyre F, Raffort J. Letter re: Machine Learning to Predict Outcomes Following Endovascular Aortic Aneurysm Repair. Vasc Endovascular Surg 2024; 58:461-462. [PMID: 38009698 DOI: 10.1177/15385744231219476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Fabien Lareyre
- Department of Vascular Surgery, Hospital of Antibes Juan-les-Pins, Antibes, France
- Inserm U1065, C3M, Université Côte d'Azur, Nice, France
| | - Juliette Raffort
- Clinical Chemistry Laboratory, University Hospital of Nice, Nice, France
- 3IA Institute, Université Côte d'Azur, Nice, France
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Park JK, Park YJ, Yang SS, Kim DI, Kim YW. Impact of Serum Albumin Levels and Body Mass Index on Outcomes of Open Abdominal Aortic Aneurysm Repair in Korean Population. Ann Vasc Surg 2024; 101:139-147. [PMID: 38211897 DOI: 10.1016/j.avsg.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Although obese patients seem to be susceptible to chronic diseases, obesity paradox has been observed in the field of vascular surgery, in which many previous studies have reported that overweight patients have good postoperative outcomes and underweight patients have poor postoperative outcomes. The purpose of our study is to evaluate the impact of body mass index (BMI) and serum albumin levels, which are evaluated as indicators of nutritional status, on outcomes of open abdominal aortic aneurysm (AAA) repair. METHODS We reviewed the vascular surgery database of a single tertiary referral center for all patients who underwent open AAA repair due to degenerative etiology from 1996 to 2021. To analyze the effect of BMI, patients were classified into 4 groups according to the Asian-Pacific classification of BMI: underweight (UW) (<18.5 kg/m2), normal weight (NW) (18.5-22.9 kg/m2), overweight (OW) (23-24.9 kg/m2), and obese (OB) (≥25 kg/m2). The χ2, Fisher's exact, and Kruskal-Wallis tests were used to compare demographics, comorbidities, radiologic findings, surgical details, and 1-year mortality rates between the 4 groups. We also compared the preoperative serum albumin levels of each group to assess nutritional status indirectly. Cox's proportional hazards model was performed to determine factors associated with mortality. A Kaplan-Meier survival analysis was performed, and the differences were analyzed by a log-rank test. We did not perform an analysis for 30-day mortality because cases of 30-day mortality in UW patients were rare due to the unbalanced distribution of the number of patients in the 4 groups. RESULTS Among a total of 678 patients, 22 were classified as UW (3.2%), 200 as NW (29.5%), 183 as OW (27.1%), and 273 as OB (40.1%). The median age was 70 (64-75) years and 577 of 678 (85.1%) patients were male gender. Higher serum albumin level was associated with decreased 1-year mortality (hazard ratio [HR], 0.3; 95% confidence interval [CI], 0.15-0.63; P = 0.001). UW patients had a higher 1-year mortality rate than NW patients (HR, 3.67; 95% CI, 1.02-13.18; P = 0.046). OB patients had a lower overall mortality rate than NW patients (HR, 0.73; 95% CI, 0.53-1; P = 0.05). CONCLUSIONS Low BMI (<18.5 kg/m2) and low serum albumin level were associated with poor 1-year survival after elective open AAA repair. These patients also need more careful preoperative intervention, like weight gain or nutritional support, for better outcomes. The obesity paradox existed in our study; high BMI (≥25 kg/m2) was associated with better overall survival after elective open AAA repair.
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Affiliation(s)
- Joon-Kee Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong-Ik Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Wook Kim
- Division of Vascular Surgery, Department of Surgery, Incheon Sejong hospital, Incheon, Korea
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Gomes VC, Parodi FE, Wood JC, Motta F, Farber MA. Rare Case of Abdominal Aortic and Multiple Visceral Aneurysms in a Pediatric Patient With PIK3CA Mutation and Vasculitis. Vasc Endovascular Surg 2024; 58:387-391. [PMID: 37944162 PMCID: PMC10996289 DOI: 10.1177/15385744231215561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Abdominal aortic aneurysms (AAA) are most commonly observed in elderly male patients and are particularly rare in children. Among the pediatric population, they are usually diagnosed in the context of connective tissue disorders, genetic mutations, or vasculitis. The same is true of visceral arteries aneurysms. This case report describes the staged management of an 11-year-old patient presenting PIK3CA mutation and a 5.8 cm infrarenal AAA associated with bilateral common iliac arteries and multiple visceral aneurysms, the largest observed in the superior mesenteric artery (SMA = 3.2 cm). After careful evaluation, decision was made to first approach the most life-threatening lesion (the infrarenal AAA due to the large diameter) and the remaining aneurysms in secondary procedures, with special attention to the SMA aneurysm. The patient underwent a staged repair, with the first phase consisting of an aortobi-iliac graft with the distal anastomosis made at the left common iliac artery and right external iliac artery. The right hypogastric artery was ligated. The second procedure consisted of SMA aneurysm repair with a plication technique, as 7 branches were visualized coming off the aneurysm sac. Postoperative pathology analysis of the aortic and SMA aneurysms sac revealed vasculitis with a mixed inflammatory pattern and a COL3A1 gene heterozygote variant. He is currently in his 18th month after the last surgical intervention, receiving immunomodulatory therapy, with a planned follow-up by the interdisciplinary team to monitor the medications' side effects and the diameter of the remaining visceral aneurysms.
