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Background: Anatomic severity grade (ASG) score is utilized to assess preoperative abdominal aortic aneurysms (AAA) and provide a quantitative data on its anatomic complexity. The aim of this study is to determine the anatomical differences and long-term survival between male and female patients undergoing elective AAA repair., Methods: All patients undergoing intact AAA repair from 2007 to 2014 were included. ASG scores were calculated based on preoperative anatomical characteristics including aortic neck, aneurysm, and iliac artery. Standard univariate analysis was used to evaluate patient and anatomical characteristics. Kaplan-Meier survival curves were used to evaluate long-term survival at 1 and 5 years., Results: A total of 379 patients were identified, of which, majority of them were males (80%). Females were on average 3 years older (mean [SD]: 74.32 [8.63] vs. 71.92 [8.64] years) and were more likely to undergo open repair (29.7% vs. 17.5%) (both P < 0.05). Both groups had similar comorbidities. The mean long-term follow-up (S.D.) was 6.21 (3.81) years. No significant difference was seen between males versus females in long-term survival at both 1 year (86.3% vs. 92.8, P = 0.06) and 5 year (68.5% vs. 72.7%, P = 0.38). In regard to the anatomical characteristics, females had shorter aortic neck length (mean in mm [S.D.]: 17.67 [1.41] vs. 27.20 [15.76]), increased tortuosity index [mean (S.D.): 1.11 (0.07) vs. 1.09 (0.07)]) and higher calcification [mean % (S.D.): 17.12 (21.17) vs. 10.59 (16.82)] (All P < 0.05). In contrast, males had larger aortic neck (mean in mm (S.D.): 23.81 (4.17) vs. 22.41 (4.16)] and iliac artery [mean in mm (S.D.): 7.70 (1.91) vs. 6.28 (1.67)] diameter (both P < 0.05). The mean total ASG score was significantly higher among females versus males [mean (S.D.): 17.23 (4.01) vs. 15.67 (3.96), P = 0.003]. After stratifying by ASG score ≥15, females had significantly lower survival at 1 year compared to males (82.6% vs. 92.1%, P = 0.04). However, this difference disappeared at 5 years., Conclusions: The data demonstrate that females present at an older age with more complex AAA anatomy than males. Based on anatomical complexities, females were more likely to undergo open repair, with a corresponding increase in 1-year mortality, but not at 5 year. The data suggest that care processes for optimization of aortic surgery in females are needed to improve 1-year survival., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Standard endovascular repair (EVAR) is not suitable in patients with hostile aortic anatomy. Open aneurysm repair (OAR) has been the gold-standard approach in managing these patients. EndoAnchors have been introduced as a technique to make EVAR in patients with short and angulated necks possible. The use of EndoAnchors in managing hostile aneurysms in octogenarians has not been studied before. Thus, the purpose of this study is to evaluate both short and long-term outcomes in octogenarians versus nonoctogenarians patients with hostile aortic anatomy undergoing EVAR using EndoAnchors., Methods: Only patients enrolled in the primary arm of the ANCHOR registry were included and stratified into octogenarians (80-89 years) and nonoctogenarians (<80 years). Standard univariate (chi-square, fisher's exact, student's t-tests) and multivariable (logistic, cox-regression) analysis was used to evaluate patients' characteristics and outcomes between octogenarians versus nonoctogenarians as appropriate., Results: Of 461 patients, 21% (N = 97) were octogenarians. Compared to nonoctogenarians, octogenarians were more likely to have a history of renal (32.0% vs. 18.4%) and genitourinary (30.9% vs. 21.2%) disease (both P < 0.05). They were also more likely to have an AAA diameter greater than 55 mm compared to nonoctogenarians (59% vs. 46%), had increased neck tortuosity index (mean [S.D.] 1.07 [0.08] vs. 1.05 [0.05]), greater proximal neck angulation (mean [S.D.]: 28.2 [17.3] vs. 23.7 [16] degrees) and were more likely to have localized (29.3% vs. 18.7%) and diffuse (25.6% vs. 20.7%) neck calcification (All P < 0.05). The overall procedural success was similar between both groups. However, octogenarians had higher rates of endoleaks at completion (32.0% vs. 21.2%, P = 0.03) and 30-day bleeding (12.4% vs. 5.8%) and cardiac (13.4% vs. 5.2%) complications (All P < 0.05). Additionally, compared to nonoctogenarians, octogenarians had lower freedom from all-cause mortality (87.90% vs. 96.50%) and type II endoleak (73.30% vs. 88.60%) based on Kaplan Meier estimates through one year (Both P < 0.05). In multivariable cox-regression analysis, octogenarians demonstrated a 5-fold increase in all cause mortality (HR [95% CI]: 5.19 [1.92-14], P = 0.001) and a 3-fold increase in type II endoleak (HR [95% CI]: 2.99 [1.54-5.81], P = 0.001) at 1-year. However, no significant difference was seen in aneurysm/device related mortality (HR [95% CI]: 1.42 [0.14-14.7], P = 0.77) and type I endoleak (HR [95% CI]: 1.71 [0.31-9.55], P = 0.54) at 1-year., Conclusions: Despite a worse aortic neck anatomy, octogenarians undergoing EVAR using EndoAnchors showed acceptable short and long-term outcomes. The results of our study could expand the utilization of EVAR in octogenarians with hostile neck., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: The role of non-steroidal anti-inflammatory drugs in aortic aneurysm disease has been debated. Animal studies demonstrated that intrathecal ketorolac reduces the inflammatory response associated with aortic clamping. However, no human-subject study evaluated this association. Therefore, we sought to explore the effects of ketorolac use in open abdominal aortic aneurysm repair., Methods: The Premier Healthcare Database (June 2009-March 2015) was inquired to capture patients who underwent open abdominal aortic aneurysm repair for non-ruptured abdominal aortic aneurysm, identified via International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Intravenous ketorolac was coded as any or none. Outcomes were in-hospital mortality, cardiac, respiratory, renal, neurological, and hemorrhagic complications. Multivariable logistic regression coarsened exact matching followed by conditional fixed-effect regression modeling were performed., Results: A total of 6394 patients were identified (ketorolac: 806; 12.6%). Patients who received ketorolac were younger and less likely to have hypertension (76.1% vs. 79.3%), diabetes mellitus (12.5% vs. 17.4%), or chronic kidney disease (8.3% vs. 21.4%; all p values   ≤   .033). There was no significant difference in medication use including oral non-steroidal anti-inflammatory drugs and malignant or musculoskeletal diseases. Mortality, respiratory, and renal complications were less prevalent with ketorolac (2.5% vs. 4.9%, 25.2% vs. 34.6%, 10.0% vs. 21.1%; p  ≤   .002). Ketorolac was associated with lower adjusted odds for those events: 0.58 (0.36-0.93), 0.53 (0.42-0.68), and 0.72 (0.60-0.86), respectively (all p values   ≤   .025). There was no association with neurological, cardiac, or hemorrhagic complications. The findings were replicated by coarsened exact matching analysis., Conclusion: This study demonstrated 40% mortality reduction with intravenous ketorolac following open abdominal aortic aneurysm repair. The survival benefit could be due to its anti-inflammatory and opioid-sparing properties. This is evident by its protective effect against respiratory outcomes. The lack of association with the classical non-steroidal anti-inflammatory drugs-related cardiac and hemorrhagic complication could be attributable to the short-term use of ketorolac compared with non-steroidal anti-inflammatory drugs chronic use.

