Current outcomes in endovascular repair of abdominal aortic aneurysms

The repair of abdominal aortic aneurysms has presently been reported to be accomplished using endovascular techniques in 60% of the cases. As technology continues to improve on the design of endovascular devices, this will only result in a progressive upward trend of this innovative method. At this time, there are multiple commercial and investigational devices available. We elect to discuss current results pertaining to the optimal candidate, characteristics, complications, and the long-term durability of aortic stent-grafts.     

The endovascular management of ruptured abdominal aortic aneurysms.

Endovascular aneurysm repair (EVAR) is a controversial technique, which remains the subject of a number of prospective randomised trials. Although questions remain regarding its long-term durability objective evidence exists which demonstrates its reduced physiological impact compared with conventional open repair. If this technique could be used in patients with ruptured abdominal aortic aneurysm (AAA) it may reduce the high peri-operative mortality. A review of the literature identified a limited experience with EVAR of ruptured AAA. Only a small number of case series with selected patients exist. The majority of patients were haemodynamically stable. However, the selective use of aortic occlusion balloons allowed successful endovascular management in a small number of unstable cases. All investigators had access to an "off the shelf" endovascular stent-graft (EVG). Per-operative mortality ranged from 9 to 45% and may reflect increasing experience and patient selection. A number of patients who underwent successful EVAR were turned down for open repair. A number of important lessons have been learned from these studies but questions remain regarding patient suitability and staffing issues. If these difficulties can be surmounted then the technique may offer an alternative to open repair.     

Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms

OBJECTIVE: Our purpose was to examine the impact of the introduction of endovascular treatment on the early outcomes of ruptured abdominal aortic aneurysms (AAAs) during 2 consecutive time periods at a single institution. METHODS: The hospital records of a single tertiary care center from 1997 to 2004 were retrospectively reviewed, and 36 consecutive patients who underwent treatment for acute ruptured AAA were identified. They were divided into 19 (53%) patients who were all treated with conventional open surgery from 1997 to 2001 (early) and 17 (47%) patients who were treated either with open (n = 4, 24%) or endovascular (n = 13, 76%) methods from 2002 to 2004 (late). All endovascular repairs were performed with commercially available bifurcated devices. Outcome measures included death, major complications, disposition at discharge (home or extended care facility), procedure time, blood loss, and hospital length of stay. RESULTS: Age, sex, and AAA size were similar between the 2 groups. Perioperative mortality in the early and late periods were 37% versus 12%, respectively (P =.13); rates of major complications were 84% versus 65%, respectively (P =.26); and discharge to home rather than extended care facility was 32% versus 59%, respectively (P =.18). Median procedure times (275 vs 149 minutes, P <.01), blood loss (3800 vs 138 mL, P <.0001), and length of stay (18 vs 6 days, P <.05) were all higher during the early period than in the late period. CONCLUSIONS: This preliminary study suggests that introduction of endovascular therapies may be potentially beneficial in the overall treatment scheme of patients with ruptured AAAs. However, longer follow-up and larger cohorts are needed to better establish its feasibility and efficacy compared with conventional open surgical repair.     

Population-based long-term outcomes of open versus endovascular aortic repair of ruptured abdominal aortic aneurysms