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Affiliation(s)
- Vivian Carla Gomes
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Federico Ezequiel Parodi
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Jacob C Wood
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Fernando Motta
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark A Farber
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Tham S, Aw D, Vijaykumar K, Cheng SC, Tay JS, Choke E. Medium-Term Survival After Unrepaired Ruptured Abdominal Aortic Aneurysm. J Endovasc Ther 2024; 31:325-329. [PMID: 36000358 DOI: 10.1177/15266028221119311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Ruptured abdominal aortic aneurysm (AAA) is almost always considered fatal without open surgical or endovascular repair. We report a case that has defied this norm and explore the possible factors involved in this exceedingly rare outcome. CASE REPORT An 87 year old gentleman presented with an acute ruptured AAA with left retroperitoneal hematoma. He was counseled for emergent repair, but opted for conservative management instead. He has remained well at the time of writing, 13 months from the rupture, with clinical resolution of symptoms along with radiological resolution of the hematoma. CONCLUSION Timely repair remains the mainstay of management for ruptured AAA, although this rare case highlights that it is possible for ruptured AAA to seal spontaneously with patient surviving up to 13 months. We have sought to hypothesize the factors in this case that may have contributed to prolonged survival following untreated ruptured AAA. CLINICAL IMPACT STATEMENT While the overwhelming evidence is that a ruptured AAA left unrepaired is fatal, our case report illustrates a rare case that shows it is possible for ruptured AAA to seal spontaneously, with patient surviving up to 13 months. We seek to hypothesize the factors that may contribute to such prolonged survival.
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Affiliation(s)
- Sarah Tham
- Department of General Surgery, Sengkang General Hospital, SingHealth Services, Singapore
| | - Darius Aw
- Department of General Surgery, Vascular and Endovascular Surgery Division, Sengkang General Hospital, SingHealth Services, Singapore
| | - Kalpana Vijaykumar
- Department of General Surgery, Vascular and Endovascular Surgery Division, Sengkang General Hospital, SingHealth Services, Singapore
| | - Shin Chuen Cheng
- Department of General Surgery, Vascular and Endovascular Surgery Division, Sengkang General Hospital, SingHealth Services, Singapore
| | - Jia Sheng Tay
- Department of General Surgery, Vascular and Endovascular Surgery Division, Sengkang General Hospital, SingHealth Services, Singapore
| | - Edward Choke
- Department of General Surgery, Vascular and Endovascular Surgery Division, Sengkang General Hospital, SingHealth Services, Singapore
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Vos CG, Fouad F, Dieleman IM, Schuurmann RC, de Vries JPP. Importance of sac regression after EVAR and the role of EndoAnchors. J Cardiovasc Surg (Torino) 2024; 65:99-105. [PMID: 38551514 DOI: 10.23736/s0021-9509.24.12992-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
The initial success and widespread adoption of endovascular aneurysm repair (EVAR) for the treatment of abdominal aortic aneurysms have been tempered by numerous reports of secondary interventions and increased long-term mortality compared with open repair. Over the past decade, several studies on postoperative sac dynamics after EVAR have suggested that the presence of sac regression is a benign feature with a favorable prognosis. Conversely, increasing sacs and even stable sacs can be indicators of more unstable sac behavior with worse outcomes in the long-term. Endoleaks were initially perceived as the main drivers of sac behavior. However, the observation that sac regression can occur in the presence of endoleaks, and vice versa - increasing sacs without evidence of endoleak - on imaging studies, suggests the involvement of other contributing factors. These factors can be divided into anatomical factors, patient characteristics, sac thrombus composition, and device-related factors. The shift of interest away from especially type 2 endoleaks is further supported by promising results with the use of EndoAnchors regarding postoperative sac behavior. This review provides an overview of the existing literature on the implications and known risk factors of post-EVAR sac behavior, describes the accurate measurement of sac behavior, and discusses the use of EndoAnchors to promote sac regression.
