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Physiological Reports Jul 2024The aim of this study was to identify risk factors for abdominal aortic aneurysm (AAA) from the largest Welsh screening cohort to date. Patients were recruited from...
The aim of this study was to identify risk factors for abdominal aortic aneurysm (AAA) from the largest Welsh screening cohort to date. Patients were recruited from 1993 (to 2015) as part of the South East Wales AAA screening programme through general practitioners. Demographic data and risk factors were collected by means of a self-report questionnaire. Statistical tests were performed to determine whether associations could be observed between AAA and potential risk factors. Odds ratios (OR) were also calculated for each of the risk factors identified. A total of 6879 patients were included in the study. Two hundred and seventy-five patients (4.0%) presented with AAA, of which 16% were female and 84% were male. Patients with AAA were older than the (no AAA) control group (p < 0.0001). The following risk factors were identified for AAA: family history of AAA (p < 0.0001); history of vascular surgery (p < 0.0001), cerebrovascular accident (p < 0.0001), coronary heart disease (p < 0.0001), diabetes (p < 0.0001), medication (p = 0.0018), claudication (p < 0.0001), smoking history (p = 0.0001) and chronic obstructive pulmonary disorder (p = 0.0007). AAA is associated with classical vascular risk factors, in addition to other less-well-documented risk factors including previous vascular surgery. These findings have practical implications with the potential to improve future clinical screening of patients in order to reduce AAA mortality.
Topics: Humans; Aortic Aneurysm, Abdominal; Male; Female; Aged; Risk Factors; Middle Aged; Prospective Studies; Longitudinal Studies; Aged, 80 and over; Wales
PubMed: 38946069
DOI: 10.14814/phy2.16130 -
Mymensingh Medical Journal : MMJ Jul 2024Abdominal aortic aneurysm remains mostly asymptomatic. It is usually detected incidentally with imaging studies. Here we present a 55 years old hypertensive, non smoker,...
Abdominal aortic aneurysm remains mostly asymptomatic. It is usually detected incidentally with imaging studies. Here we present a 55 years old hypertensive, non smoker, non diabetic, male patient who was diagnosed as a case of infrarenal abdominal aortic aneurysm. He was treated by endovascular means using endograft without laparatomy. Endografts were deployed through bilateral femoral artery cut down technique under general anesthesia. Completion angiogram following this endovascular aneurysm repair (EVAR) technique revealed good technical success with no endoleak. This hybrid procedure was performed in a cathlab having surgical instruments in hand. Three years after the procedure, patient is doing well.
Topics: Humans; Aortic Aneurysm, Abdominal; Male; Endovascular Procedures; Middle Aged; Bangladesh; Blood Vessel Prosthesis Implantation; Endovascular Aneurysm Repair
PubMed: 38944744
DOI: No ID Found -
Annals of Vascular Surgery Jun 2024Thoracic aortic aneurysms evolving within a type IIIb chronic aortic dissection are mostly treated with the deployment of an endograft. However, several cases of...
Thoracic aortic aneurysms evolving within a type IIIb chronic aortic dissection are mostly treated with the deployment of an endograft. However, several cases of dissecting aneurysms are associated with a significant dilatation of the aortic arch. These cases are usually managed in two steps : arch reconstruction or supra-aortic trunk debranching at first and a secondary graft deployment for the descending thoracic aorta. We present through this case series an alternative approach for this severe condition which consists in the replacement of the thoracic aorta from its hemi-arch to the distal thoracic or visceral aorta using a left thoracotomy. We deliberately neglected the remaining dissecting aorta if its diameter was below 45 mm, hypothesizing its non evolution after repair. From 2012 to 2021, 9 patients have been treated for a thoracic aneurysm evolving after a IIIb chronic aortic dissection using a left thoracotomy and a 19°C circulatory arrest. Immediate postoperative results show no mortality nor neurological disorders and the 7 years follow up for all of these 9 cases enlightened the absence of aneurysmal evolution especially for the distal anastomosis and the remaining dissected aorta. This work suggests that this direct approach strategy can definitively treat a thoracic dissecting aneurysm unsuitable for a simple endovascular treatment.
PubMed: 38944192
DOI: 10.1016/j.avsg.2024.04.012 -
Annals of Vascular Surgery Jun 2024To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter...
OBJECTIVES
To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter experience.
METHODS
This study retrospectively analyzed cases of OC for AET following EVAR across 12 Italian Vascular Surgery centers from 1997 to September 2022. The endpoints were as follows: 30-days mortality and major postoperative complications. Follow-up data included: survival and aortic-related complications.
