Midterm results of complicated penetrating abdominal aortic ulcer treated by aortobi-iliac endograft and embolization

BackgroundPenetrating aortic ulcer (PAU) is determined by atherosclerotic degeneration of the tunica media with disruption of the intima. Usually it is detected in the thoracic aorta, with few series describing an abdominal location. The aim of the study was to report early and late outcomes of the endovascular repair of complicated infrarenal abdominal PAU (a-PAU) by aortobi-iliac endograft and embolization.MethodsData from all complicated a-PAU submitted to endovascular repair by aortobi-iliac endograft (Cook-Zenith Alpha) between 2016 and 2021 (February) were analyzed. The a-PAU coil embolization was performed to decrease the risk of persistent type II endoleak whenever possible. Complicated a-PAU were defined according with the presence of symptoms, aortic rupture, or saccular or pseudo-aneurysm. Technical success, 30-day morbidity and mortality, and reinterventions were assessed as early outcomes. Survival, endoleaks, and freedom from reinterventions were evaluated during follow-up.ResultsOf 1153 endovascular aortic procedures, 45 cases (4%) of complicated a-PAU were identified. Fourteen cases (31%) were managed in urgent setting (symptoms, n = 10 [22%]; shock, n = 4 [9%]). The median diameter of a-PAU was 49 mm (interquartile range, 14 mm). Thirteen patients (29%) had severe femoral or iliac access (angle >90°, circumferential calcification [>50%], hemodynamic iliac stenosis or obstruction, an external iliac artery diameter of less than 7 mm, or a previous femoral surgical graft). The a-PAU embolization was performed in 30 cases (67%). Technical success was achieved in all patients. Postoperative cardiac, pulmonary and renal morbidity occurred in one (2%), two (4%), and eight (18%) patients, respectively. Two patients (4%) required reintervention within 30 days for access related complications. The 30-day mortality was 2%. At a median follow-up of 24 months (interquartile range, 18 months), no type I or III endoleaks, iliac leg occlusion, or graft infection occurred and no patient required late reinterventions; the 36-month survival rate was 72%. No a-PAU enlarged or ruptured during follow-up.ConclusionsEndovascular repair of complicated a-PAU by a low-profile aortobi-iliac endograft and embolization is safe and effective. Excellent technical results are reported even in challenging anatomic features. Midterm clinical results are satisfactory in terms of aortic-related complications or mortality, freedom from reintervention, and survival.     

Early reintervention after open and endovascular abdominal aortic aneurysm repair is associated with high mortality

Objective

Although reinterventions are generally considered more common after endovascular aneurysm repair (EVAR) than after open surgical repair (OSR), less is known about reintervention in the early postoperative period. Furthermore, there are few data regarding the impact of early reintervention on 30-day mortality. We sought to evaluate the rates and types of reintervention after abdominal aortic aneurysm (AAA) repair and the impact of reintervention on postoperative mortality.

Durability of open repair of infrarenal abdominal aortic aneurysm: a 15-year follow-up study.

PURPOSE: This study reviewed the long-term outcome of patients who underwent open repair of infrarenal abdominal aortic aneurysms (AAAs). METHODS: A retrospective study of 208 patients (188 men and 20 women) with a mean age of 65.6 years who survived elective or emergency open repair of an infrarenal AAA was conducted at a university referral hospital. Main outcome measures included late graft-related complications, survival free from any reintervention, survival free from any vascular reintervention, and overall survival rates. RESULTS: Late graft-related complications occurred in 32 patients (15.4%). A proximal para-anastomotic pseudoaneurysm developed in six patients (2.9%), and a distal pseudoaneurysm developed in 18 patients (8.7%); in seven of these cases (3.4%), it was bilateral or recurrent. A graft limb occlusion occurred in 11 patients (5.3%). These complications required 37 surgical or other invasive procedures in 27 patients (13.0%). Thirty-one vascular and/or endovascular reoperations were performed. The 5-year, 10-year, and 15-year survival free from any reintervention rates were 91.5%, 86.2%, and 72.0%, respectively. At the same intervals, the survival free from any vascular reintervention rates were 93.8%, 88.5%, and 73.9%, respectively, and the overall survival rates were 66.8%, 39.4%, and 18.0%, respectively. Complications associated with a ruptured femoral artery pseudoaneurysm, a ruptured aortic pseudoaneurysm, an aortoduodenal fistula, and the elective repair of a femoral pseudoaneurysm were the graft-related causes of death, which occurred in four patients (1.9%). Age (P <.0001) and chronic obstructive pulmonary disease (P =.002) were shown by means of multivariate analysis to be predictive of poor survival outcome, and chronic obstructive pulmonary disease (P =.02) and lower limb ischemia (P =.04) were shown to be associated with an increased need for vascular reinterventions to treat graft-related complications. CONCLUSION: Open repair of infrarenal AAAs can achieve satisfactory 15-year follow-up rates of survival free from reintervention for any graft-related complications, suggesting that surgery should still be considered the procedure of choice for infrarenal AAAs, at least in patients who are fit for surgery.     

