Search

The external validity of randomised controlled trials (RCTs) and their transferability to clinical practice is under investigated. This study aimed to analyse the exclusion criteria of recent carotid RCTs comparing carotid endarterectomy (CEA) and carotid artery stenting, and to assess the eligibility of consecutive clinical practice cohorts to those RCTs.An analysis of the clinical and anatomical exclusion criteria of RCTs for asymptomatic (SPACE-2, ACST-2, CREST-1, and CREST-2) and symptomatic carotid stenosis (SPACE-1, CREST-1, ICSS, and EVA-3S) was performed. Two hundred consecutive asymptomatic and 200 consecutive symptomatic patients, treated by CEA, or transfemoral or transcarotid artery stenting at a tertiary referral university centre were assessed for their potential eligibility for each corresponding RCT. RCT patient data were pooled and differences from the clinical practice cohort analysed. Statistics were descriptive and comparative using Fisher's exact and t tests.The number of clinical and anatomical exclusion criteria differed widely between RCTs. Potential eligibility rates of the clinical practice cohort for RCTs with regard to asymptomatic carotid stenosis were 80.5% (ACST-2), 79.5% (SPACE-2), 47% (CREST-1), and 20% (CREST-2). For RCTs on symptomatic carotid stenosis the eligibility rates were 89% (ICSS), 86.5% (EVA-3S), 64% (SPACE-1), and 39% (CREST-1). Both clinical practice cohorts were older by about three years and patients were more often male vs. the RCTs. Furthermore, a history of smoking (asymptomatic patients), hypertension (symptomatic patients), and atrial fibrillation was diagnosed more often, whereas hypercholesterolaemia and coronary heart disease (asymptomatic patients) were less prevalent. More clinical practice patients were on antiplatelets, anticoagulants, and lipid lowering drugs. Symptomatic clinical practice patients presented more often with retinal ischaemia and less often with minor hemispheric strokes than patients in the RCTs.The external validity of contemporary carotid RCTs varies considerably. Patients in routine clinical practice differ from RCT populations with respect to age, comorbidities, and medication. These data are of interest for clinicians and guideline authors and may be relevant for the design of future comparative trials.

The purpose of this study was to assess the associations between malignancy, therapeutic regimens, and aorto-iliac aneurysm (i.e., abdominal aortic aneurysm [AAA]) growth rates.A retrospective single centre analysis identified patients with an AAA plus cancer. Patients who had two or more computed tomography angiograms over six months or more and additional malignancy were included. Clinical data and aneurysm diameters were analysed. AAA growth under cancer therapy (chemotherapy or radiation) was compared with a non-cancer AAA control cohort and to meta-analysis data. Statistics included t tests and a linear regression model with correction for initial aortic diameter and type of treatment.From 2003 to 2020, 217 patients (median age 70 years; 92% male) with 246 aneurysms (58.8% AAA) and 238 malignancies were identified. Prostate (26.7%) and lung (15.7%) cancer were most frequently seen. One hundred and fifty-seven patients (72.3%) received chemotherapy, 105 patients (48.4%) radiation, and 79 (36.4%) both. Annual AAA growth (mean ± standard deviation) was not statistically significantly different for cancer and non-cancer patients (2.0 ± 2.3 vs. 2.8 ± 2.1 mm/year; p = .20). However, subgroup analyses revealed that radiation was associated with a statistically significantly reduced mean aneurysm growth rate compared with cancer patients without radiation (1.1 ± 1.3 vs. 1.6 ± 2.1 mm/year; p = .046) and to the non-cancer control cohort (1.7 ± 1.9 vs. 2.8 ± 2.1 mm/year; p = .007). Administration of antimetabolites resulted in statistically significantly increased AAA growth (+ 0.9 mm/year; p = .011), while topoisomerase inhibitors (- 0.8 mm/year; p = .17) and anti-androgens (- 0.5 mm/year; p = .27) showed a possible trend for reduced growth. Similar observations were noted for iliac aneurysms (n = 85). Additionally, the effects persisted for chemotherapy combinations (2.6 ± 1.4 substances/patient).Patients with cancer and concomitant aortic aneurysms may require intensified monitoring when undergoing specific therapies, such as antimetabolite treatment, as they may experience an increased aneurysm growth rate. Radiation may be associated with reduced aneurysm growth.

Summary: Background: To determine the adherence to supervised exercise training and underlying reasons for non-adherence amongst patients with inpatient treatment of symptomatic lower extremity peripheral arterial disease (PAD). Patients: This was a prospective questionnaire-based survey study of all consecutively treated inpatients with treatment for either intermittent claudication or chronic limb-threatening ischaemia (CLTI) surveyed at sixteen participating centres in Germany. Results: A total of 235 patients (median age 70 years) were included, thereof 29.4% females and 34.6% with CLTI. The median time from first PAD diagnosis was 4 years (IQR: 1–8). Only 11.4% have previously participated in any walking exercise programme before the index treatment, thereby 10.0% in the IC subgroup and 12.0% with CLTI. Amongst all patients, 35.6% responded they were appropriately informed about the necessity and benefits of walking exercise programmes by their hospital physicians (25.8% by general practitioners), and 65.3% agreed that adherence to supervised exercise may improve their pain-free walking distance. A total of 24.5% responded they had access to necessary information concerning local walking exercise programmes. Amongst 127 free text comments on the reasons for non-adherence to supervised exercise training, 64% of the comments contained lack of information or consent on such measures. Conclusions: Less than 12% of the patients enrolled in the current study have ever participated in a walking exercise programme during their life course. Although all practice guidelines contain corresponding class I recommendations, especially for patients suffering from IC, most patients responded that they were not appropriately informed about the necessity of exercise training along with the fact that 65% agreed that exercise may increase the pain-free walking distance. Taken all together, these results emphasise that we miss an important opportunity in the patient-physician communication. Efforts should be made to improve acceptance and application of structured walking-exercise for patients with PAD.

Introduction Visceral artery aneurysms (VAA) are a rare entity of arterial aneurysms with the imminent threat of rupture. The impact of cancer and chemotherapy on the growth of VAAs is unknown. Patients and methods A retrospective dual center cohort study of patients with concomitant VAA and different types of cancer was conducted and the impact of various chemotherapeutic agents on VAA growth was studied by sequential CT analysis. For comparison, a non-cancer all comer cohort with VAAs and no cancer was studied to compare different growth rates. The primary endpoint was aneurysm progress or regression >1.75 mm. Chi-Square Test, Fisher's-Exact-Test and Mann-Whitney test was used for statistical comparison. Results In the 17-year-period from January 2003 to March 2020, 59 patients with 30 splenic artery aneurysms, 14 celiac trunk aneurysms, 11 renal artery aneurysms and 4 other VAA and additional malignancy were identified. 20% of patients suffered from prostate cancer, the rest were heterogeneous. The most prevalent chemotherapies were alkylating agents (23%), antimetabolites (14%) and mitose inhibitors (10%). 8 patients had relevant growth of their VAA and one patient showed diameter regression (average growth rate 0.1±0.5mm/year). 29 patients with 14 splenic, 11 RAAs (seven right) and 4 celiac trunk aneurysms were available in the non-cancer comparison cohort (average growth rate 0.5±0.9mm/year, p=0.058). However, the growth rate of patients receiving operative treatment for relevant VAA growth was significantly higher (p=0.004). Conclusion VAAs grow rarely, and rather slow. Cancer and/or chemotherapy do not significantly influence the annual growth rate. Additional control examinations seem unnecessary.