RESULTS
Sixteen patients (mean age: 68.6±8.5 years) were included. Median elapsed time between EVAR to OC was 26.46 months (IQR 13.8-45.9). Proximal aortic cross-clamping site was supraceliac in 8 out of 16 (50%) patients, complete removal of the stentgraft was achieved in 75% of cases (12/16 patients). Reconstructions were: aorto-bi-iliac grafts in 8 cases (50%), 7 aorto-bi-femoral bypass grafts (43.8%), and 1 aorto-aortic tube graft (6.3%). All patients were symptomatic at presentation (68.7% unilateral acute limb ischemia, 25% bilateral acute limb ischemia, 1 patient had chronic severe claudication). Thirty-day mortality was 12.5% (2/16 patients). Overall morbidity rate was 43.8% (7 of 16 patients). No specific risk factors for early mortality were found. The overall estimated survival rate was 80.4% at 1 year, 62.5% at 2 years and 41.7% at 3 years.
CONCLUSIONS
OC for AET is typically reserved for complex cases that are not amenable to endovascular solutions. The frequent need for suprarenal clamping and complete endograft removal seem to be associated with high short-term mortality.
PubMed: 38944191
DOI: 10.1016/j.avsg.2024.04.018 -
Journal of Vascular Surgery Jun 2024Given changes in intervention guidelines and the growing popularity of endovascular treatment for aortic aneurysms, we examined the trends in admissions and repairs of...
BACKGROUND
Given changes in intervention guidelines and the growing popularity of endovascular treatment for aortic aneurysms, we examined the trends in admissions and repairs of abdominal aortic aneurysms (AAA), thoracoabdominal aortic aneurysms (TAAA), and thoracic aortic aneurysms (TAA).
METHODS
We identified all patients admitted with ruptured aortic aneurysms and intact aortic aneurysms repaired in the Nationwide Inpatient Sample (NIS) between 2004-2019. We then examined the utilization of open, endovascular, and complex endovascular repair (OAR,EVAR,cEVAR) for each aortic aneurysm location (AAA,TAAA,TAA), alongside their resulting in-hospital mortality, over time. cEVAR included branched, fenestrated, and physician modified endograft.
RESULTS
715,570 patients were identified with AAA (87% Intact-Repairs, 13% Rupture-Admissions). Both intact AAA repairs and ruptured AAA admissions decreased significantly between 2004 and 2019 (intact 41,060-34,215,p<.01; ruptured 7,175-4,625,p=.02). Out of all AAA repairs done in a given year, the use of EVAR increased (2004-2019: intact 45%-66%,p<.01; ruptured 10%-55%,p<.01) as well as cEVAR (2010-2019: intact 0%-23%,p<.01; ruptured 0%-14%,p<.01). Mortality after EVAR of intact AAAs decreased significantly by 29% (2004-2019, 0.73%-0.52%,p<.01) while mortality after OAR increased significantly by 16% (2004-2019, 4.4%-5.1%,p<.01). In the study, 27,443 patients were identified with TAAA (80% Intact, 20% Ruptured). In the same period, intact TAAA repairs trended upwards (2004-2019 1,435-1,640,p=.055) and cEVAR became the most common approach (2004-2019, 3.8%-72%,p=.055). 141,651 patients were identified with ascending, arch, or descending TAA (90% Intact, 10% Ruptured). Intact TAA repairs increased significantly (2004-2019 4,380-10,855,p<.01). From 2017-2019, the mortality after OAR of descending TAAs increased and mortality after TEVAR decreased (2017-2019: OAR 1.6%-3.1%; TEVAR 5.2%-3.8%).
CONCLUSION
Both intact AAA repairs and ruptured AAA admissions significantly decreased between 2004 and 2019. The use of endovascular techniques for the repair of all aortic aneurysm locations, both intact and ruptured, increased over the past two decades. Most recently in 2019, 89% of intact AAAs repairs, infrarenal through suprarenal, were endovascular (EVAR or cEVAR, respectively). cEVAR alone has risen to 23% of intact AAA repairs in 2019, from 0% a decade earlier. In this period of innovation, with many new options to repair aortic aneurysms while maintaining arterial branches, endovascular repair is now used for the majority of all intact aortic aneurysm repairs. Long-term data are needed to evaluate the durability of these procedures.
PubMed: 38942397
DOI: 10.1016/j.jvs.2024.06.165 -
Annals of Vascular Surgery Jun 2024In the endovascular aneurysm repair (EVAR) era, open surgical repair (OSR) is performed for ruptured abdominal aorta aneurysm (RAAA) in patients with complex aneurysm...
OBJECTIVES
In the endovascular aneurysm repair (EVAR) era, open surgical repair (OSR) is performed for ruptured abdominal aorta aneurysm (RAAA) in patients with complex aneurysm neck and technical difficulties. Understanding the risk factors of OSR is essential for the clinical selection of the ideal surgical procedure. We aimed to re-evaluate the outcomes of OSR and treatment options for RAAA.
