腹主动脉瘤合并冠心病患者三种治疗策略疗效分析

目的:分析不同手术治疗策略对合并有严重冠心病且适合行腔内修复术(EVAR)的腹主动脉瘤(AAA)患者住院期间预后的的影响。方法:采用回顾性分析2005年1月至2013年12月间,在广东省人民医院住院50岁以上确诊AAA并行冠状动脉造影的患者207例,收集临床及影像学资料,探讨AAA患者中冠心病的检出率。进一步分析合并有严重冠心病且适合行EVAR的AAA患者,根据不同手术治疗策略,分为同期EVAR+经皮冠状动脉介入治疗(PCI)组、EVAR后PCI组、PCI后EVAR组,分析不同分组患者住院期间术后不良事件发生的情况。结果:207例50岁以上AAA患者中,经冠状动脉造影确诊冠心病151例(72.9%)。93例合并有严重冠心病且适合行EVAR的AAA患者中,同期EVAR+PCI组6例(6.5%),EVAR后PCI组60例(64.5%),PCI后EVAR组27例(29.0%)。各组间年龄、性别、动脉粥样硬化危险因素、冠状动脉病变支数情况及AAA最大径等无统计学差异(P均0.05)。同期EVAR+PCI组中,无发生住院期间死亡,EVAR后PCI组出现1例(1.7%),PCI后EVAR组出现2例(7.4%),各组间住院期间病死率差异无统计学意义。同期EVAR+PCI组出现1例(16.7%)术后并发症,EVAR后PCI组10例(16.7%),PCI后EVAR组3例(11.1%),各组住院期间术后并发症发生率无统计学差异。结论:50岁以上AAA患者中有着较高的冠心病共患率。对于合并有严重冠心病且适合行EVAR的AAA患者,同期行EVAR+PCI术并不会增加术后住院期间不良事件的发生。     

腔内隔绝术在复杂型腹主动脉瘤中的应用

目的探讨复杂型腹主动脉瘤(AAA)采用腔内修复(EVAR)治疗的操作要点和临床疗效的分析。方法回顾性分析2011年1月至2016年6月安徽医科大学第一附属医院血管外科收治的27例腹主动脉瘤患者的临床资料,分为复杂型腹主动脉瘤组和普通型腹主动脉瘤组,对两组患者的术前一般资料、围手术期治疗及术后随访的进行对比分析研究。结果两组患者在疼痛症状的百分比、平均动脉瘤动脉瘤长度以及手术时长方面的差异有统计学意义(P0.05);围手术期及术后随访中术后内漏、并发症及死亡率方面的两组患者之间的差异无统计学意义(P0.05)。结论腹主动脉瘤腔内修复术对于复杂型腹主动脉瘤患者而言是一种切实可行的治疗方法。普通腹主动脉瘤和复杂型腹主动脉瘤患者之间在术前资料、围手术期和术后随访等大部分临床资料之间的差异无显著统计学意义。     

非体外循环冠状动脉旁路移植术中不同方式获取大隐静脉的近中期临床效果

目的分析非体外循环冠状动脉旁路移植术(OPCABG)不同方式获取大隐静脉的近期和中期临床效果。方法选择在我科接受择期OPCABG的患者435例,根据获取大隐静脉的方式,分为内窥镜获取大隐静脉(edoscopic vein harvesting,EVH)组217例及开放式获取大隐静脉(open vein harvesting,OVH)组218例,比较2组围术期病死率、急性心肌梗死、低心排综合征和腿部切口并发症等不良事件发生率,随访6个月和1年,比较2组静脉桥血管狭窄或闭塞比例和腿部切口并发症。结果 EVH组围术期腿部切口并发症发生率明显低于OVH组(2.30%vs 12.84%,P=0.000)。EVH组与OVH组围术期病死率(1.38%vs 2.29%,P=0.724)、急性心肌梗死(1.38%vs1.83%,P=1.000)和低心排综合征发生率(1.84%vs 2.75%,P=0.751)比较,差异均无统计学意义。术后6个月随访,EVH组与OVH组发生桥血管狭窄或闭塞比例比较,差异无统计学意义(8.76%vs 9.17%,P=1.000),EVH组腿部切口相关并发症发生率明显低于OVH组(3.69%vs 17.89%,P=0.000)。术后1年随访,EVH组与OVH组发生桥血管狭窄或闭塞比例比较,差异无统计学意义(11.52%vs 14.22%,P=0.475),EVH组腿部切口相关并发症发生率明显低于OVH组(5.53%vs 25.69%,P=0.000)。结论 EVH与OVH围术期不良事件发生率相似,但EVH术后腿部切口相关并发症发生率低于OVH,较OVH有明显优势。     

