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Minerva Chirurgica Dec 2019Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great... (Comparative Study)
Comparative Study
INTRODUCTION
Rupture of abdominal aortic aneurysm remains a fatal event in up to 65% of cases and emergency open surgery (ruptured open aneurysm repair or rOAR) has a great intraoperative mortality of about 30-50%. The introduction of endovascular repair of abdominal aortic aneurysm (ruptured endovascular aneurysm repair or rEVAR) has rapidly challenged the conventional approach to this catastrophic event. The purpose of this systematic review is to compare the outcomes of open surgical repair and endovascular interventions.
EVIDENCE ACQUISITION
A literature search was performed using Medline, Scopus, and Science Direct from August 2010 to March 2017 using keywords identified and agreed by the authors. Randomized trials, cohort studies, and case-report series were contemplated to give a breadth of clinical data.
EVIDENCE SYNTHESIS
Ninety-three studies were included in the final analysis. Thirty-five (50.7%) of the listed studies evaluating the within 30 days mortality rates deposed in favor of rEVAR, while the others (comprising all four included RCTs) failed detecting any difference. Late mortality rates were found to be lower in rEVAR group in seven on twenty-seven studies (25.9%), while one (3.7%) reported higher mortality rates following rEVAR performed before 2005, one found lower incidence of mortality at 6 months in the endovascular group but higher rates in the same population at 8 years of follow-up, and the remaining (66.7%) (including all three RCTs) failed finding any benefit of rEVAR on rOAR. A lower incidence of complications was reported by thirteen groups (46.4%), while other thirteen studies did not find any difference between rEVAR and rOAR. Each of these two conclusions was corroborated by one RCTs. Other two studies (7.2%) found higher rates of tracheostomies, myocardial infarction, and acute tubular necrosis or respiratory, urinary complications, and acute renal failure respectively in rOAR group. The majority of studies (59.0%, 72.7%, and 89.3%, respectively) and all RCTs found significantly lower rates of length of hospitalization, intensive care unit transfer, and blood loss with or without transfusion need in rEVAR group. The large majority of the studies did not specified neither the type nor the brands of employed stent grafts.
CONCLUSIONS
The bulk of evidence regarding the comparison between endovascular and open surgery approach to RAAA points to: 1) non-inferiority of rEVAR in terms of early (within 30 days) and late mortality as well as rate of complications and length of hospitalization, with trends of better outcomes associated to the endovascular approach; 2) significantly better outcomes in terms of intensive care unit transfer and blood loss with or without transfusion need in the rEVAR group. These conclusions reflect the results of the available RCTs included in the present review. Thus rEVAR can be considered a safe method in treating RAAA and we suggest that it should be preferred when technically feasible. However, more RCTs are needed in order to give strength of these evidences, bring to definite clinical recommendations regarding this subject, and assess the superiority (if present) of one or more brands of stent grafts over the others.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Aortic Rupture; Cohort Studies; Endovascular Procedures; Humans; Incidence; Postoperative Complications; Randomized Controlled Trials as Topic; Time Factors
PubMed: 29806754
DOI: 10.23736/S0026-4733.18.07768-4 -
European Journal of Trauma and... Aug 2018Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome.
METHODS
Systematic review and meta-analysis (1900-2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords "aortic balloon occlusion", "aortic balloon tamponade", "REBOA", and "Resuscitative Endovascular Balloon Occlusion" in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered.
RESULTS
A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use.
CONCLUSION
REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.
Topics: Aorta; Balloon Occlusion; Exsanguination; Hemodynamics; Humans; Resuscitation; Shock, Hemorrhagic
PubMed: 29785654
DOI: 10.1007/s00068-018-0959-y -
Value in Health Regional Issues Dec 2018Aortic aneurysm (AA) is a pathology with high morbidity and mortality. The management can be expectant, surgical, or through endovascular repair (EVAR). In Latin America...
BACKGROUND
Aortic aneurysm (AA) is a pathology with high morbidity and mortality. The management can be expectant, surgical, or through endovascular repair (EVAR). In Latin America the incidence of AA has increased and the analysis of therapeutic options, especially if they are expensive, is fundamental.
OBJECTIVE
To analyze available evidence on the effectiveness, safety and coverage policies of the EVAR.