Complications and reintervention following elective open abdominal aortic aneurysm repair: a 10-year retrospective analysis

INTRODUCTION

Recent data have shown higher rates of graft related complication or reintervention in patients undergoing endovascular aneurysm repair compared with open aneurysm surgery (OAS). However, there are fewer data available regarding procedure related reinterventions following OAS. The aim of this study was to investigate the incidence of procedure related complications and reintervention following elective open abdominal aortic aneurysm repair.

METHODS

This was a retrospective analysis of prospectively collected data from the dedicated Portsmouth POSSUM database. Data from 361 patients (median age: 72 years, 91.4% male) who underwent elective OAS between 1993 and 2004 were analysed. The incidences of early and late complications and subsequent reintervention were investigated.

RESULTS

The median follow-up duration was 10 years 4 months (range: 5 years - 16 years 4 months). There were 52 reinterventions in the follow-up period. Of these, 34.6% were for incisional hernias or small bowel obstruction with the majority of the remaining laparotomies performed for bleeding or distal ischaemic complications. Almost two-thirds (63.5%) of reinterventions occurred in the first 30 days. There were 30 emergency readmissions to the acute surgical wards that did not require reintervention.

CONCLUSIONS

OAS carries a significant reintervention rate. In this study, 54% of reinterventions were directly related to laparotomy.     

Total laparoscopic abdominal aortic aneurysms repair

AIM: The aim of the study was to describe our experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. METHODS: Between February 2002 and September 2004, we performed 49 total laparoscopic AAA repair in 45 men and 4 women. Median age was 73 years (range, 46-85 years). Median aneurysm size was 52 mm (range, 30-95 mm). ASA class of patients was II, III and IV in 16, 32 and 1 cases, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 47 patients. Seven patients were operated via a tranperitoneal left retrorenal approach and one patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 19 and 30 patients, respectively. Median operative time was 290 min (range, 160-420 min). Median clamping time was 81.5 min (range, 35-230 min). Median blood loss was 1800 cc (range, 300-6900 cc). Mortality was 6.1% (3 patients). In our early experience, two patients died of myocardial infarction. The 3rd death was due to a multiple organ failure. Thirteen major non lethal postoperative complications were observed in 9 patients (18%). Four patients had local/vascular complications, which required reintervention (8%). Nasogastric tube is now removed at the end of procedure. Median duration of ileus, return to general diet, ambulation and hospital stay were 2, 3, 3 and 10 days. With a median follow-up of 19 months (range, 8-39 months), complete recovery with patent graft was observed in 44 patients. Two patients needed a crossover femoral graft for one iliac dissection and one graft limb occlusion. CONCLUSIONS: These results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. It remains technically demanding and a previous training in videoscopic sutures is essential. Initial learning curve in laparoscopic aortic surgery with aortoiliac occlusive lesions is preferable before to begin laparoscopic AAA repair.     

