Abdominal Aortic Aneurysm Rupture is not Associated with an Up-regulation of Inflammation within the Aneurysm Wall

BackgroundThe nature of the inflammatory change within ruptured AAA has not been extensively reported. The aim of this study was to compare the inflammatory response in non-ruptured and ruptured aneurysms with emphasis on the site of rupture.MethodsNon-rupture site biopsies were taken from the anterior aneurysm sac of non-ruptured (n = 31) and ruptured AAA (n = 20). In 12 ruptured AAA, a further biopsy was taken from the rupture site. Enzyme-linked immunosorbent assay was used to quantify IL-6, IL-1beta and TNF-alpha. Quantitative immunohistochemistry was undertaken for generic lymphocytes, T-cells, and B-cells.ResultsComparing biopsies in non-ruptured AAA versus a non-rupture site biopsy from ruptured AAA; there was no significant difference in IL-6, IL-1β, TNF-alpha, generic lymphocytes, T-cell or B-cell content. Comparing ruptured AAA – non-rupture site with rupture site; IL-6 and TNF-alpha were unchanged. By contrast IL-1β and lymphocytes were lower at the rupture site compared to the non-rupture site (IL-1β 1.39 ng/mg [0.97–2.29] vs. 1.92 ng/mg [1.46–2.57], p = 0.027; generic lymphocytes 2.89% [0.51–5.51] vs. 4.73% [2.27–12.40], p = 0.018; T-cells 0.28% [0.04–1.18] vs. 0.82% [0.40–1.36], p = 0.027; B-cells 0.16% [0.04–1.14] vs. 1.30% [0.32–5.40], p = 0.021).ConclusionsThese findings suggest the biological events leading to AAA rupture may not be dependent on an up-regulation in the inflammatory process.     

Is There a Benefit of Frequent CT Follow-up After EVAR?

ObjectiveImaging follow-up (FU) after endovascular aneurysm repair (EVAR) is usually performed by periodic contrast-enhanced computed tomography (CT) scans. This study aims to evaluate the effectiveness of CT-FU after EVAR.MethodsIn this study, 279 of 304 consecutive patients (261 male, aged 74 years (interquartile range (IQR): 70–79 years) with a median abdominal aortic aneurysm (AAA) diameter of 58 mm (IQR: 53–67 mm)) underwent at least one of the yearly CT scans and plain abdominal films after EVAR. All patients received Zenith stent-grafts for non-ruptured AAAs at a single institution. Patients were considered asymptomatic when a re-intervention was done solely due to an imaging FU finding. The data were prospectively entered in a computer database and retrospectively analysed.ResultsAs a follow-up, 1167 CT scans were performed at a median of 54 months (IQR: 34–74 months) after EVAR. Twenty-seven patients exhibited postoperative AAA expansion (a 5-year expansion-free rate of 88 ± 2%), and 57 patients underwent 78 postoperative re-interventions with a 5-year secondary success rate of 91 ± 2%. Of the 279 patients, 26 (9.3%) undergoing imaging FU benefitted from the yearly CT scans, since they had re-interventions based on asymptomatic imaging findings: AAA diameter expansion with or without endoleaks (n = 18), kink in the stent-graft limbs (n = 4), endoleak type III due to stent-graft limb separation without simultaneous AAA expansion (n = 2), isolated common iliac artery expansion (n = 1) and superior mesenteric artery malperfusion due to partial coverage by the stent-graft fabric (n = 1).ConclusionsLess than 10% of the patients benefit from the yearly CT-FU after EVAR. Only one re-intervention due to partial coverage of a branch by the stent-graft would have been delayed if routine FU had been based on simple diameter measurements and plain abdominal radiograph. This suggests that less-frequent CT is sufficient in the majority of patients, which may simplify the FU protocol, reduce radiation exposure and the total costs of EVAR. Contrast-enhanced CT scans continue, nevertheless, to be critical when re-interventions are planned.     

Endovascular management for peripheral arterial trauma: The new norm?