Objective: The few randomized trials comparing endovascular with open surgical repair of ruptured abdominal aortic aneurysm (rAAA) were poorly designed and heavily criticized. The short-term and midterm survival advantages of endovascular repair remain unclear. We sought to compare the two treatment modalities using a propensity-matched analysis in a real-world setting., Methods: All ruptured cases of open surgical repair (rOSR) and endovascular aneurysm repair (rEVAR) in the Vascular Quality Initiative were analyzed (2003-2018). Raw and propensity-matched rEVAR and rOSR cohorts were compared. Primary and secondary outcomes included postoperative major adverse events (cardiovascular, pulmonary, renal, bowel or limb ischemia, reoperation) and 30-day and 1-year mortality. Univariate, multivariate, and Kaplan-Meier analyses were performed., Results: There were 4929 rAAA repairs performed, 2749 rEVAR and 2180 rOSR. Compared with rEVAR patients, rOSR patients had higher rates of myocardial ischemic events (15% vs 10%; P < .001), major adverse events (67% vs 37%; P < .001), and 30-day death (34% vs 21%; P < .001). On adjusted analysis, rOSR was predictive of 30-day mortality (odds ratio, 1.8; 95% confidence interval, 1.5-2.2). After 1:1 matching, the study cohort consisted of 724 pairs of rOSR and rEVAR. The rOSR patients had twice the length of stay (median, 10 days [interquartile range, 5-19 days] vs 5 days [interquartile range, 3-10 days]; P < .001). Univariate analysis demonstrated persistent increased 30-day mortality after rOSR (32% vs 18%; P < .001) and higher rates of myocardial infarction (14% rOSR vs 8% rEVAR; P = .002), respiratory complications (38% vs 20%; P < .001), and acute kidney injury (42% vs 26%; P < .001). Overall major adverse event rate was higher after rOSR (68% vs 35%; P < .001). Multivariable regression analysis of the propensity-matched pairs demonstrated that rOSR was associated with double the 30-day mortality compared with rEVAR (odds ratio, 2.0; 95% confidence interval, 1.6-2.7). All-cause 1-year survival was 73% and 59% after rEVAR and rOSR in the propensity-matched cohort, respectively (P < .001)., Conclusions: This is one of the largest studies of rAAA demonstrating clear short-term and midterm survival benefits of rEVAR over rOSR that persisted after matching on all major demographic, comorbid, and anatomic variables. Furthermore, patients who survived rOSR had twice the length of stay with increased rates of complications compared with rEVAR patients. These data suggest a more aggressive endovascular approach for rAAA in patients with suitable anatomy., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Hostile infrarenal proximal neck (β) anatomy of abdominal aortic aneurysm has been associated with increased risk of aneurysm-related complications after endovascular aneurysm repair (EVAR). However, there is a paucity of literature addressing the suprarenal angle (α). The aim of this study was to evaluate short- and long-term outcomes after EVAR in patients with severe suprarenal neck angulation (α >60 degrees)., Methods: A retrospective review of the medical records of 561 patients who underwent EVAR between January 2005 and December 2017 was performed. The main exclusion criteria were preoperative aneurysm rupture and fenestrated or branched endograft placement. High-resolution computed tomography images of 452 patients were available. Patients were grouped into angulated (α >60 degrees) and nonangulated (α ≤60 degrees) groups. The primary end point was freedom from type IA endoleak. Secondary end points included 30-day mortality, long-term survival, primary clinical success, and freedom from aneurysm rupture and graft migration. Primary clinical success was defined according to Society for Vascular Surgery guidelines as clinical success without the need for an additional or secondary surgical or endovascular procedure., Results: Of 452 patients, 45 (10%) were included in the angulated group (α >60 degrees). Median follow-up time was 34 months (interquartile range, 14-56 months). Compared with patients in the nonangulated group, those in the angulated group had larger neck diameter at the level of the renal arteries (mean [standard deviation], 25.6 [3.8] mm vs 24.6 [3.4] mm; P = .06) and increased β angle (mean [standard deviation], 50.5 [22.9] degrees vs 41.6 [23.9] degrees; P = .01). The 3-year freedom from type IA endoleak estimate was 80.2% for the angulated group compared with 97.8% for the nonangulated group (P < .001). The angulated group showed significantly higher 30-day mortality (11.1% vs 0.25%; P < .001).The 3-year results showed that patients in the nonangulated group had higher rates of primary clinical success (90.2% vs 67.1%; P < .001), freedom from rupture (99% vs 97.1%; P = .02), freedom from migration (100% vs 92.4%; P < .001), and long-term survival (91.6% vs 75.8%; P = .006) compared with those in the angulated group. After adjustment for age, sex, neck diameter, and β angle, severe suprarenal neck angulation was associated with higher odds of type IA endoleak (adjusted hazard ratio, 8.9; 95% confidence interval [CI], 2.9-27), loss of primary clinical success (adjusted hazard ratio, 4.8; 95% CI, 2.6-8.9), and 30-day mortality (adjusted odds ratio, 52.5; 95% CI, 5.3-514) compared with α ≤60 degrees (all P < .001)., Conclusions: This is the first report to show a significant