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Journal of Vascular Surgery Sep 2018Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Outcomes after repair of ruptured abdominal aortic aneurysm (RAAA) have improved in the last decade. It is unknown whether this has resulted in a reduction of postoperative bowel ischemia (BI). The primary objective was to determine BI prevalence after RAAA repair. Secondary objectives were to determine its major sequelae and differences between open repair (OR) and endovascular aneurysm repair (EVAR).
METHODS
This systematic review (PROSPERO CRD42017055920) followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. MEDLINE and Embase were searched for studies published from 2005 until 2018. The methodologic quality of observational studies was assessed with the Methodological Index for Non-Randomized Studies (MINORS) tool. The quality of the randomized controlled trials (RCTs) was assessed with the Cochrane Collaboration's tool for assessing risk of bias. BI prevalence and rates of BI as cause of death, reoperation, and bowel resection were estimated with meta-analyses with a random-effects model. Differences between OR and EVAR were estimated with pooled risk ratios with 95% confidence intervals (CIs). Changes over time were assessed with Spearman rank test (ρ). Publication bias was assessed with a funnel plot analysis.
RESULTS
A total of 101 studies with 52,670 patients were included; 72 studies were retrospective cohort studies, 14 studies were prospective cohort studies, 12 studies were retrospective administrative database studies, and 3 studies were RCTs. The overall methodologic quality of the RCTs was high, but that of observational studies was low. The pooled prevalence of BI ranged from of 0.08 (95% CI, 0.07-0.09) in database studies to 0.10 (95% CI, 0.08-0.12) in cohort studies. The risk of BI was higher after OR than after EVAR (risk ratio, 1.79; 95% CI, 1.25-2.57). The pooled rate of BI as cause of death was 0.04 (95% CI, 0.03-0.05), and that of BI as cause of reoperation and bowel resection ranged between 0.05 and 0.07. BI prevalence did not change over time (ρ, -0.01; P = .93). The funnel plot analysis was highly suggestive of publication bias.
CONCLUSIONS
The prevalence of clinically relevant BI after RAAA repair is approximately 10%. Approximately 5% of patients undergoing RAAA repair suffer from severe consequences of BI. BI is less prevalent after EVAR than after OR.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Humans; Intestines; Ischemia; Postoperative Complications; Risk Factors
PubMed: 30146037
DOI: 10.1016/j.jvs.2018.05.018 -
Journal of Vascular Surgery Jul 2021The aim of this study was to perform a meta-analysis of relevant published literature to investigate the impact of wide proximal aortic neck diameter on outcomes of... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of this study was to perform a meta-analysis of relevant published literature to investigate the impact of wide proximal aortic neck diameter on outcomes of endovascular aneurysm repair (EVAR) for the repair of abdominal aortic aneurysm (AAA).
METHODS
A systematic literature review was performed to examine the rate of clinical safety and effectiveness end points associated with wide proximal aortic neck diameter after EVAR for the treatment of AAA. A literature search was performed on August 9, 2019, using PubMed as the primary database and Cochrane as the secondary database. In all, there were 11 full articles included in the quantitative and qualitative analyses.
RESULTS
There was a total of 7448 patients who were treated for AAA with EVAR. Of these, 26.9% of patients were defined as having wide necks by the individual publications. The definition of wide neck varied in the literature and ranged from 25 mm or greater to 30 mm or greater. The percentage of male patients was 89.1% in the included articles. The mean or median age range was 72.7 to 76.5 years, which was similar for the wide and normal neck groups. Follow-up ranged from 2 to 5 years. Type I and Ia endoleaks occurred at a higher rate in the wide neck group compared with the normal neck group (11.3% vs 3.1%; P < .001). There was no difference in the rate of type Ib endoleaks between the wide and normal neck groups. The weighted averages of composite major adverse events and aneurysm-related mortality were all greater in the wide neck group (33.5% and 15.3%, respectively) compared with the normal neck group (21.2% and 3.9%, respectively) (P = .004).
CONCLUSIONS
The rates of type Ia endoleaks, reinterventions, and migrations were all significantly higher in the wide neck patient group compared with patients with normal aortic neck size through follow-up. The results of this literature review showed that, although EVAR for the treatment of AAA in patients with a wide aortic neck is feasible, there is a higher risk for complications, interventions, and mortality. In particular, type Ia endoleak is a risk, which could be mitigated by using proximal seal strategies.
