Patient satisfaction and chronic illness are predictors of postendovascular aneurysm repair surveillance compliance

Objective

Although lifelong surveillance is recommended by the Society for Vascular Surgery for patients undergoing endovascular aneurysm repair (EVAR) reported that compliance with long-term follow-up has been poor. We sought to identify factors that predict compliance with EVAR surveillance through analysis of patient variables and post-EVAR questionnaire results.

Prognosis review and time-to-event data meta-analysis of endovascular aneurysm repair outside versus within instructions for use of aortic endograft devices

BackgroundOur objective was to investigate whether patients undergoing standard endovascular aneurysm repair (EVAR) outside the instructions for use (IFU) have worse outcomes than patients treated within IFU.MethodsWe conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic bibliographic sources were searched up to January 2019 using a combination of controlled vocabulary (thesaurus) and free-text terms to identify studies comparing outcomes of EVAR in patients treated outside versus within IFU. Pooled estimates of dichotomous outcomes were calculated using odds ratio (OR) or risk difference (RD) and 95% confidence interval (CI). We conducted a time-to-event data meta-analysis using the inverse-variance method and reported the results as summary hazard ratio (HR) and associated 95% CI. Random-effects methods of meta-analysis were applied. We formed meta-regression models to explore heterogeneity as a result of changes in practice over time.ResultsWe identified 17 observational cohort studies published between 2011 and 2017, reporting a total of 4498 patients. The pooled prevalence of EVAR performed outside the IFU was 40% (95% CI, 33-48). Nonadherence to IFU was not associated with increased risk of perioperative mortality (RD, 0.01; 95% CI, −0.00 to 0.01; P = .23), aneurysm rupture (HR, 1.34; 95% CI, 0.30-5.93; P = .70), aneurysm-related mortality (HR, 0.88; 95% CI, 0.20-3.84; P = .86), technical failure (RD, 0.01; 95% CI, −0.03 to 0.05; P = .56), requirement for adjunctive procedures (OR, 1.48; 95% CI, 0.81-2.71; P = .20), type I endoleak (HR, 2.28; 95% CI, 0.58-8.91; P = .24), aneurysm sac expansion (HR, 0.86; 95% CI, 0.55-1.33; P = .49), or aneurysm-related reintervention (HR, 1.04; 95% CI, 0.81-1.34; P = .74). The overall mortality was significantly higher in patients treated outside the IFU (HR, 1.20; 95% CI, 1.02-1.42; P = .03). Meta-regression showed that the prevalence of EVAR performed outside the IFU has increased over time (P = .019).ConclusionsStandard EVAR outside the IFU was not found to have worse aneurysm-related outcomes than treatment within the IFU. Standard EVAR outside the IFU could be considered in selected patients who are deemed high risk for complex open or endovascular surgery.     

香港地区动脉瘤的治疗现状

目的 阐述香港动脉扩张性疾病的流行病学模式及主动脉瘤传统手术与腔内治疗术的发展现状。方法 分析香港医院管理局1999－2000年主动脉瘤统计数值,香港血管外科工作小组在公立医院主动脉瘤调查报告及香港大学外科学系血管外科833例患者经验。结果 主动脉瘤是香港地区目前第10大致命疾病,每年大概发现800例新病例,而主动脉瘤破裂率为10％,破裂病死率为80％。目前一半手术适应证为主动脉瘤破裂,有大比例患者未获手术治疗。在有经验的血管外科中心腹主动脉瘤择期手术病死率已下降至2％,而破裂手术病死率也降低为38％。结论 香港地区主动脉瘤发病率与世界发病率同步增加。近年腔内治疗术迅速发展,有一定的成效,但患者选择与随访至为重要。     

Infrarenal endovascular aneurysm repair with large device (34- to 36-mm) diameters is associated with higher risk of proximal fixation failure