METHODOLOGY
Panoramic review in the main bibliographical bases (MEDLINE, LILACS, EMBASE, Cochrane Library, DARE) and generic internet searchers, main health technology assessment (HTA) agencies and health insurance companies. Systematic reviews (SR), clinical practice guidelines (CPG), HTA and coverage policies, followed by the identification of primary studies published after the SR search date were included. A search of studies published until November 2015 in English and Spanish was carried out.
RESULTS
311 references were recovered, from which seven SRs were selected, one clinical study and 15 CPGs, consensus or coverage policies and ETS.
CONCLUSIONS
For abdominal AA, high quality evidence showed no differences inlong-term survival with the use of EVAR compared to conventional surgery, but lower early mortality was observed (OR = 0.33, 95% CI 0.20 -0.55). EVAR was associated with a greater need for re-intervention. In the case of other types of AA, further evidence is still required to establish the benefit of EVAR. The CPGs, consensus, HTAs and coverage policies identified, mostly consider open surgery as the treatment of choice, reserving the EVAR for patients with high surgical risk for conventional surgery in the presence of favorable anatomy.
Topics: Aorta; Aortic Aneurysm, Abdominal; Endovascular Procedures; Global Health; Humans; Latin America
PubMed: 29754017
DOI: 10.1016/j.vhri.2018.01.011 -
British Journal of Anaesthesia May 2018Cerebrospinal-fluid (CSF) drainage is recommended by current guidelines for spinal protection during open and endovascular repairs of thoracic and thoraco-abdominal... (Meta-Analysis)
Meta-Analysis
Cerebrospinal-fluid drain-related complications in patients undergoing open and endovascular repairs of thoracic and thoraco-abdominal aortic pathologies: a systematic review and meta-analysis.
BACKGROUND
Cerebrospinal-fluid (CSF) drainage is recommended by current guidelines for spinal protection during open and endovascular repairs of thoracic and thoraco-abdominal aortic aneurysms. In the published literature, great variability exists in the rate of CSF-related complications and morbidity. Herein, we perform a systematic review and meta-analysis on the incidence of CSF drainage-related complications, and compare the complication rates between open and endovascular repairs.
METHODS
The systematic review was conducted according to the Meta-Analysis of Observational Studies in Epidemiology guidelines. Thirty-four studies (4714 patients) were included in the quantitative analysis. The CSF drainage-related complications were categorised as mild, moderate, and severe. Pooled event rates for each complication category were estimated using a random-effect model. Random-effect uni- and multivariable meta-regression analyses were used to assess the effect of aortic-repair approach (open vs endovascular) and the CSF drainage criteria on CSF drainage-related complications.
RESULTS
The pooled event rates were 6.5% [95% confidence interval (CI): 4.3-9.8%] for overall complications, 2% (95% CI: 1.1-3.4%) for minor complications, 3.7% (95% CI: 2.5-5.6%) for moderate complications, and 2.5% (95% CI: 1.6-3.8%) for severe complications. The drainage-related-mortality pooled event rate was 0.9% (95% CI: 0.6-1.4%). The uni- and multivariable meta-regression analyses showed no difference in complication rates between the open and endovascular approaches, or between the different CSF drainage protocols.
CONCLUSION
The complication rate for CSF drainage is not negligible. Our results help define a more accurate risk-benefit ratio for CSF drain placement at the time of repair of thoracic and thoraco-abdominal aneurysms.
Topics: Aorta, Thoracic; Aortic Aneurysm, Thoracic; Drainage; Endovascular Procedures; Humans; Postoperative Complications; Treatment Outcome
PubMed: 29661408
DOI: 10.1016/j.bja.2017.12.045 -
European Journal of Vascular and... Jun 2018The incidence of spinal cord ischaemia (SCI) and subsequent paraplegia after thoracic endovascular aneurysm repair (TEVAR) and thoraco-abdominal endovascular aneurysm... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
The incidence of spinal cord ischaemia (SCI) and subsequent paraplegia after thoracic endovascular aneurysm repair (TEVAR) and thoraco-abdominal endovascular aneurysm repair is estimated to be between 2.5% and 8%. The aim of this review is to provide an overview of SCI preventive strategies in TEVAR and thoraco-abdominal repair and recommend an optimal strategy.
METHODS
Medline, Embase, and the Cochrane Library were searched for studies on TEVAR, thoraco-abdominal endovascular repair, and the use of SCI preventive measures. The review was reported according to the PRISMA statement.