Long-term durability of open abdominal aortic aneurysm repair

OBJECTIVE: In multiple comparisons of open vs endovascular (EVAR) repair of abdominal aortic aneurysms, the prior assumption that open repair produced superior durability has been challenged by advocates of EVAR. Although focus on EVAR reintervention has been intense, few contemporary studies document late outcomes after open repair; this was the goal of this study. METHODS: From January 1994 to December 1998 (chosen to ensure a minimum 5-year follow-up), 540 patients underwent elective open repair. Surveillance imaging (computed tomographic and magnetic resonance imaging scans) was obtained for 152 (57%) of the 269 patients who remained alive at a mean follow-up of 87 months. Study end points included freedom from graft-related interventions and aneurysm-related and overall survival (Kaplan-Meier test); factors predictive of these end points were determined by multivariate analysis. RESULTS: The mean age at operation was 73 years. A total of 76% of patients were male; 11% had renal insufficiency (creatinine > or =1.5 mg/dL), and 13% had chronic obstructive pulmonary disease. The aortic cross-clamp position was suprarenal in 135 (25%) patients, and 284 (53%) of patients had bifurcated grafts placed. Operative mortality (30 days) was 3%, and the median length of hospital stay was 7 days. Postoperative complications occurred in 68 (13%) patients. Predictors of postoperative complications included a history of myocardial infarction (hazard ratio [HR], 2.0; P = .01) and renal insufficiency (HR, 2.5; P = .02). The mean follow-up for all patients was 87 months. Actuarial survival was 70.7% +/- 2% and 44.3% +/- 2.4% at 5 and 10 years, respectively. Negative predictors of long-term survival included advanced age (HR, 1.1; P < .001), history of myocardial infarction (HR, 1.37; P = .02), and renal insufficiency (HR, 1.5; P = .04). Freedom from graft-related reintervention was 98.2% +/- 0.8% and 94.3% +/- 3.4% at 5 and 10 years, respectively. There were 13 late graft-related complications in 11 (2%) patients (mean follow-up, 7.2 years). Findings included seven anastomotic pseudoaneurysms (five were repaired), four graft limb occlusions, and two graft infections. Aneurysms were identified in noncontiguous arterial segments in 68 (45%) of 152 patients, most of which involved the iliac arteries and required no treatment because of small size. Late aortic aneurysms proximal to the repair were identified in 24% of patients, and 29 (19%) patients had multiple late synchronous aneurysms. CONCLUSIONS: Open repair remains a safe and durable option for the management of abdominal aortic aneurysms, with an excellent associated 10-year survival in patients who undergo operation at 75 years of age or younger. In addition, the freedom from graft-related reintervention is superior to that of EVAR. Finally, continued surveillance after open repair is appropriate and should be directed toward the detection of other aneurysms.     

Comparable perioperative mortality outcomes in younger patients undergoing elective open and endovascular abdominal aortic aneurysm repair

BackgroundEvidence for benefit of endovascular aneurysm repair (EVAR) over open surgical repair for de novo infrarenal abdominal aortic aneurysms (AAAs) in younger patients remains conflicting because of heterogeneous study populations and small sample sizes. The objective of this study was to compare perioperative and short-term outcomes for EVAR and open surgery in younger patients using a large national disease and procedure-specific data set.MethodsWe identified patients 65 years of age or younger undergoing first-time elective EVAR or open AAA repair from the Vascular Quality Initiative (2003-2014). We excluded patients with pararenal or thoracoabdominal aneurysms, those medically unfit for open repair, and those undergoing EVAR for isolated iliac aneurysms. Clinical and procedural characteristics were balanced using inverse propensity of treatment weighting. A supplemental analysis extended the study to those younger than 70 years.ResultsWe identified 2641 patients, 73% (n = 1928) EVAR and 27% (n = 713) open repair. The median age was 62 years (interquartile range, 59-64 years), and 13% were female. The median follow-up time was 401 days (interquartile range, 357-459 days). Unadjusted perioperative survival was 99.6% overall (open repair, 99.1%; EVAR, 99.8%; P < .001), with 97.4% 1-year survival overall (open repair, 97.3%; EVAR, 97.4%; P = .9). Unadjusted reintervention rates were five (open repair) and seven (EVAR) reinterventions per 100 person-years (P = .8). After propensity weighting, the absolute incidence of perioperative mortality was <1% in both groups (open repair, 0.9%, EVAR, 0.2%; P < .001), and complication rates were low. Propensity-weighted survival (hazard ratio, 0.88; 95% confidence interval, 0.56-1.38; P = .6) and reintervention rates (open repair, 6; EVAR, 8; reinterventions per 100 person-years; P = .8) did not differ between the two interventions. The analysis of those younger than 70 years showed similar results.ConclusionsIn this study of younger patients undergoing repair of infrarenal AAA, 30-day morbidity and mortality for both open surgery and EVAR are low, and the absolute mortality difference is small. The prior published perioperative mortality and 1-year survival benefit of EVAR over open AAA repair is not observed in younger patients. Further studies of long-term durability are needed to guide decision-making for open repair vs EVAR in this population.     

