Search

Objectives This study determined whether in vivo positron emission tomography (PET) of arterial inflammation (18F-fluorodeoxyglucose [18F-FDG]) or microcalcification (18F-sodium fluoride [18F-NaF]) could predict restenosis following PTA. Background Restenosis following lower limb percutaneous transluminal angioplasty (PTA) is common, unpredictable, and challenging to treat. Currently, it is impossible to predict which patient will suffer from restenosis following angioplasty. Methods In this prospective observational cohort study, 50 patients with symptomatic peripheral arterial disease underwent 18F-FDG and 18F-NaF PET/computed tomography (CT) imaging of the superficial femoral artery before and 6 weeks after angioplasty. The primary outcome was arterial restenosis at 12 months. Results Forty subjects completed the study protocol with 14 patients (35%) reaching the primary outcome of restenosis. The baseline activities of femoral arterial inflammation (18F-FDG tissue-to-background ratio [TBR] 2.43 [interquartile range (IQR): 2.29 to 2.61] vs. 1.63 [IQR: 1.52 to 1.78]; p, Central Illustration

Venous leg ulcers (VLUs) have a significant impact on approximately 3% of the adult population worldwide, with a mean NHS wound care cost of £7600 per VLU over 12 months. The standard care for VLUs is compression therapy, with a significant number of ulcers failing to heal with this treatment, especially with wound size being a risk factor for non‐healing. This multicentre, prospective, randomised trial evaluated the safety and effectiveness of autologous skin cell suspension (ASCS) combined with compression therapy compared with standard compression alone (Control) for the treatment of VLUs. Incidence of complete wound closure at 14 weeks, donor site closure, pain, Health‐Related Quality of Life (HRQoL), satisfaction, and safety were assessed in 52 patients. At Week 14, VLUs treated with ASCS + compression had a statistically greater decrease in ulcer area compared with the Control (8.94 cm2 versus 1.23 cm2, P = .0143). This finding was largely driven by ulcers >10 to 80 cm2 in size, as these ulcers had a higher mean percentage of reepithelialization at 14 weeks (ASCS + compression: 69.97% and Control: 11.07%, P = .0480). Additionally, subjects treated with ASCS + compression experienced a decrease in pain and an increase in HRQoL compared with the Control. This study indicates that application of ASCS + compression accelerates healing in large venous ulcers.

BACKGROUND Adequate tissue perfusion is an important prognostic and diagnostic factor during the management of lower limb peripheral arterial disease. Convenient and real-time tissue perfusion monitoring remains an elusive challenge. METHODS Tissue perfusion on the dorsal and plantar surfaces of both feet of 20 participants was measured during and after cuff-induced ischemia using a novel 4-channel, laser-based perfusion monitoring device based on diffuse speckle contrast analysis technology (Pedra sensors). Participants were free of significant peripheral arterial disease. Transcutaneous partial pressure of oxygen (TcPO2) measurements were recorded concurrently for comparison. RESULTS Pedra sensors detected perfusion changes significantly more quickly than TcPO2 sensors. One minute after induced ischemia, the mean percent changes from baseline values (before ischemia) were -22.7±32.0% and -3.1±8.8% (P

Objective Background: The operative caseload of a surgeon has a positive influence on post-operative outcomes. For surgical trainees to progress effectively, maximising operating room exposure is essential, vascular surgery being no exception. Our aim was to ascertain the impact of supervised trainee led vs. expert surgeon led procedures on post-operative outcomes, across three commonly performed vascular operations. Methods A literature search was undertaken using the MEDLINE, Web of Science, and Cochrane databases up to 1 January 2018. Studies reporting outcomes following major lower limb amputation, fistula formation, or carotid endarterectomy (CEA) that involved a direct comparison between supervised trainee and experts were included, with odds ratios (ORs) calculated. Primary outcomes varied depending on the specific procedure: amputations—rate of amputation revision within 30 days; fistula formation—primary patency; CEA—stroke rate at 30 days. Meta-analysis with the Mantel-Haenszel method was performed for each outcome. Results Sixteen studies were included in the final review. Overall, trainees accounted for a third of all procedures analysed ( n = 2 421/7 017; 34.5%). Only one study was identified that described rates of amputation revision, precluding any further analysis. Four studies on fistula formation were included, showing no significant difference in outcomes between trainees and experts in primary patency (OR 1.68, 95% confidence interval [CI] 0.42–6.75). Nine studies were identified reporting post-CEA stroke rates, also demonstrating no difference between trainees and experts (OR 0.89, 95% CI 0.59–1.32). Conclusion In select cases, with appropriate training and suitable experience, supervised trainees can perform surgical procedures without any detriment to patient care. To ensure high standards for patients of the future, supported training programmes are essential for today's surgical trainees.

Key Clinical Message We report a case of lung adenocarcinoma‐associated hypercoagulability leading to venous limb gangrene, managed successfully with argatroban and then dabigatran. Use of idarucizumab permitted diagnostic investigations, leading to targeted antineoplastic therapy with crizotinib, surgical resection with curative intent, and continued survival over 2 years after the index event.

Branched thoracic aortic aneurysm repair requires arterial access from above the diaphragm in order to insert the visceral branches. This is routinely performed from the subclavian, axillary or carotid arteries and less commonly direct thoracic aorta puncture. The left ventricular apex is an alternative access route which is commonly used for percutaneous aortic valve replacement and rarely used for EVAR, FEVAR and TEVAR access. Here we describe two patients for which the left ventricular apex was the most suitable available access to the visceral branches during a branched thoracic aortic aneurysm repair. This access should be considered as an alternative approach if conventional arterial access is not available.