BackgroundEndovascular therapy is well studied in atraumatic conditions; and there appears to be a growing interest in its application to traumatic injuries. The objective of this study is to compare open and endovascular techniques in the management of peripheral arterial trauma.MethodsThis is a retrospective review of patients admitted to a Level I Trauma Center sustaining injuries to the subclavian, axillary, superficial femoral, and popliteal arteries. Demographics, surgical interventions, complications, and clinical outcomes were evaluated in patients requiring open or endovascular repair between 2009 and 2015.ResultsSixty-eight patients with 70 total arterial injuries were identified. There were 10 subclavian, 14 axillary, 15 superficial femoral, and 31 popliteal artery injuries.Endovascular (n = 20) compared to open repairs (n = 50) were more commonly performed: by vascular surgeons (90% vs. 54%, p = 0.01); in older patients (median age: 38 years vs. 25, p = 0.01); primarily involving upper extremity injuries (60% vs. 24%, p = 0.01). Furthermore, endovascular repairs less commonly required fasciotomy (15% vs. 46%, p = 0.03) and trended towards lower transfusion requirements (50% vs. 77%, p = 0.06). Patients undergoing open repair had lower pre-hospital systolic blood pressures (110 vs. 120, p = 0.03) and lower initial hematocrit (31.5 vs. 36.2, p = 0.02).However, outcomes between groups were trending higher in the endovascular group with respect to limb salvage rates at discharge (94% vs. 89%), median length of stay (14 days vs. 9), and median follow-up (288 days vs. 92) compared to the open group, but the data were not statistically significant. There was increasing utilization of endovascular repair over time (7% of total procedures in 2009; 50% in 2014).ConclusionsOverall, endovascular and open techniques were not statistically different in early outcomes. Endovascular therapy appears to provide some advantage when it comes to: challenging anatomy, decreasing blood product utilization, and minimizing physiologic derangement. However, patients with injuries resulting in free hemorrhage or significant external blood loss may still be best served with open repair. Despite this, given the increasing use of endovascular techniques, close collaboration is needed between trauma and endovascular specialists to properly select the optimal management for patients with peripheral arterial trauma.     

An Emergency EVAR Service Reduces Mortality in Ruptured Abdominal Aortic Aneurysms

ObjectivesThe aim of this study was to compare all in-hospital mortality for ruptured abdominal aortic aneurysms (rAAAs) before and after the establishment of an emergency EVAR (eEVAR) service.Design and methodsAn eEVAR service was established in January 2006, since when all patients presenting with rAAAs have been considered for endovascular repair. Data for all rAAAs presenting between January 2006 and December 2007 was prospectively collected (Group 1). This patient group was compared to those presenting with rAAA between January 2003 and December 2005 when eEVAR was not offered at our institution (Group 2). These records had also been collected prospectively and submitted to the National Vascular Database (NVD).ResultsA total of 50 rAAAs (17 eEVAR, 29 open repairs, 4 palliated) presented after the introduction of eEVAR (Group 1) and 71 in the historical Group 2 of which 54 underwent open repair and 17 were palliated. The total in-hospital mortality was significantly lower in Group 1 20% (eEVAR (n = 1), 6%: Open (n = 5), 17%: palliated (n = 4), 100%) when compared to Group 2 54% (Open (n = 21), 39%: palliated (n = 17), 100%) (p = 0.000001). Furthermore similar significant differences were seen in 30-day operative mortalities between the two groups 13% in Group 1 versus 39% in Group 2 (p = 0.0003). In addition the proportion of patients who were palliated has significantly decreased (8% Group 1 versus 24% Group 2, p = 0.01).ConclusionsThe establishment of an eEVAR service has significantly reduced in-hospital mortality for patients presenting with ruptured abdominal aortic aneurysms.     

Search for Serum Biomarkers Associated with Abdominal Aortic Aneurysm Growth – A Pilot Study

IntroductionSerological biomarkers could reflect asymptomatic infrarenal aortic aneurysm (AAA) activity and guide patient management.ReportSerum concentrations of C-reactive protein (CRP), alpha 1-antitrypsin and lipoprotein(a) were measured in blood samples from 35 AAA patients and 35 controls and correlated with the aortic diameter and AAA growth in the previous 12 months.We found a positive correlation between CRP and AAA diameter (r = 0.46; p = 0.007) and alpha 1-antitrypsin and AAA growth (r = 0.55; p = 0.004).ConclusionsAlpha 1-antitrypsin may be a promising biomarker of AAA growth.     