ObjectiveExisting data regarding endovascular aortic repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) are conflicting in their findings. The purpose of this paper was to determine the long-term outcomes of EVAR vs open surgical repair (OSR) for treatment of rAAA.MethodsA population-based retrospective cohort study of all patients 40 years or more that underwent OSR or EVAR of rAAA in Ontario, Canada, from 2003 to 2016 was conducted. Administrative data from the province of Ontario was used as the data source. The propensity for repair approach was calculated using a logistic regression model including all covariates and used for inverse probability of treatment weighting. Cox proportional hazards regression was conducted using the weighted cohort to determine the survival and major adverse cardiovascular event (MACE)-free survival of EVAR relative to OSR for rAAA up to 10 years after repair.ResultsA total of 2692 rAAA (261 EVAR [10%] and 2431 OSR [90%]) repairs were recorded from April 1, 2003, to March 31, 2016. Mean follow-up for the entire cohort was 3.4 years (standard deviation [SD], 3.9 years), with a maximum follow-up of 14.0 years. OSR patients were followed for a mean of 3.5 years (SD, 4.0 years) and maximum of 14.0 years, and EVAR patients were followed for a mean of 2.7 years (SD, 2.7 years) and a maximum of 11.4 years. Median survival was 2.7 years overall, and 2.5 and 3.7 years for OSR and EVAR patients, respectively. There were no significant baseline differences between EVAR and OSR patients after inverse probability of treatment weighting. EVAR patients were at lower hazard for all-cause mortality (hazard ratio, 0.49; 95% confidence interval, 0.37-0.65; P < .01), and MACE (hazard ratio, 0.51, 95% confidence interval, 0.40-0.66; P < .01) within 30 days of repair. There were no statistically significant differences between EVAR and OSR in the hazard for all-cause mortality or MACE from 30 days to 5 years, and 5 to 10 years. Despite this, the upfront mortality and MACE benefits of EVAR persisted for more than 4.5 years after repair.ConclusionsThis population-based cohort study using administrative data from Ontario, Canada, demonstrated lower hazards for all-cause mortality and MACE within 30 days of operation in favor of EVAR, but no differences in the mid- or longer-term results. More work is needed to understand and improve the long-term outcomes of ruptured endovascular aortic aneurysm repair and ruptured open surgical repair.     

Significance of endoleaks after endovascular repair of abdominal aortic aneurysms: The EUROSTAR experience

OBJECTIVE: The purpose of this study was to assess the incidence, risk factors, and consequences of endoleaks after endovascular repair of abdominal aortic aneurysm. METHODS: Data on 2463 patients were collected from 87 European centers and recorded in a central database. Preoperative data were compared for patients with collateral retrograde perfusion (type II) endoleak (group A), patients with device-related (type I and III) endoleaks (group B), and patients in whom no endoleak was detected (group C). Only endoleaks observed after the first postoperative month of follow-up were taken into consideration. Regression analysis was performed to investigate statistical relationships between the occurrence and type of endoleak and preoperative patient and morphologic characteristics, operative details, type of device, and experience of the operating team. In addition, postoperative changes in aneurysmal morphology, the need for secondary interventions, conversions to open repair, aneurysmal rupture, and mortality during follow-up were compared between these study groups. RESULTS: Patients in group A had a higher prevalence of a patent inferior mesenteric artery compared with patients without endoleak. Patients in group B were treated more frequently than patients in group C by an operating team with experience of less than 30 procedures. The mean follow-up period was 15.4 months. Secondary interventions were needed in 13% of the patients. Rupture of the aneurysm during follow-up occurred in 0.52% (1/191) in group A, 3.37% (10/297) in group B, and 0.25% (5/1975) in group C. Life table analysis comparing the three study groups demonstrated a significantly higher rate of rupture in group B than in group C (P =.002). The incidence of conversion to open repair during follow-up was higher in group B than in the other two study groups (P <.01). Death was related to the aneurysm or to endovascular repair of the aneurysm in 7% of patients. Secondary outcome success, defined as absence of rupture and conversion, was significantly higher in group A and C compared with that in group B (P =.006 and P =.0001, respectively). CONCLUSIONS: The presence of device-related endoleaks correlated with a higher risk of aneurysmal rupture and conversion compared with patients without type I or III endoleaks. Type II endoleak was not associated more often with these events. Consequently, intervention in type II endoleak should only be performed in case of increase of aneurysm size.     

The outcome of endovascular repair of small abdominal aortic aneurysms

OBJECTIVE: To assess the outcome of endovascular repair (EVAR) of small abdominal aortic aneurysms (AAA, 相似文献   

Open and endovascular elective treatment of abdominal aortic aneurysms: a real-world experience

Purpose

To present a real-world experience of the elective treatment of abdominal aortic aneurysms (AAAs) using both open repair (OR) and endovascular repair (EVAR).

Methods

Data from patients treated consecutively between January 1, 2000 and December 31, 2014 were collected retrospectively and reviewed. The primary outcomes were 30-day mortality and complication rates, freedom from reintervention, and survival in the long-term.

Results

We analyzed data on 1112 patients (660 EVAR, 452 OR). The 30-day mortality and complications rates were higher after OR than after EVAR (2.9 vs. 1.1%, P?=?.03 and 24.7 vs. 1.1%, P?<?.0001, respectively). At 10 years, survival was 66.1 ± 3.2% after OR and 78.1 ± 2.2% after EVAR (P?=?.0006) and freedom from reintervention was 93.5 ± 1.8% after OR and 88.4 ± 1.8% after EVAR (P?=?.005). The preoperative aneurysm diameter was significantly associated with the development of type Ia endoleaks after EVAR (P?<?.0001) and of a proximal pseudoaneurysm after OR (P?<?.0001).