Topics: Aged; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Female; Graft Occlusion, Vascular; Humans; Male; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Vascular Patency
PubMed: 33722632
DOI: 10.1016/j.jvs.2021.02.043 -
Journal of Cardiothoracic Surgery Jul 2023Valve-sparing aortic root replacement (VSARR) is a safe and effective surgical procedure to treat aortic root aneurysm. This meta-analysis aimed to investigate how this... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Valve-sparing aortic root replacement (VSARR) is a safe and effective surgical procedure to treat aortic root aneurysm. This meta-analysis aimed to investigate how this procedure might differ in patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV).
DESIGN
Meta-analysis with meta-regression and systematic review.
SETTING
Systematic search in the following databases: PubMed, Cochrane Central Register of Controlled Trials, and Embase.
INTERVENTIONS
All observational studies of VSARR in patients with BAV or TAV were included in our study. Studies were included without any restrictions on language or publication date. A trial sequential analysis and a post-hoc meta-regression was performed on the main outcomes.
RESULT
Eleven articles met the inclusion criteria. A total of 1138 patients in BAV group, and 2125 patients in TAV group. No significant differences in gender and age were observed between BAV and TAV patients. BAV and TAV patients showed no differences in in-hospital mortality rate [0.00% vs. 1.93%; RR (95% CI) 0.33 (0.09, 1.26), I = 0%, P = 0.11] and the rate of in-hospital reoperation [5.64% vs. 5.99%; RR (95% CI) 1.01(0.59, 1.73), I = 33%, P = 0.98]. The overall long-term mortality rate of BAV patients was better than that of TAV patients [1.63% vs. 8.15%; RR (95% CI) 0.34 (0.13, 0.86), I = 0%, P = 0.02]. During the follow-up observation period, patients in TAV group showed small but no statistic advantage in 3-year, 5-year, and over 10-year incidences of reintervention. Regarding the secondary endpoints, the two groups showed similar aortic cross-clamping time and total cardiopulmonary bypass time.
CONCLUSION
The VSARR techniques yielded similar clinical outcomes in both BAV and TAV patients. Although patients with BAV might have a higher incidence of reinterventions after initial VSARR, it is still a safe and effective approach to treat aortic root dilation with or without aortic valve insufficiency. TAV patients showed small but no statistic advantage in long-term (over 10 years) reintervention rate, which means, patients with BAV may face a higher risk of reintervention in the clinic.
Topics: Humans; Aortic Valve; Bicuspid Aortic Valve Disease; Heart Valve Diseases; Aorta; Tricuspid Valve; Transcatheter Aortic Valve Replacement; Aortic Valve Stenosis; Retrospective Studies; Treatment Outcome; Observational Studies as Topic
PubMed: 37400892
DOI: 10.1186/s13019-023-02329-8 -
Journal of Vascular Surgery Aug 2018We performed a systematic review and meta-analysis aiming to assess the mortality and morbidity of all published case series on thoracoabdominal aortic aneurysms (TAAAs)... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
We performed a systematic review and meta-analysis aiming to assess the mortality and morbidity of all published case series on thoracoabdominal aortic aneurysms (TAAAs) in experienced centers treated with open repair.
METHODS
A systematic search of the literature published until April 2017 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Separate meta-analyses were conducted for overall in-hospital mortality for TAAA, mortality according to the type of TAAA, spinal cord ischemia, paraplegia and paraparesis, cardiac events, stroke, acute kidney failure, and bowel ischemia. A metaregression analysis was performed with volume of the center, percentage of ruptured cases among the series, length of in-hospital stay, and publication year as covariates.
RESULTS
A total of 30 articles were included in the meta-analysis, corresponding to a total of 9963 patients who underwent open repair for TAAAs (543 ruptured). The pooled mortality rate among all studies was 11.26% (95% confidence interval [CI], 9.56-13.09). Mortality was 6.97% (95% CI, 3.75-10.90), 10.32% (95% CI, 7.39-13.63), 8.02% (95% CI, 6.37-9.81), and 7.20% (95% CI, 4.19-10.84) for Crawford types I, II, III, and IV, respectively. Pooled spinal cord ischemia rate was estimated at 8.26% (95% CI, 6.95-9.67), whereas paraparesis and paraplegia rates were 3.61% (95% CI, 2.25-5.25) and 5% (95% CI, 4.36-5.68), respectively. We estimated a pooled cardiac event rate of 4.41% (95% CI, 1.84-7.95) and a stroke rate of 3.11% (95% CI, 2.36-3.94), whereas the need for permanent dialysis rate was 7.92% (95% CI, 5.34-10.92). Respiratory complications after surgery were as high as 23.01% (95% CI, 14.73-32.49). Metaregression analysis evidenced a statistically significant inverse association between mortality and the volume of cases performed in the vascular center (t = -2.00; P = .005). Interestingly, a more recent year of study publication tended to be associated with decreased in-hospital mortality (t = -1.35; P = .19).