Operative mortality rate for elective abdominal aortic aneurysm repair is not increased by the presence of a previous or concurrent thoracic or thoracoabdominal aortic dissection

BACKGROUND: The objective of this study was to determine the likelihood of mortality after abdominal aortic aneurysm (AAA) repair in patients with thoracic or thoracoabdominal aortic dissection. METHODS: Fourteen patients (11 men, three women) with known thoracic or thoracoabdominal aortic dissections underwent elective AAA repair from 1986 to 2001, including three patients with acute dissections (less than 14 days) and 11 patients with chronic dissections (14 days or longer). All 14 patients had type III aortic dissections. Stent graft exclusion of the aortic dissection was performed in one patient before AAA repair. Preoperative patient characteristics, intraoperative events, perioperative complications, and 30-day and 1-year mortality rates were assessed. RESULTS: Elective AAA repair in the setting of thoracic or thoracoabdominal aortic dissection in this series was associated with no 30-day mortality and a 1-year mortality rate of 7.1%. Furthermore, preoperative patient characteristics, intraoperative events, and perioperative complications did not appear to be associated with late, 1-year, mortality. CONCLUSION: Elective AAA repair in the setting of acute or chronic aortic dissection is associated with mortality rates similar to those generally attributed to elective AAA repair without accompanying aortic dissection. Nevertheless, the conduct of the operation is usually complex, especially in the setting of an acute aortic dissection.     

Elective open operation for abdominal aortic aneurysm in octogenarians--survival analysis of 105 patients.

OBJECTIVES: To study early mortality and long-term survival of patients more than 80 years of age having elective open repair for abdominal aortic aneurysm (AAA). DESIGN: Retrospective multicenter cohort study. MATERIAL: One hundred and five patients, 23 women and 82 men, with a median age of 82 years, operated at three Norwegian hospitals during the period 1983-2002. METHOD: Survival analyses were based on data from medical records and the Norwegian Registrar's Office of Births and Deaths. Expected survival was based on mortality rates of the general population, matched by age, sex, and calendar period. Relative survival was calculated as the ratio between the observed and the expected survival. RESULTS: During the study period there has been a 10 fold increase in octogenarians treated with open operation for AAA. Early mortality (30-day) for the whole group of patients was 10.5% (95% confidence interval (95% CI) 5.3-18.0), and similar for both genders. The 5-year survival rate was 47% (95% CI 35.9-57.4), and not significantly different from that of a matched group in the general population. Patients aged 84 years or more had a median survival time of 35 months (95% CI 18.5-51.6). CONCLUSION: The number of AAA operations in octogenarians has increased considerably during 20 years. Octogenarians operated electively for AAA has higher 30-day mortality as compared to younger patients. Their long-term survival appears similar to a matched control group. The benefit of surgery must be carefully considered against the perioperative risk, especially for the oldest octogenarians.     

Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade

OBJECTIVE: The proper role of endovascular abdominal aortic aneurysm repair (EVAR) remains controversial, largely due to uncertain late results. We reviewed a 12-year experience with EVAR to document late outcomes. METHODS: During the interval January 7, 1994 through December 31, 2005, 873 patients underwent EVAR utilizing 10 different stent graft devices. Primary outcomes examined included operative mortality, aneurysm rupture, aneurysm-related mortality, open surgical conversion, and late survival rates. The incidence of endoleak, migration, aneurysm enlargement, and graft patency was also determined. Finally, the need for reintervention and success of such secondary procedures were evaluated. Kaplan-Meier and multivariate methodology were used for analysis. RESULTS: Mean patient age was 75.7 years (range, 49-99 years); 81.4% were male. Mean follow-up was 27 months; 39.3% of patients had 2 or more major comorbidities, and 19.5% would be categorized as unfit for open repair. On an intent-to-treat basis, device deployment was successful in 99.3%. Thirty-day mortality was 1.8%. By Kaplan-Meier analysis, freedom from AAA rupture was 97.6% at 5 years and 94% at 9 years. Significant risk factors for late AAA rupture included female gender (odds ratio OR, 6.9; P = 0.004) and device-related endoleak (OR, 16.06; P = 0.009). Aneurysm-related death was avoided in 96.1% of patients, with the need for any reintervention (OR, 5.7 P = 0.006), family history of aneurysmal disease (OR, 9.5; P = 0.075), and renal insufficiency (OR, 7.1; P = 0.003) among its most important predictors. 87 (10%) patients required reintervention, with 92% of such procedures being catheter-based and a success rate of 84%. Significant predictors of reintervention included use of first-generation devices (OR, 1.2; P < 0.01) and late onset endoleak (OR, 64; P < 0.001). Current generation stent grafts correlated with significantly improved outcomes. Cumulative freedom from conversion to open repair was 93.3% at 5 through 9 years, with the need for prior reintervention (OR, 16.7; P = 0.001) its most important predictor. Cumulative survival was 52% at 5 years. CONCLUSIONS: EVAR using contemporary devices is a safe, effective, and durable method to prevent AAA rupture and aneurysm-related death. Assuming suitable AAA anatomy, these data justify a broad application of EVAR across a wide spectrum of patients.     