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Affiliation(s)
- Cornelis G Vos
- Department of Surgery, Martini Hospital, Groningen, the Netherlands
| | - Fatima Fouad
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands -
| | - Isabel M Dieleman
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Richte Cl Schuurmann
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Jean-Paul Pm de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
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Karaolanis GI, Papazoglou DD, Donas KP, Helfenstein F, Kotelis D, Makaloski V. Physician-modified versus chimney endografting for pararenal aortic aneurysms: a systematic review and meta-analysis. J Cardiovasc Surg (Torino) 2024; 65:124-131. [PMID: 38635285 DOI: 10.23736/s0021-9509.24.12995-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
INTRODUCTION We performed a systematic review and meta-analysis to assess the existing published evidence regarding the safety and efficacy of the endovascular aortic repair with chimney technique (ch-EVAR) and physician-modified stent-grafts (PMSGs) for the treatment of pararenal aortic aneurysm repair. EVIDENCE ACQUISITION A systematic search of all relevant studies reported until October 2023 according to the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines was performed. The pooled 30-day mortality, peri- and postoperative complication rates were estimated using fixed or random effect methods. EVIDENCE SYNTHESIS A total of 679 study titles were identified by the initial search strategy, of which 16 were considered eligible for inclusion in the meta-analysis. A total of 1094 patients (ch-EVAR N.=861 and PMSG N.=233) (90% male) were identified. The pooled 30-day mortality rate was 3.4% for ch-EVAR and 2.6% for PMSG. The major adverse events (MAE) in the early period was 14.7% for ch-EVAR and 18.5% PMSG, respectively. Higher occlusion rate was observed of the chimney stents grafts (8.2%) than the bridging stents (1.4%) during the follow-up period. CONCLUSIONS Ch-EVAR and physician-modified technology are safe with low 30-day mortality in elective settings for pararenal aortic aneurysms repair. No significant differences were seen between the two surgical methods regarding the early major adverse events rate. However, higher occlusion rate for the chimneys can be expected over time.
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Affiliation(s)
- Georgios I Karaolanis
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland -
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece -
| | - Dimitrios D Papazoglou
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Konstantinos P Donas
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Rhein Main Vascular Center, Department of Vascular and Endovascular Surgery, Asklepios Clinics Langen, Wiesbaden, Seligenstadt, Germany
| | | | - Drosos Kotelis
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vladimir Makaloski
- Department of Vascular Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Ullah N, Kiu Chou W, Vardanyan R, Arjomandi Rad A, Shah V, Torabi S, Avavde D, Airapetyan AA, Zubarevich A, Weymann A, Ruhparwar A, Miller G, Malawana J. Machine learning algorithms for the prognostication of abdominal aortic aneurysm progression: a systematic review. Minerva Surg 2024; 79:219-227. [PMID: 37987755 DOI: 10.23736/s2724-5691.23.10130-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Abdominal aortic aneurysm (AAA), often characterized by an abdominal aortic diameter over 3.0 cm, is managed through screening, surveillance, and surgical intervention. AAA growth can be heterogeneous and rupture carries a high mortality rate, with size and certain risk factors influencing rupture risk. Research is ongoing to accurately predict individual AAA growth rates for personalized management. Machine learning, a subset of artificial intelligence, has shown promise in various medical fields, including endoleak detection post-EVAR. However, its application for predicting AAA growth remains insufficiently explored, thus necessitating further investigation. Subsequently, this paper aims to summarize the current status of machine learning in predicting AAA growth. EVIDENCE ACQUISITION A systematic database search of Embase, MEDLINE, Cochrane, PubMed and Google Scholar from inception till December 2022 was conducted of original articles that discussed the use of machine learning in predicting AAA growth using the aforementioned databases. EVIDENCE SYNTHESIS Overall, 2742 articles were extracted, of which seven retrospective studies involving 410 patients were included using a predetermined criteria. Six out of seven studies applied a supervised learning approach for their machine learning (ML) models, with considerable diversity observed within specific ML models. The majority of the studies concluded that machine learning models perform better in predicting AAA growth in comparison to reference models. All studies focused on predicting AAA growth over specified durations. Maximal luminal diameter was the most frequently used indicator, with alternative predictors being AAA volume, ILT (intraluminal thrombus) and flow-medicated diameter (FMD). CONCLUSIONS The nascent field of applying machine learning (ML) for Abdominal Aortic Aneurysm (AAA) expansion prediction exhibits potential to enhance predictive accuracy across diverse parameters. Future studies must emphasize evidencing clinical utility in a healthcare system context, thereby ensuring patient outcome improvement. This will necessitate addressing key ethical implications in establishing prospective studies related to this topic and collaboration among pivotal stakeholders within the AI field.