Endovascular Repair of the Thoracic Aorta: Predictors of 30-Day Mortality in Patients on the New Zealand Thoracic Aortic Stent Database (NZ TAS)

ObjectivesTo evaluate data in the New Zealand Thoracic Aortic Stent database to try and identify a scoring system that could predict 30-day mortality in patients undergoing stenting of the descending thoracic aorta (TEVAR).DesignRetrospective analysis of the New Zealand thoracic aortic stent database between December 2001 and August 2007.Materials and methodsThe 30-day mortality of the 122 patients is 7.38% (n = 9). Risk factors were recorded based on the Society of Thoracic Surgeons (STS) risk score. Glasgow aneurysm score was calculated and the pathology being treated analysed. Univariate analyisis was carried out.ResultsThe mortality of three pathology groups was compared. 30-day mortality was 2.04% (n = 1) in the elective aneurysm group, 17.95% (n = 7) in the complicated Stanford type B dissection group, and 0% (n = 0) in the trauma group. Thirty-day mortality is significantly higher in the dissection group compared with the elective aneurysm (p = 0.02) and trauma (p = 0.03) groups. The most frequent risk factors in the dissection group of patients were peripheral vascular disease, smoking and hypertension. Although percentage mortality is higher with increasing GAS, the results are not statistically significant (p = 0.34). No independent risk factors were identified from the STS risk score data.ConclusionNo specific risk score system seems to be able to predict mortality in TEVAR patients.     

Evidence that Statins Protect Renal Function During Endovascular Repair of AAAs

ObjectivesSeveral studies have documented a slight but significant deterioration of renal function after endovascular repair of abdominal aortic aneurysm (AAA) (EVAR). The aim of this retrospective study was therefore to investigate whether medication with statins may favourably affect perioperative renal function.Material and MethodsFrom January 2000 to January 2008, out of a total cohort of 287 elective patients receiving endovascular repair of their AAA or aortoiliac aneurysm, 127 patients were included in the present study, as their medication was reliably retrievable. Patients were divided according to whether their medication included statins (>3 months). Second, they were subdivided according to their supra- (SR) or infrarenal (IR) endograft fixation. Serum creatinine (SCr) and creatinine (CrCl) clearance were determined preoperatively, postoperatively, at 6 and 12 months. Patients with known pre-existing renal disease, with incorrect placement of the stent graft resulting in severe renal artery stenosis, and with occlusion or renal parenchymal infarction were excluded from the study.ResultsPatients receiving an infrarenal fixation of their graft had no change in the renal function, regardless whether they were on statins or not. In patients with SR fixation not receiving statins, a deterioration in renal function was observed in the early postoperative period ((SCr) preoperative vs. SCr postoperative: 1.02 ± 0.2 vs. 1.11 ± 0.28, p < 0.001 and (Cr.Cl) preoperative vs. Cr.Cl postoperative: 74.1 ± 21.4 vs. 68.0 ± 21.4, p < 0.001), whereas patients on statins experienced no change in renal function (SCr preoperative vs. SCr postoperative: 0.99 ± 0.24 vs. 1.02 ± 0.20 n.s. and Cr.Cl preop vs. Cr.Clpostop.: 76.4 ± 19.1 vs. 74.28 ± 20.50, n.s.). During follow-up, a constant worsening of renal function at 6 and 12 months was observed, irrespective of the medication with statins.ConclusionsThe present study suggests a slight immediate deterioration of the renal function using (SR) fixation, and this could be prevented by the use of statins. During follow-up, statins did not protect from further renal deterioration. Broader studies are needed to confirm a definitive relation between statin use and renal protection during the endovascular repair of AAA.     