METHODS
Patients who underwent OSR for RAAA between January 2010 and December 2022 were enrolled in this single-center, retrospective observational study. Preoperative status, operative findings, and postoperative course were retrospectively reviewed. The Cox proportional hazards model was used to evaluate the association between age and early postoperative mortality.
RESULTS
Among 142 patients, 43 (30.3%) and 99 (69.7%) were aged ≥80 and <80 years, respectively. Postoperative mortality within 30 days occurred in 24 (16.9%) patients (11/43 [25.6%] and 13/99 [13.1%] patients aged ≥80 and <80 years, respectively; hazard ratio [HR]=1.95; P=0.069). In a multivariable analysis, increased postoperative mortality within 30 days was associated with age ≥80 years (adjusted HR, aHR=2.36; P=0.049), the presence of pre- or intraoperative cardiopulmonary arrest (aHR=12.0; P<0.001), and postoperative gastrointestinal disorder (aHR=4.42; P=0.003).
CONCLUSIONS
EVAR may be preferable in older people; however, its use in cases of pre- or intraoperative cardiopulmonary arrest or perioperative gastrointestinal disorders remains controversial, and a careful discussion on the surgical indications is needed in such cases.
PubMed: 38942379
DOI: 10.1016/j.avsg.2024.04.016 -
Annals of Vascular Surgery Jun 2024Advanced endovascular techniques, such as fenestrated stent grafts, are nowadays available that permit minimally invasive treatment of complex abdominal aortic... (Review)
Review
Expert-based narrative review on contemporary use of an off-the-shelf multibranched endograft for endovascular treatment of thoracoabdominal aortic aneurysms: device design, anatomical suitability, technical tips, peri-operative care, clinical applications, and real-world experience.
Advanced endovascular techniques, such as fenestrated stent grafts, are nowadays available that permit minimally invasive treatment of complex abdominal aortic aneurysms. However, thoracoabdominal aortic aneurysm (TAAA) patients have anatomic limitations to fenestrated stent-grafts, given a large lumen, i.e. the gap between the endograft and the inner aortic wall. This has led to the development of branched endovascular aneurysm repair (BEVAR) as the ideal option for such patients. The Zenith t-Branch multibranched endograft (Cook Medical, Bloomington, Ind), which has been commercially available in Europe to treat TAAA since June 2012, represents a feasible off-the-shelf (OTS) alternative for treatment of such pathologies, especially in the urgent setting, for patients who cannot wait the time required for manufacturing and delivery of custom-made endografts. The device's anatomical suitability should be considered, especially for female patients with smaller iliofemoral vessels. Several tips may help deal with particularly complex scenarios (such as, for instance, in case of narrow inner aortic lumens or when treating patients with failure of prior EVAR), and a broad array of techniques and devices must be available to ensure technical and clinical success. Despite promising early outcomes, concerns remain particularly regarding the risk for spinal cord ischemia and further assessment of long-term durability is needed, including the rate of target vessel instability and need for secondary interventions. As the published evidence mainly comes from retrospective registries, it is likely that reported outcomes may suffer from an intrinsic bias as most procedures reported to date have been caried out at high-volume aortic centers. Nonetheless, with the never-ceasing adoption of new and refined techniques, outcomes are expected to ameliorate.
PubMed: 38942377
DOI: 10.1016/j.avsg.2024.05.006 -
Annals of Vascular Surgery Jun 2024Investigate readmission rates, diagnoses associated with readmission, and associations with mortality through 90-days post-operatively after elective endovascular...
OBJECTIVES
Investigate readmission rates, diagnoses associated with readmission, and associations with mortality through 90-days post-operatively after elective endovascular thoracic and thoracoabdominal aortic repair overall and by extent of coverage.
METHODS
A cohort of index elective non-traumatic endovascular thoracic and thoracoabdominal aortic cases from 2010-2018 was derived from the Vascular Implant Surveillance and Interventional Outcomes Network. Cohort readmissions within 90-days postoperative were examined both overall and by Crawford extent (CE) of aortic coverage. Postoperative mortality was examined by reason for readmission and CE.
RESULTS
The cohort consisted of 2,093 patients who underwent endovascular thoracic and thoracoabdominal aortic repair (1,541 CE 0A/0B; 240 CE 1-3; 312 CE 4-5). Cumulative risk for 90-day readmission was 34.3% in CE 0A/0B repairs, 33.4% in CE4-5 repairs and 47.4% in CE 1-3 repairs. Compared to CE 0A/B, patients with CE 1-3 repairs experienced an increased risk of readmission within 90 days postoperatively after adjusting for preoperative factors (aHR 1.27(1.00,1.61) while the readmission risk for CE 4-5 repairs did not differ significantly (aHR 0.83 (0.64,1.06). Significant risk factors for 90-day readmission included COPD, dialysis dependence, limited ambulation, visceral/spinal ischemia, and in-hospital stroke. Discharge to home was protective against readmission (HR 0.65, CI 0.54-0.79). Patients with a readmission within 90-days had a 7.89-fold increase in 90-day mortality (HR 7.84; 5.17, 11.9) compared to those not readmitted.