Objective Endovascular abdominal aortic aneurysm repair (EVAR) sometimes requires internal iliac artery (IIA) coverage to achieve a landing zone in the external iliac artery. The aim of this study was to determine complication rates following IIA exclusion. Materials and methods A systematic review of key journals was undertaken from January 1980 to April 2016. Studies detailing occlusion (using coils or plugs) or coverage of the IIA with outcome data were included. Weighted means were calculated for continuous variables. Meta-analysis was performed when comparative data were available. Quality was assessed using the GRADE system. Results Sixty-one non-randomised studies (2671 patients; 2748 IIAs) were analysed. Fifteen per cent of EVARs require IIA sacrifice. Buttock claudication (BC) occurred in 27.9% of patients, although 48.0% resolved after 21.8 months. BC rates were 32.6% with coils, 23.8% with plugs, and 12.9% with coverage alone, and less with unilateral (vs. bilateral) IIA treatment (OR 0.57, 95% CI 0.36–0.91). More proximal coil placement resulted in lower rates of BC (OR 0.12, 95% CI 0.03–0.48). Erectile dysfunction occurred in 10.2% of males, with higher rates after coiling. Type II endoleaks were more frequent after covering alone; however re-interventions were rare. Significant ischaemic events (bowel/gluteal/spinal ischaemia) were very rare. Plugs were quicker to place and required less radiation (p < .001) than coils. GRADE scoring was very low for all outcomes. Conclusion Overall the quality of reported data on IIA sacrifice is poor. Buttock claudication and erectile dysfunction occurred frequently after IIA sacrifice. Where both options are technically possible, plugs could be considered preferential to coils, and placed as proximally in the IIA as possible.

Patients with abdominal aortic aneurysm (AAA) are at significant risk of cardiovascular (CV) events. Recent implementation of AAA-screening means thousands of patients are now diagnosed with small-AAA; however, CV risk factors are not always addressed. This study aimed at assessing and quantifying the CV characteristics of patients with small AAA following the introduction of screening programmes.CV profiles of 384 men with a small AAA (55 mm diameter) were assessed through the United Kingdom Aneurysm Growth Study (UKAGS), a nationwide prospective cohort study of men with small AAA. A prospective local cohort of an additional 142 patients with small AAA with available blood pressure (BP) and lipid profiles was also included and followed-up for 1 year.In the UKAGS population, 54% were current and 30% ex-smokers; 58% were hypertensive and 54% hypercholesterolaemic. In the local group, 54% were current and 40% were ex-smokers, and 94% were hypertensive. Patients were not more likely to receive CV medication after entering AAA surveillance in either group. All local patients were clustered "high-risk" for future CV events based on the Framingham score (mean 21.8%, 95% CI 20.0-23.6), JBS-2 (16.3%, 14.7-17.9) and ASSIGN (25.2%, 22.7-27.7). No change was seen in systolic BP levels between baseline and 1 year (140.9 mmHg vs. 142.5 mmHg, p=.435). A rise was seen in cholesterol (4.0 mmol-4.2 mmol, p.0001) values at 1 year.This study suggests that patients with small AAA are at significant risk for developing CV events and this is not currently addressed, which is evident by the "high-risk" CV risk profiles of these patients despite being in AAA surveillance. Design and implementation of a CV risk reduction programme tailored for this population is necessary.

The Valiant Navion stent graft system (Medtronic, Santa Rosa, Calif) is a new iteration of a thoracic endograft for the treatment of descending thoracic aortic aneurysms. Herein, the 30-day primary safety and efficacy outcomes and secondary end points are presented.The Valiant EVO global clinical trial is a prospective, nonrandomized, single-arm trial. Patient enrollment occurred from April 2016 to October 2017. The primary end point was defined as access and/or deployment failure and/or a major device effect (MDE), including device-related secondary procedures, device-related mortality, conversion to open surgery, or thoracic aortic aneurysm rupture within 30 days of the index procedure. Other measures of stent graft performance including procedural data, rates of secondary procedures, and frequency of endoleaks are also reported.Of the 87 consecutive patients undergoing thoracic endovascular aneurysm repair who were enrolled, 33 (37.9%) were female with 61 (70.9%) presenting with severe access artery tortuosity and 66 (85.7%) with high thoracic aortic tortuosity per core laboratory evaluation. The mean procedure duration was 88.7 ± 53.4 minutes and geographical differences existed such as percutaneous access (37/52 [71.2%]) in the United States and surgical cut down in the outside of the U.S. sites (28/35 [80.0%]). There were no access or deployment failures and only 2.3% of the patients (2/87; P .0001; performance goal of 16%) experienced a MDE within 30 days of the index procedure. Two secondary procedures (n = 1 retrograde type A dissection; n = 1 aortic arch rupture) were required, and in the first 30 days, two patients died leading to a freedom from all-cause mortality of 97.7%. Endoleaks at 1 month were reported in 2.5% of patients (n = 1 type Ia; n = 1 type II).Access/deployment failures, MDEs, and endoleaks were rare in the first 30 days of the Valiant Evo clinical trial. The Valiant Navion thoracic stent graft system has shown encouraging 30-day results in this challenging cohort and trial patients will continue to be followed through 5 years.

Arterial calcification in different arterial beds has been observed to be an independent predictor of mortality. The association of abdominal visceral artery calcium with all-cause mortality remains unexplored. Patients who had undergone contrast-enhanced computerized tomography (CT) imaging for routine assessment of peripheral arterial disease (PAD) were considered for this study. A novel calcium score (abdominal visceral arteries calcium [AVAC]) for the abdominal visceral arteries (celiac axis, superior mesenteric, and renal arteries) was calculated using a modified Agatston score. Cumulative AVAC was defined as sum total of the calcium score of above individual arteries. The primary outcome was all-cause mortality. The association of AVAC with all-cause mortality was assessed. Of the 134 consecutive patients, 89 were included for analysis. Median follow-up duration was 72 (47-91) months since CT imaging; 35 (39%) patients died during this period. Hypertension and cumulative AVAC score had a significant association with all-cause mortality ( P < .05). Cumulative visceral abdominal artery calcification is associated with all-cause mortality in patients with PAD. Future prospective studies are warranted to investigate this relationship in PAD and other patient cohorts.