Objective This is a description of the German healthcare landscape regarding carotid artery disease, assessment of hospital incidence time courses for carotid endarterectomy (CEA) and carotid artery stenting (CAS), and simulation of potential effects of minimum hospital caseload requirements for CEA and CAS. Methods The study is a secondary data analysis of diagnosis related group statistics data (2005–2016), provided by the German Federal Statistical Office. Cases encoded by German operation procedure codes for CEA or CAS and by International Classification of Diseases (ICD-10) codes for carotid artery disease were included. Hospitals were categorised into quartiles according to annual caseloads. Linear distances to the closest hospital fulfilling hypothetical caseload requirements were calculated. Results A total of 132 411 and 33 709 patients treated with CEA and CAS from 2012 to 2016 were included. CEA patients had lower rates of myocardial infarction (1.4% vs. 1.8%) and death (1.2% vs. 4.0%), and CAS patients were more often treated after emergency admission (38.1% vs. 27.1%). Age standardised annual hospital incidences were 67.2 per 100 000 inhabitants for CEA and 16.3 per 100 000 inhabitants for CAS. The incidence for CEA declined from 2005 to 2016, with CAS rising again until 2016 after having declined from 2010 to 2013. Regarding distance from home to hospital, centres offering CEA are distributed more homogeneously across Germany, compared with those performing CAS. Hypothetical introduction of minimum annual caseloads (> 20 for CEA; > 10 for CAS) imply that 75% of the population would reach their hospital after travelling 45 km for CEA and 70 km for CAS. Conclusion Differences in spatial distribution mean that statutory minimum annual caseloads would have a greater impact on CAS accessibility than CEA in Germany. Presumably because of a decline in carotid artery disease and a transition towards individualised therapy for asymptomatic patients, hospital incidence for CEA has been declining.

Hinsichtlich der Anzahl an Publikationen, grundlagenwissenschaftlichen Projekten und klinischen Studien bleibt die deutsche Gefaschirurgie im internationalen Vergleich innerhalb des Fachs sowie im nationalen Vergleich mit anderen chirurgischen Fachern zuruck. Ziel dieses Beitrags ist es, die zentrale Rolle des vascular surgeon scientist fur die akademische Gefaschirurgie, insbesondere als Bindeglied zwischen (Grundlagen‑)Forschung und Patientenversorgung herauszustellen. Ferner sollen Anstose zur sinnvollen Umsetzung eines Cinician-scientist-Programms in der Gefaschirurgie gegeben werden. Es erfolgte eine selektive Literaturrecherche. Auserdem wurde das Modell des vascular surgeon scientist durch Beitrage von Co-Autoren unterschiedlicher gefaschirurgischer Ausbildungsstande aus verschiedenen Blickwinkeln beleuchtet. Dem vascular surgeon scientist kommt eine entscheidende Rolle in der modernen Gefaschirurgie zu. Er vollzieht die Translation von der (Grundlagen‑)Forschung uber die Patientenversorgung bis hin zur Weiterentwicklung medizinischer „devices“ und ist somit Triebfeder des gefaschirurgischen Fortschritts. Die zentrale Stellung verlangt ausgepragte Fahigkeiten und die Vereinigung beruflicher und personlicher Bedurfnisse. Intensivierung der gefaschirurgischen Lehre, Mentoring und strukturierte Programme konnten zentrale Punkte zur Vertiefung eines Vascular-surgeon-scientist-Konzepts sein und so zur Starkung der akademischen Gefaschirurgie in Deutschland beitragen.

Zusammenfassung Hintergrund Deutschland weist im Hinblick auf die regionale Siedlungsstruktur starke Unterschiede auf. Neben dicht bevolkerten Grosstadten mit einem engen Netzwerk an gefaschirurgischer Versorgung existieren weite Landstriche, in denen der Zugang zu einer gefaschirurgischen Versorgung aus raumlicher und zeitlicher Sicht eingeschrankt ist. Ziel dieser Sekundardatenanalyse ist es deshalb, die Krankenhausinzidenz, Therapieform und Mortalitat des nicht-rupturierten abdominalen Aortenaneurysmas (nrAAA) in Abhangigkeit vom siedlungsstrukturellen Kreistyp des Patientinnen- und Patientenwohnorts zu untersuchen. Methode Es wurden die Mikrodaten der DRG-Statistik des Statistischen Bundesamtes der Jahre 2005–2014 ausgewertet. Eingeschlossen wurden Patientinnen und Patienten, die wegen eines nrAAA (ICD-10 Code I71.4) stationar aufgenommen und operativ therapiert wurden. Die Identifikation von offen-chirurgisch und endovaskular behandelten Fallen erfolgte anhand des Operationen- und Prozedurenschlussels. Die Einteilung der Patientinnen und Patienten erfolgte gemas des vom Bundesinstituts fur Bau-, Stadt- und Raumforschung definierten siedlungsstrukturellen Kreistyps (KT1 Kreisfreie Grosstadt, KT2 Stadtischer Kreis, KT3 Landlicher Kreis mit Verdichtungsansatzen, KT4 Dunn besiedelter landlicher Kreis) bezogen auf den Wohnort der Patientinnen und Patienten. Die alters-, geschlechts- und risikoadjustierte Assoziation zwischen KT und Krankenhausmortalitat wurde mit einem multivariablen Mehrebenen-Regressionsmodell analysiert. Zur Risikoadjustierung wurde der fur administrative Daten validierte Elixhauser-Komorbiditats-Score verwendet. Ergebnisse Von 95.452 eingeschlossenen Fallen waren 88 % Manner, das mittlere Alter betrug 72 Jahre. In KT1 wohnten 28.970 (30 %) Patientinnen und Patienten, in KT2 37.759 (40 %), in KT3 14.442 (15 %) und in KT4 14.281 (15 %). Die Krankenhausinzidenz betrug 12,4 pro 100.000 Einwohnerinnen und Einwohner in KT1, 11,8 in KT2, 10,8 in KT3 und 11,2 in KT4 ( Schlussfolgerung Die Studie zeigt, dass sich sowohl die Krankenhausinzidenz als auch die Therapieform (endovaskular vs. offen) zwischen den siedlungsstrukturellen Kreistypen leicht unterschied, jedoch kein statistisch signifikanter Zusammenhang zwischen der Krankenhausmortalitat und dem Kreistyp im Sinne eines Stadt-Land-Gefalles bei nrAAA besteht.

Obwohl valide Daten zur bevolkerungsbezogenen Pravalenz und Inzidenz des abdominalen Aortenaneurysmas (AAA) in Deutschland noch fehlen, ist auf dem Boden von nationalen Screeningprogrammen in Schweden, USA und England von einer Haufigkeit des AAA in Hohe von 1,5 bis 3,6 % unter Mannern uber 65 Jahren auszugehen. Die Behandlung des AAA erfolgt in Deutschland sektorenubergreifend und interdisziplinar, wobei im stationaren Sektor etwa 12.000 invasive Prozeduren zur Behandlung intakter (90 %) und rupturierter AAA stattfinden. In Ubereinstimmung mit der internationalen Versorgungsrealitat erfolgten dabei etwa 70 % (intakt) bzw. 30 % (rupturiert) aller Behandlungen endovaskular (EVAR). Die Daten aus verschiedenen administrativen und klinischen Registern zur Krankenhaussterblichkeit bestatigen mit etwa 1 % nach EVAR und bis zu 5 % nach offen-chirurgischer Behandlung des intakten AAA die Ergebnisse randomisierter Studien und Metaanalysen (26 % bzw. 42 % bei Behandlung der Ruptur). In Deutschland werden in > 500 Krankenhausern AAA behandelt. Eine signifikante Korrelation zwischen hoher jahrlicher Fallzahl und niedriger Krankenhausletalitat wurde mehrfach auf dem Boden verschiedener Datenquellen bestatigt. Eine Mindestmenge von 30 AAA-Operationen pro Jahr erscheint hinsichtlich der Erreichbarkeit von Krankenhausern sinnvoll. Trotz der zahlreichen verfugbaren Studien und Prasenz des Themas in Fachjournalen und Kongressen sind zahlreiche Fragen weiterhin ungeklart.

