Search

Background: In patients with a symptomatic abdominal aortic aneurysm (sAAA), acute intervention theoretically reduces rupture risk prior to surgery whereas delayed intervention provides surgery under optimised conditions. In the present study we evaluated differences in 30-day mortality in patients with a sAAA operated within 12 hours compared to patients who received treatment after 12 hours and who were optimized for surgery., Methods: All patients with a sAAA who were treated within one week after presentation were included in the analyses. The 30-day mortality rates of patients operated within 12 hours were compared to those operated after 12 hours, adjusted for type of operation and for all potential confounders., Results: Of the 89 included patients, 37 patients received surgery within 12 hours. In patients treated within 12 hours, 30-day mortality rate was 6 (16.2%) compared to 3 (5.8%) in patients treated after 12 hours (odds ratio 0.316; CI 0.074-1.358). When adjusted for type of operation and other confounders, odds ratios were 0.305 (CI 0.066-1.405) and 0.270 (CI 0.015-4.836), respectively., Conclusions: In a substantial amount of patients with an alleged symptomatic AAA, delayed surgery with patient optimisation might be justified. However, specific criteria in order to select patients that might benefit from delayed surgery need further investigation.

The aim of the paper is to prospectively describe early and mid-term outcomes for emergency endovascular aneurysm repair (eEVAR) versus open surgery in acute abdominal aortic aneurysms (aAAAs), both unruptured (symptomatic) and ruptured. We enrolled all consecutive patients treated for aAAA at our center between April 2002 and April 2008. The main outcome parameters were 30-day, 6- and 12-month mortality (all-cause and aneurysm-related). Two hundred forty patients were enrolled in the study. In the unruptured aAAA group (n = 111), 47 (42%) underwent eEVAR. The 30-day, 6- and 12-month mortality rates were 6, 13 and 15% in the eEVAR group versus 11% (NS), 13% (NS) and 16% (NS) in the open group, respectively. In the ruptured aAAA group (n = 129), 25 (19%) underwent eEVAR (mortality rates: 20, 28 and 36%, respectively) compared with 104 (81%) patients who underwent open surgery (mortality rates: 45% (P = 0.021), 60% (P = 0.004) and 63% (P = 0.014), respectively). In conclusion, the present study showed a reduced 30-day, 6- and 12-month mortality of eEVAR compared with open surgery in all patients with aAAA, mainly due to a lower mortality in the ruptured aAAA group. Late aneurysm-related mortality occurred only in the eEVAR group.

Objective: The aim of the study was evaluating the diagnostic value of plasma matrix metalloproteinase- (MMP)-2 and -9 and tissue inhibitor of MMP-1 (TIMP-1) for endoleak detection after endovascular aneurysm repair (EVAR)., Report: Consecutive EVAR patients (n = 17) with endoleak and matched controls without endoleak (n = 20) were prospectively enrolled. Increased levels of MMP-9 were observed in patients with endoleak (P < 0.001). Regression analysis showed no significant influence of age, sex or abdominal aortic aneurysm (AAA) size. The receiver operating characteristic (ROC) curve of plasma MMP-9 levels showed that a cut-off value of 55.18 ng ml(-1) resulted in 100% sensitivity and 96% specificity with an AUC value of 0.988 (P < 0.001) to detect endoleak., Conclusions: Plasma MMP-9 levels appear to discriminate between patients with and without an endoleak with high sensitivity and specificity., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: Anastomotic pseudoaneurysms and true para-anastomotic aneurysms after initial open abdominal aortic prosthetic reconstruction often need reintervention because they are at risk for rupture. However, open surgical reinterventions are technically challenging procedures with high mortality and morbidity rates. In the present multicenter study, we describe the long-term clinical course in an expanded number of patients who underwent endovascular repair of para-anastomotic aneurysms after previous open reconstruction., Methods: The study included all patients who were treated with an endovascular stent graft between July 1999 and July 2009 for an aortoiliac anastomotic pseudoaneurysm or a true para-anastomotic aneurysm after previous aortic prosthetic reconstruction for aneurysmal or occlusive disease in one of the four participating centers. Main outcomes were long-term complications, reinterventions and conversion rate, mortality, and hospital length of stay., Results: An endovascular stent graft was used to treat 58 patients (53 men; mean age, 71 ± 9 years), with 80 aortic or iliac pseudoaneurysms or true para-anastomotic aneurysm, or both. Bifurcated stent grafts were used in 32 patients, endovascular tube grafts in eight, aortouniiliac stent grafts in seven, and iliac extension grafts in 11. Stent graft deployment was successful in 55 patients, for a technical success rate of 95%. Median hospital admission was 3 days (range, 1-122 days). The 30-day and in-hospital mortality rates were 3.4% (n = 2) and 6.9% (n = 4), respectively. The 30-day clinical success rate was 91% (n = 53). Median follow-up was 41 months (range, 0-106 months). The cumulative and procedural-related mortality during follow-up was 19% (n = 11) and 10% (n = 6), respectively. Follow-up computed tomography angiography revealed nine endoleaks (three type I; six type II) in eight patients and endotension in two patients. The overall reintervention and conversion rate during follow-up was 26.9% (n = 15) and 6.9% (n = 4), respectively. Life-table analysis showed reduced freedom from reintervention for aortouniiliac and tube stent grafts. Type I endoleaks were observed in 25% of patients with endovascular aortic tube grafts for proximal anastomotic aneurysms., Conclusions: The present study demonstrates that endovascular repair of para-anastomotic aortic and iliac aneurysms after initial prosthetic aortic surgery is safe and durable in patients with an appropriate anatomy. The long-term follow-up showed fewer complications occurred after procedures with bifurcated stent grafts compared with procedures with tube grafts, aortouniiliac, or iliac extension stent grafts., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