Objective Endovascular aneurysm sealing (EVAS) with the Nellix stent graft system is a novel concept in the management of abdominal aortic aneurysm (AAA) that aims to reduce the prevalence of all endoleaks following endovascular repair. There are few data describing the longer-term durability of this approach. The aim was to report the longer-term outcomes following EVAS in a single centre. Methods This is a retrospective review of all patients that underwent Nellix at Cambridge University Hospitals Foundation Trust. Factors that are described as device failure include secondary sac rupture, graft explantation, further surgical procedures for Type 1 endoleak, or major migration of the stent grafts with pressurisation of the aortic sac. Results A total of 161 patients have been treated with Nellix. The indications included primary AAA ( n = 115), ruptured AAA ( n = 4), salvage of other aortic grafts ( n = 18), primary iliac aneurysm ( n = 6), and chimney EVAS (ChEVAS) for pararenal AAA ( n = 18). In total there have been 42 graft failures in patients treated with EVAS for primary AAA. The 4 year freedom from graft failure was 42% in patients treated for primary AAA. Failures mostly occurred more than 2 years post-Nellix implant. There were eight secondary sac ruptures (incidence 2.4 per 100 person years) and there have been 14 graft explants. Conclusions Failure of aneurysm sealing following treatment with Nellix has been more common than anticipated and can cause aortic rupture. Post-operative surveillance of Nellix stent grafts is crucial to identify features of failure.

Endovascular aneurysm sealing (EVAS) using the Nellix system is a new and different method of abdominal aortic aneurysm repair. Normal postoperative imaging has unique appearances that change with time; complications also have different and specific appearances. This consensus document on the imaging findings after Nellix EVAS is based on the collective experience of the sites involved in the Nellix EVAS Global Forward Registry and the US Investigational Device Exemption Trial. The normal findings on computed tomography (CT), duplex ultrasound, magnetic resonance imaging, and plain radiography are described. With time, endobag appearances change on CT due to contrast migration to the margins of the hydrogel polymer within the endobag. Air within the endobag also has unique appearances that change over time. Among the complications after Nellix EVAS, type I endoleak usually presents as a curvilinear area of flow between the endobag and aortic wall, while type II endoleak is typically small and usually occurs where an aortic branch artery lies adjacent to an irregular aortic blood lumen that is not completely filled by the endobag. Procedural aortic injury is an uncommon but important complication that occurs as a result of overfilling of the endobags during Nellix EVAS. The optimum imaging surveillance algorithm after Nellix EVAS has yet to be defined but is largely CT-based, especially in the first year postprocedure. However, duplex ultrasound also appears to be a sensitive modality in identifying normal appearances and complications.

Based on the results of histopathological studies, inflammation within atherosclerotic tissue is now widely accepted as a key determinant of the disease process. Conventional imaging methods can highlight the location and degree of luminal stenosis but not the inflammatory activity of the plaque. Iron oxide-based MRI contrast media particularly ultrasmall supermagnetic particles of iron oxide have shown potential in assessing atheromatous plaque inflammation and in determining efficacy of antiatherosclerosis pharmacological treatments. In this paper, we review current data on the use of ultrasmall superparamagnetic iron oxides in atherosclerosis imaging with focus on ferumoxtran-10 and ferumoxytol. The basic chemistry, pharmacokinetics and dynamics, potential applications, limitations and future perspectives of these contrast media nanoparticles are discussed.

INTRODUCTION: Acute kidney injury (AKI) following ruptured abdominal aortic aneurysm (rAAA) repair is common and multifactorial. A standard definition of AKI after endovascular repair (EVAR), the Aneurysm Renal Injury Score (ARISe), has been proposed to facilitate standardised reporting and thus improve understanding of this issue.METHODS: Data were collected retrospectively on AKI in a prospectively maintained database of all patients treated for rAAA in a single tertiary referral centre since the availability of routine out of hours emergency EVAR. The ARISe score was used to describe the degree of AKI and factors which correlated with poor renal outcomes were assessed.RESULTS: Two-hundred and five patients were treated between January 2006 and April 2014. Of these, 125 were treated with open repair (OSR) and 80 were treated with EVAR. Severe AKI (defined as ARISe score ≥3) occurred in 36% of patients. After correction for confounders, patients treated with OSR were significantly more likely to develop severe AKI (43% vs. 26%, p = .02). There was no significant difference in preoperative serum creatinine between groups, but increased preoperative serum creatinine was strongly associated with severe AKI postoperatively (p < .001). Age, sex, endograft type, and preoperative CT scanning were not associated with differences in renal outcomes. Clamp position above renal arteries was predictive of severe AKI in patients treated with OSR (p < .01). Patients suffering severe AKI had significantly higher mortality at 30 days and 12 months (28% vs. 5% and 44% vs. 13%, p < .001 for both comparisons).CONCLUSION: Severe AKI is common following successful repair of rAAA. In this large case series of high-risk patients, OSR was associated with significantly higher rates of severe AKI compared with EVAR, despite the increased dose of contrast involved in EVAR and the older age of these patients. In turn, severe AKI was associated with higher mortality rates.

Contrast medium-induced acute kidney injury (CI-AKI) is a predominant cause of hospital-acquired renal insufficiency. With an increasing number of contrast medium-enhanced radiological procedures being performed in a rapidly increasing ageing population in the Western world, it is imperative that more attention is given to understand the aetiology of CI-AKI to devise novel diagnostic methods and to formulate effective prophylactic and therapeutic regimens to reduce its incidence and its associated morbidity and mortality. This article presents high-yield information on the above-mentioned aspects of CI-AKI, primarily based on results of randomised controlled trials, meta-analyses, systematic reviews and international consensus guidelines.

Mechanochemical ablation (MOCA) is a nonthermal nontumescent technique used in the treatment of superficial venous disease. This review analyzed the available data on the efficacy and safety of MOCA. A systematic literature search was performed. Of 101 studies identified, 14 were suitable for inclusion. The studies were found to be heterogeneous in design, and the quality of evidence was found to be low or very low. MOCA was demonstrated to be effective in the short-term with minimal complications. Consensus guidelines and definitions of reporting outcome measures must be standardized to allow comparison with other techniques.