Background: Peripheral arterial disease (PAD) and acute limb ischemia (ALI) pose an increasing strain on health care systems. The objective of this study was to describe the German health care landscape and to assess hospital utilization with respect to PAD and ALI. Methods: Secondary data analysis of diagnosis-related group statistics data (2009–2018) provided by the German Federal Statistical Office. Inclusion of cases encoded by the International Classification of Diseases (ICD-10) codes for PAD and arterial embolism or thrombosis. Construction of line diagrams and choropleth maps to assess temporal trends and regional distributions. Results: A total of 2,589,511 cases (median age 72 years, 63% male) were included, of which 2,110,925 underwent surgical or interventional therapy. Overall amputation rate was 17%, with the highest rates of minor (28%) and major amputations (15%) in patients with tissue loss. In-hospital mortality (overall 4.1%) increased in accordance to Fontaine stages and was the highest in patients suffering arterial embolism or thrombosis (10%). Between 2009 and 2018, the annual number of PAD cases with tissue loss (Fontaine stage IV) increased from 97,092 to 111,268, whereby associated hospital utilization decreased from 2.2 million to 2.0 million hospital days. Hospital incidence and hospital utilization showed a clustering with the highest numbers in eastern Germany, while major amputation rate and mortality were highest in northern parts of Germany. Conclusions: Increased use of endovascular techniques was observed, while hospital utilization to treat PAD with tissue loss has decreased. This is despite an increased hospital incidence. Addressing socioeconomic inequalities and a more homogeneous distribution of dedicated vascular units might be advantageous in reducing the burden of disease associated with PAD and ALI.

Summary: Background: Type II endoleak (T2EL) after endovascular aortic repair is associated with AAA sac enlargements in up to 25%, reduction of attachment zones and rarely with aortic rupture. Indications for therapy and efficacy of interventions of T2EL are not clearly established. Transarterial embolization with application of ethylene-vinyl alcohol copolymer has been described with varying outcomes. Aim of this study is to evaluate durability of OnyxTM embolization (OE) in T2EL in a consecutive series at a single tertiary vascular center. Patients and methods: Demographic data, technical success, pre- and postoperative aneurysm growth, morbidity, mortality and reintervention rates during hospital stay as well as in follow up were recorded in patients treated with OE for T2EL between 01/2015 and 12/2017. The primary endpoint was defined as persistence or reoccurrence of T2EL (durability of OE). Results: In total 15 patients (78 ± 6 years, 13 men) were treated with OE because of sac enlargement (average growth of 12 ± 8%, n = 12), persistent bleeding after AAA rupture (n = 2) or persistent T2EL with stable but large aneurysm diameter (n = 1). Mean length of stay was 8 ± 11 days. Technical success was 93.3% (n = 14). Inhospital-morbidity was 26.7%, in-hospital- and 1-year-mortality rate were 6.6% (n = 1) and 20.0% (n = 3). T2EL persisted in 20.0% (n = 3) despite of OE. Re-EL-II occurred after 40 (30–114) days in 33.3% (n = 5). Reintervention rate was 13.3% (n = 2, at day 48 and 319). Altogether clinical success with stable aneurysm diameter was achieved in 80.0% (n = 12), but durable elimination of EL was only achieved in 46.7% of patients (n = 7). Conclusions: OE is technically possible in more than 90% of patients but might be associated with severe complications. Durability of this treatment is low, since T2EL persist or reoccur in more than 50% of all patients. OE of T2EL should be reserved for few selected cases.

Die Karotisstenose ist im Fachbereich Gefaschirurgie das einzige Krankheitsbild, fur das eine bundesweite gesetzlich verpflichtende Qualitatssicherung (QS) durchgefuhrt wird. Im Folgenden werden die Qualitatsziele zur Karotisrevaskularisation (Karotisendarteriektomie und Stentimplantation) mit den erhobenen Qualitatsindikatoren (QI) im QS-Verfahren beschrieben. Die QIs wurden zusammengefasst und in Kontext mit der Literatur gesetzt. Zur Uberprufung von Qualitatszielen werden verschiedene Mase wie QIs, Transparenzkennzahlen und Sentinel-Event-Indikatoren verwendet. Hiervon haben nur QIs einen festgelegten Referenzbereich. Das Ziel der Karotisrevaskularisation ist die Schlaganfallprophylaxe. Beim gesetzlichen QS-Verfahren „Karotisrevaskularisation“ werden daher zwei Qualitatsziele verfolgt, die mithilfe von QIs uberpruft werden: Die Indikationsstellung und eine niedrige Komplikationsrate des primaren Endpunkts Schlaganfall und Tod. Fur die Komplikationsrate wird als QI das risikoadjustierte Verhaltnis der beobachteten zur erwarteten Rate an periprozeduralen Schlaganfallen oder Todesfallen berechnet. Bundesweit lag das adjustierte Risiko fur CEA uber die Jahre zwischen 2,1 und 2,9 % und fur CAS zwischen 3,1 und 4,5 %. Die Karotisrevaskularisation ist die einzige gefaschirurgische Prozedur, bei der eine gesetzlich vorgeschriebene QS mit Uberprufung der Indikationsstellung und periprozeduralem Schlaganfall- und Letalitatsrisiko erfolgt. Damit besteht ein wichtiges Tool zur Sicherung der Versorgungsqualitat bei der invasiven Behandlung von Karotisstenosen in Deutschland. Mit zunehmender wissenschaftlicher Evidenz ist eine konstante Anpassung der QIs notwendig.

Zusammenfassung Hintergrund Akute und chronische Durchblutungsstörungen der unteren Extremitäten sind häufig und treten mit zunehmendem Lebensalter vermehrt auf. Ziel dieser Studie ist die Erfassung der Krankenhausinzidenz peripherer Durchblutungsstörungen in Deutschland sowie der Behandlungsverfahren und der behandelnden Fachabteilungen. Methoden Zur Analyse wurde die DRG-Statistik des gesamten Bundesgebiets der Jahre 2005 bis 2018 verwendet. Zur Analyse der Krankenhausmortalität, der versorgenden Fachabteilung, der Belegungstage sowie der bundeslandspezifischen Krankenhausinzidenz wurde der aktuellste verfügbare Berichtsjahrgang 2017 der „Tiefgegliederten Diagnosedaten“ analysiert. Die Einteilung der klinischen Stadien orientierte sich an den administrativen ICD-10 Codes für die pAVK-Stadien I-IV. Ergebnisse Die altersstandardisierte Krankenhausinzidenz der PAVK I-IV betrug zuletzt 231 pro 100.000 Einwohner (EW), die der arteriellen Embolie/Thrombose 23 pro 100.000 EW. Die absolute Anzahl an offenen und endovaskulären Prozeduren sowie Prozeduren bei arterieller Embolie/Thrombose und Amputation stieg stetig von 2005 (ca. 260.000) bis 2018 (ca. 620.000) an. Offen-chirurgische Eingriffe bei pAVK stiegen um 35 %, bei arterieller Embolie/Thrombose um 56 % und endovaskuläre Verfahren um 141 %. Majoramputationen nahmen um 30 % von 25.902 auf 17.237 ab, die der Minoramputationen von 37.102 auf 46.193 um +21 % zu. Die Krankenhausmortalität der pAVK I–IV betrug in 2017 im Mittel für Männer 2,3 % und für Frauen 2,8 %, bei der arteriellen Embolie/Thrombose waren dies 6,8 und 12,0 %. Schlussfolgerungen Die Krankenhausinzidenz von Männern ist höher als die von Frauen; eine Altersabhängigkeit ist bei beiden Geschlechtern vorhanden. Deutliche Unterschiede in der Krankenhausinzidenz zeigen sich zwischen den Bundesländern. Die Anzahl an endovaskulären Prozeduren zur Behandlung einer pAVK oder arteriellen Embolie nehmen weiterhin stetig zu, während die Rate an Majoramputationen abnimmt.