传统开腹手术和腔内修复术治疗腹主动脉瘤破裂的临床对照研究

目的:分析比较传统开腹手术与腔内修复手术治疗腹主动脉瘤破裂的临床疗效。方法:选取2013年1月至2014年12月,我院收治的54例腹主动脉瘤患者为研究对象,根据患者所采用的手术方式将患者分为两组,分别为开腹手术组和腔内手术组。比较分析两种手术方法术中出血量、输血量,术后ICU观察时间、禁食时间、住院时间、以及手术费用;记录患者围手术期的并发症发生率和病死率,同时在患者出院后对两组患者每隔3个月进行随访,比较两组患者两年生存率及并发症发生率。结果:腔内手术组的出血量、手术时间、ICU观察时间、术后禁食时间以及术后住院时间均小于开腹手术组,差异有统计学意义(P<0.05),但是手术费用则明显高于开腹手术组,差异有统计学意义(P<0.05);围手术期,腔内手术组的肺部并发症和电解质紊乱发生率均低于开腹手术组,差异具有统计学意义(P<0.05),病死率以及其他并发症发生率差异无统计学意义;术后随访腔内手术组的生存率均高于开腹手术组,差异有统计学意义(P<0.05)。结论:腔内修复术治疗腹主动脉瘤破裂具有手术时间短、创伤性小、术后恢复时间短,长期疗效好等优点,值得临床推广应用。     

慢性肾功能不全患者腹主动脉瘤腔内修复术治疗策略的可行性及疗效分析

目的探讨慢性肾功能不全(CRI)患者的腹主动脉瘤(AAA)腔内修复术(EVAR)治疗策略的可行性和有效性。方法对19例合并CRI的AAA患者采用针对CRI的改良EVAR治疗策略,同时选择40例肾功能正常患者采用常规手术方式作为对照组,比较2组患者在诊疗过程、治疗结果和并发症方面的差异。采用GraphPad 8.0统计软件对数据进行分析。依据数据类型分别采用t检验、χ~2检验或Fisher检验对数据进行组间比较。结果 19例患者均顺利完成EVAR治疗,围术期无患者死亡。CRI患者术后血肌酐值较术前无明显升高(P=0.610 9);1例(5.26%)因双侧肾动脉不全覆盖,行双侧肾动脉支架植入术;2例(10.53%)轻微Ⅱ型内漏,未干预;1例(5.26%)发生穿刺点血肿或感染;2例(10.53%)术后发热。所有患者围术期均未出现急性肾功能衰竭、急性脊髓、肢体缺血等严重并发症,2组间总并发症发生率无显著差异。术后3个月患者复查结果均提示支架形态位置良好、无内漏,AAA瘤腔内完全血栓化,各分支动脉血流通畅。随访期(2～28个月,中位15个月)内,1例患者因急性心肌梗死死亡,其余患者未发生支架移位、急(慢)性肾功能衰竭、肢体缺血等严重并发症。结论针对CRI患者所使用的EVAR治疗策略,可有效保护肾功能,降低术后对比剂相关并发症发生率,有效扩大EVAR术的适应证范围。     