Simultaneous Aortic and Coronary Assessment in Abdominal Aortic Aneurysm Patients by Thoraco-abdominal 64-Detector-row CT Angiography: Estimate of the Impact on Preoperative Management: A Pilot Study

ObjectivesTo estimate the influence of information on the coronary arteries obtained from routine thoraco-abdominal CT angiography (CTA) on pre-operative clinical management in abdominal aortic aneurysm (AAA) patients.MethodsTwenty-eight AAA patients underwent pre-operative thoraco-abdominal electrocardiography (ECG)-gated 64-detector-row CTA to evaluate aortic pulsatility for prosthesis size matching. Retrospectively, the coronaries were reconstructed from the same data set and scored on a per segment basis for stenosis (0%, ≤50% or >50%) and grading confidence (poor, adequate or high). An experienced cardiologist was presented information on patient characteristics obtained from patient records and CTA findings. Suggested changes in European Society of Cardiology guidelines based patient management based on CTA information were scored.ResultsOn CTA, 17 patients (61%) had significant coronary disease (>50% stenosis) including left main (n = 4), single (n = 7) and multiple (n = 6) vessel disease. Grading confidence was adequate or high in 86% of proximal and middle segments. Based on CTA findings, patient management would have been changed in 4 out of the 28 patients (14%; 95% CI 1–27%) by adding coronary angiography (n = 4). In five patients who underwent coronary artery bypass grafting previously, CT did not change management but confirmed graft patency.ConclusionsInformation on coronary pathology and coronary bypass graft patency can be readily obtained from thoraco-abdominal CTA and may alter pre-operative patient management, as shown in 14% of AAA patients in our study.     

Association of IL-2RA and IL-2RB genes with erosive status in early rheumatoid arthritis patients (ESPOIR and RMP cohorts)

ObjectivesTo assess the impact of single nucleotide polymorphisms (SNPs) in IL-2RA (rs2104286) and IL-2RB (rs743777 and rs3218253) genes on the risk of erosions in rheumatoid arthritis (RA) patients.MethodsThis work is derived from 2 prospective cohorts of early RA: ESPOIR (n = 439) and RMP (n = 180). The proportions of patients with erosions at baseline and 1 year according to the genotypes of IL2RA (rs2104286) or the haplotypes constructed with the 2 SNPs of IL2RB were compared in the whole population and in ACPA positive patients. A meta-analysis assessing the risk of erosion depending on the haplotypes of the 2 SNPs of IL-2RB was performed using the Mantel-Haenszel method. A multivariate model was used to assess the independent effect of the haplotypes of IL-2RB on the risk of erosions.ResultsThe AC haplotype of IL-2RB carriage was significantly associated with the rate of erosions in ACPA positive patients in ESPOIR cohort (rate of erosions: AC/AC: 78% versus GC or GT/GC or GT: 44%, p = 0.001). A meta-analysis of ESPOIR and RMP cohorts confirmed that the carriage of AC haplotype was significantly associated with the rate of erosions at 1 year in the whole sample (OR[95%CI] = 1.92[1.14–3.22], p = 0.01) and in ACPA positive patients (OR[95%CI] = 3.34[1.68–6.67], p = 0.0006). A multivariate model in ESPOIR cohort demonstrated the independent effect of the carriage of the AC haplotype (6.03[1.94–18.69], p = 0.002) on the risk of erosions in ACPA+ patients.ConclusionA haplotype constructed with 2 SNPs located on IL-2RB gene was associated with erosive status in early RA.     

French collaborative group series on giant intracranial aneurysms: Current management