increase in operative mortality in patients undergoing EVAR with severely angulated suprarenal neck. Patients who survive the operation are at increased risk of secondary interventions. These findings suggest that EVAR should be used with caution in patients with severe α angulation and underpin the role of close follow-up in this particular population., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Although blood transfusion can be lifesaving in active hemorrhage or severe anemia, it is also associated with increased morbidity and mortality. Several trials have established this risk and therefore defined a restrictive standard for transfusion, but this threshold and the risk of transfusions have not been specifically examined in vascular surgery patients. We therefore sought to assess transfusion practices and outcomes of anemic patients undergoing elective endovascular aneurysm repair (EVAR)., Methods: The Vascular Quality Initiative database was queried for patients undergoing EVAR between the years 2008 and 2017. Anemic patients were included in the study and were further stratified into mild anemia, defined by a hemoglobin level of 10 to 13 g/dL in men or 10 to 12 g/dL in women, and moderate to severe anemia, defined by a hemoglobin level <10 g/dL. The primary study outcomes were in-hospital mortality and complications., Results: Among 27,777 EVAR patients, one-third (n = 9232) were anemic and included in the study. One-fifth (n = 1866) of anemic patients received a perioperative transfusion. Transfused patients were more likely to have a history of cardiovascular disease. In-hospital mortality was significantly higher for anemic patients who received transfusions, both in mild anemia (mortality, 3.6% vs 0.4% in no transfusion; P < .001) and in moderate to severe anemia (4.5% vs 1.3%; P < .01). Morbidity was also significantly higher, with anemic patients who received a transfusion having higher rates of myocardial infarction, congestive heart failure, dysrhythmias, renal complications, leg ischemia, respiratory complications, and reoperation compared with anemic patients who did not receive any transfusion. The 30-day mortality was also higher in transfused patients (P < .001). After adjustment for patients' demographics, comorbidities, and operative factors, transfusion in anemic patients was associated with a nearly 4.4-fold increased odds of in-hospital mortality (odds ratio [OR], 4.38; 95% confidence interval [CI], 2.72-7.05; P < .001) and 4.3-fold higher odds of any in-hospital complication (OR, 4.31; 95% CI, 3.47-5.34; P < .001). This was more pronounced among patients with mild anemia, with 5.7 times (OR, 5.7; 95% CI, 1.78-18.0) and 4.3 times (OR, 4.3; 95% CI, 3.46-5.29) the odds of in-hospital mortality and complications, respectively., Conclusions: Among anemic patients undergoing elective EVAR, transfusion is associated with an increased risk of death and in-hospital complications, even after controlling for patients' comorbidities and operative factors. These data suggest that the restrictive use of blood transfusions might be safer in vascular surgery EVAR patients. Medical management of anemia may be warranted in these patients to reduce morbidity and mortality; however, further studies are needed to evaluate effectiveness., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study is to use a large, nationally representative vascular database to assess differences in patient characteristics, aortic neck anatomy, and outcomes between men and women following open (open aneurysm repair [OAR]) and endovascular (endovascular aneurysm repair [EVAR]) abdominal aortic aneurysm (AAA) repair., Methods: Patients undergoing AAA repair from 2003 to 2018 in Vascular Quality Initiative were identified and stratified by procedure (EVAR vs OAR). Thirty-day mortality and major in-hospital complications were assessed between genders within each operative cohort. An EVAR subset analysis was performed to assess differences in aortic neck anatomy; hostile neck anatomy was defined as length <15 mm (L < 15), angle >60° (A > 60), and/or diameter >28 mm (D > 28). Standard univariate and multivariable analyses were performed., Results: A total of 50 213 patients were identified: 9263 (19%) OAR and 40 950 (82%) EVAR. In both cohorts, majority of patients were men (OAR 73% and EVAR 81%). Women were more likely to have a hostile neck (31.7% vs 24.1%, P < .001), L < 15 (19.8% vs 11.9%, P < .001), and A > 60 (11.5% vs 5.4%, P < .001). Men had larger aneurysm (mean, 57 vs 55 mm, P < .001) and were more likely to have D > 28 (14.0% vs 10.6%, P < .001). Women undergoing EVAR were more likely to undergo aortic extensions (21.9% vs 16.0%) and receive higher contrast volume. After adjusting for potential confounders, female gender was associated with 86% and 50% increased risk of 30-day mortality in OAR and EVAR, respectively. Women were more likely than men to experience renal, cardiac, and pulmonary complications only in the EVAR cohort. Women had a 2-fold increased odds of developing type 1 endoleak., Conclusion: Our study demonstrates unfavorable neck anatomy occurs more frequently in women compared to men. Women were also at an increased risk of developing major complications, particularly following EVAR. Careful patient selection is indicated in all patients to reduce complications, with special attention in women with hostile neck.