急、慢性降主动脉夹层腔内修复术的单中心对比分析

目的比较急性和慢性降主动脉夹层行腔内修复(endovascular aortic repair,EVAR)治疗的近、远期临床疗效。方法回顾性分析沈阳军区总医院2002年4月至2014年12月的456例(急性期342例,慢性期114例)诊断为降主动脉夹层,并行EVAR治疗的患者的临床特点及手术参数等临床资料,并对术后近、远期临床随访结果进行对比分析。同时,分析降主动脉夹层患者的临床特征与术后死亡的关系。结果与慢性期组比较,急性期组前胸及后背部疼痛、胸腔积液、急性肾功能不全、D-二聚体(0.5 ng/mL)的患者比例显著升高,差异均具有统计学意义(P均0.05)。急性期组入院收缩压、入院心率高于慢性期组,差异有统计学意义(P0.001)。两组间EVAR相关参数比较,差异均无统计学意义(P0.05)。术后近期结果(术后30 d内):两组间全因病死率,主动脉源性死亡、内漏、截瘫、再发夹层、主动脉夹层破裂、急性肾功能不全患者比例比较,差异均无统计学意义(P0.05)。远期随访结果(术后30 d以后):两组间病死率,内漏、再发夹层、主动脉夹层破裂的患者比例比较,差异均无统计学意义(P0.05)。Logistic回归分析显示人院胸腔积液(OR=39.793;95%aCI:12.540-126.269;P0.001)、冠状动脉粥样硬化性心脏病(冠心病)(OR=4.724;95%CI:1.921-11.617;P=0.001)与EVAR术后死亡存在独立相关性。结论 EVAR治疗Stanford B型主动脉夹层安全有效,但是急性期患者术后近期病死率较慢性期具有增高趋势,两组间远期病死率相近;胸腔积液、冠状动脉粥样硬化性心脏病为EVAR术后死亡的独立危险因素。     

腹主动脉瘤合并2型糖尿病的临床分析

目的:探讨腹主动脉瘤(AAA)合并2型糖尿病的临床特点和治疗效果。方法:回顾分析1991年1月至2016年6月我科AAA合并2型糖尿病研究组患者96例,同时以手术方式为匹配因素选取不合并2型糖尿病的AAA对照组患者96例进行分析。结果:两组相比术前检查中冠心病(P<0.01)、高脂血症(P<0.05)、高血压(P<0.01)、外周动脉病发病率高(P<0.05)差异有统计学意义,LDL-C、LDL-C/HDL-C增高(P<0.01),而HDL-C降低(P<0.01),围术期循环、呼吸系统并发症率高(P<0.05)差异有统计学意义,手术失血量、ICU入住时间等差异无统计学意义,术后随访中支架及人工血管通畅率差异无统计学意义、循环系统并发症例数虽较对照组多(11/8)但差异无统计学意义。结论:对于合并2型糖尿病的AAA患者不仅应注意控制血糖,而且需加强冠心病、高血脂、高血压的控制,通过精细熟练的手术操作和细致的围术期管理减少并发症的出现,并进行密切的术后随访。     

不同手术时机对老年股骨转子间骨折康复效果影响的观察

目的探讨不同手术时机对老年股骨转子间骨折康复效果的影响。方法选取该院2013-01~2015-05收治的老年股骨转子间骨折患者40例为研究对象,以随机数字表法分为早期组与延期组,每组20例,早期组1周内进行手术,延期组1周后手术,比较两组术后并发症发生率;随访12个月比较两组生活质量、髋关节功能变化及病死率。结果早期组并发症发生率为15.0%,与延期组(45.0%)比较差异有统计学意义(P0.05)。两组术前日常生活能力评分(ADL)及髋关节功能评分比较差异无统计学意义(P0.05),术后6个月早期组ADL及髋关节功能评分分别为(55.16±11.19)分、(77.16±7.58)分,与延期组[(42.77±12.99)分、(65.11±6.97)分]比较差异有统计学意义(P0.05),12个月时两组评分比较差异无统计学意义(P0.05)。随访1年,早期组病死3例,病死率为15.0%;延期组病死4例,病死率为20.0%,两组病死率比较差异无统计学意义(χ2=0.173,P0.05)。结论早期手术可降低老年股骨转子间骨折患者并发症发生率,尤其在预防长期卧床导致的感染性并发症及压疮方面效果显著,且可改善患者术后6个月生活质量及髋关节功能,而不同手术时机对病死率的影响仍有待大样本量的深入研究。     