OBJECTIVES: The first large-scale randomised trial (Immediate Management of the Patient with Rupture: Open Versus Endovascular repair [IMPROVE]) for endovascular repair of ruptured abdominal aortic aneurysm (rEVAR) has recently finished recruiting patients. The aim of this study was to examine the impact on survival after rEVAR when the IMPROVE protocol was initiated in a high volume abdominal aortic aneurysm (AAA) centre previously performing rEVAR.METHODS: One hundred and sixty-nine patients requiring emergency infrarenal AAA repair from January 2006 to April 2013 were included. Eighty-four patients were treated before (38 rEVAR, 46 open) and 85 (31 rEVAR, 54 open) were treated during the trial period. A retrospective analysis was performed.RESULTS: Before the trial, there was a significant survival benefit for rEVAR over open repair (90-day mortality 13% vs. 30%, p = .04, difference remained significant up to 2 years postoperatively). This survival benefit was lost after starting randomisation (90-day mortality 35% vs. 33%, p = .93). There was an increase in overall 30-day mortality from 15% to 31% (p = .02), while there was no change for open repair (p = .438). There was a significant decrease in general anaesthetic use (p = .002) for patients treated during the trial. Randomised patients had shorter hospital and intensive treatment unit stays (p = .006 and p = .03 respectively).CONCLUSIONS: The change in survival seen during the IMROVE trial highlights the need for randomised rather than cohort data to eliminate selection bias. These results from a single centre reinforce those recently reported in IMPROVE.

BackgroundEmergency endovascular repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) may have lower operative mortality rates than open surgical repair. Concerns remain that the early survival benefit after EVAR for rAAA may be offset by late reinterventions. The aim of this study was to compare reintervention rates and cost-effectiveness of EVAR and open repair for rAAA.MethodsA retrospective analysis was undertaken of patients with rAAA undergoing EVAR or open repair over 6 years. A health economic model developed for the cost-effectiveness of elective EVAR was used in the emergency setting.ResultsSixty-two patients (mean age 77·9 years) underwent EVAR and 85 (mean age 75·9 years) had open repair of rAAA. Median follow-up was 42 and 39 months respectively. There was no significant difference in 30-day mortality rates after EVAR and open repair (18 and 26 per cent respectively; P = 0·243). Reintervention rates were also similar (32 and 31 per cent; P = 0·701). The mean cost per patient was €26 725 for EVAR and €30 297 for open repair, and the cost per life-year gained was €7906 and €9933 respectively (P = 0·561). Open repair had greater initial costs: longer procedural times (217 versus 178·5 min; P < 0·001) and intensive care stay (5·0 versus 1·0 days; P = 0·015). Conversely, EVAR had greater reintervention (€156 939 versus €35 335; P = 0·001) and surveillance (P < 0·001) costs.ConclusionThere was no significant difference in reintervention rates after EVAR or open repair for rAAA. EVAR was as cost-effective at mid-term follow-up. The increased procedural costs of open repair are not outweighed by greater surveillance and reintervention costs after EVAR.

BACKGROUND: Functional magnetic resonance (MR) imaging of atheroma using contrast media enables assessment of the systemic severity of atherosclerosis in different arterial beds. Whether black-blood imaging has similar ability remains widely unexplored. In this study, we evaluate whether black-blood imaging can differentiate carotid plaques of patients with and without coronary artery disease (CAD) in terms of morphological and biomechanical features of plaque vulnerability, thereby allowing assessment of the systemic severity nature of atherosclerosis in different arterial beds. METHODS: Forty-one patients with CAD and 59 patients without CAD underwent carotid black-blood MR imaging. Plaque components were segmented to identify large lipid core (LC), ruptured fibrous cap (FC), and plaque hemorrhage (PH). These segmented contours of plaque components were used to quantify maximum structural biomechanical stress. RESULTS: Patients with CAD and without CAD had comparable demographics and comorbidities. Both groups had comparable prevalence of morphological features of plaque vulnerability (FC rupture, 44% versus 41%, P = .90; PH, 58% versus 47%, P = .78; large LC, 32% versus 47%, P = .17), respectively. The maximum biomechanical stress was not significantly different for both groups (241versus 278 kPa, P = .14) respectively. CONCLUSIONS: Black-blood imaging does not appear to have the ability to differentiate between the morphological and biomechanical features of plaque vulnerability when comparing patients with and without symptomatic atherosclerotic disease in a distant arterial territory such as coronary artery.

Objective Emergency Endovascular Aortic Aneurysm Repair (eEVAR) is a rapidly evolving approach to ruptured Abdominal Aortic Aneurysms (rAAA). Yet longer-term outcomes following eEVAR remain unclear. This study compares mid-term outcomes of eEVAR and open rAAA. Methods A prospective database for all patients undergoing eEVAR and open rAAA from January 2006 to April 2010 was analysed. Patients were offered eEVAR if anatomically suitable. Results 52 patients (45 male, median age 78 years (62–92 years), underwent eEVAR, 50 patients (44 male, median age = 71 (62–95 years) underwent open rAAA repair. In-hospital mortalities were 12% (6/52) for eEVAR, 32% (16/50) for open repair. There were five re-interventions (10%) in the eEVAR group. The peri-operative survival benefits of eEVAR over open rAAA repair were maintained at 1 and 2 years post-operatively with open repair demonstrating a two-fold increased risk of mortality (Hazard ratio 2.2, Fisher Exact test, 95% Confidence Interval (CI) 1.108–4.62, p = 0.0122). Overall survival was 81% at 1 year, 73% at 2 years for eEVAR, and 62% at 1 year and 52% at 2 years for open rAAA repair. Conclusion EEVAR is associated with excellent mid-term survival in this cohort. We would recommend eEVAR as the management of choice for rAAA in anatomically suitable patients where local facilities and expertise exist.