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Affiliation(s)
- Nazifa Ullah
- Faculty of Medicine, University College London, London, UK
| | - Wing Kiu Chou
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Robert Vardanyan
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK -
- Research Unit, The Healthcare Leadership Academy, London, UK
| | - Arian Arjomandi Rad
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
- Research Unit, The Healthcare Leadership Academy, London, UK
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Viraj Shah
- Department of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Saeed Torabi
- Department of Anesthesiology, University Hospital Cologne, Cologne, Germany
| | - Dani Avavde
- Department of Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Arkady A Airapetyan
- Department of Research and Academia, National Institute of Health, Yerevan, Armenia
| | - Alina Zubarevich
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Weymann
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department of Cardiothoracic Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - George Miller
- Research Unit, The Healthcare Leadership Academy, London, UK
- Centre for Digital Health and Education Research (CoDHER), University of Central Lancashire Medical School, Preston, UK
| | - Johann Malawana
- Research Unit, The Healthcare Leadership Academy, London, UK
- Centre for Digital Health and Education Research (CoDHER), University of Central Lancashire Medical School, Preston, UK
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Li R, Luo Q, Green D, Huddleston SJ. Weekend Admission is Associated with Higher Kidney Failures after Thoracic Endovascular Aneurysm Repair for Stanford Type B Aortic Dissection. Vasc Endovascular Surg 2024; 58:372-381. [PMID: 37978945 DOI: 10.1177/15385744231217622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Weekend effect characterized by worse perioperative outcomes has been demonstrated in some surgery patients admitted on weekends, as opposed to weekdays. This study aimed to examine weekend effect on open surgical repair or thoracic endovascular aneurysm repair (TEVAR) for Stanford Type B Aortic Dissection (TBAD). METHODS Patients who underwent TBAD repair were identified in National/Nationwisde Inpatient Sample from Q4 2015-2020. Open surgery and TEVAR were examined separately. Multivariable analyses were performed comparing in-hospital perioperative outcomes of patients under weekday and weekend admission. Adjusted preoperative variables included sex, age, race, socioeconomic status, hospital characteristics, clinical symptoms, comorbidities, and elective/non-elective admission. Also, length of stay, days from admission to operation, and total hospital charge were compared. RESULTS Among patients who underwent open TBAD repair, 1321 were admitted on weekdays and 340 on weekends. Among patients who underwent TEVAR for TBAD, 2018 were admitted on weekdays and 440 wereadmitted on weekends. There was no difference in open repair outcomes between those admitted on weekdays vs weekends. In TEVAR, weekend admission was associated with higher post-procedural kidney failure (1.14% vs .20%, aOR = 4.11, P = .04) and superficial wound complications (2.73% vs 1.49%, aOR = 2.2, P = .03) but lower respiratory complications (5.80% vs 3.64%, aOR = .47, P = .01). Also, in TEVAR, weekend admission was associated with longer time from admission to operation (3.92 ± .27 vs 2.35 ± .09 days, P < .01). CONCLUSIONS Renal malperfusion was a common indication for TBAD repair. TBAD patients admitted over the weekend and underwent TEVAR had higher post-procedural kidney failure, which may be due to delayed diagnosis and treatment.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DOC, USA
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Qianyun Luo
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Derrick Green
- Division of Vascular Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
- Minneapolis Veterans Administration Medical Center, USA
| | - Stephen J Huddleston
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Donas KP. The myth of Daedalus and Icarus: fly between the extremes - pushing the limits of endovascular therapy in complex aortic aneurysms carries risks. J Cardiovasc Surg (Torino) 2024; 65:83-84. [PMID: 38635288 DOI: 10.23736/s0021-9509.24.13065-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Konstantinos P Donas
- Department of Vascular and Endovascular Surgery, Rhein Main Vascular Center, Asklepios Clinics Wiesbaden, Seligenstadt, Germany -
- Department of Vascular Surgery, Inselspital Bern, University of Bern, Bern, Switzerland -
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Langen, Langen, Germany -