Clinical effect of abdominal aortic aneurysm endografting: 7-year concurrent comparison with open repair

OBJECTIVE: We compared the effectiveness and clinical outcome of open repair versus endovascular aortic aneurysm repair (EVAR) in achieving prevention of abdominal aortic aneurysm (AAA)-related death and graft-related complications. METHODS: Over 7 years from 1997 to 2003, 1119 consecutive patients underwent elective treatment of infrarenal AAAs, 585 with open repair and 534 with EVAR. Patients were regularly followed up at 1, 6, 12 months, and every 6 months thereafter, in EVAR group, and at 3 and 12 months, and yearly thereafter after open repair. Preoperative, intraoperative, and follow-up data were stored in a prospective database. RESULTS: Median follow-up was similar in the 2 groups: 33 months (interquartile range [IQR], 13-50 months) in the EVAR group vs 35 months (IQR, 15-54 months) in the open repair group. EVAR group patients were older than patients in the open repair group: 73 years vs 72 years (P = .04). There were statistical significant differences between the EVAR group and the open repair group with respect to AAA median diameter (52 mm vs 56 mm), coronary disease rate (46% vs 37%; P = .001), pulmonary disease rate (56% vs 38%; P < .0001), and American Society of Anesthesiologists IV score rate (16% vs 6%; P < .0001). Thirty-day mortality in the EVAR group was 0.9% (5 of 534 patients), compared with 4.1% (24 of 585 patients; P = .001) in the open repair group, and major morbidity was 9.1% (49 of 534 patients) vs 18.6% (109 of 585 patients; P < .0001), respectively. The incidence of secondary procedures in the EVAR group was 15.7%, compared with 3% in the open repair group (P < .0001). There were no deaths related to secondary procedures in either group. Six AAAs (1.1%) ruptured after EVAR, 3 of which were fatal; in the open repair group 1 patient (0.2%) underwent successful repeat operatation to treat iliac pseudoaneurysm rupture 5 years after the original procedure. Kaplan-Meier estimates for freedom from aneurysm-related death at 84 months were 97.5% in the EVAR group and 95.9% in the open repair group (log rank test, P = .008). Kaplan-Meier survival estimates at 84 months were 67.1% in the open repair group and 66.9% in the EVAR group (P = NS). At the same interval the risk for secondary procedures was 49.4% for the EVAR group and 7.1% for the open repair group. Of the 11 variables analyzed with logistic analysis, open surgery (hazard ratio [HR], 11; 95% confidence interval [CI], 2.5-54.2; P = .002), American Society of Anesthesiologists IV score (HR, 7.1; 95% CI, 2.7-18.8; P = .0001), and age (HR, 1.06; 95% CI, 1.04-1.13; P = .04) were positive independent predictors of perioperative mortality. CONCLUSION: Our data suggest that at a maximum follow-up of 7 years, patients who undergo EVAR show lower perioperative and late aneurysm-related mortality compared with a younger and substantially healthier group of patients with aneurysms treated with open repair. The higher need for secondary procedures in the endovascular group did not affect superiority of the overall performance of EVAR in the early and late intervals.     

Effects of Suprarenal Aortic Cross-Clamping and Adjunctive Renal Reconstruction on Outcomes of Open Abdominal Aortic Aneurysm Repair

Purpose: To analyze our contemporary experience in open abdominal aortic aneurysm (AAA) repair. We focused on the effects of suprarenal (SR) aortic cross-clamping and adjunctive renal reconstruction (RR) on postoperative outcomes.Methods: We retrospectively reviewed our institutional data of 141 consecutive patients who received elective open AAA repair between January 2014 and December 2020.Results: Seventy-five procedures were performed with SR aortic cross-clamping, 20 of which required an adjunctive RR. Patients in the SR group had a higher incidence of postoperative acute kidney injury (AKI) (18.7% vs. 7.6%, P = 0.045). There were no significant between-group differences in other major complications. The 30-day mortality rate in the infrarenal (IR) and SR groups was 0% and 1.3%, respectively. After a median follow-up of 33 months, the rates of chronic renal decline in the IR (18.2%) and SR (21.3%) groups were similar. All reconstructed renal arteries were patent without reintervention. The 5-year overall survival rate in the IR and SR groups was 88.8% and 83.2%, respectively.Conclusions: SR aortic cross-clamping was associated with postoperative AKI but neither SR aortic cross-clamping nor RR affected the long-term renal function or mortality. Open repair remains an essential option for patients with AAA, especially those with complex anatomy.     