CONCLUSIONS
Our study showed that despite the advances in open surgical techniques, the morbidity and mortality of the technique continue to remain considerable. Despite the focus on mortality and spinal cord ischemia, respiratory complications, permanent postoperative renal dialysis, stroke rate, and cardiac events also affect the outcome. The estimated trend of lower mortality in high-volume centers suggests that perhaps this type of service should be provided in a few reference centers that have an established record and experience in the management of these patients.
Topics: Aged; Aortic Aneurysm, Thoracic; Aortic Rupture; Blood Vessel Prosthesis Implantation; Clinical Competence; Hospitals, High-Volume; Hospitals, Low-Volume; Humans; Length of Stay; Middle Aged; Postoperative Complications; Risk Factors; Time Factors; Treatment Outcome
PubMed: 30037680
DOI: 10.1016/j.jvs.2018.03.410 -
European Journal of Vascular and... Dec 2016Despite technical advances of fenestrated and branched endografts, endovascular exclusion of aneurysms involving renal, visceral, and/or supra-aortic branches remains a... (Review)
Review
OBJECTIVE
Despite technical advances of fenestrated and branched endografts, endovascular exclusion of aneurysms involving renal, visceral, and/or supra-aortic branches remains a challenge. In situ fenestration (ISF) of standard endografts represents another endovascular means to maintain perfusion to such branches. This study aimed to review current indications, technical descriptions, and results of ISF.
METHOD
A review of the English language literature was performed in Medline databases, Cochrane Database, Web of Science, and Scopus using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Sixty-seven relevant papers were selected. Thirty-three papers were excluded, leaving 34 articles as the basis of the present review.
RESULTS
Most experimental papers evaluated ISF feasibility and assessed the consequences of ISF on graft fabric. Regarding clinical papers, 73 ISF procedures have been attempted in 58 patients, including 26 (45%) emergent and three (5%) bailout cases. Sixty-five (89%) ISF were located at the level of the arch, and eight (11%) in the abdominal aorta. Graft perforation was performed by physical, mechanical, or unspecified means in 33 (45%), 38 (52%), and two vessels (3%), respectively. ISF was technically successful in 68/73 (93%) arteries. At 30 days, two (3.4%) patients died in the setting of an aorto-bronchial fistula and an aorto-oesophageal fistula, respectively. No post-operative death, major complication, or endoleak was described as secondary to the ISF procedure. With follow-up between 0 and 72 months, four (6.9%) late deaths were noted, unrelated to the aorta. One (1.7%) LSA stent was stenosed without symptoms.
CONCLUSIONS
Although there may be publication bias, multiple techniques were described to perform ISF with satisfactory short-term results. Long-term data remain scarce. Aortic endograft ISF is an off-label procedure that should not be used outside emergent bailout techniques or investigational studies. A comparison with alternative techniques of preserving aortic side branches is needed.
Topics: Animals; Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Postoperative Complications; Prosthesis Design; Risk Factors; Stents; Time Factors; Treatment Outcome
PubMed: 27843111
DOI: 10.1016/j.ejvs.2016.10.001 -
Journal of Vascular Surgery May 2020Concerns about the long-term durability of endovascular aortic aneurysm repair and the requirement for explantation of stents in the case of infection demonstrate the...
OBJECTIVE
Concerns about the long-term durability of endovascular aortic aneurysm repair and the requirement for explantation of stents in the case of infection demonstrate the continued need for open abdominal aortic aneurysm (AAA) repair. However, with the increased complexity and decreasing volume of open cases performed, maintenance of skills and training of younger surgeons are challenging. The aim of this review was to identify and to examine studies pertaining to open AAA simulation, with focus on methods and outcomes.
METHODS
We performed a systematic review of the literature to identify primary research pertaining to open AAA repair through the use of simulators. The primary outcome was to identify predominant modes of simulator design and validated assessment tools that could demonstrate improvement in trainee skills. Secondary outcomes included identifying participant numbers needed to power studies and whether tools not validated externally contributed to the studies.