急性B型主动脉夹层分类差异对腔内修复术疗效及安全性的影响

目的探讨急性B型主动脉夹层分类差异对体外开窗腔内修复术(thoracic endovascular repair,TEVAR)的疗效及安全性的影响。方法选取我院2013年3月—2015年3月收治的复杂型急性B型主动脉夹层病人37例设为复杂组,将同期非复杂型急性B型主动脉夹层病人48例设为非复杂组,均采用TEVAR术治疗。比较两组30 d死亡率、围术期并发症发生率、二次干预率、动脉扩张率、假腔消失率、手术前后最大动脉直径水平及随访生存率等。结果两组30 d死亡率、围术期并发症发生率、二次干预率、动脉扩张率及假腔消失率比较差异无统计学意义(P0.05);复杂组术后6个月和12个月最大动脉直径均显著高于术前(P0.05);且复杂组术后同一时间点最大动脉直径均显著高于非复杂组(P0.05);非复杂组手术前后最大动脉直径比较差异无统计学意义(P0.05);同时两组随访生存率比较差异无统计学意义(P0.05)。结论 EVAR治疗复杂型和非复杂型急性B型主动脉夹层在围术期并发症风险和随访生存率方面效果较为接近;但其用于非复杂型急性B型主动脉夹层病人治疗更有助于促进动脉管腔重塑。     

婴幼儿法洛四联症1期根治术时机选择

目的:评价婴幼儿法洛四联症(TOF)早期根治术后效果。方法:2002年1月至2006年6月,我科共手术治疗<36个月婴幼儿TOF 87例,年龄(2~36)个月,平均(17.2±5.6)个月:<6个月14例(16.1%)、7~12个月34例(39.1%)、13~36个月39例(44.8%)。比较不同年龄组手术病死率、围手术期处理、术后并发症及随访结果。结果:2例(2.3%)死于术后低心排出量综合征,1例(1.2%)死于术后心律失常。不同年龄组术后并发症差异无统计学意义。术后6个月以下患儿更多需要升压药维持,但术后呼吸机通气时间、ICU停留时间、住院时间差异无统计学意义。回访时间2.0~6.0年,平均(3.5±1.6)年,56例(66.7%)例患儿存在不同程度肺动脉瓣反流,2例(2.3%)残余右心室流出道梗阻,3例(3.4%)室缺残余分流再次手术矫治。结论:对<6个月婴儿TOF一期根治手术病死率和术后并发症低,手术年龄不影响术后效果。     

Endovascular Repair of a Large Ruptured Abdominal Aortic Aneurysm Using Monitored Anesthesia Care and Local Anesthesia

Over the last decade, there has been a paradigm shift in the treatment of ruptured abdominal aortic aneurysm (AAA) from open repair to endovascular aneurysm repair (EVAR). Regardless of the method used during emergent rupture, open verses endovascular repair, the overall mortality remains high. Recent studies have compared patient outcomes using different types of anesthesia during elective EVAR procedures. The data show that during an elective EVAR, monitored anesthesia care (MAC) with local anesthesia is not only just as safe as general anesthesia, but it offers other potential benefits as well. There is limited data in regards to patient outcomes using MAC and local anesthesia during cases of large ruptured aneurysms that are treated with EVAR. This case report discusses the treatment of a patient who presented with a large 13 cm ruptured AAA which was successfully repaired using EVAR with MAC and local anesthesia.     

Resultados a cinco años de la reparación electiva del aneurisma de aorta abdominal infrarrenal en un hospital universitario de Argentina

Objective:

Few data about outcomes of elective infrarenal abdominal aortic aneurysm (AAA) repair in Latin America have been published. The objective of the present study is to address this aspect in our population.

Method:

Retrospective cohort, in which patients with infrarenal AAA undergoing elective surgical or endovascular repair from January 2011 to May 2017 at a university hospital in Autonomous City of Buenos Aires were consecutively included. The primary endpoints were perioperative mortality and all-cause mortality during follow-up. Among the secondary endpoints, the requeriment of reinterventions was assessed.

Results:

195 patients were included. Open surgery was performed in 72 patients (36.9%) and endovascular aortic repair (EVAR) in 123 (63.1%). Perioperative mortality in the surgery group was 2.8%, while no deaths were recorded in the endovascular group (p = 0.06). The median follow-up was 38 months. No statistically significant difference was found in long-term mortality incidence rate between patients who underwent EVAR and those who underwent open surgery (7% per year vs. 6.7% per year, p = 0.8). The requirement of reinterventions was significantly higher in the endovascular group (9.0% vs. 0%, p = 0.01).