Purpose: To assess the feasibility and safety of the endovascular aneurysm sealing (EVAS) technique in the treatment of acute abdominal aortic aneurysm (AAA). Methods: A retrospective, multicenter, observational study was conducted at 8 centers (7 European and 1 in New Zealand) experienced with EVAS in the elective setting. From February 2013 to April 2015, 58 patients (mean age 74±9 years; 46 men) with an acute AAA were treated (28 ruptured and 30 symptomatic). The primary endpoint of the study was 30-day mortality; secondary endpoints included endoleak, reinterventions, and 30-day morbidity. Results: The overall intensive care unit and hospital stays were 2.2±6.6 days and 9.7±11.4 days, respectively. Thirty-day mortality rates were 32% (9/28) for the ruptured group and 7% (2/30) for the symptomatic group, with morbidity rates of 57% and 17%, respectively. Early endoleak was present in only 2 (3%) patients, one in each group; both leaks were type Ia. Reinterventions within 30 days were performed in 8 patients in the ruptured group; in the symptomatic patients, the only perioperative reintervention was embolization a type Ia endoleak. The mean follow-up was 9.3±3.1 months in the ruptured group and 12.4±5.4 months in the symptomatic group. The mean aneurysm diameter at 30-day follow-up was 71.8±16.0 mm compared with 74.7±15.7 mm preoperatively in the ruptured group and 66.1±13.5 mm compared with 65.8±13.0 mm in the symptomatic group. Conclusion: EVAS in the acute setting appears safe and feasible and concordant with the literature for endovascular aneurysm repair. More robust prospective and comparative data are required to establish the position of the technique in the treatment algorithm of acute AAA.

Background— Aneurysm expansion rate is an important indicator of the potential risk of abdominal aortic aneurysm (AAA) rupture. Stress within the AAA wall is also thought to be a trigger for its rupture. However, the association between aneurysm wall stresses and expansion of AAA is unclear. Methods and Results— Forty-four patients with AAAs were included in this longitudinal follow-up study. They were assessed by serial abdominal ultrasonography and computed tomography scans if a critical size was reached or a rapid expansion occurred. Patient-specific 3-dimensional AAA geometries were reconstructed from the follow-up computed tomography images. Structural analysis was performed to calculate the wall stresses of the AAA models at both baseline and final visit. A nonlinear large-strain finite element method was used to compute the wall-stress distribution. The relationship between wall stresses and expansion rate was investigated. Slowly and rapidly expanding aneurysms had comparable baseline maximum diameters (median, 4.35 cm [interquartile range, 4.12 to 5.0 cm] versus 4.6 cm [interquartile range, 4.2 to 5.0 cm]; P =0.32). Rapidly expanding AAAs had significantly higher shoulder stresses than slowly expanding AAAs (median, 300 kPa [interquartile range, 280 to 320 kPa] versus 225 kPa [interquartile range, 211 to 249 kPa]; P =0.0001). A good correlation between shoulder stress at baseline and expansion rate was found ( r =0.71; P =0.0001). Conclusion— A higher shoulder stress was found to have an association with a rapidly expanding AAA. Therefore, it may be useful for estimating the expansion of AAAs and improve risk stratification of patients with AAAs.

Rationnelle Le traitement antiagregant a ete implique comme facteur de risque de survenue d’hematome apres endarteriectomie carotidienne (EC). Etant donne l’utilisation croissante des antiagregants alternatifs agissant par des voies inhibitrices differentes, nous avons etudie l’incidence des reinterventions pour saignement apres EC. Methodes Les donnees ont ete prospectivement enregistrees sur tous les patients ayant une EC a Leicester, Royaume-Uni entre novembre 1997 et octobre 2001. Les donnees de ceux necessitant une reintervention pour saignement ont ete etudiees sur une base cas temoins appareilles par l’âge et le sexe a partir de la base de donnees globale. L’evaluation de la demographie des patients, de l’histoire du traitement, et des soins peroperatoires et postoperatoires a ete faite. Resultats Un total de 448 patients ont ete passes en revue et 27 (6,03%) cas de saignement postoperatoire ont ete identifies qui ont necessite une exploration. En depit de l’utilisation repandue des antiagregants avant chirurgie, il n’y avait pas de risque superieur de saignement lie a leur utilisation identifiee sur l’analyse univarie. Les patients qui ont eu une reintervention pour saignement avaient une frequence plus elevee de l’hypertension post EC (21/27 de cas contre 25/54 temoins, respectivement ; p = 0,014). Les patients qui ont eu une reintervention chirurgicale pour saignement ont egalement eu plus de transfusions (± 1,33 1,3 contre 0,02 unite de ± 0,1 ; ≤ 0,0001 de p ) et une plus longue duree de sejour hospitalier (± 4,9 2,2 jours contre ± 2,9 2,3 jours ; p = 0,001) bien qu’il n’y ait eu aucune augmentation de la morbidite ou de la mortalite. Conclusion L’utilisation des plus recents antiagregants avant la chirurgie n’a pas ete associee a un plus grand risque de saignement apres EC dans cette etude. La surveillance etroite de la tension arterielle, pre- et postoperatoire, semble etre importante, et un protocole pour sa prise en charge est recommande.

Objectives\ud \ud New and re-designed stent grafts for endovascular aortic aneurysm repair (EVAR) are released regularly. Manufacturers use data from registries to assess stent graft performance, but little is known about the ability of such registries to detect rates of clinically relevant complications. The aim of this paper was to perform a systematic review and meta-analysis to determine pooled failure rates for EVAR stent grafts, to define an acceptable non-inferiority limit for these devices, and then to calculate the number of patients needed for a new device to achieve non-inferiority against published devices.\ud \ud \ud Data sources and review methods\ud \ud MEDLINE and EMBASE were searched for studies reporting outcomes of specific EVAR grafts being used for intact infrarenal abdominal aortic aneurysms, from inception to November 2016. Meta-regression was performed to pool data and calculate the patient numbers needed to detect non-inferiority of a future graft performance. An expert consensus was performed to define adequate standards for device safety.\ud \ud \ud Results\ud \ud One hundred and forty-seven moderate quality papers involving 27,058 patients were included. Multiple outcomes were pooled. Of these, the estimated rate (±standard error) of overall endoleak (excluding Type II) at 2 years was 5.7 ± 0.6%. The pooled re-intervention rate was 11.1 ± 0.7% at 2 years. There were differences in pooled endoleak rates between different stent graft types. Expert consensus defined non-inferiority as better performance than the worst performing 25% of stent grafts. The most popular outcome in the expert consensus was cumulative endoleak rate (excluding Type II). The number of patients who would need to be enrolled in a registry to demonstrate non-inferiority at this level was 525. Only two of 147 included studies achieved this. The second most popular choice in the expert consensus was re-intervention rate; 492 patients are required to demonstrate this.\ud \ud Conclusions\ud \ud Five hundred and twenty-five patients need to be entered into a registry to demonstrate non-inferiority to previous stent grafts. Almost all previous publications have captured lower patient numbers. With performance varying between devices, and new devices being introduced regularly, there is an urgent need to capture higher quality long-term data on EVAR stent grafts.