ObjectiveEndovascular aneurysm repair (EVAR) has become the standard of care for infrarenal aneurysms. Endografts are commercially available in proximal diameters up to 36 mm, allowing proximal seal in necks up to 32 mm. We sought to further investigate clinical outcomes after standard EVAR in patients requiring large main body devices.MethodsWe performed a retrospective review of a prospectively maintained database for all patients undergoing elective EVAR for infrarenal abdominal aortic aneurysms at a single institution from 2000 to 2016. Only endografts with the option of a 34- to 36-mm proximal diameter were included. Requisite patient demographics, anatomic and device-related variables, and relevant clinical outcomes and imaging were reviewed. The primary outcome in this study was proximal fixation failure, which was a composite of type IA endoleak and stent graft migration >10 mm after EVAR. Outcomes were stratified by device diameter for the large-diameter device cohort (34-36 mm) and the normal-diameter device cohort (<34 mm).ResultsThere were 500 patients treated with EVAR who met the inclusion criteria. A total of 108 (21.6%) patients received large-diameter devices. There was no difference between the large-diameter cohort and the normal-diameter cohort in terms of 30-day (0.9% vs 0.95%; P = .960) or 1-year mortality (9.0% vs 6.2%; P = .920). Proximal fixation failure occurred in 24 of 392 (6.1%) patients in the normal-diameter cohort and 26 of 108 (24%) patients in the large-diameter cohort (P < .001). There were 13 (3.3%) type IA endoleaks in the normal-diameter cohort and 16 (14.8%) in the large-diameter cohort (P < .001). Stent graft migration (>10 mm) occurred in 15 (3.8%) in the normal-diameter cohort and 16 (14.8%) in the large-diameter cohort (P < .001). After multivariate analysis, only the use of Talent (Medtronic, Minneapolis, Minn) endografts (odds ratio [OR], 4.50; 95% confidence interval [CI], 1.18-17.21) and neck diameter ≥29 mm (OR, 2.50; 95% CI, 1.12-5.08) remained significant independent risk factors for development of proximal fixation failure (OR, 3.99; 95% CI, 1.75-9.11).ConclusionsStandard EVAR in patients with large infrarenal necks ≥29 mm requiring a 34- to 36-mm-diameter endograft is independently associated with an increased rate of proximal fixation failure. This group of patients should be considered for more proximal seal strategies with fenestrated or branched devices vs open repair. Also, this group likely needs more stringent radiographic follow-up.     

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目的 探讨腹主动脉瘤合并消化器官恶性肿瘤的外科治疗方法。方法 回顾性分析9例腹主动脉瘤合并消化器官恶性肿瘤病全铁临床和手术资料。结果 腹主动脉瘤和消化器官恶性肿瘤同期手术6例，其中3例腹主动脉瘤行外包裹术；分期手术1例，仅作恶性肿瘤根治2例。同期手术2例和仅作恶性肿瘤根治2例仍生存。2例死于术后并发症，3例死于心脏疾患和肿瘤晚期。无一例死于腹主动脉瘤破裂。结论 腹主动脉瘤与消化器官恶性肿瘤并存时，应优先处理有急诊手术指征的病变。如均无症状时，应优先处理恶性肿瘤，在病人情况许可的情况下，应考虑同期手术治疗腹主动脉瘤，否则应采取分期手术。     

室间隔夹层瘤的超声诊断(附4例报告)

目的 总结室间隔夹层瘤的超声心动图诊断及临床应用价值。方法1985～2005年超声诊断罕见的室间隔夹层瘤4例。超声主要取左室长轴、四腔心、五腔心、大动脉短轴及非标准切面，观察主动脉窦的形态及结构：如扩张窦瘤的大小、窦壁厚度、窦瘤破口的部位、窦瘤破口与室间隔之间的关系，主动脉窦瘤与室间隔夹层瘤之间交通口的大小，测量形成室间隔夹层瘤的大小及夹层瘤左、右室面的厚度，结合彩色多普勒观察心动周期夹层瘤与主动脉窦瘤血流动态变化，频谱多普勒测量窦瘤与室间隔夹层瘤之间的血流速度。结果4例室间隔夹层瘤均为主动脉右窦破人室间隔基底段，且均行手术治疗证实超声诊断。结论超声心动图对室间隔夹层瘤可直接做出诊断，超声诊断价值在于早发现、早诊断、及早治疗，并可为外科选择手术方式提供重要的有价值的依据。     

Velocities of type II endoleaks on Doppler ultrasonography predict outcome

ObjectiveWe sought to determine whether flow velocities measured using Doppler ultrasonography after endovascular aortic aneurysm repair (EVAR) can predict for resolution of type II endoleaks without intervention. We also assessed the relationship of the flow velocities to sac growth and the need for intervention. We hypothesized that hemodynamic properties suggesting low flow velocity would predict for resolution of type II endoleaks.MethodsThe data from 23 patients with type II endoleaks identified on Doppler ultrasonography after EVAR from January 2014 to December 2017 were retrospectively analyzed. The 23 patients with type II endoleaks were split into two groups. Group 1 included the 13 patients with resolved endoleaks or shrinking sac size and group 2, the 10 patients with an increasing sac size or those requiring intervention to seal the endoleak because of an increased sac size. We analyzed the velocities of the endoleak nidus.ResultsDoppler ultrasound velocities were significantly lower in patients with resolved type II endoleaks and those with a shrinking aneurysm sac size compared with those demonstrating an increase in aneurysm sac size (42.6 ± 25.2 cm/s vs 219.5 ± 84.1 cm/s; P < .0001). Of the 10 patients in group 2, nine had required intervention with either translumbar embolization or transarterial embolization, with only two experiencing complete resolution of the type II endoleak, despite the intervention. All patients in group 2 had had ≥1 duplex ultrasound scan with endoleak nidus velocities >100 cm/s. In contrast, no patient in group 1 had had any duplex ultrasound scan with endoleak nidus velocities >100 cm/s.ConclusionsThe Doppler ultrasound velocities of type II endoleaks might be able to predict for spontaneous resolution of type II endoleaks or increased sac growth. Type II endoleaks on Doppler ultrasonography with endoleak nidus velocities >100 cm/s can persistent, even with attempted treatment.     