Treatment delays for patients exiting an aortic aneurysm surveillance programme

Background: We have previously reported abdominal aortic aneurysm (AAA)‐related mortality in patients who have completed surveillance. This study investigates the journey time of patients who exited the AAA surveillance programme at Christchurch Hospital and underwent elective repair to determine the factors contributing to the interval between completing surveillance and undergoing surgical repair. Methods: A retrospective review of patient notes was carried out for 25 patients who underwent elective repair of their AAA after exiting the surveillance programme between November 2000 and September 2005. Results: The median time interval between exiting the programme and undergoing repair for patients fit for repair was 6 months. During this waiting period, there were two aneurysm‐related deaths. Analysis of the patient journeys showed that those with significant comorbidity, that is, patients who required additional investigation by other clinicians (n = 7), had a median time to repair of 35 weeks. This was substantially increased compared with a median time of 22.5 weeks to repair for the rest (n = 18). Conclusion: At our institution the median time for completion of surveillance to repair was 6 months. An AAA with a diameter of 55 mm has an expected risk of rupture of 5%, with mortality approaching 90%. In our series, mortality was 4.9% (two patients died while awaiting repair), consistent with expected figures. Factors contributing to this delay of 6 months to repair were identified. Modifications to this journey are suggested to improve the time interval and therefore hopefully reduce the aneurysm‐related mortality in this group.     

Thoracoabdominal aortic aneurysm repair after prior aortic surgery

PURPOSE: The purpose of this study was to determine whether the morbidity and mortality of surgery for thoracoabdominal aortic aneurysm (TAAA) in patients with prior aortic surgery are increased. METHODS: The results for all patients undergoing operation for TAAA at a single institution were reviewed. RESULTS: Over a 10-year interval, 279 patients (136 women and 143 men) underwent aortic replacement for TAAA. The mean patient age was 68 years (range, 34-90). The extent of aortic replacement was relatively evenly distributed: type I (91), type II (54), type III (78), or type IV (56). Of these 279 patients, 76 (27%) had undergone prior aortic surgery. Prior infrarenal AAA was the most common prior procedure (56, 20%). Reoperation for prior failed TAAA repair was performed in 20 (7%) patients. A history of Marfan syndrome was highly associated with the need for remedial TAAA procedures (P <.0001). Overall 30-day mortality was 11.4% (32). Mortality was independent of prior aortic surgery (P =.98), prior AAA (P =.84), prior TAAA (P =.61), and gender (P =.18). Postoperative complications were seen in 67 (24%) patients and were more likely in patients who had undergone prior AAA surgery (P =.008). TAAA repair in patients with recurrent TAAA was not associated with higher morbidity (P =.33). Paraplegia (10) occurred in type I (3), type II (2), and type III (5) aneurysms but not in type IV (0), and its development was associated with higher mortality (P =.01). Prior aortic surgery was not found to be predictive of paraplegia (P =.90), although 30% of patients who developed paraplegia had a history of prior AAA repair. CONCLUSIONS: Aortic reoperation for TAAA is required in a significant number of patients, particularly those with Marfan syndrome. Therefore, ongoing surveillance of the residual aorta is mandatory. Postoperative complications are more likely to occur in patients after prior infrarenal aortic replacement, but mortality is not significantly increased. Special technical considerations exist for remedial procedures after failed TAAA repair to provide protection for the spinal cord, kidneys, and viscera. Patients with failed TAAA procedures or progression of aneurysmal extent should be offered reoperation when indicated.     