Popliteal artery aneurysms are the most common of the peripheral aneurysms. Rupture is a rare complication of these aneurysms. Here we present a case of a ruptured popliteal aneurysm in a patient with severe joint disease and immobility due to rheumatoid arthritis. The condition was treated endovascularly with an Amplatzer arterial occlusion device. The aneurysm was successfully thrombosed without inducing critical limb ischemia, as the distal popliteal was chronically occluded. Ligation of peripheral aneurysms is an infrequent treatment without simultaneous bypass graft placement. Endovascular occlusion of ruptured popliteal aneurysms should be considered a valid therapeutic strategy where exclusion bypass is not required due to distal arterial occlusion.

Purpose: To evaluate the midterm feasibility, efficacy and safety of internal iliac artery branch grafts for endovascular repair of aortoiliac, common iliac, and internal iliac artery aneurysms. Methods: Between December 2006 and September 2008, 8 patients underwent elective endovascular repair of aortoiliac, common iliac, and internal iliac artery aneurysms. Computed tomography aortography (CTA) was used to detect postoperative endoleak, stent migration, branch patency, and aneurysm sac expansion. Results: All stent grafts were correctly implanted. However, intraoperative branch occlusion occurred in 2 of 8 cases. Both occlusions have been managed conservatively, with only 1 patient suffering detrimental symptoms. One endoleak was found. Median follow up by CT was 402 days (range 77 to 718 days). No patients died. Conclusions: Midterm results are encouraging for endovascular branch grafts to include the internal iliac artery. However, patient selection is of great importance and our series illustrates the value of caution and multidisciplinary teamwork.

Objectives Compare carotid plaque morphology of acute symptomatic, recently symptomatic and asymptomatic patients (groups 1, 2 and 3 respectively) with carotid artery disease using high resolution magnetic resonance imaging (MRI), to identify high-risk plaque characteristics best associated with risk of recurrent thrombo-embolic events. Methods 60 patients underwent multi-contrast imaging of their internal carotid arteries. Different plaque components were manually delineated on acquired axial images to assess the difference in prevalence of plaque hemorrhage, fibrous cap (FC) rupture and FC thickness among the three groups. Results 55% acute symptomatic patients had plaque hemorrhage vs. 35% for recently symptomatic group and 5% for asymptomatic group ( p -value: group 1 vs. 3: 0.001, group 2 vs. 3: 0.04). Type 1 hemorrhage was more common in acute symptomatic patients than recently symptomatic patients (40% vs. 5%, p =0.01). Type 2 hemorrhage was more common in recently symptomatic vs. acute symptomatic patients (15% vs. 30%). FC rupture was observed in 50% of patients in group 1 vs. 35% of group 2 patients ( p =0.02) but none in group 3. The mean minimum FC thickness was same in acute and recently symptomatic groups (600±200μm), compared to 800±200μm for asymptomatic patients ( p -value: 0.03 and 0.007 respectively). Good correlation was present among the three MR readers (intra-class correlation coefficient=0.71). Conclusion High resolution MRI can differentiate plaque components associated with increased risk of thrombo-embolic events.

Objectives Platelet function exhibits circadian variation with highest levels of activity in the morning and plays a central role in arterial thrombotic events, including thrombotic stroke following carotid endarterectomy (CEA). Prior to the platelet-rich thrombus occluding the carotid artery, multiple embolic signals are detected in the middle cerebral artery using transcranial Doppler ultrasound. We hypothesized that patients undergoing CEA early in the day may be at an increased stroke risk and this would manifest as an increased postoperative embolic count. Methods Data were collected prospectively on 235 patients undergoing primary CEA. Accurate start and finish times were recorded in addition to the number of postoperative emboli detected in the first three hours after CEA using transcranial Doppler (TCD) monitoring. Results For operations finishing before midday, there was a 3.6-fold increase in the number of emboli detected relative to afternoon finishes (53.2 vs 14.8, P = .002) with similar results for starts before 10:30am (48.1 vs 14.7, P =.002). There was also a significant correlation between start time and emboli count ( P = .02). Of the 55 patients with no postoperative emboli, only 19 had a morning start (relative risk 0.63, P = .011). Patients were 6.9 times more likely to require treatment with Dextran-40 to prevent progression onto a thrombotic stroke if their CEA finished before midday ( P = .008). Conclusion There is a significantly increased rate of postoperative embolization for operations begun earlier in the day. Carotid endarterectomies performed in the afternoon may be at less risk of developing postoperative thrombotic stroke.

Objectives The aim of this study was to evaluate the effects of low-dose (10 mg) and high-dose (80 mg) atorvastatin on carotid plaque inflammation as determined by ultrasmall superparamagnetic iron oxide (USPIO)-enhanced carotid magnetic resonance imaging (MRI). The hypothesis was that treatment with 80 mg atorvastatin would demonstrate quantifiable changes in USPIO-enhanced MRI-defined inflammation within the first 3 months of therapy. Background Preliminary studies indicate that USPIO-enhanced MRI can identify macrophage infiltration in human carotid atheroma in vivo and hence may be a surrogate marker of plaque inflammation. Methods Forty-seven patients with carotid stenosis >40% on duplex ultrasonography and who demonstrated intraplaque accumulation of USPIO on MRI at baseline were randomly assigned in a balanced, double-blind manner to either 10 or 80 mg atorvastatin daily for 12 weeks. Baseline statin therapy was equivalent to 10 mg of atorvastatin or less. The primary end point was change from baseline in signal intensity (ΔSI) on USPIO-enhanced MRI in carotid plaque at 6 and 12 weeks. Results Twenty patients completed 12 weeks of treatment in each group. A significant reduction from baseline in USPIO-defined inflammation was observed in the 80-mg group at both 6 weeks (ΔSI 0.13; p = 0.0003) and at 12 weeks (ΔSI 0.20; p Conclusions Aggressive lipid-lowering therapy over a 3-month period is associated with significant reduction in USPIO-defined inflammation. USPIO-enhanced MRI methodology may be a useful imaging biomarker for the screening and assessment of therapeutic response to “anti-inflammatory” interventions in patients with atherosclerotic lesions. (Effects of Atorvastatin on Macrophage Activity and Plaque Inflammation Using Magnetic Resonance Imaging [ATHEROMA]; NCT00368589 )