Objective: We sought to assess whether sex-related differences in timely repair of ruptured abdominal aortic aneurysm (rAAA) were associated with excess risk of early mortality in women., Summary Background Data: rAAA is a surgical emergency and timeliness of intervention affects outcomes. A door-to-intervention time of <90 minutes is recommended., Methods: All rAAA repairs in the Vascular Quality Initiative from 2003 to 2017 were reviewed. Patients were stratified by sex and time-delay cohorts. Univariate and multivariate analyses were performed., Results: There were 3719 rAAA repairs, of which 797 (21%) were performed in women. Sex did not affect repair type: open versus endovascular (21% females, each). Despite similar presentation delays [median 6 hours (inter quartile range, IQR: 3-16)], admission-to-intervention time was longer for women than men [median 1.5 hours (IQR 1-4] vs 1.2 hours (IQR 1-3), P=0.047]. Overall, 45% of patients had a >90-minute delay from admission to repair, with more women than men experiencing this delay (49% vs 44%, P=0.01). Neither were more likely to undergo transfer for treatment. After risk adjustment, female sex was associated with a 48% increase in 30-day mortality. Sex differences in mortality were no longer observed in patients with intervention delays of ≤90 minutes. In patients with >90-minute delays, a 77% increase in 30-day mortality of women over men was noted., Conclusions: Nearly half of rAAA patients have a door-to-intervention time longer than recommended societal guidelines. Sex differences in mortality after rAAA repair seem to be driven by in-hospital treatment delays.

Objective: Bowel ischemia (BI) is a serious complication after abdominal aortic aneurysm (AAA) repair. We sought to identify the incidence and risk factors associated with the development of postoperative BI and the post-BI outcomes for patients undergoing open aortic repair (OAR) and endovascular aortic repair (EVAR) of AAAs., Methods: A retrospective analysis was conducted for all patients who had undergone OAR or EVAR from 2003 to 2017 using the Vascular Quality Initiative database. Univariate (Student's t test, χ 2 , median) and multivariable (logistic regression) analyses were used to identify independent factors associated with postoperative BI and compare the post-BI in-hospital outcomes and mortality., Results: We identified 45,474 patients who had undergone infrarenal AAA repair (OAR, 21.5%; EVAR, 78.5%). The overall incidence of postoperative BI was 1.9% (OAR, 6.2% vs EVAR, 0.8%; P < .001). OAR was associated with a threefold increased odds of BI compared with EVAR (adjusted odds ratio [aOR], 3.24; 95% confidence interval [CI], 2.49-4.22; P < .001). The independent factors associated with BI after OAR included older age (aOR per year of age, 1.02; 95% CI, 1.00-1.03), congestive heart failure (aOR, 1.44; 95% CI, 1.05-1.98), and ruptured aneurysm (aOR, 4.16; 95% CI, 2.98-5.81; P < .01 for all). We also found that transfusion ≥1 U (aOR, 1.69; 95% CI, 1.30-2.20), a transperitoneal approach (aOR, 2.13; 95% CI, 1.03-1.87), supraceliac clamping (aOR, 1.58; 95% CI, 1.08-2.33), and inferior mesenteric artery reimplantation (aOR, 1.41; 95% CI, 1.06-1.89) were associated with greater odds of BI after OAR (P < .01 for all). Similarly, we found that ruptured aneurysms, a longer operative time, and transfusion of ≥1 U of blood were associated with BI after EVAR (P < .001 for all). For both OAR and EVAR, the postoperative stay (median, 13 days [interquartile range (IQR), 7-26 days] vs 7 days [IQR, 5-10 days] and 11 days [IQR, 4-23 days] vs 1 day [IQR, 1-3 days], respectively) and 30-day mortality (35.0% vs 6.4% and 40.5% vs 1.9%, respectively) were significantly higher for patients with BI (P < .001 for all). The predictors of mortality for patients with BI were surgical management (aOR, 2.05; 95% CI, 1.28-3.30), older age (aOR, 1.05; 95% CI, 1.02-1.07), symptomatic aneurysm (aOR, 1.26; 95% CI, [0.60-2.62), ruptured aneurysm (aOR, 2.23; 95% CI, 1.43-3.48), longer operative time (aOR, 1.11; 95% CI, 1.01-1.22), and postoperative renal complications (aOR, 2.98; 95% CI, 1.80-4.96; P < .05 for all)., Conclusions: Confirming the results from previous studies, we found that BI is more common after a ruptured aneurysm and OAR. Other associated intraoperative factors included a transperitoneal approach, supraceliac clamping, and a reimplanted inferior mesenteric artery. More than one third of patients who developed postoperative BI in our cohort had died within 30 days after AAA repair. The factors associated with mortality after BI included surgical management and postoperative renal failure. A high index of suspicion for the signs and symptoms of BI should be maintained postoperatively for patients presenting with the risk factors identified., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background:: Fenestrated endovascular repair (FEVAR) and chimney endovascular repair (ChEVAR) endovascular repair offer a less invasive alternative to open aortic repair (OAR) in managing juxtarenal, pararenal, and suprarenal abdominal aortic aneurysms (AAAs). The aim of this study is to evaluate the 30-day postoperative outcomes following endovascular and open repair of nonruptured AAA involving the renal vessels., Study Design:: All patients undergoing endovascular (FEVAR and ChEVAR) and open repair of juxtarenal, pararenal, and suprarenal AAA in National Surgical Quality Improvement Program database from 2012 to 2016 were included. Continuous and categorical covariates were analyzed using medians and χ 2 /Fisher exact test, respectively. Multivariable logistic regression analyses were performed to evaluate primary (mortality) and secondary (renal and cardiopulmonary failure) outcomes between open versus endovascular approach., Results:: A total of 1191 patients underwent AAA repair using open (72%) or endovascular (FEVAR: 14%, ChEVAR: 14%) approach. In univariate analysis, no significant difference in 30-day mortality was seen between the 3 groups (FEVAR: 2.47% vs ChEVAR: 7.32% vs OAR: 6.13%, P = .13). However, 30-day major complications including renal failure (9.36% vs 6.10% vs 1.85%, P = .003) and cardiopulmonary complications (19.77% vs 3.66% vs 4.94%, P < 001) failure were significantly higher in patients undergoing OAR versus ChEVAR versus FEVAR. After adjusting for potential confounders, OAR was associated with 2- to 5-folds increased risk of mortality (odds ratio, OR [95% confidence interval, CI]: 2.14 [1.09-4.21], P = .03), renal (OR [95% CI]: 2.87 [1.48-5.57], P = .002), and cardiopulmonary failure (OR [95% CI]: 4.63 [2.47-8.67], P < .001) compared to any endovascular repair., Conclusion:: Using a large national surgical data set, our study found 2- to 5-folds higher mortality and morbidity in patients undergoing open versus endovascular repair of AAA involving the renal vessels. Endovascular repair seems to be a safer approach, especially when managing older patients with AAA.