In patients presenting with a ruptured abdominal aortic aneurysms (AAA), a choice can be made whether or not to offer treatment (selective treatment policy). Patients with a realistic expectation of survival after surgery, identified by several available prediction models, can be offered two treatment options: conventional "open" surgical repair and endovascular "minimally invasive" repair. Conventional open repair carries a significant morbidity and mortality, due to the combined effects of general anaesthesia and surgical exposure. Based on anatomical criteria assessed on a pre-operative CT angiography scan, approximately half of the ruptured AAA are suitable for endovascular aneurysm repair (EVAR). The majority of comparative studies show a clear trend towards lower perioperative mortality for endovascular repair compared to open surgery. The overall analyses of EVAR compared to open surgery, taking one randomised controlled trial and 23 available observational studies into account, showed a 38% decrease in 30-day or hospital mortality rate (Peto odds ratio 0.62; 95% CI 0.52 to 0.74). However, these mainly observational studies show considerable heterogeneity. Furthermore, potential selection bias, selecting patients for endovascular repair constituting a haemodynamically lower-risk category with a more favourable EVAR suitable anatomic configuration, makes a proper comparison unlikely. Therefore, randomised controlled trials, although difficult to perform in an acute severe condition like ruptured AAA, are needed to identify possible benefits of EVAR over open surgery in patients with a ruptured AAA.