CONCLUSIONS
Increasing extent of endovascular thoracic and thoracoabdominal aortic repair was associated with higher 90-day readmission rates. Readmission for all CE was associated with near 8-fold increased risk of mortality. Risk factors associated with increased risk for readmission included pulmonary insufficiency, renal disease, and poor functional status. These findings can inform stakeholders about investment of resources to improve processes of care that both target prevention and mitigate risk of readmission after elective endovascular thoracic and thoracoabdominal aortic repair.
PubMed: 38942375
DOI: 10.1016/j.avsg.2024.05.007 -
Annals of Vascular Surgery Jun 2024Abdominal aortic aneurysm (AAA) screening has been offered to 65-year-old men living in Oslo, Norway, since May 2011. A significant number of AAA-related deaths occurred...
INTRODUCTION
Abdominal aortic aneurysm (AAA) screening has been offered to 65-year-old men living in Oslo, Norway, since May 2011. A significant number of AAA-related deaths occurred in individuals who are not eligible for screening. The primary aim of this study was to describe the group of patients admitted to Oslo University Hospital with a ruptured AAA after the implementation of the local AAA screening project. The following parameters were investigated: AAA detection prior to rupture, surveillance status, eligibility for screening and comorbidities. We also sought to compare outcomes (repair rates and 30-day mortality) between patients with and without an AAA detected prior to rupture.
METHODS
This cohort study included patients admitted acutely to Oslo University Hospital due to a symptomatic or ruptured AAA in the period January 2011 to December 2022. Data on demographics, prior AAA detection, surveillance status, treatment and mortality were collected retrospectively through electronic medical records.
RESULTS
We identified 200 patients with a symptomatic or ruptured AAA, among which 79 (40%) had an AAA detected prior to rupture - one (1%) through screening and 78 (39%) incidentally. Up to 30% of the incidentally detected AAAs were not under any surveillance. Six patients were found eligible for screening: one had attended, three were non-attenders and two had not been invited. Patients with an incidentally detected AAA prior to rupture had a more advanced age and a significantly higher degree of comorbidities than patients without a previously detected AAA, and the repair rates in these groups were 56% and 84% respectively (p < 0.001). Adjusted for comorbidities and risk factors, the odds ratio for repair among patients with incidentally detected AAA was 0.56 (p = 0.292). The 30-day mortality was not significantly different between the two groups (p = 0.097).
CONCLUSION
Most patients with a ruptured AAA were not eligible for screening, but 39% of the patients had an incidentally detected AAA prior to rupture. Standardized reporting and follow-up of incidentally detected AAAs is thus identified as an additional measure to organized screening in the effort to reduce AAA-related mortality.
PubMed: 38942371
DOI: 10.1016/j.avsg.2024.04.017 -
Annals of Vascular Surgery Jun 2024Low wall shear stress (WSS) is predictive of aortic aneurysm growth and rupture. Yet, estimating WSS in a clinical setting is impractical whereas measuring aneurysm...
OBJECTIVES
Low wall shear stress (WSS) is predictive of aortic aneurysm growth and rupture. Yet, estimating WSS in a clinical setting is impractical whereas measuring aneurysm geometry is feasible. This study investigates the association between saccular aneurysm geometry of the infrarenal aorta and WSS.
METHODS
Starting with a non- aneurysmal, patient-specific, computational fluid dynamics model of the aorta, saccular aneurysms of varying geometry were created by incrementally increasing the neck width and sac depth from 1cm to 4cm. The aspect ratio (the ratio between sac depth and neck width) varied between 0.25 and 4. The peak WSS, time- averaged WSS (TAWSS), and oscillatory shear index (OSI) were measured within the aneurysm sac.
RESULTS
Decreasing the neck width from 4cm to 1cm decreased the peak WSS by 69% and the TAWSS by 83%. Increasing the sac depth from 1cm to 4cm decreased the peak WSS by 55% and OSI by 37%. The aspect ratio was negatively correlated to peak WSS (Rs -0.85, p<0.001).
CONCLUSIONS
In saccular aneurysms of the infrarenal aorta, a smaller neck width, deeper aneurysm sac, and larger aspect ratio are associated with lower peak WSS.
PubMed: 38942368
DOI: 10.1016/j.avsg.2024.04.015