To compare the perioperative morbidity and mortality following endovascular aneurysm repair (EVAR) with a bifurcated stent-graft versus an aortomonoiliac stent-graft combined with a femorofemoral crossover graft.A prospectively maintained database of patients undergoing EVAR over a 7-year period (January 2001 to June 2008) was interrogated retrospectively to identify all patients receiving either a bifurcated or an aortomonoiliac stent-graft. Patients undergoing emergency treatment or renal/mesenteric fenestrated or iliac branched EVAR were excluded. Data retrieval found 210 patients (194 men; mean age 75 years) who had been treated with 41 aortomonoiliac stent-grafts and 169 bifurcated devices. The impact of preoperative and intraoperative variables on postoperative morbidity was assessed by means of univariate and multivariate logistic regression analysis.Significant postoperative complications occurred in 41% (17/41) of aortomonoiliac stent-graft patients compared to 14% (23/169) of bifurcated stent-graft patients (p = 0.0001). Univariate logistic regression analyses identified patient age, operating time, and implantation of an aortomonoiliac stent-graft as significant predictors of postoperative complications. In a multivariate logistic regression model, only implantation of an aortomonoiliac stent-graft was independently associated with postoperative complications (p = 0.003).Compared to EVAR with a bifurcated device, the implantation of an aortomonoiliac stent-graft and crossover bypass is associated with higher patient morbidity similar to rates reported after open repair. These patients comprise a high-risk endovascular group and require careful postoperative management in order to minimize complications.

Mycotic pseudoaneurysms of the peripheral arteries are rare and can occur as an extension of localized infection or from systemic sepsis. In some cases, no obvious source of infection may be identified. Both endovascular and open surgical management options are available for this important condition. We report a mycotic pseudoaneurysm of the superficial femoral artery in a patient associated with systemic immunosuppression secondary to Cushing disease that was successfully managed with open surgical repair and autologous bypass grafting. This unusual case highlights the potential for serious adverse cardiovascular sequelae of Cushing disease and the need for awareness of such complications in this patient group.

Marfan syndrome (MFS) is an inherited disorder of connective tissue that is historically associated with high mortality due to disorders of the cardiovascular system. Over the past 40 years, surgery to the aortic root and thoracoabdominal aorta has resulted in a significantly prolonged life expectancy. More recently, techniques for endovascular repair of the aortic complications of MFS have been described. In this article we review the relative merits of open and endovascular approaches to thoracic aortic complications in MFS, comparing outcomes from contemporary literature. A reasonably large body of evidence has developed concerning the surgical treatment of the aortic root, ascending thoracic aorta, and arch in MFS. It is clear from large series that pathology, such as acute type A dissections and aneurysmal dilatation, can be successfully repaired with low mortality. Recently published series, although reporting smaller numbers, have demonstrated that the same is true for open surgical replacement of descending thoracic and thoracoabdominal aortic aneurysms. The evidence for thoracic endovascular aortic repair in MFS is much more limited. Small series and registry or case reports describe a heterogeneous group of patients with only short-term follow-up. Outcomes of endovascular repair are mixed, with questionable longevity. Reoperation is, however, common in MFS, and minimally invasive techniques may provide a bridging role or alternative solution when revisiting the hostile surgical field.

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

Abnormal aortic arch anatomy is relatively uncommon but most frequently involves an aberrant right subclavian artery. Rarely, it is associated with aneurysmal dilatation of a chronic type B dissection. Under such circumstances, the abnormal anatomy may complicate therapeutics options. Furthermore, controversy exists regarding the use of surgical or endovascular techniques in patients with aortic aneurysms and underlying arteriopathies. The current literature is limited with regard to reporting of the latter. We present a hybrid approach to repair such an aneurysm in a patient with Marfan syndrome. In a 2-stage procedure, involving initial supra-aortic bypass to all aortic arch branches, followed by endovascular stent graft deployment, the aneurysm was successfully excluded. There were no immediate complications and no evidence of endoleak at 3 months postoperatively, with thrombosis of the false lumen in the chest. By adapting hybrid open and endovascular techniques, complex thoracic aneurysms may be successfully treated in the short term in the presence of an underlying arteriopathy.