ObjectivesGiant intracranial aneurysms represent a major therapeutic challenge for each surgical team. The aim of our study was to extensively review the French contemporary experience in treating giant intracranial aneurysms in order to assess the current management.Patients and methodsThis retrospective multicenter study concerned consecutive patients treated for giant intracranial aneurysms (2004–2008) in different French university hospitals (Bordeaux, Caen, Clermont-Ferrand, Lille, Lyon, Nice, Paris-Lariboisière, Rouen et Toulouse). Different variables were analyzed: the diagnostic circumstances, the initial clinical status based on the WFNS scale, aneurysmal features and exclusion procedure. At 6 months, the outcome was evaluated according to the modified Rankin Scale (mRS): favorable (mRS 0-2) and unfavorable (mRS 3-6). A multivariate logistic regression model included all the independent variables with P < 0.25 in the univariate analysis (P < 0.05).ResultsA total of 79 patients with a mean age of 51.5 ± 1.6 years (median: 52 years; range: 16–79) were divided into two groups, with the ruptured group (n = 26, 32.9%) significantly younger (P < 0.05, Student's-t-test) than the unruptured group (n = 53, 67.1%). After SAH, the initial clinical status was good in 12 patients (46.2%), and in the unruptured group, the predominant diagnosis circumstance was a pseudo-tumor syndrome occurring in 22 (41.5%). The first procedure of aneurysm treatment in the global population was endovascular in 42 patients (53.1%), microsurgical in 29 (36.7%) and conservative in 8 (10.2). An immediate neurological deterioration was reported in 38 patients (48.1%) after endovascular treatment in 19 (45.2% of endovascular procedures), after miscrosurgical in 15 (51.7% of microsurgical procedures) and after conservative in 4 (the half). At 6 months, the outcome was favorable in 45 patients (57%) and after multivariate analysis, the predictive factors of favorable outcome after management of giant cerebral aneurysm were the initial good clinical status in cases of SAH (P < 0.002), the endovascular treatment (P < 0.005), and the absence of neurological deterioration (P < 0.006). The endovascular procedure was obtained as a predictive factor because of the low risk efficacy of indirect procedures, in particular a parent vessel occlusion.ConclusionThe overall favorable outcome rate concerned 57% of patients at 6 months despite 53.8% of poor initial clinical status in cases of rupture. The predictive factors for favorable outcome were good clinical status, endovascular treatment and the absence of postoperative neurological deterioration. Endovascular treatment should be integrated into the therapeutic armenmatarium against giant cerebral aneurysms but the durability of exclusion should be taken into account during the multidisciplinary discussion by the neurovascular team.     

Endovascular repair of abdominal aortic aneurysm: Getting out of trouble

The standard techniques of endovascular aneurysm repair sometimes fail to produce atraumatic stent-graft delivery of hemostatic implantation, and additional maneuvers are required to avoid conversion to open repair. Between June 1996 and May 1997 elective endovascular aneurysm repair was performed in 33 high risk patients, using a Z-stent-based prosthesis. Challenging anatomic features included: short neck (<15 mm) in four cases, angulated neck (>60°) in seven, iliac aneurysm in six, and iliac tortuosity (>80°) in 24. There were no deaths, no renal failure, no pulmonary failure, no graft thrombosis, no migration, and no conversions to open surgery. Deviations from standard technique were required to treat iliac artery dissection, iliac artery stenosis, and leaks resulting from proximal stent malalignment, proximal stent malposition, and distal stent malposition. The necessary adjunctive maneuvers included: additional stent placement, additional stent-graft placement, and balloon dilatation. Mean operating time was 191 ± 72 min, mean contrast volume was 148 ±76 ml, and mean blood loss was 314 ± 427 ml. Mean time from operation to discharge from the hospital was 3.5 ± 1.67 days. These short-term results demonstrate that endovascular aneurysm repair is safe and effective in high risk patients, only if adjunctive maneuvers are available to supplement standard technique.     

Sex differences in perioperative outcomes after complex abdominal aortic aneurysm repair