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Huynh C, Liu I, Sommer A, Menke L, Reilly L, Gasper W, Hiramoto J. Descending thoracic aortic mural ulceration is associated with postoperative spinal cord ischemia after branched endovascular aortic aneurysm repair. J Vasc Surg 2024; 79:732-739. [PMID: 38036115 DOI: 10.1016/j.jvs.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVE Paraplegia is one of the most feared complications after thoracoabdominal aortic aneurysm repair. The purpose of this study is to determine whether aortic thrombus characteristics are associated with spinal cord ischemia (SCI) after branched endovascular aneurysm repair (BEVAR). METHODS From April 2011 to April 2020, 62 patients underwent elective BEVAR for thoracoabdominal aortic aneurysm and pararenal aortic aneurysms using a low-profile device and had a complete preoperative computed tomography angiography of the aorta from the sinotubular junction to the aortic bifurcation. Aortic thrombus was evaluated for thrombus thickness ≥5 mm, thrombus >2/3 of aortic circumference, and the presence of an ulcer-like thrombus. One point was assigned at each 5 mm axial image if all 3 criteria were met, resulting in a total "shaggy score" for the entire aorta. Data on demographics, procedural details, and outcomes were collected prospectively. All patients underwent a standard spinal cord protection protocol, including routine cerebrospinal fluid drainage. In July 2016, an insulin infusion protocol (IIP) was initiated to maintain postoperative blood glucose levels <120 mg/dL for 48 hours. The primary clinical end point was postoperative SCI. RESULTS 10 (16%) patients developed postoperative SCI: 6 with transient paraparesis, 2 with persistent paraparesis, and 2 with persistent paraplegia. Patients with SCI were older, had higher shaggy scores, and were less likely to have been on an IIP. There were no significant differences in demographics, aneurysm type, or operative parameters. In a logistic multivariate regression model for SCI, age (odds ratio [OR]: 1.2 [1.1-1.4], P = .02) and shaggy score (OR: 1.2 [1.1-1.4], P = .02) were independently associated with increased risk of SCI, whereas treatment with the IIP was associated with lower risk of SCI (OR: 0.04 [0.006-0.50], P = .05). Of the individual components of the shaggy score, higher descending thoracic aortic ulcer scores were the most strongly associated with postoperative SCI (P = .009). CONCLUSIONS Preoperative characterization of aortic wall thrombus is an important adjunctive tool for individualized clinical decision-making and patient counseling about the risk of SCI after BEVAR.
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Affiliation(s)
- Cindy Huynh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Iris Liu
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Anne Sommer
- University of California, San Francisco School of Medicine, San Francisco, CA
| | - Laura Menke
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Linda Reilly
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Gomes VC, Parodi FE, Ohana E, Farber MA. Case Series on Double-Barrel Stenting for the Renal Arteries Associated With Fenestrated Repair (FEVAR) of Complex Anatomy Aortic Aneurysms. Vasc Endovascular Surg 2024; 58:399-404. [PMID: 37962531 PMCID: PMC10996290 DOI: 10.1177/15385744231215589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
The double-barrel stenting (DBS) is a technique in which 2 parallel stents are simultaneously deployed through the same reinforced fenestration, into 2 adjacent target vessels. Prior reports describe the application of this technique for the treatment of superior mesenteric artery dissection with aneurysmal degeneration, coronary artery bifurcations, aortic arch branches, and intracranial aneurysms. The DBS technique is particularly useful in the context of fenestrated repair (FEVAR) of complex anatomy aortic aneurysms when the origin of visceral arteries branch off the aorta very close to each other or present early branches. We herein describe a case series including 7 patients who underwent a FEVAR procedure for thoracoabdominal and juxtarenal aortic aneurysms in which the presence of accessory renal arteries (ARA) or early renal branches was the reason for the application of this technique. Technical success was 100% and all stents were patent in the last follow-up CT scan (follow-up range: 1.8-62.8 months). There was only 1 small endoleak from indetermined source potentially related to the DBS, but the aneurysm sac decreased in size during follow-up and no secondary intervention was needed. Therefore, the DBS technique is a viable option for the incorporation of ARA or early renal branches to a fenestrated repair of aortic aneurysms with complex anatomy.
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Affiliation(s)
- Vivian Carla Gomes
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Federico Ezequiel Parodi
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Elad Ohana
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark A. Farber
- Vascular Surgery Division, Department of Surgery, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
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