Background: Fenestrated endovascular aneurysm repair (FEVAR) has expanded the indications of this minimally invasive procedure to include patients with pararenal aneurysms. The actual cost of this relatively newer technology compared with standard endovascular aneurysm repair (EVAR) has not been studied before. Thus, the aim of this study was to analyze in-hospital costs and adverse outcomes in patients undergoing FEVAR vs EVAR for intact abdominal aortic aneurysms (AAAs)., Methods: Using the Premier Healthcare Database (2012-2015), we identified all patients who underwent elective EVAR and FEVAR. Univariable (χ 2 test, Student t-test, median test) and multivariable (logistic regression and generalized linear modeling) analyses were implemented to examine in-hospital cost and adverse outcomes adjusting for patients' demographics, comorbidities, and regional characteristics., Results: A total of 17,689 elective endovascular AAA repairs were performed; 1641 patients underwent FEVAR (9%), and the remaining 16,048 patients underwent standard EVAR (91%). Patients undergoing FEVAR were more likely to be white (86.3% vs 84.3%; P = .03). Both groups had similar comorbidities except for cerebrovascular disease, which was higher among patients undergoing FEVAR (8.4% vs 6.7%; P = .01). The total length of hospital stay was slightly higher in patients undergoing FEVAR compared with EVAR (mean [standard deviation], 2.40 [3.39] days vs 2.23 [3.10] days; P = .03). The rates of any complication (11.3% vs 9.6%), renal injury (5.8% vs 4.3%), and neurologic injury (0.7% vs 0.4%) were significantly higher in the FEVAR group (all P < .05). No differences were seen in mortality (0.8% vs 0.5%) or cardiac (4.9% vs 4.4%), pulmonary (2.4% vs 2.2%), and bowel (1.5% vs 1.2%) complications between the two groups (all P > .05). In multivariable logistic regression analysis, FEVAR was associated with 40% increased odds of renal failure (odds ratio, 1.40; 95% confidence interval [CI], 1.11-1.76; P = .004) and 91% increased odds of neurologic injury (odds ratio, 1.91; 95% CI, 1.02-3.57; P = .04). The median total cost of the treatment was also significantly higher among patients undergoing FEVAR ($28,227 vs $26,781; P < .001). After adjustment, generalized linear modeling analysis showed that the cost of FEVAR was on average $1612 higher than the cost of EVAR (adjusted cost, $1612; 95% CI, $1123-$2101; P < .001)., Conclusions: In this large cohort of elective endovascular AAA repairs, compared with standard EVAR, FEVAR is associated with significantly increased odds of renal and neurologic injury. In addition, despite adjusting for patients' demographics, comorbidities, and major complications, total cost of FEVAR was significantly higher compared with standard EVAR. This is likely driven by the additional cost of fenestrated endografts and by the increased rate of complications related to FEVAR., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Anemia is associated with increased cardiac adverse events during the early postoperative period because of high physiologic stress and increased cardiac demand. The aim of this study was to assess the surgical outcomes and prognostic implications of anemia in patients undergoing repair of intact abdominal aortic aneurysms (AAAs)., Methods: A retrospective analysis of all patients who underwent open aortic repair (OAR) or endovascular aneurysm repair (EVAR) in the Vascular Quality Initiative database (2008-2017) was performed. Patients with preoperative polycythemia, patients with ruptured aneurysms, and patients transfused with >4 units of packed red blood cells were excluded. Hemoglobin levels were categorized into three groups: moderate-severe anemia (<10 g/dL), mild anemia (10-12 g/dL in women and 10-13 g/dL in men), and no anemia (>12 g/dL in women and >13 g/dL in men). Multivariate logistic models and coarsened exact matching were used to analyze the association between anemia and 30-day mortality and between anemia and major in-hospital complications after OAR and EVAR., Results: A total of 34,397 patients were identified undergoing AAA repair. Of those, 28.5% had mild anemia and 4.3% had moderate-severe anemia. In both OAR (n = 6112) and EVAR (n = 28,285), patients with moderate-severe anemia had significantly higher rates of in-hospital adverse events, such as in-hospital mortality, myocardial infarction, renal and respiratory complications, and reoperation, compared with patients with mild or no anemia. They also had higher rates of 30-day mortality. After multivariate analysis and 1:1 coarsened exact matching, no association was found between anemia and 30-day mortality and other in-hospital outcomes in patients undergoing OAR. On the other hand, in EVAR, moderate-severe anemia was associated with 2.7 times the odds of 30-day mortality (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.69-4.18), 2.5 times the odds of renal complications (OR, 2.47; 95% CI, 1.78-3.43; P < .05), and twice the risk of acute congestive heart failure (OR, 1.96; 95% CI, 1.18-3.25) and respiratory complications (OR, 2.01; 95% CI, 1.26-3.19). Mild anemia was also associated with increased odds of 30-day mortality and renal and respiratory complications in patients undergoing EVAR. Interestingly, preoperative blood transfusion in mildly anemic patients undergoing EVAR was associated with double the odds of in-hospital major adverse cardiac events (stroke, death, and myocardial infarction; OR, 2.1; 95% CI, 1.38-3.11; P < .001)., Conclusions: Preoperative anemia is associated with higher odds of 30-day mortality and in-hospital adverse outcomes after EVAR but not after OAR. These findings highlight the need to incorporate anemia into the preoperative risk assessment of patients undergoing EVAR. Future studies are needed to assess the efficacy of medical therapies in improving postoperative outcomes in anemic patients undergoing AAA repair., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Obesity is a worldwide epidemic, particularly