This dataset supports the findings of the vascular e-Learning during the COVID-19 pandemic survey (the EL-COVID survey). The General Data Protection Regulation (GDPR) of the European Union was taken into consideration in all steps of data handling. The survey was approved by the institutional ethics committee of the Primary Investigator and an online English survey consisting of 18 questions was developed ad-hoc. A bilingual English-Mandarin version of the questionnaire was developed according to the instructions of the Chinese Medical Association in order to be used in mainland People's Republic of China. Differences between the two questionnaires were minor and did affect the process of data collection. Both questionnaires were hosted online. The EL-COVID survey was advertised through major social media. All national and regional contributors contacted their respective colleagues through direct messaging on social media or by email. Eight national societies or groups supported the dissemination of the EL-COVID survey. The data provided demographics information of the EL-COVID participants and an insight on the level of difficulty in accessing or citing previously attended online activities and whether participants were keen on citing these activities in their Curricula Vitae. A categorization of additional comments made by the participants are also based on the data. The survey responses were filtered, anonymized and submitted to descriptive analysis of percentage.

In many vascular centers an endovascular first policy for the treatment of abdominal aortic aneurysms (AAA) has resulted in endovascular aortic repair (EVAR) outnumbering open aortic repair (OAR). The declining routine in OAR raises the question whether this might influence procedural outcomes and diminish surgical expertise for current and future vascular surgeons. We aimed to analyze OAR outcomes, AAA morphology and procedural details over the past 15 years while an endovascular first approach was successively implemented.All patients operated for (i)ntact infra-/juxtarenal AAA between January 1, 2005 and December 31, 2019 were identified. Outcome parameters were length of stay (hospital/ICU), in-hospital mortality and medical/surgical complications. Operative details were clamping zone, access and graft configuration. AAA anatomy including neck and iliac parameters was analyzed with Endosize©. Logistic regression, uni- and multivariate analysis were applied.293 patients received elective OAR for iAAA. Baseline characteristics (age, sex, hypertension, smoking, occlusive disease, coronary disease, hyperlipidemia, diabetes, renal insufficiency and obesity) did not change over time. The number of OAR dropped significantly (-0.5 cases/year p = 0.02). The procedure time (2005-2007: 192.2 ± 87.5min to 2017-2019: 235.6 ± 88.2min; p = 0.0001) and the length of stay (2005-2007: 12.0 ± 7.9 to 2017-2019: 17.0 ± 23.1; p = 0.03) increased significantly, whereas the in-hospital mortality, length of ICU stay and complication rates didn't, nor did AAA anatomy. Upon multivariate analysis, annual number of OAR and any additional anastomosis significantly influenced procedure time, trainee involvement, for example, did not. Hospital length-of-stay depended on patient age (p = 0.002), complication rates (p0.0001) and procedure time (p = 0.006).Mortality and complication rates for OAR have remained low and constant. With the increase of EVAR, the absolute number of OARs has decreased significantly. However, the total procedure time has increased and depends significantly on the annual number of OARs in total and per surgeon. This might influence outcome parameters and should be implanted in future surgical education.

Background The corona virus disease (COVID-19) pandemic has radically changed the possibilities for vascular surgeons and trainees to exchange knowledge and experience. The aim of the present survey is to inventorize the e-learning needs of vascular surgeons and trainees as well as the strengths and weaknesses of vascular e-Learning. Methods An online survey consisting of 18 questions was created in English, with a separate bilingual English-Mandarin version. The survey was dispersed to vascular surgeons and trainees worldwide through social media and via direct messaging from June 15, 2020 to October 15, 2020. Results Eight hundred and fifty-six records from 84 different countries could be included. Most participants attended several online activities (>4: n = 461, 54%; 2–4: n = 300, 35%; 1: n = 95, 11%) and evaluated online activities as positive or very positive (84.7%). In deciding upon participation, the topic of the activity was most important (n = 440, 51.4%), followed by the reputation of the presenter or the panel (n = 178, 20.8%), but not necessarily receiving accreditation or certification (n = 52, 6.1%). The survey identified several shortcomings in vascular e-Learning during the pandemic: limited possibility to attend due to lack of time and increased workload (n = 432, 50.5%), no protected/allocated time (n = 488, 57%) and no accreditation or certification, while technical shortcomings were only a minor problem (n = 25, 2.9%). Conclusions During the COVID-19 pandemic vascular e-Learning has been used frequently and was appreciated by vascular professionals from around the globe. The survey identified strengths and weaknesses in current e-Learning that can be used to further improve online learning in vascular surgery.

Real-world data are gaining increasing attention as an inevitable adjunct to the evidence gathered by randomized controlled trials (RCT). Registry data are often limited through voluntary participation of selected physicians, hospitals and patients (selection bias) as well as insufficient data validation (information bias); however, secondary analysis of statutorily collected data can overcome some of these limitations and enable nationwide (full) surveys to be conducted. This is especially important for the analysis of structural aspects of health care. This article provides an introduction to the methodology of secondary data analysis of routine data in Germany that are collected on the basis of statutory regulations. The article emphasizes the strengths and limitations and gives an overview of possible applications, including recent examples focusing on vascular medicine.

Hospital incidence, treatment modality, and in hospital mortality after surgery are reported for thoraco-abdominal aortic aneurysms (TAAAs) treated by endovascular or open means in Germany from 2005 to 2014.Data were extracted from diagnosis related group statistics from the German Federal Statistical Office. All inpatient cases with a diagnosis of ruptured and non-ruptured TAAA (ICD-10 I71.5 and I71.6) and procedure codes for fenestrated or branched endovascular aortic repair (f/bEVAR 5-38a.7x and 5-38a.8x), open aortic repair (OAR 5-384.4), or hybrid procedure (5-384.b/c, 5-38a.a/b/8/80) were included. To adjust for sex, age, medical risk (Elixhauser comorbidity score), type of procedure, and type of admission, a multilevel multivariable regression model with robust error variance was applied. The primary outcome was in hospital mortality; secondary outcomes were organ complications. The relationship between annual hospital volume and outcome was analysed.A total of 2607 cases (406 rTAAA, 2201 nrTAAA) were included. f/bEVAR was performed in 856 cases (32.8%), OAR in 1422 cases (54.5%), and hybrid repair in 354 cases (13.6%). Endovascular repair became more frequent over time (6% in 2005 vs. 76% in 2014 for nrTAAA). Hypertension (75.2%), peripheral artery disease (including abdominal aortic aneurysm, 49.5%), other heart diseases (44.6%), coronary heart disease (30.6%), and renal failure (28.7%) were the most frequently coded comorbidities. The number of hospitals treating TAAAs almost tripled within 9 years. The in hospital mortality was 46.1% for rTAAA and 15.9% for nrTAAA. f/bEVAR (RR 0.35, 0.24-0.51) and high hospital volume (p .001) were significantly associated with decreased in hospital mortality. Aortic rupture, increasing age, and comorbidity were significantly associated with higher mortality (RR 3.17, 2.45-4.09; 1.52, 1.32-1.76, and 1.05, 1.04-1.06).Seventy-six percent of all TAAAs were treated endovascularly in 2014 with increasing frequency over a decade. In hospital mortality is lower with endovascular repair and in high volume centres. Aortic rupture, age, and severe comorbidities are associated with worse outcomes.