RESULTS
There were 309 unique papers identified, from which five papers met the inclusion criteria. The selected papers used a combination of synthetic (commercial and homemade) and cadaveric simulators. A variety of validated and nonvalidated assessment metrics were used, including Objective Structured Assessment of Technical Skills, global rating scales, and realism surveys. Three of the five papers used blinding as part of their assessments. Mean participant numbers were 30.8 ± 25.7 and with the exception of one paper consisted entirely of surgical trainees in dedicated general or vascular surgery training programs.
CONCLUSIONS
Several options are currently available for open AAA simulation, all of which demonstrate improved scoring metrics after simulator use. Validated scoring systems, the Objective Structured Assessment of Technical Skills in particular, were most frequently used to deliver objective results. Whereas junior trainees derive the most benefit, senior trainees also showed significant improvements, demonstrating that simulation benefits all levels of surgical trainees. Low numbers of participants were sufficient to achieve statistical benefit within individual studies.
Topics: Aortic Aneurysm, Abdominal; Clinical Competence; Humans; Simulation Training; Stents; Vascular Surgical Procedures
PubMed: 31831316
DOI: 10.1016/j.jvs.2019.10.009 -
Journal of Vascular Surgery Mar 2023To provide an updated systematic literature review summarizing current evidence on aortic neck dilatation (AND) after endovascular aortic aneurysm repair (EVAR) in... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To provide an updated systematic literature review summarizing current evidence on aortic neck dilatation (AND) after endovascular aortic aneurysm repair (EVAR) in patients with infrarenal abdominal aortic aneurysm.
METHODS
An extensive electronic search in major electronic databases was conducted between January 2000 and December 2021. Eligible for inclusion were observational studies that followed up with patients (n ≥ 20) undergoing EVAR with self-expanding endografts, for 12 or more months, evaluated AND with computed tomography angiography and provided data on relevant outcomes. The primary end point was the incidence of AND after EVAR, and the secondary end points were the occurrence of type Ia endoleak, stent graft migration, secondary rupture, and reintervention.
RESULTS
We included 34 studies with a total sample of 12,038 patients (10,413 men; median age, 71 years). AND was defined clearly in 18 studies, but significant differences in AND definition were evidenced. The pooled incidence of AND based on quantitative analysis of 16 studies with a total of 9201 patients (7961 men; median age, 72 years) was calculated at 22.9% (95% confidence interval [CI], 14.4-34.4) over a follow-up period ranging from 12 months to 14 years. The risk of a type Ia endoleak was significantly higher in AND patients compared with those without AND (odds ratio, 2.95; 95% CI, 1.10-7.93; P = .030). Similarly, endograft migration was more common in the AND group compared with the non-AND group (odds ratio, 5.95; 95% CI, 1.80-19.69; P = .004). The combined incidence of secondary rupture and reintervention did not differ significantly between the two groups, even though the combined effect was in favor of the non-AND group.
CONCLUSIONS
Proximal AND after EVAR is common and occurs in a large proportion of patients with infrarenal abdominal aortic aneurysm. AND can influence the long-term durability of proximal endograft fixation and is significantly related to adverse outcomes, often leading to reinterventions.
Topics: Male; Humans; Aged; Blood Vessel Prosthesis Implantation; Endoleak; Treatment Outcome; Dilatation; Risk Factors; Endovascular Procedures; Retrospective Studies; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis
PubMed: 35948244
DOI: 10.1016/j.jvs.2022.07.182 -
NPJ Digital Medicine Jan 2022Machine learning (ML) is a rapidly advancing field with increasing utility in health care. We conducted a systematic review and critical appraisal of ML applications in... (Review)
Review
Machine learning (ML) is a rapidly advancing field with increasing utility in health care. We conducted a systematic review and critical appraisal of ML applications in vascular surgery. MEDLINE, Embase, and Cochrane CENTRAL were searched from inception to March 1, 2021. Study screening, data extraction, and quality assessment were performed by two independent reviewers, with a third author resolving discrepancies. All original studies reporting ML applications in vascular surgery were included. Publication trends, disease conditions, methodologies, and outcomes were summarized. Critical appraisal was conducted using the PROBAST risk-of-bias and TRIPOD reporting adherence tools. We included 212 studies from a pool of 2235 unique articles. ML techniques were used for diagnosis, prognosis, and image segmentation in carotid stenosis, aortic aneurysm/dissection, peripheral artery disease, diabetic foot ulcer, venous disease, and renal artery stenosis. The number of publications on ML in vascular surgery increased from 1 (1991-1996) to 118 (2016-2021). Most studies were retrospective and single center, with no randomized controlled trials. The median area under the receiver operating characteristic curve (AUROC) was 0.88 (range 0.61-1.00), with 79.5% [62/78] studies reporting AUROC ≥ 0.80. Out of 22 studies comparing ML techniques to existing prediction tools, clinicians, or traditional regression models, 20 performed better and 2 performed similarly. Overall, 94.8% (201/212) studies had high risk-of-bias and adherence to reporting standards was poor with a rate of 41.4%. Despite improvements over time, study quality and reporting remain inadequate. Future studies should consider standardized tools such as PROBAST and TRIPOD to improve study quality and clinical applicability.