ObjectiveFemale sex is associated with worse outcomes after infrarenal abdominal aortic aneurysm (AAA) repair. However, the impact of female sex on complex AAA repair is poorly characterized. Therefore, we compared outcomes between female and male patients after open and endovascular treatment of complex AAA.MethodsWe identified all patients who underwent complex aneurysm repair between 2011 and 2017 in the American College of Surgeons National Surgical Quality Improvement Program targeted vascular module. Complex repairs were defined as those for juxtarenal, pararenal, or suprarenal aneurysms. We compared rates of perioperative adverse events between female and male patients stratified by open AAA repair and endovascular aneurysm repair (EVAR). We calculated propensity scores and used inverse probability-weighted logistic regression to identify independent associations between female sex and our outcomes.ResultsWe identified 2270 complex aneurysm repairs, of which 1260 were EVARs (21.4% female) and 1010 were open repairs (30.7% female). After EVAR, female patients had higher rates of perioperative mortality (6.3% vs 2.4%; P = .001) and major complications (15.9% vs 7.6%; P < .001) compared with male patients. In contrast, after open repair, perioperative mortality was not significantly different (7.4% vs 5.6%; P = .3), and the rate of major complications was similar (29.4% vs 27.4%; P = .53) between female and male patients. Furthermore, even though perioperative mortality was significantly lower after EVAR compared with open repair for male patients (2.4% vs 5.6%; P = .001), this difference was not significant for women (6.3% vs 7.4%; P = .60). On multivariable analysis, female sex remained independently associated with higher perioperative mortality (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.3-4.9; P = .007) and major complications (OR, 2.0; 95% CI, 1.3-3.2; P = .002) in patients treated with EVAR but showed no significant association with mortality (OR, 0.9; 95% CI, 0.5-1.6; P = .69) or major complications (OR, 1.1; 95% CI, 0.8-1.5; P = .74) after open repair. However, the association of female sex with higher perioperative mortality in patients undergoing complex EVAR was attenuated when diameter was replaced with aortic size index in the multivariable analysis (OR, 1.9; 95% CI, 0.9-3.9; P = .091).ConclusionsFemale sex is associated with higher perioperative mortality and more major complications than for male patients after complex EVAR but not after complex open repair. Continuous efforts are warranted to improve the sex discrepancies in patients undergoing endovascular repair of complex AAA.     

Multidisciplinary management of posterior fossa dural arteriovenous fistula: A single-center experience

PurposeThe management of posterior fossa dural arteriovenous fistulas (pfDAVFs) is challenging. Here, we show how multidisciplinarity leads to their successful management, even in complex cases.MethodsAll pfDAVFs managed from 2010 to 2019 at our center were reviewed. The preoperative clinical and radiological characteristics, their management and the occlusion rate were retrieved. The radiological and functional outcomes were retrieved at discharge and last follow-up (FU).Resultsn = 27 patients were included (6 females, mean age: 61-years-old, mean FU: 22.5 months). n = 8 patients presented with cerebral hemorrhage. Among patients with ruptured pfDAVFs, n = 7 had headache, n = 4 had ataxia, and n = 2 had impaired level of consciousness. In the unruptured group N (n = 19), n = 7 patients had headache, n = 6 patients had focal neurological deficit, n = 4 patients had tinnitus, n = 3 (had ataxia, and one presented with seizure. n = 24 patients were treated by endovascular therapy (EVT), n = 2 patients were treated by microsurgery (MS) and n = 1 patient was managed with a combined approach. Re-treatment was necessary in n = 6 patients. n = 24 patients showed total exclusion at last FU. n = 2 patients died during the first 30 days; n = 1 patient died during FU.ConclusionsWhile EVT should be advocated as the first line therapy whenever possible, MS should not be banned from the treatment armamentarium. Neurosurgeons must be able to achieve direct surgical occlusion when the angioarchitecture speaks against EVT.     

Surgical Therapy of Extracranial Carotid Artery Aneurysms: Long-Term Results over a 24-Year Period

BackgroundTo evaluate long-term results of surgical therapy of extracranial carotid artery aneurysms (ECCA) and to provide a morphologic classification for individual surgical reconstruction techniques.Patient and methodsThis retrospective analysis includes 57 patients (43 male, mean age 61.9 years.) with 64 carotid reconstructions for ECCA between 1980 and 2004. In 29 (50.9%) of the patients there was found a cerebral ischemic event as an initial symptom (18 transient ischemic attacks, 11 strokes). In patients without cerebral events, the presenting symptom was pulsatile cervical mass in 19 and cranial nerve dysfunction in 3 cases. ECCA was morphologically stratified in Type I = isolated aneurysms of the internal carotid artery (n = 25), Type II = aneurysms of the complete internal carotid artery with involvement of the bifurcation (n = 8), Type III = aneurysms of the carotid bifurcation (n = 20), Type IV = combined aneurysm of the internal and common carotid artery (n = 5) and Type V = isolated aneurysm of the common carotid artery (n = 6).ResultsPerioperative stroke rate was 1.6%. 4 patients suffered from transient ischemic attacks (6.3%). Permanent and transient cranial nerve injury rate was 6.3% and 20.3% respectively. After 5, 10, 15 and 20 years the actuarial survival was 90%, 77%, 65% and 57%. The ipsilateral stroke-free time was 96%, 96%, 93% and 87%, respectively.ConclusionsSurgical reconstruction of extracranial carotid aneurysms is a safe procedure with good long-term results. The risk of a permanent, perioperative cerebral neurological deficit is low, but there is a considerable risk of cranial nerve injury.     