BACKGROUND The German quality assurance guideline on abdominal aortic aneurysm (AAA) was implemented by the Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) in 2008. The aims of this study were to verify the association between hospital case volume and outcome and to assess the hypothetical effect of minimum caseload requirements. METHODS The German diagnosis-related groups statistics for the years 2012 to 2016 were scrutinized for AAA (ICD-10 GM I71.3/4) with procedure codes for endo - vascular or open surgical treatment. The primary endpoint was in-hospital mortality. Logistic regression models were used for risk adjustment, and odds ratios (OR) were calculated as a function of the annual hospital-level case volume of AAA. In a hypo - thetical approach, the linear distances for various minimum caseloads (MC) were evaluated to assess accessibility. RESULTS The mortality of intact AAA (iAAA) was 2.7% (men [M] 2.4%, women [W] 4.2%); ruptured AAA (rAAA), 36.9% (M 36.9%, F 37.5%). An inverse relationship between annual hospital case volume of AAA and mortality was confirmed (iAAA/rAAA: from 3.9%/51% [

In Germany, the regional settlement structure is heterogenous, ranging from densely populated cities with a tight network of vascular health care to large regions in which access to health care is limited in terms of space and time. Therefore, the aim of this secondary data analysis was to investigate the association between the settlement structure of the patient's home district (KT), and the hospital incidence, type of therapy, and mortality of non-ruptured abdominal aortic aneurysms (nrAAA).The microdata of the DRG statistics of the Federal Statistical Office for the years 2005-2014 were evaluated. All patients with nrAAA (ICD-10 Code I71.4) who were admitted to a German hospital and treated by open surgery and endovascular repair were included. Classification of treatment was based on the German Operation and Procedure Code. Patients were grouped according to the settlement structure of their home district defined by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (KT1 independent city, KT2 urban district, KT3 rural district, KT4 sparsely populated region). The age-, sex- and risk-adjusted association between the type of settlement structure and in-hospital mortality was analysed using a multivariable multi-level regression model. The Elixhauser co-morbidity score validated for administrative data was used for risk adjustment.Of 95,452 cases included, 88 % were men. Mean age was 72 years. There were 28,970 (30 %) patients in KT1, 37,759 (40 %) in KT2, 14,442 (15 %) in KT3 and 14,281 (15 %) in KT4. The hospital incidence was 12.4 per 100,000 inhabitants in KT1, 11.8 in KT2, 10.8 in KT3 and 11.2 in KT4 (p 0.001, falling trend). The proportion of EVAR treatment was 56 % in KT1, 54 % in KT2, 57 % KT3, and 59 % in KT4 (p 0.001, increasing trend). The raw hospital mortality of patients from KT1 to KT4 was 3.4 %, 3.4 %, 3.2 % and 3.6 %, respectively (p=0.553 for trend). The multivariable regression analysis revealed no statistically significant association between the KT and hospital mortality (KT1=reference, RR KT2=0.97 [95% CI 0.79-1.15], RR KT3=0.98 [0.81-1.14], RR KT4=0.98 [0.86-1.11]).The study shows that both the hospital incidence and the type of therapy (endovascular vs. open) differed between the settlement structural district types, but there is no urban-rural gap regarding in-hospital mortality of treated nrAAA.

Background Revascularization strategies for chronic mesenteric ischemia (CMI) include open (OR) and endovascular (ER) modalities. The primary objective of this study was to analyze the safety and effectiveness of OR and ER and the impact of clinical and morphological variables on early and midterm outcomes in a consecutive series of CMI patients in a tertiary referral center. Patients and methods From 2004 to 2017, all CMI patients treated with OR and ER were retrospectively identified. Patient records, preoperative imaging, as well as peri- and postoperative outcomes were analyzed. Univariable and multivariable analysis was performed to identify clinical or morphological variables affecting reintervention rates within 2 years. Results In total, 63 patients (33% male; mean age 71, range 60–76 years) were treated by ER (41 patients) or OR (22 patients) for CMI. Mean follow-up was 26 (10–71) months. 30-day mortality was 0.0% after ER and 4.5% after OR (p = 0.069); 30-day morbidity was 9.8% vs. 31.8%, respectively (p = 0.030). Length of stay was significantly longer after OR (14 vs. 4 days; p p = 0.14). Overall survival did not differ after 2 years (OR 85% vs. ER 86%; p = 0.35). Multivariable analysis revealed that smoking was associated with higher risk of reintervention (hazard ratio, HR: 4.14; 95% confidence interval, CI 1.11–15.53; p = 0.03). Additionally, a nonsignificant trend of lower reintervention rates after OR was detected (HR 0.23 95% CI 0.05–1.08; p = 0.06). Conclusion Due to a lower invasiveness, despite the higher reintervention rate, an “endovascular first” strategy is justified and recommended.

Purpose: Outcomes of open iliac artery repair (OIR) and endovascular iliac artery repair (EVIR) were compared at a tertiary referral vascular center. Methods: From 2004 to 2015, all patients treated for isolated iliac artery aneurysms (IAAs) were retrospectively identified, and patient records and computed tomography (CT) scans were analyzed. The primary end point was overall survival; secondary end points were 30-day mortality and morbidity and freedom from reintervention. For follow-up, data from outpatient visits and CT scans following a standard surveillance protocol were used. Results: A total of 106 IAAs in 94 patients were treated (mean follow-up: 35.7 months; 66 OIR; 40 EVIR). Six (15%) aneurysms from the EVIR group and 4 (6.1%) from open-operated IAA presented in the state of rupture. There was no difference in overall survival between EVIR and OIR ( P = .14). In multivariable analysis, higher risk of death was associated with ruptured IAA (rIAA; hazard ratio [HR]: 40.44, 95% confidence interval [CI]: 2.05-796.18; P = .02) and coronary heart disease (HR: 11.07, 95% CI: 1.94-63.36; P < .01). The 30-day mortality was 1.9% overall (0% OIR, 5.0% EVIR, P = .27), but there were no differences between OIR and EVIR in 30-day morbidity ( P = .11). Freedom from reintervention was higher for OIR than for EVIR ( P < .01). In multivariable analysis, a higher reintervention rate was seen in EVIR (HR: 10.80, 95% CI: 2.20-53.01; P < .01) and in rIAA (HR: 12.02, 95% CI: 1.31-111.11; P = .03). Conclusion: Iliac artery aneurysmss can be safely and effectively treated by EVIR or OIR regarding 30-day morbidity, mortality, and long-term survival, although freedom from reintervention is significantly lower after EVIR.