PubMed: 35046493
DOI: 10.1038/s41746-021-00552-y -
European Journal of Vascular and... Jul 2018Colon ischaemia (CI) is a significant complication of open (OR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With a rapid increase in EVAR uptake,... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Colon ischaemia (CI) is a significant complication of open (OR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With a rapid increase in EVAR uptake, contemporary data demonstrating the differing rates and outcomes of CI between EVAR and OR, particularly in the elective setting, are lacking. The aim was to characterise the risk and consequences of CI in elective AAA repair comparing EVAR with OR.
METHODS
A systematic review and meta-analysis of the literature was performed using the Cochrane collaboration protocol and reported according to the PRISMA guidelines. PubMed, MedLine, and EMBASE were searched for studies reporting CI rates after elective AAA repair. Ruptured AAAs were excluded from analysis.
RESULTS
Thirteen studies reporting specific outcomes of CI after elective AAA repair, containing 162,750 evaluable patients (78,151 EVAR and 84,599 OR) were included. All studies found a higher risk of CI with OR than with EVAR. Three studies performed confounder adjustment with CI rates of 0.5-1% versus 2.1-3.6% (EVAR vs. OR) and combined odds ratio of 2.7 (2.0-3.5) for the development of CI with OR versus EVAR. The majority of cases of CI occurred within 30 days and were associated with variable mortality (0-73%) and re-intervention rates (27-54%). GRADE assessment of evidence strength was very low for all outcomes. There was a high degree of heterogeneity between studies both methodologically and in terms of CI rates, re-intervention, mortality, and time to development of CI.
CONCLUSIONS
EVAR is associated with a reduced incidence of CI compared with OR.
Topics: Aortic Aneurysm, Abdominal; Aortic Rupture; Colon; Elective Surgical Procedures; Endovascular Procedures; Humans; Ischemia; Laparotomy; Postoperative Complications; Reoperation; Risk Factors; Time Factors
PubMed: 29636250
DOI: 10.1016/j.ejvs.2018.03.005 -
Journal of Cardiac Surgery Dec 2022New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons of all temperature levels have rarely been performed. We performed direct and indirect comparisons of deep hypothermic circulatory arrest (DHCA) (≤20°C), moderate hypothermic circulatory arrest (MHCA) (20.1-25°C), and mild hypothermic circulatory arrest (mild HCA) (≥25.1°C) in a network meta-analysis.
METHODS
The literature was systematically searched for all papers published through February 2022 reporting on clinical outcomes after aortic arch surgery utilizing DHCA, MHCA and mild HCA. The primary outcome was operative mortality. The secondary outcomes were postoperative stroke and acute kidney failure (AKI).
RESULTS
A total of 34 studies were included, with a total of 12,370 patients. DHCA was associated with significantly higher postoperative incidence of stroke when compared with MHCA (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.19-1.78) and mild HCA: (OR, 1.50, 95% CI, 1.14-1.98). Furthermore, DHCA and MHCA were associated with higher operative mortality when compared with mild HCA (OR 1.71, 95% CI, 1.23-2.39 and OR 1.50, 95% CI, 1.12-2.00, respectively). Separate analysis of randomized and propensity score matched studies showed sustained increased risk of stroke with DHCA in contrast to MHCA and mild HCA (OR, 1.61, 95% CI, 1.18-2.20, p value = .0029 and OR, 1.74, 95% CI, 1.09-2.77, p value = .019).
CONCLUSIONS
In the included studies, the moderate to mild hypothermia strategies were associated with decreased operative mortality and the risk of postoperative stroke. Large-scale prospective studies are warranted to further explore appropriate temperature management for the treatment of aortic arch pathologies.
Topics: Humans; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Treatment Outcome; Temperature; Network Meta-Analysis; Retrospective Studies; Circulatory Arrest, Deep Hypothermia Induced; Stroke; Cerebrovascular Circulation; Perfusion
PubMed: 36378895
DOI: 10.1111/jocs.17206