Conclusion

In the long-term, EVAR was associated with higher reintervention rates, but better survival than OR. The preoperative AAA diameter was the most important predictor of the development of endoleaks after EVAR and proximal pseudoaneurysm after OR.

     

Results of endovascular exclusion of abdominal aortic aneurysms

According to the principles of minimal invasive surgery a reduced operative trauma and complication rate are the main goals of endovascular aneurysm exclusion. From July 1996 to August 1999 we found 75 patients eligible for endovascular aneurysm therapy. The procedure was primarily successful in 95% of the patients. In the first time we had to switch to open surgery in 4 patients. There was 1 procedure related death. Most frequent later complications were graft occlusion (9.7%) and type I, II and III leakages (14.1%), which were partially repaired using endovascular techniques and partially by use of open surgery. In a selected group of patients the middle term results of infrarenal aneurysm therapy by endovascular stent graft implantation are promising.     

Contemporary outcomes for ruptured abdominal aortic aneurysms using endovascular balloon control for hypotension

ObjectiveRuptured abdominal aortic aneurysm (rAAA) continues to portend significant mortality, despite ruptured endovascular aneurysm repair (rEVAR), enhanced perioperative care, and endovascular balloon control (EBC) for hypotension. We review our academic institution's experience using a protocol of EBC for all hypotensive patients, irrespective of type of repair.MethodsA retrospective review was conducted of 66 cases of rAAA treated at a single academic institution from 2007 to 2016 using EBC for hypotensive patients. Demographics, comorbidities, intraoperative parameters, and clinical outcomes were recorded. Patients were studied with respect to hemodynamic status, rEVAR, or ruptured open aortic repair in the setting of EBC for hypotension.ResultsrEVAR was performed in 43 patients (65%) and ruptured open aortic repair in 23 patients (35%). rAAA was treated in 51 men (77%). Mean rAAA size was 7.6 mm, and mean age of the patients was 73 years. Perioperative survival was 82%. Overall survival at 30 days, 1 year, and 5 years was 71%, 65%, and 52%. Blood transfusion and severe hypotension were significant predictors of mortality at 30 days on multivariable analysis (odds ratio of 1.2 [P = .08] and 39 [P = .03], respectively). Severe hypotension was defined as a mean arterial blood pressure <65 mm Hg and vasopressor use and was present in 59% of the cohort. Normotension was defined as an absence of these conditions and was present in 12%, with 29% of patients exhibiting moderate hypotension. There was no difference in 30-day survival between normotensive and moderately hypotensive patients. The 30-day survival for severely hypotensive patients was 61% vs 85% for moderately hypotensive patients (P = .003), with a significant difference between groups that persisted at 1 year (85% vs 51%; P = .008) and 5 years (66% vs 51%; P = .017).ConclusionsGood midterm outcomes for moderately hypotensive and normotensive patients can be obtained using an EBC protocol for hypotension with a regionalized transport system directly to the operating room. Severely hemodynamically unstable rAAA patients still pose a significant challenge despite mitigation of hypotension by EBC, suggesting that survival may be compromised by factors other than hypotension alone. We still advocate for the use of EBC for all hypotensive patients as part of a defined rAAA protocol before definitive repair.     

Anemia and postoperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms

Objective

Anemia is associated with increased cardiac adverse events during the early postoperative period because of high physiologic stress and increased cardiac demand. The aim of this study was to assess the surgical outcomes and prognostic implications of anemia in patients undergoing repair of intact abdominal aortic aneurysms (AAAs).

Repair of abdominal aortic aneurysms. A statewide experience

The results of elective treatment of abdominal aortic aneurysms are excellent in many institutions. To our knowledge, however, no study has compared the results in a large geographic area in which patients were treated by a variety of surgeons and hospitals. We studied the results of repairing abdominal aortic aneurysms for all Medicare recipients during a single year in Kentucky. One hundred thirty-six operations were performed by 52 surgeons in 31 hospitals. Overall operative mortality was 18%; elective and emergency operative mortality rates were 6% and 49%, respectively. Advancing age did not affect outcome, but mortality due to ruptured aneurysms was higher in smaller hospitals than in larger hospitals. The low mortality for elective repair of abdominal aortic aneurysms in an elderly population by numerous surgeons in divergent hospitals is a strong indication for its liberal use compared with the high mortality and morbidity of emergency surgery.     