Background There is increasing awareness that women may have worse outcomes following repair of abdominal aortic aneurysm (AAA). The aim of this study was to analyse the association between sex, age and in-hospital mortality after AAA using hospital episode data collected routinely at the nationwide level. Methods Data were extracted from the nationwide statutory Diagnosis Related Group statistics provided by the German Federal Statistical Office. Patients with a diagnosis of intact (non-ruptured) AAA (ICD-10 GM I71.4) and procedure codes (OPS; 2005–2013) for endovascular aneurysm repair (EVAR) (5-38a.1*) or open aneurysm repair (5-384.5, 5-384.7), treated from 2005 to 2013, were included. A multilevel multivariable regression model was applied to adjust for medical risk (using the Elixhauser co-morbidity score), type of procedure, type of admission, and to account for clustering of patients within centres. The primary outcome was in-hospital mortality. Results Some 84 631 patients were identified, of whom 10 039 (11·9 per cent) were women. Women were significantly older than men at admission (median 74 (i.q.r. 69–80) versus 72 (66–77) years; P < 0·001). EVAR was used less frequently in women (48·1 versus 54·7 per cent; P < 0·001). The in-hospital mortality rate was higher in women, overall (5·0 versus 3·1 per cent; relative risk 1·60, 95 per cent c.i. 1·45 to 1·75), and for EVAR (2·8 versus 1·5 per cent; RR 1·90, 1·60 to 2·30) and open repair (6·8 versus 5·0 per cent; RR 1·36, 1·22 to 1·52). In-hospital mortality increased with age and was highest in patients aged over 80 years. In multivariable regression analysis, female sex (RR 1·20, 1·07 to 1·35) and age per 10-year increase (RR 1·83, 1·73 to 1·95) were independent risk factors for higher in-hospital mortality. Conclusion In Germany, women were older when undergoing AAA repair and were less likely to receive EVAR. Mortality rates were higher in older patients and in women, irrespective of the surgical technique used.

Die Transparenz des Behandlungsaufwands ist eine Grundvoraussetzung fur das Verstandnis entstehender Kosten. Nur eine gleichzeitige Betrachtung der Kosten und Erlose kann hierbei die Grundlage fur strategische Entscheidungen sein. Die Kostentragerrechnung wird als Instrument fur DRGs (Diagnosis Related Groups) und ZE (Zusatzentgelt) in der Behandlung abdominaler und thorakoabdominaler Aortenerkrankungen am Beispiel fenestrierter und gebranchter Endoprothesen (FEVAR, BEVAR) beschrieben. Hierbei werden exemplarisch Kosten und reale Erlose aus jeder DRG vorgestellt. Beispielfalle aus dem Jahr 2016 wurden dafur erfasst und hinsichtlich aller Kosten und Erlose (inkl. Zusatzentgelte) analysiert. 50–70 % der Gesamtkosten von FEVAR/BEVAR werden durch Materialkosten verursacht. Die Deckung der entstehenden Kosten lasst sich nur durch ein abrechenbares Zusatzentgelt gewahrleisten. Dies setzt die korrekte Erfassung aller tatsachlichen Kosten durch die Krankenhausverwaltung voraus. Nur so kann sichergestellt werden, dass bei den Verhandlungen des Zusatzentgeltes (zumeist im Folgejahr) alle notwendigen Daten und Informationen zur Verfugung stehen. Die Komplexitat der Kosten- und Erlosstruktur bei der Behandlung von Aortenpathologien kann insbesondere bei haufiger Anwendung von masgeschneiderten („custom-made device/CMD“) Stentprothesen ein relevantes finanzielles Risiko fur das Gesamtbudget einer Klinik darstellen.

Collecting biological tissue samples in a biobank grants a unique opportunity to validate diagnostic and therapeutic strategies for translational and clinical research. In the present work, we provide our long-standing experience in establishing and maintaining a biobank of vascular tissue samples, including the evaluation of tissue quality, especially in formalin-fixed paraffin-embedded specimens (FFPE). Our Munich Vascular Biobank includes, thus far, vascular biomaterial from patients with high-grade carotid artery stenosis (n = 1567), peripheral arterial disease (n = 703), and abdominal aortic aneurysm (n = 481) from our Department of Vascular and Endovascular Surgery (January 2004⁻December 2018). Vascular tissue samples are continuously processed and characterized to assess tissue morphology, histological quality, cellular composition, inflammation, calcification, neovascularization, and the content of elastin and collagen fibers. Atherosclerotic plaques are further classified in accordance with the American Heart Association (AHA), and plaque stability is determined. In order to assess the quality of RNA from FFPE tissue samples over time (2009⁻2018), RNA integrity number (RIN) and the extent of RNA fragmentation were evaluated. Expression analysis was performed with two housekeeping genes—glyceraldehyde 3-phosphate dehydrogenase (GAPDH) and beta-actin (ACTB)—using TaqMan-based quantitative reverse-transcription polymerase chain reaction (qRT)-PCR. FFPE biospecimens demonstrated unaltered RNA stability over time for up to 10 years. Furthermore, we provide a protocol for processing tissue samples in our Munich Vascular Biobank. In this work, we demonstrate that biobanking is an important tool not only for scientific research but also for clinical usage and personalized medicine.

Reduced lower-limb blood flow has been shown to lead to asymmetrical abdominal aortic aneurysms (AAAs) but the mechanism of action is not fully understood. Therefore, small animal ultrasound (Vevo2100, FUJIFILM VisualSonics) was used to longitudinally study mice that underwent standard porcine pancreatic elastase (PPE) infusion (n = 5), and PPE infusion with modified 20% iliac artery stenosis in the left (n = 4) and right (n = 5) iliac arteries. Human AAA computed tomography images were obtained from patients with normal (n = 9) or stenosed left (n = 2), right (n = 1), and bilateral (n = 1) iliac arteries. We observed rapid early growth and rightward expansion (8/9 mice) in the modified PPE groups (p < 0.05), leading to slightly larger and asymmetric AAAs compared to the standard PPE group. Further examination showed a significant increase in TGFβ1 (p < 0.05) and cellular infiltration (p < 0.05) in the modified PPE group versus standard PPE mice. Congruent, yet variable, observations were made in human AAA patients with reduced iliac outflow compared to those with normal iliac outflow. Our results suggest that arterial stenosis at the time of aneurysm induction leads to faster AAA growth with aneurysm asymmetry and increased vascular inflammation after 8 weeks, indicating that moderate iliac stenosis may have upstream effects on AAA progression.

Background Abdominal aortic aneurysm (AAA) has an age-dependent prevalence of 2% to 11% and is a leading cause of death in men aged >65 years if not treated surgically. Today, endovascular aneurysm repair (EVAR) is performed in up to 80% of elective cases and 60% of ruptured cases. Although EVAR improves perioperative, early, and midterm outcomes, it is associated with specific complications, especially endoleaks (ELs). Type II EL occurs in up to 30% of procedures; however, aneurysm sac expansion and rupture are rare, and currently nothing is known about the morphologic changes in this condition. In this study, we investigate the aneurysm wall morphology in secondary expanding human AAA samples after EVAR with persistent type II EL in comparison to nonaneurysmatic control aortic and AAA samples. Methods Samples were acquired from the aneurysm sac during retroperitoneal feeder vessel ligation in a cohort of 10 patients with secondary expansion after EVAR and type II EL diagnosed by computed tomography and contrast-enhanced ultrasound. Control tissues included 42 AAAs and 13 control aortae published previously. Hematoxylin and eosin staining and immunohistochemistry for CD3/4/31/68 and Ki67 were performed for morphologic analysis. Terminal deoxynucleotidyl transferase deoxyuridine triphosphate nick end labeling (TUNEL) assays allowed quantification of apoptosis. Reverse transcription-polymerase chain reaction was used to quantify gene expression and Western blot to quantify collagen expression. Results Secondary expansion of 33.8% ± 30% during 5 years was seen after EVAR before reoperation. The aneurysm wall after expansion shows significant thinning of the intima-media layer accompanied by a scarcity of cells, with only a little chronic inflammation left compared with AAA samples. Macrophages are seen in abundance, and matrix metalloproteinase expression is significantly upregulated. Relevant apoptosis is not noticed. Fibrous tissue is reduced, and a collagen turnover to different subtypes is noted in comparison to nonaneurysmatic control aorta and AAA. In addition, the transcription factors vascular endothelial growth factor, Kruppel-like factor 4, and BCL2, elevated in AAA, are significantly reduced after secondary expansion. Conclusions The aneurysm sac morphology after EVAR with persistent type II EL is characterized by atrophy and proteolysis suggestive of structural weakening. These results should be considered for the follow-up schedule as well as for the potential treatment of this most frequent EVAR complication.