Inter–rater reliability of the simplified Modified Rankin Scale as an outcome measure for treated cerebral aneurysm patients

BackgroundThe modified Rankin scale (mRS) is commonly used as a clinical outcome measure in aneurysm trials, but inter–observer reliability in treated patients has not been tested.MethodsWe reviewed the literature on inter–observer reliability studies of the mRS. Sixty patients with ruptured (n = 47) or unruptured (n = 13) aneurysms treated with endovascular methods (n = 34) or surgical clipping (n = 26) were independently evaluated by a neurosurgeon, a stroke neurologist, and a novice research assistant, and a simplified mRS score assigned. Results were analyzed using Gwet's AC_1/2 reliability coefficients (K_G).ResultsNo previous reports validating the reliability of the mRS in treated aneurysm patients were identified. Using the mRS 0–5, inter–rater agreement was almost perfect (K_G = 0.89 [0.86–0.93]). Agreement between raters remained almost perfect regardless of the rater's expertise. Agreement was almost perfect (K_G = 0.87 [0.77–0.96] when the mRS was dichotomized 0–2 vs 3–5, but fell to moderate when dichotomized 0–1 vs 2–5 (K_G = 0.59 (0.42–0.75). Agreement using the 0–2 vs 3–5 dichotomized mRS remained almost perfect for coiled (K_G = 0.90), clipped (K_G = 0.82), ruptured (K_G = 0.84), and unruptured (K_G = 0.95) aneurysms. Dichotomization of results at 0–1 vs 2–5 would have resulted in an (undesirable) significant difference in good outcomes between raters (P = .003), but not at 0–2 vs 3–5 (P = .52).ConclusionThe simplified mRS appears to be a reliable clinical outcome measure for treated cerebral aneurysm patients. When needed, dichotomization is more reliable at mRS 0–2 vs 3–5 than at 0–1 vs 2–5. The simplified mRS is a promising tool in the functional assessment of aneurysm patients recruited in pragmatic care trials.     

Influencia del acceso laparoscópico en la mortalidad cáncer-específica de los pacientes con cáncer de vejiga en un estadio pTa-2pN0R0 tratados con cistectomía radical

Introduction and objectiveMinimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality.Material and methodA retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n = 191) and laparoscopic radical cystectomy (LRC) (n = 74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival.Results90.9% were males with a median age of 65 years and a median follow-up period of 65.5 (IQR 27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P = .0001), a longer time between TUR and cystectomy (P = .04), a lower rate of intraoperative transfusion (P = .0001), a lower pT stage (P = .002) and a lower incidence of infection associated with surgical wounds (P = .04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P = .007). Open approach to cystectomy multiplied the risk of mortality by 3.27.ConclusionsIn our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.     

Estudio observacional retrospectivo correlacionando las fracturas traumáticas de pelvis y sus lesiones asociadas según la clasificación de Tile

IntroductionPelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification.MethodsRetrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016.ResultsA total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P=.032), and Tile B with sacral fractures (P=.033) and visceral injuries (P=.049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock.ConclusionsTile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.     