Use of hybrid aortic stent grafts for endovascular repair of abdominal aortic aneurysms: indications and outcomes

BACKGROUND: Only two aortic stent grafts (Ancure-Guidant, Menlo Park, CA, and AneuRx-Medtronic, Sunnyvale, CA) have been FDA-approved for endovascular aortic aneurysm repair (EndoAAA). These grafts differ significantly in construction and clinical advantage, and combining components of these grafts (hybrid graft) is occasionally necessary. The role and outcome of hybrid aortic stent grafts is unknown. METHODS: All EndoAAA procedures during an 18-month period (10/99-4/01) were reviewed using the hospital record and a computer registry. Endografts were classified as hybrid if components from more than one type of stent graft were used or standard if constructed from only one stent graft type. Hybrid grafts were further classified as "anticipated" or "unanticpated." Outcomes were compared between hybrid and standard grafts using Fisher's exact test. RESULTS: One hundred forty-five EndoAAA repairs were performed (AneuRx, 67; Ancure, 70; and custom-made, 8) of which 14 (9.6%) were hybrid grafts. The majority of hybrid grafts (11) were constructed by adding AneuRx aortic or iliac cuffs to Ancure grafts. In most cases, the need for a hybrid graft was unanticipated (10) and related to an intraoperative proximal type I endoleak (7). Conversion to open operation was avoided in six patients by constructing hybrid grafts. When anticipated (4), hybrid grafts were constructed to treat complex iliac aneurysms. Outcomes in all categories were similar (P > 0.05) for hybrid vs standard grafts: technical success (93 vs 99%), conversion toopen AAA (7.1 vs 2.3%), vascular complications (7.1 vs 7.6%), systemic complications (21 vs 11%), endoleak (15 vs 14%), and rupture (0 vs 0%). CONCLUSIONS: The short-term safety and effectiveness of hybrid grafts are similar to those of standard grafts. Combining graft components to create hybrid grafts may increase the ability to treat complex iliac aneurysmal disease and may reduce conversions to open AAA repair. Thus, access to multiple graft types may be an important factor in the success and safety of EndoAAA repair.     

Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms

INTRODUCTION: The successful application of endovascular techniques for the elective repair of abdominal aortic aneurysms (AAAs) has stimulated a strong interest in their possible use in dealing with a long-standing surgical challenge: the ruptured abdominal aortic aneurysm (RAAA). The use of a conventional open procedure to repair ruptured aneurysms is associated with a high operative mortality of 45% to 50%. In this study, we evaluated the current frequency of endovascular repair of RAAAs in four large states and the impact of this technique on patient outcome. METHODS: We examined discharge data sets from 2000 through 2003 from the four states of California, Florida, New Jersey, and New York, whose combined population represents almost a third of the United States population. Proportions and trends were analyzed by chi2 analysis and continuous variables by the Student's t test. RESULTS: We found that since the year 2000, endovascular repair has begun to emerge as a viable treatment option for RAAAs, accounting for the repair of 6.2% of cases in 2003. During the same period, the use of open procedures for RAAAs declined. The overall mortality rate for the 4-year period was significantly lower for endovascular vs open repair (39.3% vs. 47.7%, P = .005). Moreover, compared with open repair, endovascular repair resulted in a significantly lower rate of pulmonary, renal, and bleeding complications. Survival after endovascular repair correlated with hospital experience, as assessed by the overall volume of elective and nonelective endovascular procedures. For endovascular repairs, mortality ranged from 45.9% for small volume hospitals to 26% for large volume hospitals (P = .0011). Volume was also a determinant of mortality for open repairs, albeit to a much lesser extent (51.5% for small volume hospitals, 44.3% for large volume hospitals; P < .0001). CONCLUSION: We observed a benefit to using endovascular procedures for RAAAs in institutions with significant endovascular experience; however, the analysis of administrative data cannot rule out selection bias as an explanation of better outcomes. These data strongly endorse the need for prospective studies to clarify to what extent the improved survival in RAAA patients is to be attributed to the endovascular approach rather than the selection of low-risk patients.