Abstract. Background: Cathepsins have been described in the pathogenesis of abdominal aortic aneurysm (AAA), their exact role, especially in collagen degradation, is still unclear. The aim of the present study was therefore to analyse relevant cathepsins in human AAA tissue samples in relation to collagen I, III, and their degradation products. Materials and methods: Samples from 37 AAA patients obtained from elective open surgical repair and eight healthy non-aneurysmatic aortas from kidney donors were included. Expression of cathepsins B, D, K, L, S, cystatin C, collagen I and III, their degraded products C-Telopeptide of type 1 and 3 collagen (CTX-I, CTX-III), cellular markers for leukocytes (CD45), T cells (CD3), macrophage scavenger receptor-1 (MSR-1), synthetic, and contractile smooth muscle cells (SMCs) (smoothelin: SMTH, collagen I and III, myosin heavy chain: MHC, embryonic smooth muscle myosin heavy chain: SMemb) were determined at messenger RNA (mRNA) level, using SYBRGreen-based quantitative PCR and at protein level using enzyme-linked immunosorbent assay (ELISA). Results: Expression of cathepsins B, D, L, and S at mRNA level was significantly elevated in AAA compared to control aorta (1.7-fold, p = 0.025; 2.5-fold, p = 0.002; 2.6-fold, p = 0.034; and 7.0-fold, p = 0.003). Expression of cathepsin S correlated significantly with leukocytes and macrophages (ρ = 0.398, p = 0.033 and ρ = 0.422, p = 0.020), synthetic SMCs were significantly associated with cathepsins B, D, and L (ρ = 0.522, p = 0.003; ρ = 0.431, p = 0.015 and ρ = 0.467, p = 0.008). At protein level, cathepsins B and S were elevated in AAA compared to controls (5.4-fold, p = 0.001 and 7.3-fold, p < 0.001). Significant correlations were observed between collagen I, its degraded product, and cathepsin S (r = –0.350, p = 0.034 and r = +0.504, p < 0.001). Expression of cathepsin B was associated with SMCs, expression of cathepsin S with inflammatory cells. Conclusions: Particularly cathepsin S was associated with the degradation product of collagen I and thus might be involved in the progression of AAA. Furthermore, cathepsin S correlated with inflammatory cells.

The aim of the study was to analyze clinical, morphological and structural predictors of the outcome of open and endovascular surgery on non-ruptured (nr) and ruptured (r) abdominal aortic aneurysms (AAA) in a quality assurance registry of the German Vascular Society (Deutsche Gesellschaft fur Gefaschirurgie und Gefasmedizin, DGG). The study focused in particular on a possible relationship between annual hospital caseload and outcome. Between 1999 and 2010 a total of 36,594 surgical procedures for nrAAA and 4859 surgical procedures for rAAA were recorded in 201 hospitals. Categorical and quantitative characteristics are summarized in descriptive statistics. To analyze a relationship between annual hospital caseload and in-hospital mortality, the hospitals were divided into volume groups. A mixed logistic regression model was used to compare the groups. Additionally, a univariate model with volume groups as an influencing variable was adjusted to the data, as well as multivariate models with volume groups, type of surgery, age, AAA size, ASA score and presence of an additional iliac aneurysm or inflammatory AAA as independent variables. The mean age was 71.0 years (± 8.1) in nrAAA and 73.8 years (± 9.1) in rAAA. In total, 66.7 % of patients with nrAAA and 88.3 % in rAAA presented with ASA ≥ 3. In nrAAA, 37 % of patients received endovascular aortic repair (EVAR), 11.8 % for rAAA. In-hospital mortality for nrAAA was 2.7 % [open aortic repair (OAR) 3.6 %, EVAR 1.3 %], for rAAA 39 % (OAR 41.2 %, EVAR 21.8 %). Univariate analysis showed increasing age, ASA ≥ 3, increasing aneurysm size, inflammatory AAA and OAR to be significant predictors of higher in-hospital mortality in both nrAAA, and rAAA. A significant survival benefit for the treatment of nrAAA could be shown for patients treated in hospitals with a caseload of ≥ 31 operative procedures per year (compared to 1–20 operative procedures/year). Hospitals with higher annual caseloads also showed a trend towards decreased mortality in rAAA. Multivariate analysis showed increasing age, AAA diameter ≥ 6 cm, ASA ≥ 3 and OAR to be independent predictors of perioperative fatality in nrAAA and rAAA. In nrAAA, an annual AAA volume of 50–62 cases was an independent predictor of lower in-hospital mortality. Comorbidities (ASA score) and increasing age are significant predictors of increased in-hospital mortality in nrAAA and rAAA. A higher annual volume is associated with lower in-hospital mortality in nrAAA. For both elective and emergency AAA treatment, a referral to a hospital with a high annual AAA caseload should be considered.

Objectives Nationwide population based data on epidemiology and surgical treatment of descending thoracic aortic (DTA) aneurysms are not available for Germany. The aim was to assess the in hospital incidence, and to report outcomes of patients who received surgical treatment. Methods Data were acquired by analysing the diagnosis related group (DRG) statistics of the German Federal Statistical Office. All inpatient cases of ruptured (rDTA aneurysm, ICD Code I71.1) or non-ruptured DTA aneurysm (nrDTA aneurysm; I71.2) who received thoracic endovascular (TEVAR; OPS procedure code 5-38a.7/70/8/80) or open aortic repair (OAR; OPS 5–384.3) between 2005 and 2014 were included. To adjust for sex, age, medical risk (Elixhauser comorbidity score), type of procedure, and type of admission, a multilevel multivariable regression model with robust error variance was applied. The primary outcome was in hospital mortality; secondary outcomes were organ complications. A volume outcome analysis was performed. Results A total of 48,098 cases of DTA aneurysm (5,848, 12.2% rDTA aneurysm) were identified. The average age was 69 ± 12 years. 65.2% were male. Frequent comorbidities were hypertension (74.9%), peripheral artery disease (including abdominal aortic aneurysm, 42.6%), other heart diseases (41.6%), coronary heart disease (26.2%), and renal failure (22.5%). Surgical treatment was received by 4969 patients (10.3%): 4057 TEVAR (81.6%) and 912 OAR (18.4%) procedures. Mortality for rDTA aneurysm was 42.9% (OAR) and 22.3% (TEVAR). It was 10.5% and 3.7% for DTA aneurysm, respectively. Rupture, increasing age, and higher comorbidity score were significantly associated with higher mortality (RR 6.66, 5.33–8.25; 1.28, 1.17–1.40; and 1.06, 1.05–1.08, respectively). Endovascular treatment was associated with lower mortality (RR 0.31, 0.23–0.41). Hospital volume was not significantly associated with in hospital mortality. Conclusions Eighty per cent of patients treated surgically for a DTA aneurysm receive endovascular therapy, with low peri-operative mortality in non-ruptured cases. Elective endovascular repair should be considered for individuals at a high risk of rupture who are fit for surgery. Open repair, increased age, and a high comorbidity score are associated with higher mortality.