RESULTS
The final analysis included 43 studies (7168 patients). All studies are cohort studies (non-comparative cohorts n = 37, comparative cohorts n = 6) and largely performed retrospectively (n = 27). The included studies had an average MINORS score of 9 (range 6-13) for non-comparative studies and 15.5 (range 12-18) for comparative studies. Transient SCI occurred in 5.7% (450/7,168, 95% CI 4.5-6.9%), permanent SCI in 2.2% (232/7,168, 95% CI 1.6-2.8%). There was a trend towards increased SCI incidence for more "high risk" cohorts. Avoidance of hypotension resulted in a slightly lower permanent SCI rate 1.8% (102/4216, 95% CI 1.2-2.3%) than the overall cohort. A very low SCI estimate (transient and permanent) was found in the subgroup of studies (2 studies, n = 248) using (mild) peri-operative hypothermia (transient SCI 0.8%, permanent SCI 0.4%). In the subgroup using temporary permissive endoleak, there was a transient SCI estimate (15.4%), with a permanent SCI estimate of 4.8%. The remaining preventive measures did not significantly impact transient or permanent SCI estimates.
CONCLUSION
Low overall transient and permanent SCI rates are achieved during endovascular thoracic and thoraco-abdominal aortic repair. Based on the presented data, the use of selective spinal fluid drainage in high risk patients seems justified. Peri-operative hypotension should be avoided and treated where possible. The use of mild hypothermia is promising in small cohorts, but requires further evaluation. Further high quality data are essential to establish a definitive preventive strategy.
Topics: Aortic Aneurysm, Abdominal; Aortic Aneurysm, Thoracic; Endovascular Procedures; Epidemiologic Methods; Humans; Postoperative Complications; Spinal Cord Ischemia
PubMed: 29525741
DOI: 10.1016/j.ejvs.2018.02.002 -
European Journal of Vascular and... Apr 2018Screening for abdominal aortic aneurysm (AAA) during transthoracic echocardiography (TTE) may be an effective targeted screening strategy. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Screening for abdominal aortic aneurysm (AAA) during transthoracic echocardiography (TTE) may be an effective targeted screening strategy.
OBJECTIVE
The aim was to assess the feasibility of AAA screening during TTE and to estimate the prevalence of AAA in patients undergoing TTE.
METHODS
Electronic bibliographic sources were interrogated using a combination of free text and controlled vocabulary searches to identify studies reporting on AAA screening during TTE. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. Fixed effect or random effects models were used to calculate pooled prevalence estimates.
RESULTS
Twenty observational cohort studies were identified reporting a total of 43,341 participants (23,291 men and 20,050 women). Hypertension was reported in 41% (95% CI 38-43), hypercholesterolemia in 31% (95% CI 29-32), diabetes mellitus in 20% (95% CI 19-22), and tobacco use in 37% (95% CI 35-38). The aorta was visualised in 86% (95% CI 84-88) of the screened population. The pooled prevalence of AAA in the entire screened population was 0.033 (95% CI 0.024-0.044). The pooled prevalence of AAA in men was 0.046 (95% CI 0.032-0.065) and in women it was 0.014 (95% CI 0.008-0.022). The mean age of participants in whom an AAA was detected ranged across the studies from 66 to 85 years. The mean diameter of the aneurysm identified ranged across the studies from 35 mm to 45 mm. Clinical outcomes in participants with a detected AAA were poorly reported.
CONCLUSIONS
Screening for AAA during TTE may identify a population group with a high risk of AAA in whom targeted screening may be beneficial. Further research is required to investigate the cost-effectiveness and clinical benefits of AAA screening in this setting.
Topics: Aortic Aneurysm, Abdominal; Diabetes Mellitus; Echocardiography; Humans; Hypercholesterolemia; Hypertension; Mass Screening; Risk Factors; Smoking
PubMed: 29433798
DOI: 10.1016/j.ejvs.2018.01.003 -
Medicine Dec 2017Coronary artery aneurysm (CAA) with concomitant aneurysms at multiple sites is quite unusual and rare. The characteristics and the etiology of this phenomenon are... (Review)
Review
BACKGROUND
Coronary artery aneurysm (CAA) with concomitant aneurysms at multiple sites is quite unusual and rare. The characteristics and the etiology of this phenomenon are unknown.
METHODS
Herein, we present a case with right coronary aneurysm with concomitant abdominal aorta as well as right renal artery aneurysm. A systematic review of the literatures regarding CAA with other coexisting aneurysms at multiple locations was also conducted on Medline and Embase databases.