Conclusions:

Survival analyses demonstrated no statistically significant differences in perioperative and long-term mortality for patients who underwent EVAR compared with those who underwent open surgery, while the former had a higher rate of reinterventions. The results observed in our population do not differ from those published in the United State or Europe.     

Sexual dysfunction after conventional and endovascular AAA repair: results of the DREAM trial.

PURPOSE: To assess sexual function in the first postoperative year after elective endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysm (AAA). METHODS: In the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, 153 patients (141 men; mean age 71 years, range 53-85) were randomly allocated to EVAR (n=77) or OR (n=76). Sexual functioning was evaluated preoperatively and at 5 times in the first postoperative year (3, 6, 13, 26, and 52 weeks) using a questionnaire derived from the Medical Outcomes Study. The proportions of patients reporting sexual dysfunction for any of 5 aspects (interest, pleasure, engagement, orgasm, and erection) and any increase in the magnitude of dysfunction were compared between EVAR and OR. RESULTS: Preoperatively, the proportion of patients reporting sexual dysfunction in at least 1 aspect was 66% for the OR group and 74% in the EVAR group (p=NS). Surgery had a clear impact on sexual dysfunction. The proportion of patients reporting sexual dysfunction on at least 1 aspect increased to 79% in the OR group and 82% in the EVAR group. The magnitude of sexual dysfunction increased in both groups on all 5 aspects at 3 weeks postoperatively, but this was more pronounced in the OR group (interest: OR p=0.038 vs. EVAR p=0.071; pleasure: OR p=0.009 vs. EVAR p=0.065; engagement: OR p=0.006 vs. EVAR p=0.054; orgasm OR p=0.023 vs. EVAR p=0.112, and erection: OR p=0.046 vs. EVAR p=0.030). At 6 weeks, the OR group still reported a significant increase in 3 aspects (pleasure p=0.031, engagement p=0.010, and orgasm p=0.003), whereas the EVAR group no longer showed a significant difference. From 3 months on, both groups had returned to baseline. CONCLUSIONS: EVAR and open elective AAA repair both have an impact on sexual function in the early postoperative period. After EVAR, recovery to preoperative levels is faster than after open repair, but at 3 months, sexual dysfunction levels are similar in both groups.     

Endovascular Treatment versus Open Repair for Abdominal Aortic Aneurysms: The Influence of Fitness in Decision Making

Two methods of repair are currently available for an abdominal aortic aneurysm (AAA), open aneurysm repair and endovascular aneurysm repair (EVAR). The decision making depends on the balance of risks and benefits. The treating physician must take into account the patient''s life expectancy, the patient''s fitness, the anatomic suitability that makes endovascular repair possible, and finally the patient''s preference. The patient''s fitness is an important variable predicting the outcome of AAA surgical reconstruction. The hypothesis is that the impact of risk factors upon perioperative mortality might differ between patients undergoing open repair and endovascular repair. The purpose of this review article is to investigate whether fitter patients with a large AAA benefit more from having endovascular rather than open repair. According to the available data, there is emerging evidence that patients at high medical risk for open repair may benefit from EVAR while in low risk patients with suitable anatomy for EVAR, both techniques have similar effects. There is rising evidence that a patient with ruptured AAA would benefit more from an endovascular procedure if eligible, and thus fitness in such emergencies is not the first priority but anatomical suitability for EVAR.     

腹主动脉瘤腔内修复技术在90岁以上老年患者中应用的评价

目的探讨年龄逾90岁的腹主动脉瘤（AAA）患者行腔内修复术治疗的安全性和有效性。方法 2003年5月至2011年3月,12例年龄逾90岁的AAA患者接受主动脉腔内修复技术（EVAR）治疗,其中急诊手术2例。平均年龄（91.7±1.5）岁,其中11例为男性（91.7%）。统计技术成功率、围手术期并发症、死亡率;术后3,6,9,12个月及每年进行随访,进行CT或超声检查。结果 7例行全身麻醉,5例行局部麻醉,技术成功率为100%,无中转开刀手术患者;2例采用Endurant支架,4例采用Talent支架,6例采用Zenith支架;手术时间（3.4±1.3）h,出血量（220.5±60.5）ml,术后住院时间（8.4±2.3）d;30d死亡率为8.3%,1年死亡率为16.7%,3年死亡率为41.7%,5年死亡率为75%;11例术后30d仍存活的患者,平均术后生存时间为28.5个月（9～73个月）。结论对于年龄逾90岁的AAA患者,EVAR手术成功率高,围手术期死亡率和并发症发生率低,但从中远期结果来看部分患者的手术获益是有限的,因此术前个体化评估十分重要。     