Objective This study aimed to analyze the spatial distribution and regional variation of the hospital incidence and in hospital mortality of abdominal aortic aneurysms (AAA) in Germany. Methods German DRG statistics (2011–2014) were analysed. Patients with ruptured AAA (rAAA, I71.3, treated or not) and patients with non-ruptured AAA (nrAAA, I71.4, treated by open or endovascular aneurysm repair) were included. Age, sex, and risk standardisation was done using standard statistical procedures. Regional variation was quantified using systematic component of variation. To analyse spatial auto-correlation and spatial pattern, global Moran's I and Getis-Ord Gi* were calculated. Results A total of 50,702 cases were included. Raw hospital incidence of AAA was 15.7 per 100,000 inhabitants (nrAAA 13.1; all rAAA 2.7; treated rAAA 1.6). The standardised hospital incidence of AAA ranged from 6.3 to 30.3 per 100,000. Systematic component of variation proportion was 96% in nrAAA and 55% in treated rAAA. Incidence rates of all AAA were significantly clustered with above average values in the northwestern parts of Germany and below average values in the south and eastern regions. Standardised mortality of nrAAA ranged from 1.7% to 4.3%, with that of treated rAAA ranging from 28% to 52%. Regional variation and spatial distribution of standardised mortality was not different from random. Conclusions There was significant regional variation and clustering of the hospital incidence of AAA in Germany, with higher rates in the northwest and lower rates in the southeast. There was no significant variation in standardised (age/sex/risk) mortality between counties.

Objectives The aim of this study was to analyse the association between annual hospital procedural volume and post-operative outcomes following repair of abdominal aortic aneurysms (AAA) in Germany. Methods Data were extracted from nationwide Diagnosis Related Group (DRG) statistics provided by the German Federal Statistical Office. Cases with a diagnosis of AAA (ICD-10 GM I71.3, I71.4) and procedure codes for endovascular aortic repair (EVAR; OPS 5–38a.1*) or open aortic repair (OAR; OPS 5–38.45, 5–38.47) treated between 2005 and 2013 were included. Hospitals were empirically grouped to quartiles depending on the overall annual volume of AAA procedures. A multilevel multivariable regression model was applied to adjust for sex, medical risk, type of procedure, and type of admission. Primary outcome was in hospital mortality. Secondary outcomes were complications, use of blood products, and length of stay (LOS). The association between AAA volume and in hospital mortality was also estimated as a function of continuous volume. Results A total of 96,426 cases, of which 11,795 (12.6%) presented as ruptured (r)AAA, were treated in >700 hospitals (annual median: 501). The crude in hospital mortality was 3.3% after intact (i)AAA repair (OAR 5.3%; EVAR 1.7%). Volume was inversely associated with mortality after OAR and EVAR. Complication rates, LOS, and use of blood products were lower in high volume hospitals. After rAAA repair, crude mortality was 40.4% (OAR 43.2%; EVAR 27.4%). An inverse association between mortality and volume was shown for rAAA repair; the same accounts for the use of blood products. When considering volume as a continuous variate, an annual caseload of 75–100 elective cases was associated with the lowest mortality risk. Conclusions In hospital mortality and complication rates following AAA repair are inversely associated with annual hospital volume. The use of blood products and the LOS are lower in high volume hospitals. A minimum annual case threshold for AAA procedures might improve post-operative results.

Background: Aim of this study was to analyze hospital incidence, type of treatment, and hospital mortality rates of patients with abdominal aortic aneurysm (AAA) in Germany from 2005 to 2014. Methods: Microdata of the diagnosis-related group (DRG) statistics compiled by the German Federal Statistical Office for the years 2005-2014 were analyzed. Patients who were hospitalized for a ruptured AAA (rAAA, ICD-10 code I71.3, treated either surgically or conservatively) or received surgical treatment for an unruptured AAA (nrAAA, ICD-10-Code I71.4, treated either with open surgery or an endovascular procedure) were included in the analysis. The "European Standard Population 2013" was used for direct standardization of the hospital incidences. In-hospital mortality was calculated with standardization for age and risk. Results: The standardized overall hospital incidence of AAA was 27.9 and 3.3 cases per 100 000 people for men and women, respectively;over the period of the study, the incidence of rAAA fell by 30% in both sexes and that of nrAAA rose by 16% in men and 42% in women. The percentage of patients receiving endovascular treatment rose from 29% to 75% in patients with nrAAA and from 8% to 36% in patients with rAAA. The age-and risk-standardized in-hospital mortality of nrAAA was 3.3% in men and 5.3% in women. The in-hospital mortality of surgically treated rAAA was 39% in men and 48% in women. Conclusion: The hospital incidence of AAA rose from 2005 to 2014, while that of rAAA fell. Endovascular treatment became more common for nrAAA as well as rAAA, and in-hospital mortality fell for both.

Objective Acute type B aortic dissections (TBADs) can have immediate or delayed complications within the first 2 weeks. Because the majority of clinical series retrospectively categorized TBAD, the incidence and outcome of delayed complications in initially uncomplicated TBAD within the first 14 days are not well described. Methods We retrospectively analyzed 86 patients (78% male; age, 62.5 ± 13 years) with acute TBAD treated consecutively between January 2004 and May 2016 at a tertiary referral center. All TBADs were confirmed by computed tomography angiography (CTA) on admission, after 2 to 5 days, and after 10 to 14 days. Study end points were the incidence of immediate and delayed complications (aortic rupture, malperfusion, rapid aortic expansion >4 mm, pain or hypertension resistant to medical therapy) and in-hospital mortality. In addition, we looked at CTA-detected morphometric variables (maximum diameters of descending aorta, false lumen [FL], and primary entry tear; number of intimal tears; FL configuration; true lumen collapse; course of the dissection) and their association with delayed complications. Finally, we assessed treatment modalities and clinical outcomes. Results Of all TBADs, 22 (26%) presented with immediate complications (rupture, n = 11); 64 patients (74%) were initially assessed as having uncomplicated TBAD. Of these 64 patients, 24 (28% of all 86) suffered from delayed complications (malperfusion, n = 10; aortic rupture, n = 3; early expansion >4 mm, n = 8; refractory pain, n = 2; uncontrollable hypertension, n = 1) at a median interval of 7.1 (2-14) days after symptom onset. During the first 14 days, 40 patients (46%) remained uncomplicated. The CTA analysis revealed a significant association of initial thoracic aortic diameter ( P = .009), size of the primary entry tear ( P = .018), true lumen collapse ( P = .019), and partially thrombosed FL ( P = .019) with the occurrence of delayed complications within the first 14 days. Of the patients with delayed complications, 87.5% underwent surgery (90% thoracic endovascular aortic repair, 10% peripheral revascularization); 12.5% in this group died following aortic rupture before they received surgical repair. The mortality of patients with delayed complicated TBAD was significantly higher compared with those who remained uncomplicated within the 14-day period (12.5% vs 0%; P = .0221). Conclusions Delayed complications in initially uncomplicated acute TBAD are not infrequent. Morphologic variables like maximum diameter of the descending aorta, primary entry tear, true lumen collapse, and partially thrombosed FL were associated with an increased risk of delayed complications in initially uncomplicated TBAD. Future clinical research must verify the predictive role of clinical and morphologic variables in the acute phase, particularly with regard to a possible early surgical treatment to prevent a fatal outcome.

Zielsetzung Analyse der Daten des Qualitatssicherungsprojekts „Bauchaortenaneurysma“ der Deutschen Gesellschaft fur Gefaschirurgie und Gefasmedizin (DGG) im Hinblick auf klinische, morphologische und strukturelle Pradiktoren fur ein erhohtes perioperatives Risiko offener und endovaskularer Operationen bei nicht rupturierten (nr) und rupturierten (r) abdominalen Aortenaneurysmen (AAA). Der mogliche Zusammenhang zwischen Krankenhausfallzahl/Jahr und perioperativer Letalitat war von besonderem Interesse.