RESULTS
A total of 76 patients (male gender: 58; age: 37.4 ± 26.5) including the present case were included in the final study. The most common etiology of CAA with multiple aneurysms was Kawasaki (43.3%) and atherosclerotic disease (16.4%). CAA was the most frequently found at the right coronary artery (62.7%), following, left anterior descending (51%), left main (43.1%), and left circumflex (35.3%). The most common concomitant aneurysms were abdominal aorta (52.6%) and iliac artery (50%). In addition, 60.5% of the patients had an involved bilateral peripheral artery.
CONCLUSION
CAA with coexisting systemic aneurysms in multiple sites is quite rare. And it usually involves multiple aneurysms at the coronary and bilateral peripheral arteries simultaneously. Currently, there are no general consensus regarding the clinical characteristics, diagnostic method, and treatment of these cases.
Topics: Aneurysm; Biomarkers; Coronary Aneurysm; Diagnosis, Differential; Diagnostic Imaging; Female; Humans; Middle Aged; Risk Factors
PubMed: 29390352
DOI: 10.1097/MD.0000000000009230 -
European Journal of Vascular and... Feb 2018New and re-designed stent grafts for endovascular aortic aneurysm repair (EVAR) are released regularly. Manufacturers use data from registries to assess stent graft... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
New and re-designed stent grafts for endovascular aortic aneurysm repair (EVAR) are released regularly. Manufacturers use data from registries to assess stent graft performance, but little is known about the ability of such registries to detect rates of clinically relevant complications. The aim of this paper was to perform a systematic review and meta-analysis to determine pooled failure rates for EVAR stent grafts, to define an acceptable non-inferiority limit for these devices, and then to calculate the number of patients needed for a new device to achieve non-inferiority against published devices.
DATA SOURCES AND REVIEW METHODS
MEDLINE and EMBASE were searched for studies reporting outcomes of specific EVAR grafts being used for intact infrarenal abdominal aortic aneurysms, from inception to November 2016. Meta-regression was performed to pool data and calculate the patient numbers needed to detect non-inferiority of a future graft performance. An expert consensus was performed to define adequate standards for device safety.
RESULTS
One hundred and forty-seven moderate quality papers involving 27,058 patients were included. Multiple outcomes were pooled. Of these, the estimated rate (±standard error) of overall endoleak (excluding Type II) at 2 years was 5.7 ± 0.6%. The pooled re-intervention rate was 11.1 ± 0.7% at 2 years. There were differences in pooled endoleak rates between different stent graft types. Expert consensus defined non-inferiority as better performance than the worst performing 25% of stent grafts. The most popular outcome in the expert consensus was cumulative endoleak rate (excluding Type II). The number of patients who would need to be enrolled in a registry to demonstrate non-inferiority at this level was 525. Only two of 147 included studies achieved this. The second most popular choice in the expert consensus was re-intervention rate; 492 patients are required to demonstrate this.
CONCLUSIONS
Five hundred and twenty-five patients need to be entered into a registry to demonstrate non-inferiority to previous stent grafts. Almost all previous publications have captured lower patient numbers. With performance varying between devices, and new devices being introduced regularly, there is an urgent need to capture higher quality long-term data on EVAR stent grafts.
Topics: Aorta, Abdominal; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Equivalence Trials as Topic; Humans; Prosthesis Failure; Registries; Reoperation; Stents; Treatment Outcome
PubMed: 29288059
DOI: 10.1016/j.ejvs.2017.11.013 -
Journal of Medical Case Reports Sep 2017Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature... (Review)
Review
BACKGROUND
Clostridium septicum-infected aortic aneurysm is a fatal and rare disease. We present a fatal case of C. septicum-infected aortic aneurysm and a pertinent literature review with treatment suggestions for reducing mortality rates.
CASE PRESENTATION
A 58-year-old Japanese man with an unremarkable medical history presented with a 3-day history of mild weakness in both legs, and experienced paraplegia and paresthesia a day before admission. Upon recognition of signs of an abdominal aortic aneurysm and paraplegia, we suspected an occluded Adamkiewicz artery and performed a contrast-enhanced computed tomography scan, which revealed an aortic aneurysm with periaortic gas extending from his chest to his abdomen and both kidneys. Antibiotics were initiated followed by emergency surgery for source control of the infection. However, owing to his poor condition and septic shock, aortic repair was not possible. We performed bilateral nephrectomy as a possible source control, after which we initiated mechanical ventilation, continuous hemodialysis, and hemoperfusion. A culture of the samples taken from the infected region and four consecutive blood cultures yielded C. septicum. His condition gradually improved postoperatively; however, on postoperative day 10, massive hemorrhage due to aortic rupture resulted in his death.