Treatment of Complex Aneurysmal Disease with Fenestrated and Branched Stent Grafts

ObjectivesTo describe our experience of treating juxtarenal (JRAAA's <4 mm neck) and thoracoabdominal aortic aneurysms (TAAA's) using fenestrated and branched stent graft technology.DesignProspective single centre experience.MethodsSince 2005, 29 fenestrated/branched procedures have been performed. 15 patients are studied with JRAAAs (n = 7; median neck length 0 mm (IQR 0–3.8)) or TAAAs (type I (n = 2), III (n = 2), IV (n = 4)). ASA grade III in 12/15. Maximum diameter of aneurysm 64 mm (56–74 mm). Aneurysms were excluded using covered stents or branches from the main body to patent visceral vessels (40 target vessels total). Pre-operative and follow-up CT scans (1, 3, and 12 months) were analysed by a single Vascular Interventional Radiologist.ResultsTechnical success for cannulation and stenting of target vessels was 98%. In-hospital mortality was 0%. One patient underwent conversion to open repair. Five had major complications including one paraplegia (type III TAAA) with subsequent recovery. Median length of stay was 9 days (IQR 7–18.75).At a median follow-up of 12 months (9–14), CT confirmed 36/37 (97%) target vessels remain patent. Sac size increased >5 mm in one patient only. There were no type I endoleaks, three type II endoleaks (one embolised, two under surveillance) and three type III endoleaks (two successfully treated percutaneously, one aneurysm ruptured 18 months after endografting and died).ConclusionIn selected patients, fenestrated and branched stents appear to be a safe and effective alternative to surgery for juxtarenal and thoracoabdominal aneurysms. The complication and mortality rates are low. The long-term durability of this procedure, however, needs to be proven.     

Clinical and Angiographic Follow-up of Spontaneous Isolated Superior Mesenteric Artery Dissection

ObjectivesTo observe the clinical features and angiographic findings in patients with a spontaneous isolated superior mesenteric artery dissection (SISMAD) and to identify any correlation between them.MethodsFrom a single institution, 32 patients (22 symptomatic patients at presentation; mean age 54 years; men 97%) with SISMAD were retrospectively reviewed. All patients were available for clinical follow-up after treatment (conservative, n = 28, 88%, open or endovascular superior mesenteric artery (SMA) reconstruction, n = 4, 12%), and follow-up CT scans were available in 28 patients (mean 22 months, range 1–80 months).ResultsWe found a positive correlation between pain severity and dissection length (p = 0.03, ρ = 0.50, Spearman's partial correlation analysis). After conservative treatment, only one patient (3%) required bowel resection, and there was no difference in outcome between patients who were treated with anticoagulation or anti-platelet therapy and those who were not (p = 1.00, Fisher's exact test). No patients had progression of their lesion on the follow-up CT angiography.ConclusionsIn SISMAD patients, dissection length is positively associated with more severe clinical symptoms. After conservative treatment, we observed a benign clinical course and no CT progression of the dissection, even without anticoagulation or anti-platelet therapy. Based on our observation, patients with SISMAD can be treated conservatively without anticoagulation therapy.     

Aortic Length Changes During Abdominal Aortic Aneurysm Formation,Expansion and Stabilisation in a Rat Model

BackgroundDeterminants of extracellular matrix (ECM) destruction/reconstruction balance influencing abdominal aortic aneurysm (AAA) diameter may impact length.ObjectiveDocument aortic lengthening, its correlation to diameter, and determine how treatments that impact diameter also affect length.MethodsThree hundred and fifty-five diameter and length measurements were performed in 308 rats during AAA formation, expansion and stabilisation in guinea pig aortas xenografted in rats. Impact of modulation of ECM destructive/reconstructive balance by endovascular Vascular Smooth Muscle Cell (VSMCs) seeding, TIMP-1, PAI-1 and TGF-beta1 overexpression on length has been assessed.ResultsLength increased in correlation with diameter during formation (correlation coefficient (cc): 0.584, P < 0.0001) and expansion (cc: 0.352, P = 0.0055) of AAAs. Overexpression of TIMP-1 and PAI-1 decreased lengthening (P = 0.02 and 0.014, respectively) demonstrating that elongation is driven by matrix metalloproteinases and their activation by the plasmin pathway. Overexpression of TGF-beta1 controlled length in formed AAAs (17.3 ± 9.6 vs. 5.9 ± 7.4 mm, P = 0.022), but not VSMC seeding, although both therapies efficiently prevented further diameter increase. Length and diameter correlation was lost after biotherapies.ConclusionLength increases in correlation with diameter during AAA formation and expansion, as a consequence of ECM injury driven by MMPs activated by the plasmin pathway. Correlation between length and diameter increases is not universally preserved.