in Western society. It predisposes surgical patients to an increased risk of adverse outcomes. The aim of our study was to use a nationally representative vascular database and to compare in-hospital outcomes in obese vs nonobese patients undergoing elective open aortic repair (OAR) and endovascular aneurysm repair (EVAR)., Methods: All patients undergoing elective abdominal aortic aneurysm repair were identified in the Vascular Quality Initiative database (2003-2017). Obesity was defined as body mass index ≥30 kg/m 2 . Univariable (Student t-test and χ 2  test) and multivariable (logistic regression) analyses were implemented to compare in-hospital mortality and any major complications (wound infection, renal failure, and cardiopulmonary failure) in obese vs nonobese patients., Results: We identified a total of 33,082 patients undergoing elective OAR (nonobese, n = 4605 [72.4%]; obese, n = 1754 [27.6%]) and EVAR (nonobese, n = 18,338 [68.6%]; obese, n = 8385 [31.4%]). Obese patients undergoing OAR and EVAR were relatively younger compared with nonobese patients (mean age [standard deviation], 67.55 [8.26] years vs 70.27 [8.30] years and 71.06 [8.22] years vs 74.55 [8.55] years), respectively; (both P < .001). Regardless of approach, obese patients had slightly longer operative time (OAR, 259.02 [109.97] minutes vs 239.37 [99.78] minutes; EVAR, 138.27 [70.64] minutes vs 134.34 [69.98] minutes) and higher blood loss (OAR, 2030 [1823] mL vs 1619 [1642] mL; EVAR, 228 [354] mL vs 207 [312] mL; both P < .001). There was no significant difference in mortality between the two groups undergoing OAR and EVAR (OAR, 2.9% vs 3.2% [P = .50]; EVAR, 0.5% vs 0.6% [P = .76]). On multivariable analysis, obese patients undergoing OAR had 33% higher odds of renal failure (adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 1.09-1.63; P = .006) and 75% higher odds of wound infections (adjusted OR, 1.75; 95% CI, 1.11-2.76; P = .02) compared with nonobese patients. However, in patients undergoing EVAR, no association was seen between obesity and any major complications. A significant interaction was found between obesity and surgical approach in the event of renal failure, in which obese patients undergoing OAR had significantly higher odds of renal failure compared with those in the EVAR group (OR interaction , 1.36; 95% CI, 1.05-1.75; P = .02)., Conclusions: Using a large nationally representative database, we demonstrated an increased risk of renal failure and wound infections in obese patients undergoing OAR compared with nonobese patients. On the other hand, obesity did not seem to increase the odds of major adverse outcomes in patients undergoing EVAR. Further long-term prospective studies are needed to verify the effects of obesity after abdominal aortic aneurysm repair and the implications of these findings in clinical decision-making., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Open aortic repair (OAR) is associated with higher risk of mortality compared with endovascular aneurysm repair (EVAR). The aim of this study was to compare failure to rescue (FTR) after major predischarge complications in patients undergoing OAR and EVAR., Methods: Patients who underwent OAR or EVAR in the American College of Surgeons National Surgical Quality Improvement Program between 2011 and 2015 were selected. Patients with ruptured aneurysm and those with type IV thoracoabdominal aneurysms were excluded. The primary outcome was FTR, defined as 30-day mortality in patients who developed at least one complication during their hospital stay. Univariable and multivariable statistics were used., Results: A total of 9097 patients underwent abdominal aortic aneurysm repair. Of those, 3291 (36.2%) had at least one major predischarge complication, 82.5% after OAR (95% confidence interval [CI], 80.9%-84.1%) vs 21.3% after EVAR (95% CI, 20.4%-22.3%; P < .001). Increased FTR was seen after aneurysm rupture, cardiac arrest, septic shock, and acute kidney injury. On multivariable analysis, FTR was not significantly different between OAR and EVAR (adjusted odds ratio, 0.87; 95% CI, 0.61-1.24; P = .44). Propensity score matching and coarsened exact matching showed similar results., Conclusions: Although EVAR has fewer complications and lower in-hospital mortality than OAR, FTR after major predischarge complications does not depend on the type of surgical approach. When an in-hospital major complication occurs after EVAR, surgeons should be alert that FTR risk resulting in mortality is similar to that of OAR. Therefore, there is no safety net with EVAR., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Prior studies have shown that octogenarians have a higher risk of mortality than nonoctogenarians undergoing open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Fenestrated endovascular aneurysm repair (F-EVAR) was approved by the Food and Drug Administration (FDA) in 2012 and has been used as a less invasive approach to treat patients with suboptimal neck anatomy with favorable outcomes compared with traditional OAR. The aim of the study is to compare 30-day outcomes of F-EVAR versus OAR in octogenarians undergoing repair of AAA involving the visceral vessels in the United States., Methods: All patients with postoperative diagnosis of nonruptured AAA repair were identified in the National Surgical Quality Improvement Program database (2006-2015). Univariate and multivariate analyses were implemented to examine 30-day morbidity and mortality adjusting for patient demographics and comorbidities., Results: A total of 548 octogenarians underwent repair of nonruptured AAA involving the visceral vessels, of which 242 (44%) were F-EVARs, and 306 (56%) were OARs. Octogenarians undergoing F-EVAR were on average 1-year older (median age [interquartile range]: 83 [82, 86] versus 82 [81, 85], P = 0.004) and more likely to be male (82% vs. 64%, P < 0.001) compared with OAR. Prevalence of diabetes (13% vs. 6%, P = 0.005) and progressive renal failure (57% vs. 