Influence of ischemic heart disease on early and late mortality after aortic reconstruction for abdominal aortic aneurysm and aortoiliac occlusive disease

A retrospective study was undertaken to assess the influence of ischemic heart disease (IHD) on the early and late mortality of patients undergoing elective repair of an abdominal aortic aneurysms (AAA) or aortoiliac occlusive disease (AIOD). The patients were divided into IHD and non-IHD groups on routine clinical grounds. Among 157 patients with AAA, postoperative myocardial infarction occurred in 12.8% of the IHD group compared with 0.9% of the non-IHD group (P less than 0.05). The late mortality rate in the IHD group was higher than in the non-IHD group (p less than 0.05), and the mortality rate from myocardial infarction was 30% in the IHD group compared with 13% in the non-IHD group. Among 119 patients with AIOD, clinical evidence of IHD was found in 24 patients and extra-anatomical bypass was performed in 54% of these patients, compared with 35% of the patients in the non-IHD group. There was no occurrence of postoperative myocardial infarction. This study shows that an aggressive diagnostic approach should be taken for patients with AAA who have clinical evidence of IHD and that reevaluation of IHD should be performed in patients with AIOD after aortic reconstructive surgery.     

Intra-abdominal packing for uncontrollable haemorrhage during ruptured abdominal aortic aneurysm repair.

OBJECTIVE: Intra-abdominal packing is a valuable adjunct in patients with abdominal trauma and uncontrollable bleeding but few data exist regarding early and late outcome associated with this technique in patients with ruptured abdominal aortic aneurysm (AAA). METHODS: Interrogation of a prospective vascular surgical database identified 23 patients (22 men; median age 69, range 59-82, years) with ruptured AAA who required intra-abdominal packing for control of coagulopathic haemorrhage after insertion of an aortic graft between January 1982 and December 2003. Co-morbidity, operative and outcome data were retrieved. RESULTS: Haemostasis was achieved and packs were removed within 48 h in 20 patients. In those patients who had a graft inserted, the peri-operative mortality rate was 12 of 23 (52%) patients (vs. 172 of 455 (38%) patients who were not packed, NS). Three (13%) patients developed early intra-abdominal sepsis, which was universally fatal: graft-enteric fistula, intra-abdominal abscess with necrotizing fasciitis of the abdominal wound, and infected retroperitoneal haematoma. Two of 11 (18%) survivors developed late graft-related infective complications: major aortic graft infection at 6 months and symptomatic infected para-anastomotic aortic false aneurysm at 39 months. Early and late intra-abdominal infective complications were significantly more common in patients who were packed than in those who were not (packed: five of 23, 22% vs. non-packed: five of 455, 1%; p < 0.001). CONCLUSION: These data demonstrate that intra-abdominal packing in coagulopathic patients with ruptured AAA can achieve an acceptable survival rate. However, this technique may be associated with an increased incidence of early and late intra-abdominal infective complications.     

Durability of open surgical repair of type IV thoracoabdominal aortic aneurysm

Objective

Perioperative outcomes and late mortality after open type IV thoracoabdominal aortic aneurysm (TAAA) repair are known, yet risk of late graft and subsequent aortic events is infrequently described. Such data are increasingly important as endovascular repair becomes an option and are the subject of this study.

Long-term survival and late complications after repair of ruptured abdominal aortic aneurysms

Purpose:Long-term survival and late vascular complications in patients who survived repair of ruptured abdominal aortic aneurysms (RAAA) is not well known. The current study compared late outcome after repair of RAAA with those observed in patients who survived elective repair of abdominal aortic aneurysms (AAA). Methods:The records of 116 patients, 102 men and 14 women (mean age: 72.5 (8.3 years), who survived repair of RAAA (group I) between 1980 to 1989 were reviewed. Late vascular complications and survival were compared with an equal number of survivors of elective AAA repair matched for sex, age, surgeon, and date of operation (group II). Survival was also compared with the age and sex-matched white population of west-north central United States. Results:Late vascular complications occurred in 17% (20/116) of patients in group I and in 8% (9/116) in group II. Paraanastomotic aneurysms occurred more frequently in group I than in group II (17 vs. 8,p = 0.004). At follow-up, 32 patients (28%) were alive in group I (median survival: 9.4 years) and 53 patients (46%) were alive in group II (median survival: 8.7 years). Cumulative survival rates after successful RAAA repair at 1, 5, and 10 years were 86%, 64%, and 33%, respectively. These were significantly lower than survival rates at the same intervals after elective repair (97%, 74%, and 43%, respectively, p = 0.02) or survival of the general population (95%, 75%, and 52%, respectively,p < 0.001). Coronary artery disease was the most frequent cause of late death in both groups. Vascular and graft-related complications caused death in 3% (3/116) in group I and 1% (1/116) in group II. Cox proportional hazards modeling identified age p = 0.0001), cerebrovascular disease p = 0.009), and number of days on mechanical ventilation p = 0.01) to be independent prognostic determinants of late survival in group I. Conclusions:Late vascular complications after repair of RAAA were higher and late survival rates lower than after elective repair. These data support elective repair of AAA. As two-thirds of the patients discharged after repair of RAAA are alive at 5 years, aggressive management of RAAA remains justified. (J Vasc Surg 1998;27:813-20.)     