Endovascular aneurysm repair offers a survival advantage and is cost-effective compared with conservative management in patients physiologically unfit for open repair

ObjectiveThe endovascular aneurysm repair-2 (EVAR-2) trial suggested that EVAR in patients unfit for open surgical repair (OSR) failed to provide a significant overall survival advantage compared with conservative management. The aim is to compare survival and cost-effectiveness in patients with poor cardiopulmonary exercise test (CPET) metrics who underwent EVAR or were managed conservatively.MethodsA prospective database of all CPETs (1435 patients) performed to assess preoperative fitness for abdominal aortic aneurysm repair was maintained. A total of 350 patients deemed unfit for OSR underwent EVAR or were managed conservatively. A 1:1 propensity-matched analysis incorporating age, gender, anaerobic threshold, and aneurysm size was used to compare survival. Cost-effectiveness analysis was based on the economic model for the National Institute for Health and Care Excellence clinical guideline on abdominal aortic aneurysm treatment.ResultsPropensity matching produced 122 pairs of patients in the EVAR and conservative management groups. The median overall survival for the EVAR group was significantly longer than that for the conservative management group (84 vs 30 months, P < .001). One-, three-, and five-year mortality in the EVAR group was 7%, 40%, and 68%, respectively, compared with 25%, 68%, and 82% in the conservative management group, all P < .001. The increment cost-effectiveness ratio for EVAR was £8023 (US$11,644) per quality-adjusted life year gained compared with £430,602 (US$624,967) in the National Institute for Health and Care Excellence guideline, which is based on EVAR-2 results.ConclusionsEVAR offers a survival advantage and is cost-effective in selected patients deemed unfit for OSR based on CPET compared with conservative management.     

A rare case of giant coronary artery aneurysm in the context of multiple arterial aneurysms

INTRODUCTIONWhilst the incidence of CAA has been reported as up to 5%, giant CAA (>2 cm) is rare.PRESENTATION OF CASEWe present a rare case of 3 cm × 4 cm giant coronary artery aneurysm (CAA) in the context of aorto-iliac aneurysmal disease, treated by staged open surgical repair.DISCUSSIONAbdominal aortic aneurysm (AAA) and CAA share risk factors and aetiological mechanisms, therefore should be considered, particularly when CAA is diagnosed in the first instance.CONCLUSIONSSurgical intervention for diagnosed giant CAA appears to be the treatment of choice in the reported literature, with the order of intervention when AAA co-exists remaining a point for debate.     

腹主动脉瘤腔内修复术中特殊近端锚定区的处理

目的探讨腹主动脉瘤腔内修复术（EVAR）中特殊近端锚定区的处理方法。方法1997年7月至2005年7月对41例特殊类型腹主动脉瘤（瘤颈过短、严重成角、严重钙化、附壁血栓、形态不规则等）的腔内修复术中，根据情况分别采用近端裸支架跨肾动脉技术、覆盖部分肾动脉并肾动脉支架成形技术、针对成角选择合理产品、近端裸支架内支撑技术、近端延长支架型血管内支撑技术、“凹口”状支架型血管保留肾动脉技术来处理特殊近端锚定区的病变。结果41例EVAR中原发性近端Ⅰ型内漏发生率17．1％（7／41），随诊发现原发性内漏4例自愈，3例转化为持续性内漏，另发现4例继发性内漏。术后30d近端Ⅰ型内漏发生率17.1％（7／41）。无中转开腹手术及术中瘤体破裂、肾梗死等情况发生。结论对特殊近端锚定区的病例，通过相关技术处理可以使之适合腔内治疗。     