47%, P = 0.03) was also higher in patients undergoing F-EVAR compared with OAR. Thirty-day postoperative mortality was higher after OAR (8.5% vs. 4.1%, P = 0.04). Secondary outcomes including cardiopulmonary (27.1% vs. 5.8%, P < 0.001) and renal injury (10.8% vs. 2.1%, P < 0.001) were also significantly higher in OAR compared with F-EVAR. After adjusting for patients' demographics and comorbidities, OAR had almost 4-fold increased risk of 30-day postoperative mortality compared with F-EVAR (odds ratio [95% confidence interval]: 3.90 [1.48-10.31], P = 0.006)., Conclusions: In this large national cohort of octogenarians undergoing repair for complex AAA's, we showed that F-EVAR is associated with significantly lower postoperative morbidity and mortality than open repair. One of the main limitations of the study is the lack of anatomical data. However, despite that, our findings support the shifting paradigm toward minimally invasive approach in this frail population for treatment of complex AAA's. Further studies are needed to evaluate the long-term benefit of any repair in octogenarians., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The majority of previous studies, including randomized controlled trials, have failed to provide sufficient evidence of superiority of endovascular aneurysm repair (EVAR) over open aortic repair (OAR) of ruptured abdominal aortic aneurysm (rAAA) while comparing mortality and complications. This is in part due to small study size, patient selection bias, scarce adjustment for essential variables, single insurance type, or selection of only older patients. This study aimed to provide real-world, contemporary, comprehensive, and robust evidence on mortality of EVAR vs OAR of rAAA., Methods: A retrospective observational cohort study was performed of rAAA patients registered in the Premier Healthcare Database between July 2009 and March 2015. A multivariate logistic regression model was operated to estimate the association between procedure types (OAR vs EVAR) and in-hospital mortality. The final model was adjusted for demographics (age, sex, race, marital status, and geographic region), hospital characteristics (urban or rural, teaching or not), and potential confounders (hypertension, diabetes, hypercholesterolemia, obesity, ischemic heart disease, chronic kidney disease, symptoms of critical limb ischemia, chronic obstructive pulmonary disease, smoking, and alcoholism). Furthermore, coarsened exact matching was applied to substantiate the result in the matched cohort., Results: There were a total of 3164 patients with rAAA (1550 [49.0%] OAR and 1614 [51.0%] EVAR). Mortality was 23.79% in the EVAR group compared with 36.26% in the OAR group (P < .001). The adjusted odds ratios of mortality (1.91; 95% confidence interval [CI], 1.62-2.25; P < .001), cardiac complication (1.54; 95% CI, 1.22-1.96; P < .001), pulmonary failure (1.90; 95% CI, 1.60-2.24; P < .001), renal failure (1.90; 95% CI, 1.61-2.23; P < .001), and bowel ischemia (2.40; 95% CI, 1.70-3.35; P < .001) were significantly higher after OAR compared with EVAR. We further applied coarsened exact matching, which followed the same pattern of mortality (odds ratio, 1.68; 95% CI 1.41-1.99; P < .001) and all major complications., Conclusions: Although the choice of repair of rAAA is highly dependent on the experience of the operating team and the anatomic suitability of the patient, this contemporary analysis of a large cohort of rAAA showed significantly higher adjusted risk of mortality in OAR compared with EVAR and substantially higher complications., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Reducing readmissions is an important target for improving patient care and enhancing health care quality and cost-effectiveness. The aim of this study was to assess rates, risk factors, and indications of 30-day readmission after open aortic repair (OAR) and endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs)., Methods: A retrospective analysis of the Premier Healthcare Database from 2009 to 2015 was performed. Indications for readmission after the index procedure, risk factors, and outcomes of the index admission and rehospitalization were evaluated. Multivariate logistic models were used to assess the association between 30-day readmission and different patient and hospital factors., Results: A total of 33,332 AAA repair procedures were identified: 27,483 (82.5%) EVAR and 5849 (17.5%) OAR. The overall rate of 30-day readmission was 8.1%, and it was greater after OAR (12.9% vs 7.1% in EVAR; P < .001). In general, the most common specific readmission diagnoses were infectious complications (16.1%), followed by respiratory and cardiac complications (11.8% and 11.3%, respectively). After multivariate adjustment, OAR was associated with higher 30-day readmission compared with EVAR (adjusted odds ratio, 1.11; 95% confidence interval, 1.0-1.2; P = .04). Other risk factors of 30-day readmission included female gender, emergency and urgent procedures, certain patient comorbidities (dyslipidemia, congestive heart failure, history of transient ischemic attack, previous cardiac surgery, chronic obstructive pulmonary disease, asthma, chronic kidney disease, peripheral vascular disease, and history of malignant disease), and hemorrhage/shock/bleeding occurring during the index admission as well as nonhome discharge. Readmitted patients had an overall in-hospital mortality of 3.6% and paid a median rehospitalization cost of $7757., Conclusions: Our study shows that around 8.1% of patients undergoing infrarenal AAA repair were readmitted within 30 days. Because many readmissions are unrelated to the index procedure or caused by factors that are nonmodifiable or nonidentifiable at discharge, efforts should focus on discharge planning and improving the decision process regarding discharge destination as well as postdischarge coordination of care for high-risk patients., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We aim to describe trends in