Objective: The reported mortality reduction of emergency endovascular aneurysm repair (eEVAR) compared with open repair in patients with a ruptured abdominal aortic aneurysm (rAAA), as observed in observational studies, might be flawed by selection bias based on anatomical suitability for eEVAR. In the present study, we compared mortality in EVAR suitable versus non-EVAR-suitable patients with a ruptured AAA who were all treated with conventional open repair., Materials and Methods: In all patients presenting with a suspected rAAA, computed tomography angiography (CTA) scanning was performed. All consecutive patients with a confirmed rAAA on preoperative CTA scan and treated with open repair between April 2002 and April 2008 were included. Anatomical suitability for eEVAR was determined by two blinded independent reviewers. Outcomes evaluated were mortality (intra-operative, 30-day, and 6-month), morbidity, complications requiring re-intervention and length of hospital stay., Results: A total of 107 consecutive patients presented with a rAAA and underwent preoperative CTA scanning. In 25 patients, eEVAR was performed. In the 82 patients who underwent open repair, CTA showed an EVAR-suitable rAAA in 33 patients (41.8%) and a non-EVAR-suitable rAAA in 49 patients. Thirty-day and 6-month mortality rate was 15/33 (45.5%; 95% confidence interval (CI) 28.1-63.7) and 18/33 (54.5%; 95% CI 36.4-71.9) in the EVAR-suitable group versus 24/49 (49.0%; 95% CI 34.4-63.7) (P=0.75) and 29/49 (59.2%; 95% CI 44.2-73.0) (P=0.68) in the non-EVAR-suitable group, respectively., Conclusions: The present study suggests that anatomical suitability for EVAR is not associated with lower early and midterm mortality in patients treated with open ruptured AAA repair. Therefore, the reported reduction in mortality between eEVAR and open repair is unlikely due to selection bias based on anatomical AAA configuration., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Efficacy results of endovascular repair (rEVAR) for ruptured abdominal aortic aneurysm (rAAA) compared with open surgery are based on several observational studies containing selection bias. The present study compared rEVAR with open surgery in EVAR-suitable patients with an rAAA who all underwent the same preoperative imaging protocol., Methods: Our policy is to perform a computed tomography angiography on all patients with a suspected rAAA. rEVAR was performed when the rEVAR-vascular surgeon was on call and the patient was suitable for EVAR. Afterwards, two experienced independent blinded experts assessed all computed tomography angiography (CTA) scans on EVAR-suitability. Only EVAR-suitable patients were included in the main analyses. Outcome parameters included mortality (intraoperative, 30-day, and 6-month), complications, reinterventions, and length of hospital stay., Results: From April 2002 until March 2008, 132 consecutive patients with suspected rAAAs were presented. Preoperative CTA confirmed rAAA in 104 patients, of whom 25 underwent rEVAR, and 79 underwent open surgery. In retrospect, the 25 rEVAR patients and 33 patients in the open group were judged EVAR-suitable by the experts. At baseline, there was an equal distribution of physiologic and anatomic characteristics as well as comorbidity. In EVAR-suitable patients, the intraoperative, 30-day, and 6-month mortality was 4.0% (1 of 25), 20.0% (5 of 25), and 28.0% (7 of 25) after rEVAR compared with 6.1% (2 of 33; P >.99), 45.5% (15 of 33; P = .04), and 54.5% (18 of 33; P = .04) after open surgery, respectively. Median length of hospital stay was 9.5 days (interquartile range, 5.0-20.5) after rEVAR and 17.0 days (interquartile range, 9.5-28.0) after open surgery (P = .03)., Conclusions: In EVAR-suitable patients, an absolute perioperative mortality reduction of 25.5% of rEVAR over open surgery was found, which was still present at 6 months of follow-up. These data suggest that rEVAR is a superior treatment option for EVAR-suitable patients with an rAAA compared with an open surgery., (Crown Copyright (c) 2010. Published by Mosby, Inc. All rights reserved.)

Purpose: To compare diagnostic accuracy between contrast-enhanced ultrasound (US) and computed tomographic (CT) angiography to detect changes in abdominal aortic aneurysm (AAA) size and endoleaks during follow-up after endovascular aneurysm repair (EVAR)., Materials and Methods: Between May 2006 and December 2008, 83 patients were consecutively enrolled for contrast-enhanced US and CT angiography imaging during surveillance after EVAR, yielding 127 paired examinations. Comparative analysis was performed for the anteroposterior and transverse maximal diameters of the aneurysm sac and for the presence or absence of endoleak, as determined by US and CT angiography., Results: Contrast-enhanced US demonstrated significantly more endoleaks, predominantly of type II, compared with CT angiography (53% vs 22% of cases). The number of observed agreements was 77 of 127 (61%), indicating a low level of agreement (kappa value of 0.237). US was as accurate as CT angiography in the assessment of maximal aneurysm sac diameters, as shown by Bland-Altman analyses and low coefficients of variation (8.0% and 8.6%, respectively). The interobserver variability for AAA size measurement by US was low, given the interclass correlation coefficients of 0.99 and 0.98 for anteroposterior and transverse maximal diameters, respectively., Conclusions: Contrast-enhanced US may be an alternative to CT angiography in the follow-up of patients after EVAR. As US reduces exposure to the biologic hazards associated with lifelong annual CT angiography, including cumulative radiation dose and nephrotoxic contrast agent load, contrast-enhanced US might be considered as a substitute for CT angiography in the surveillance of patients after EVAR.

Currently, two treatment options for ruptured abdominal aortic aneurysms (AAA) are available: conventional open surgical repair and endovascular minimally invasive repair. Open repair carries a significant morbidity and mortality rate, most probably due to the combined effects of general anaesthesia and surgical exposure. Based on anatomical characteristics as assessed by CT scan, approximately half of the patients with a ruptured AAA are eligible for endovascular minimally invasive repair. The majority of comparative studies show a clear trend towards a lower perioperative mortality rate for endovascular repair compared to open surgery (18-24% and 34-38%, respectively) and more rapid recovery. However, these mainly observational studies show considerable heterogeneity. Furthermore, potential selection bias, where patients with a more favourable anatomic and haemodynamic profile are more likely to be selected for endovascular repair, makes a proper comparison barely possible.The potential benefits of endovascular repair over open surgery are currently being evaluated in a large randomised study.