EndoSuture aneurysm repair versus fenestrated aneurysm repair in patients with short neck abdominal aortic aneurysm

ObjectiveThe aim of this study was to compare midterm results of EndoAnchors in EndoSuture aneurysm repair (ESAR) versus fenestrated endovascular aneurysm repair (FEVAR) in short neck abdominal aortic aneurysm (AAA).MethodsAll patients who underwent an ESAR procedure for a short neck AAA at our center between September 2017 and May 2020 were considered for analysis. To form the control group, preoperative computed tomography angiography of patients who underwent FEVAR for juxtarenal AAA between April 2012 and May 2020 were reviewed and patients who met short neck criteria selected. A propensity-matched score on neck length and neck diameter was calculated, resulting in 18 matched pairs. AAA shrinkage, type Ia endoleaks (EL), AAA-related reinterventions, and AAA-related deaths were compared.ResultsThe median AAA diameter was 54 mm (interquartile range [IQR], 52-61 mm) versus 58 mm (IQR, 53-63 mm) with a median neck length of 8 mm (IQR, 6-12 mm) vs 10 mm (IQR, 6-13 mm) in ESAR and FEVAR patients, respectively. Technical success was 100% in both groups. Procedural success was 94% in the ESAR group versus 100% in the FEVAR group. The median procedure duration was 138 mm (IQR, 113-182 mm) vs 240 mm (IQR, 199-293 mm) ( P < .001) and the median length of stay was 2 days (IQR, 2-3 days) vs 7 days (IQR, 6-7 days) (P < .001) in ESAR and FEVAR patients, respectively. No major hospital complications were observed in ESAR patients compared with two in FEVAR patients (11%) with one transient acute kidney injury and one transient paraplegia. The median follow-up was 23 months (IQR, 19-33 months) vs 36 months (IQR, 22-57 months) with 67% versus 61% AAA shrinkage in the ESAR and FEVAR groups, respectively (P = .73). No type Ia EL, proximal neck-related reinterventions, or AAA-related deaths were observed in either group. No AAA-related reintervention was observed in the ESAR group versus three reinterventions in the FEVAR group (P = .23).ConclusionsESAR seems to be a safe technique with no major postoperative complications or reinterventions observed during follow-up. It seems to offer similar midterm results as FEVAR in terms of type Ia EL, aneurysm shrinkage, and aneurysm-related mortality. ESAR seems to be a good off-the-shelf alternative to FEVAR in case of technical constraints.     

The 30-day mortality of ruptured abdominal aortic aneurysms: influence of gender, age, diameter and comorbidities

AIM: The aim of this study was to determine the influence of gender, age, the aneurysm diameter and comorbidity on the 30-day mortality after open repair of ruptured abdominal aortic aneurysms (AAA). METHODS: Between January 1, 1993, and December 31, 2006 all consecutive patients who underwent open repair for a ruptured AAA at the tertiary care of Catharina teaching Hospital were included in this study (N=186). Patients who underwent endovascular repair of their ruptured abdominal aortic aneurysms were excluded from this study. Patient and procedure characteristics were collected and analyzed in relation to 30-day mortality. The association between age, gender, diameter of AAA and comorbidity with 30-day mortality was analyzed with c2 are and logistic regression; a P value <0.05 was considered significant. RESULTS: In this study there were 186 patients with ruptured AAA repair with an 30-day mortality of 36.6% (68/186). Among female patient 30-day mortality was 45.8% (11/24) compared with 35.2% (57/162) among male patients (P=0.31). Patients of 80 years and older had a 61.3% (19/31) 30-day mortality where younger patients had 33% (51/155) 30-day mortality (P=0.02). Thirty-day mortality was 47.2% (17/36) for patients with an AAA less than 65 mm compared with 34% (36/104) for patients with an AAA of 65 mm or larger (P=0.16). Multivariate analysis demonstrated age was a significant predictor of ruptured AAA repair mortality (P=0.017). CONCLUSION: In this study, age was the only significant risk factor of 30-day mortality after open repair in patients with ruptured AAA.