CONCLUSIONS
In this patient, C. septicum was thought to have entered his blood through a gastrointestinal tumor, infected the aorta, and spread to his kidneys. However, we were uncertain whether there was an associated malignancy. A literature review of C. septicum-related aneurysms revealed the following: 6-month mortality, 79.5%; periaortic gas present in 92.6% of cases; no standard operative procedure and no guidelines for antimicrobial administration established; and C. septicum was associated with cancer in 82.5% of cases. Thus, we advocate for early diagnosis via the identification of periaortic gas, as an aortic aneurysm progresses rapidly. To reduce the risk of reinfection as well as infection of other sites, there is the need for concurrent surgical management of the aneurysm and any associated malignancy. We recommend debridement of the infectious focus and in situ vascular graft with omental coverage. Postoperatively, orally administered antibiotics must be continued indefinitely (chronic suppression therapy). We believe that these treatments will decrease mortality due to C. septicum-infected aortic aneurysms.
Topics: Aneurysm, Infected; Aortic Aneurysm, Abdominal; Aortic Rupture; Clostridium Infections; Clostridium septicum; Early Diagnosis; Fatal Outcome; Gas Gangrene; Humans; Infarction; Magnetic Resonance Imaging; Male; Middle Aged; Nephrectomy; Spinal Cord Ischemia; Tomography, X-Ray Computed
PubMed: 28931420
DOI: 10.1186/s13256-017-1422-0 -
Journal of Vascular Surgery Jan 2018Endovascular repair of the ascending aorta is currently limited to patients at high surgical risk with aortic diseases originating above the sinotubular junction. A... (Review)
Review
OBJECTIVE
Endovascular repair of the ascending aorta is currently limited to patients at high surgical risk with aortic diseases originating above the sinotubular junction. A number of different endovascular technologies and approaches have been used, although no consensus exists regarding a standardized technique. To better understand real-world endovascular approaches to the ascending aorta, we performed a comprehensive review of the types of endovascular aortic stents and associated vascular access used in repair of the ascending aorta.
METHODS
A search of the MEDLINE database was conducted from January 1, 1995, through January 31, 2017, with the search term "ascending aortic stent." Studies involving endovascular stenting in which the primary therapy was confined exclusively to the ascending aorta were included. Studies involving hybrid arch procedures and surgical replacement of the ascending aorta associated with aortic stenting were excluded. The type of aortic stent, underlying aortic disease, and surgical approach were recorded along with outcomes, need for reinterventions, and follow-up.
RESULTS
A total of 46 publications that focused on primary endovascular repair of the ascending aorta were identified. Thirteen different aortic stent grafts of various designs were used in 118 total patients. The most commonly used device types were thoracic stents (n = 84 [71.2%]) along with abdominal cuffs (n = 13 [11%]) and custom-made grafts (n = 12 [10.2%]). The most commonly treated aortic disease was type A aortic dissection (n = 59 [50%]), followed by aortic pseudoaneurysm (n = 35 [29.7%]), aortic aneurysm (n = 6 [5.1%]), penetrating atherosclerotic ulcer (n = 5 [4.2%]), and acute aortic rupture (n = 3 [2.5%]). Femoral arterial access was used in 62.7% of patients (n = 74); transapical (n = 17 [14.4%]), carotid (n = 15 [12.7%]), and axillary (n = 8 [6.8%]) approaches were also used. The overall type I endoleak rate was 18.6% (n = 22), with 11 patients (9.3%) requiring reintervention. Other complications included all-cause mortality (n = 18 [15.2%]), conversions to open surgery (n = 4 [3.4%]), and cerebrovascular complications (n = 4 [3.4%]). Aorta-related mortality was 5% (n = 6), and average follow-up was 17.2 months.
CONCLUSIONS
Despite the absence of a dedicated aortic stent graft for the ascending aorta, patients with a range of ascending aortic diseases are being successfully treated by endovascular technologies. For optimal outcomes, patient selection is critical to align aortic anatomy with the limited device sizing options, and it should be reserved for patients at high surgical risk.
Topics: Aorta; Aortic Diseases; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Patient Selection; Postoperative Complications; Reoperation; Stents; Treatment Outcome
PubMed: 28844469
DOI: 10.1016/j.jvs.2017.06.099