破裂腹主动脉瘤的外科治疗

目的探讨急诊腹主动脉瘤切除人工血管移植术治疗破裂腹主动脉瘤的经验。方法总结1999年4月至2005年4月外科手术治疗破裂腹主动脉瘤20例，采用钳夹阻断膈下腹主动脉或Foley氏球囊管腔内阻断瘤颈上腹主动脉后行急诊腹主动脉瘤切除人工血管移植术，应用分叉型人工血管12例，直型人工血管8例。结果急诊腹主动脉瘤切除人工血管移植手术30d围手术期死亡率40％（8例），死亡原因包括急性肾功能衰竭4例，多器官功能衰竭2例，呼吸循环衰竭2例。存活12例，术后合并症包括急性肾功能不全、肺部感染、凝血机制障碍和腹泻等共11例，均经治疗后痊愈。随访观察6～60个月，无人工血管血栓形成和感染等并发症以及随访期死亡发生。结论破裂腹主动脉瘤外科手术治疗死亡率仍然很高，早期确定诊断，紧急外科手术治疗，术后加强围手术期管理是降低破裂腹主动脉瘤死亡率的关键。     

再次及多次主动脉瘤手术的临床分析

目的：总结13例共27次主动脉瘤手术的经验。方法：全组13例中男8例,女5例,2次手术者12例,3次手术1例,再次手术距前次手术平均50个月（22d-233个月）,首次手术分别是：主动脉根部置换7例,慢性B型夹层行胸降主动脉人工血管置换3例,肾动脉下方腹主动脉瘤切除人工血管置换1例,急性A型夹层行主动脉瓣及升主动脉成形,川崎病行升主动脉人工血管置换和左冠状动脉前降支成形各1例,再次手术分别是因残余夹层扩大行全弓置换加ElephantTrunk1例,胸降主动脉置换2例,2例再发弓部夹层,1例行根部置换＋部分弓部置换,1例行升弓部置换;2例胸降主动脉瘤,1例胸腹主动脉瘤,1例B型夹层,常温阻断下行人工血管置换术,1例根部瘤在中低温体外循环下行根部置换术,川崎病再发无名动脉和弓部动脉瘤行无名动脉及部分弓置换1例,1例A型夹层升主动脉及主动脉瓣成形术后感染性假性动脉瘤形成,1例再发升主动脉瘤行升主动脉置换;1例根部置换再行弓降部置换术后,再发弓部动脉瘤,第3次手术行全弓置换,再手术时采用深低温停循环8例,常温阻断4例,中低温体外循环2例。结果：术后4例出现脑部并发症,1例肝功能异常,均治愈,无住院死亡。随访远期死亡3例,另有2例随访6个月和70个月,现待手术。结论：再次手术以再发或多发动脉瘤（包括主动脉夹层）为最常见原因,其次是残余夹层进一步发展,再次手术一定要积极,以免延误手术时机导致死亡。应根据再次手术的部位选择基本方法,累及弓部需深低温停循环并选择性脑灌注,远弓部和胸,腹主动脉可用常温阻断或股一股转流,如无法游离阻断则需要深低温停循环,累及根部则只需要一般体外循环,大出血和昏迷是再次手术最危险的并发症,尽早建立体外循环,低温和停循环期间的脑灌注可有效预防这类并发症。     

Exclusion of complex aortic aneurysm with chimney endovascular aortic repair is applicable in a minority of patients treated with fenestrated endografts

OBJECTIVESThe Medtronic Endurant II stent graft has recently received Conformité Européenne (CE) approval for the use in chimney endovascular aortic repair (ChEVAR) for the treatment for juxtarenal aortic aneurysms. The aim of this study was to assess the percentage of patients treated by fenestrated endovascular repair who would have been alternatively suitable for the treatment by the CE approved Medtronic ChEVAR. Open in a separate windowMETHODSPreoperative computed tomography scans of 100 patients who underwent fenestrated endovascular aortic repair (FEVAR) between April 2013 and February 2017 were retrospectively assessed for the applicability of the ChEVAR technique according to the Medtronic instructions for use. Eligibility criteria included an aortic neck diameter of 19–30 mm, a minimum infrarenal neck length of 2 mm, a total proximal sealing zone of at least 15 mm, thrombus in the aortic neck in ˂25% of the circumference, and maximum aortic angulations of 60° in the infrarenal, 45° in the suprarenal segment and ˂45° above the superior mesenteric artery.RESULTSAccording to CE-approved inclusion criteria, 19 individuals (19%) would have been eligible for ChEVAR. In 81 patients, at least 1 measure was found outside instructions for use: (i) excluding factor was detected in 26 patients, (ii) incongruous measures in 28 patients and in 27 patients, 3–5 measures were outside the instructions for use. The most frequently identified excluding factor was an insufficient infrarenal neck at ˂2 mm length (n = 63; 63%).CONCLUSIONSPatients with juxta- or pararenal aneurysm treated by FEVAR are in 19% of the cases alternatively suitable for the treatment by ChEVAR within CE-approved instructions for use. While ChEVAR is suitable in many emergency cases, FEVAR offers a broader applicability in an elective setting.