Endografting increases total volume of AAA repairs but not at the expense of open surgery: experience in more than 1000 patients.

PURPOSE: To compare the volume of open graft replacements (OGR) for abdominal aortic aneurysm (AAA) versus endovascular aneurysm repairs (EVAR) over time and after modifying selection criteria. METHODS: A review was conducted of 1021 consecutive patients who underwent AAA repair from 1989 through 2002: 496 elective OGRs for infrarenal AAAs (STANDARD), 289 elective EVARs for infrarenal AAAs, 59 complex OGRs for suprarenal AAAs, and 177 emergent OGRs for ruptured AAAs. Patients from 1995 to 2002 were divided into 2 groups based on shifting treatment strategies; 454 patients were treated by STANDARD or EVAR at the surgeon's discretion between 1995 and 2000 (post EVAR). The second group comprised 161 patients treated in 2001-2002 after the introduction of "high-risk" screening criteria (age > or = 72 years, diabetes mellitus, renal dysfunction, impaired pulmonary function, or ASA class IV) that dictated EVAR whenever anatomically feasible. For comparison, 170 STANDARD repairs performed in the 6 years prior to EVAR served as a control. RESULTS: While surgery for ruptured AAAs remained fairly stable over the 14-year period, the number of patients undergoing elective repair increased due to the implementation of EVAR. During the 6 years after its introduction, EVAR averaged 34.3 patients per year; after 2001, the annual frequency of EVAR increased to 41.5 (p > 0.05). In like fashion, the rate of STANDARD repairs increased to 41.3 patients per year versus 28.3 before EVAR (p = 0.032). ASA class IV patients increased by almost 9 fold in the recent period versus pre EVAR (p = 0.006). The overall mortality after elective infrarenal AAA repair decreased between the pre and post EVAR periods (6.5% versus 3.7%, p > 0.05) and fell still further to 1.2% in the most recent period (p = 0.021 versus pre EVAR). CONCLUSIONS: The implementation of an EVAR program increases the total volume of AAA repairs but does not reduce open surgical procedures. By allocating patients to EVAR or open repair based their risk factors, mortality was markedly reduced.     

Paradigm shifts in abdominal aortic aneurysm management based on vascular registries

Abdominal aortic aneurysm (AAA) is a relatively common and potentially fatal disease. The management of AAA has undergone extensive changes in the last two decades. High quality vascular surgical registries were established early and have been found to be instrumental in the evaluation and monitoring of these changes, most notably the wide implementation of minimally invasive endovascular surgical technology. Trends over the years showed the increased use of endovascular aneurysm repair (EVAR) over open repair, the decreasing perioperative adverse outcomes and the early survival advantage of EVAR. Also, data from the early EVAR years changed the views on endoleak management and showed the importance of tracking the implementation of new techniques. Registry data complemented the randomized trials performed in aortic surgery by showing the high rate of laparotomy‐related reinterventions after open repair. Also, they are an essential tool for the understanding of outcomes in a broad patient population, evaluating the generalizability of findings from randomized trials and analysing changes over time. By using large‐scale data over longer periods of time, the importance of centralization of care to high‐volume centres was shown, particularly for open repair. Additionally, large‐scale databases can offer an opportunity to assess practice and outcomes in patient subgroups (e.g. treatment of AAA in women and the elderly) as well as in rare aortic pathologies. In this review article, we point out the most important paradigm shifts in AAA management based on vascular registry data.     