failure to rescue (FTR) among elderly patients undergoing elective open aortic aneurysm repair (OAR) and endovascular aortic aneurysm repair (EVAR)., Materials and Methods: All patients aged ≥80 y recorded in the Vascular Quality Initiative database (2002-2014) undergoing nonruptured infrarenal AAA repair were included. Primary outcome was FTR, defined as percentage of deaths in patients who had a complication within 30 d of surgery. Univariable and multivariable statistics were used to identify risk factors for FTR following OAR and EVAR procedures., Results: 975 elderly patients underwent AAA repair during the study period (EVAR = 667, OAR = 308). Overall FTR was 10%, most commonly related to acute kidney injury (62%) and respiratory failure (53%). Independent predictors of FTR included female gender (odds ratio [OR] 1.95), multiple comorbidities (OR 1.98), renal insufficiency (OR 1.97), peripheral vascular disease (OR 2.42), and perioperative vasopressor use (OR 4.49) (all, P < 0.02). Obesity was protective (OR 0.58, P = 0.02). FTR was higher following OAR versus EVAR (14% versus 9%; P = 0.02) on univariable analysis, but there was no significant difference between operative approaches after risk adjustment (OR 1.15, P = 0.60). Comparing elderly versus younger patients (n = 2854), FTR was significantly higher for the elderly for both OAR (OR 2.0, 95% CI 1.36-3.01) and EVAR (OR 1.60, 95% CI 1.07-2.40)., Conclusions: FTR after AAA repair is not uncommon among elderly patients and could explain the higher mortality observed in this group compared to the general population. Overall health status should be carefully considered when weighing the risks versus benefits of performing AAA repair in patients aged ≥80 y., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Age is a well-known risk factor for postoperative death in patients with abdominal aortic aneurysms (AAA), and the efficacy of open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR) remains controversial in the elderly population. The aim of this study was to determine the predictors of 30-d mortality after AAA repair in elderly population., Methods: Using the National Surgical Quality Improvement Program vascular-targeted database (2011-2014), we identified all patients aged >70 y who underwent OAR and EVAR for nonruptured AAA. Univariate and multivariable logistic regression analyses were implemented to examine postoperative mortality adjusting for patient demographics and characteristics., Results: A total of 4229 nonruptured AAA repairs were performed (OAR: 360 [8.5%] versus EVAR: 3869 [91.5%]). Most patients were males (79 %) and White (81%) with a mean age of 78 ± 6 y. Obesity was more prevalent in EVAR group (31% versus 24%, P = 0.008). Whereas, smoking was more likely to be seen in patients undergoing an OAR (35% versus 22%, P < 0.001). The 30-d mortality was significantly higher after OAR versus EVAR (8% versus 2%, P < 0.001). After adjusting, OAR was associated with almost five times higher mortality than EVAR (adjusted odds ratio: 4.88; 2.85-8.34, P < 0.001)., Conclusions: This study reflects contemporary real world outcomes of nonruptured AAA repair in the elderly. Open repair was associated with almost fivefold increase in mortality compared with endovascular repair. Elderly patients who are functionally dependent are less likely to benefit from AAA repair, whether OAR or EVAR. Further prospective studies are required to better understand the predictors of mortality after AAA repair in the geriatric population which could guide decision-making and improve outcomes in this population., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Concurrent renal artery angioplasty and stenting (RAAS) during endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysm (AAA) has been practiced in an attempt to maintain renal perfusion. The aim of this study was to identify the current practice of RAAS during EVAR and its effect on perioperative renal outcome., Methods: Patients with infrarenal AAA were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP, 2011-2014) database. Baseline characteristics of patients with concurrent RAAS during EVAR were compared with those of patients who underwent EVAR only. Bivariate and multivariable logistic regression analyses controlling for patients' demographics, comorbidities, and operative factors were used to evaluate the predictors of 30-day acute renal failure (ARF). Sensitivity analysis was done to evaluate the role of RAAS in patients with prior kidney disease., Results: Overall, 6183 patients underwent EVAR for infrarenal AAA during the study period. Of them, 281 patients had RAAS during EVAR (4.5%). The median age of the patients was 74 years; 81.7% of the cohort was male, but a higher proportion of female patients received EVAR + RAAS compared with patients who underwent EVAR only (26.3% vs 17.9%; P < .001). There was no difference between groups in terms of comorbidities, being on dialysis, or functional status, yet the EVAR + RAAS group had a higher proportion of patients with glomerular filtration rate <60 mL/min/1.73 m 2 (45.2% vs 37.2%; P = .011). RAAS was associated with significantly higher odds for development of ARF (adjusted odds ratio [aOR], 4.27; 95% confidence interval [CI], 2.06-8.84; P < .001). Other highly predictive factors of 30-day ARF were glomerular filtration rate <60 (aOR, 2.92; 95% CI, 1.47-5.78; P = .002), emergency status (aOR, 2.97; 95% CI, 1.21-7.27; P = .017), and ruptured AAA as the indication for EVAR (aOR, 4.74; 95% CI, 1.80-12.50; P = .002). Patients with prior kidney disease who had EVAR + RAAS demonstrated a 12-fold higher odds for 30-day ARF (aOR, 12.37; 95% CI, 4.66-32.89; P < .001)., Conclusions: Concurrent RAAS was found to be a significant determinant of adverse renal outcomes after EVAR for infrarenal AAA. This effect was present even after controlling for patients' risk factors that might contribute to postoperative ARF., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)