Endovascular Abdominal Aortic Aneurysm Repair (EVAR) in the geriatric population

Abdominal aortic aneurysm (AAA) is a relatively common pathology among the elderly. More people above the age of 80 will have to undergo treatment of an AAA in the future. This review aims to summarize the literature focusing on endovascular repair of AAA in the geriatric population. A systematic review of the literature was performed, including results from endovascular abdominal aortic aneurysm repair (EVAR) registries and studies comparing open repair and EVAR in those above the age of 80. A total of 15 studies were identified. EVAR in this population is efficient with a success rate exceeding 90% in all cases, and safe, with early mortality and morbidity being superior among patients undergoing EVAR against open repair. Late survival can be as high as 95% after 5 years. Aneurysm-related death over long-term follow-up was low after EVAR, ranging from 0 to 3.4%. Endovascular repair can be offered safely in the geriatric population and seems to compare favourably with open repair in all studies in the literature to date.     

Early and midterm results after open and endovascular repair of ruptured abdominal aortic aneurysms in a comparative analysis.

PURPOSE: To compare early and midterm results of open versus endovascular aortic repair of ruptured abdominal aneurysms (rAAA). METHODS: A retrospective analysis was performed of 58 consecutive patients with rAAA who were treated with open or endovascular aneurysm repair (EVAR) at a single center between January 2000 and December 2005. Patients without definitive signs of rupture (symptomatic patients) were excluded from the study. Twenty-nine patients (21 men; median age 71 years) were treated using endovascular techniques (EVAR group) and 29 (28 men; median age 71 years) with open repair (OR group).The hemodynamic status at the time of admission was evaluated with respect to blood pressure, pulse rate, and hemoglobin level to reduce selection bias. Patients underwent follow-up by clinical examination and computed tomography. RESULTS: The 30-day mortality rate was 31% (9/29) in each group (p = 1.0); the morbidity rates also did not differ between groups [16 (55.2%) EVAR vs. 18 (62.1%) OR; p = 0.9]. There was 1 (3.4%) primary conversion in the EVAR group and 7 (24.1%) endoleaks [3 (10.3%) primary; 4 (13.8%) secondary]. There was no difference between the groups with regard to intensive care unit stay (4 days for EVAR vs. 3 days for OR, p = 0.98) or total hospital stay (9 days for EVAR vs. 12 days for OR, p = 0.69). After a mean follow-up of 40.25 months (range 1-70), the midterm mortality rates did not differ [5 (17.2%) EVAR vs. 3 (10.3%) OR, p = 0.41]. CONCLUSION: EVAR of rAAAs is feasible, with equal early and midterm mortality rates compared to open repair. When a defined patient selection is used for rupture, including hemodynamic status, there is no evidence of a better outcome with EVAR in emergency cases.     

Endovascular treatment of aortic aneurysms: State of the art

Opinion statement  Abdominal aortic aneurysms (AAAs) continue to be a leading cause of death, with increasing incidence and prevalence. Endovascular aneurysm repair (EVAR) now represents the most common method of AAA repair in the United States. Ongoing improvements in endovascular stent-graft technology have occurred since the first published report of EVAR in 1991. These improvements have led to multiple US Food and Drug Administration-approved devices, streamlined operative techniques, and extended applicability of EVAR. Despite these facts, basic anatomic considerations still eliminate many patients from being offered EVAR. Distinct advantages of EVAR over open repair have been demonstrated, including a less invasive operative exposure, decreased transfusion requirements, shortened intensive care unit and hospital stay, and decreased perioperative mortality. It is our opinion that in 2009, anatomically suitable patients should be offered EVAR as first-line therapy, except for the less common scenario of the young and fit patient, for which open repair should be strongly considered. Use of EVAR for ruptured AAAs also has shown promise, yielding survival results commensurate with the best single-center results with open repair for rupture. However, questions remain regarding the long-term efficacy of EVAR in preventing aneurysm-related death for all patients treated with this technique. As device improvements and technical advances continue, it is reasonable to expect that long-term results will improve as well. Furthermore, the advent of fenestrated and multi-branch endograft technology is expanding indications, and will continue to enlarge the percentage of patients who will be considered acceptable candidates for EVAR. Lastly, randomized clinical trials are under way to determine whether the generally accepted threshold of 5.5 cm for elective open AAA repair should be decreased in patients who are candidates for EVAR. Until further data emerge, standard guidelines for elective aneurysm repair should remain the norm.