BackgroundDextran-40 is effective in reducing postoperative Doppler-detectable embolization in patients undergoing carotid endarterectomy (CEA). Dextrans are thought to have antithrombotic and antiplatelet effects. The mode of action is unclear. In rats, dextran blocks uptake of tissue plasminogen activator (tPA) by mannose-binding receptors. Because this would have the effect of enhancing endogenous fibrinolysis, we explored this effect of dextran-40 on fibrinolysis in man.MethodsTwenty patients undergoing endovascular stenting for abdominal aortic aneurysm were randomized to receive 100 mL of 10% dextran-40 or saline, over 1 hour, during their operation in addition to heparin. Blood samples were taken preoperatively, intraoperatively (immediately after operative procedure), and 24 hours postoperatively. Thrombi were formed in a Chandler loop and used to assess endogenous fibrinolysis over 24 hours, measured as the fall in thrombus weight, and the release of fluorescently labelled fibrinogen from the thrombus. Plasma samples were analyzed for markers of fibrinolysis; plasmin-antiplasmin (PAP), PAI-1, and t-PA, and for functional von Willebrand factor (vWF). Platelet response to thrombin and other agonists was measured by flow cytometry.ResultsThrombi formed ex vivo from the intraoperative blood samples from the dextran-treated patients exhibited significantly greater fibrinolysis vs preoperative samples, seen both as a significantly greater percentage reduction in thrombus weight (from 34.7% to 70.6% reduction) and as an 175% increase in the release of fluorescence (P < .05). Fibrinolysis returned to baseline levels the next day. No change was seen in the saline-treated group. Plasma levels of PAP and PAI-1 increased significantly postoperatively in the dextran-treated group vs the saline group (P < .05). The postoperative level of functional VWF was significantly lower in the dextran-treated group vs controls. A specific reduction occurred in the platelet response to thrombin, but not to other agonists, in the intraoperative samples from the dextran-treated group (11.1% vs 37.1%; P = .022), which was not seen in the controls.ConclusionsThese data are consistent with a rise in plasmin due to dextran blockade of tPA uptake in vivo, leading to enhanced fibrinolysis, cleavage of vWF and of the platelet protease-activated receptor-1 (PAR-1) thrombin receptor. This suggests that dextran exerts a combined therapeutic effect, enhancing endogenous fibrinolysis, whilst also reducing platelet adhesion to vWF and platelet activation by thrombin. The proven antithrombotic efficacy of low-dose dextran in carotid surgery may be applicable to wider therapeutic use.Clinical RelevanceDextran-40 is an effective therapeutic agent in the reduction of thromboembolic events after carotid surgery, but its mechanism of action is unclear. We describe a laboratory study of the effect of dextran-40 in man that clearly demonstrates that dextran-40 enhances fibrinolysis through a mechanism that is compatible with blockade of uptake of tissue plasminogen activator in vivo. This study was conducted in patients undergoing aortic aneurism repair for logistic reasons, but the data support the use of dextran-40 in patents undergoing carotid endarterectomy and may suggest wider applications for the use of dextran to augment fibrinolysis/thrombolysis in other thrombotic diseases.

Summary Background: Stimulation of therapeutic angiogenesis using gene therapy is a novel intervention for peripheral vascular disease (PVD). Despite encouraging outcomes from animal studies and phase 1 trials, results from larger trials in this area have been conflicting. We undertook a systematic review and meta-analysis of randomised controlled trials in this field, to clarify the current situation. Methods: Medline, Embase, trial registries, the American Heart Association (AHA) abstract database and article reference lists were searched to identify randomised controlled trials of gene therapy for treatment of PVD. The outcomes were change in peak walking time and claudication onset time at 90 and 180 days post-treatment, and change in ankle-brachial pressure index (ABPI) at 90 days. Weighted mean differences (WMD) were calculated for these outcomes. Results: Five eligible randomised clinical trials were identified, containing 508 patients. There were no significant differences between control and intervention groups for any outcomes, irrespective of whether low-dose or high-dose gene therapy was tried. Conclusion: The available data suggests that gene therapy confers no benefit on patients with PVD. Closer examination of the individual trials shows that several have an excessive placebo response, which may go some way to explaining our result. Further research in this area in needed.

ObjectiveTo compare the results of emergency open repair of acute (ruptured or symptomatic intact) abdominal aortic aneurysms with that of endovascular repair.MethodsA systematic literature search was performed to identify series that reported comparative outcomes. PubMed, Embase, the randomized controlled trial (RCT) register, and all relevant major journals were searched independently by two researchers. The outcome measures were 30-day mortality, intensive care unit (ICU) stay, hospital stay, blood loss, and operative time.ResultsTwenty-three studies were identified. Of these, only one was a randomized controlled trial, which is now halted. The total number of patients in the pooled data was 7040 (730 emergency endovascular aneurysm repair [eEVAR]). Emergency EVAR was associated with a significant reduction in mortality (pooled odds ratio 0.624; 95% confidence interval [CI] 0.518 to 0.752; P < .0001). The eEVAR group's ICU stay was reduced by 4 days (pooled effect size estimate −0.70; 95% CI −1.05 to −0.35; P < .0001) and hospital stay with eEVAR was reduced by 8.6 days (pooled effect size estimate −0.33; 95% CI −0.50 to −0.16; P = .0001). In addition, eEVAR was also associated with a significant reduction in blood loss (pooled effect size estimate −1.88 liters; 95% CI −2.49 to −1.27; P < .0001) and reduced procedure time (pooled effect size estimate −0.65; 95% CI −0.95 to −0.36; P < .0001).ConclusionThis meta-analysis suggests benefits to the selected group of patients undergoing this minimally invasive procedure. There is a reduction in the high mortality, prolonged intensive care requirement and total hospital stay, which are historically associated with open repair. It also indicates that most patients are fit enough to undergo computerized tomography (CT) scanning in acute settings. However, because of heterogeneity and bias in the outcomes these results should be interpreted with caution.

Endovascular repair is rapidly becoming the treatment of choice for thoracic aortic disease, which oftentimes involves or lies in close proximity to the left subclavian artery (LSA). In order to extend the proximal landing zone for the stent-graft and obtain an adequate seal, the LSA ostium is often covered, with or without concomitant subclavian artery revascularization. In this article, we review the LSA anatomy and consequences of LSA coverage as a backdrop for a discussion of the ramifications of LSA coverage during endovascular thoracic aortic repair (TEVAR). Early series reported high rates of LSA revascularization as an adjunct to endovascular repair for aortic pathology adjacent to the LSA ostium. Initial reports of low morbidity associated with simple LSA ostium coverage are not supported by contemporary literature, which suggests revascularization reduces the risks of cerebrovascular accident and spinal cord ischemia. Coverage of the LSA without revascularization may be justified only in emergency situations or when thorough investigations of cerebral and vertebrobasilar circulation have concluded that the risk to brain and spinal cord is low. Subclavian revascularization should be considered in the presence of a dominant left vertebral artery, bilateral carotid artery disease, an occluded/stenosed right vertebral artery, presence of a left internal mammary artery graft, or when a long length of thoracic aorta is covered.

Hemophilia, an X-linked disorder due to clotting factors VIII or IX deficiency, is associated with recurrent hemorrhage into joints, soft tissue, and organs. Recombinant factor VIII concentrates are available for the treatment of bleeding complications. However, inhibitors to factor VIII develop in 25% to 35% of patients with severe hemophilia A, making the management of bleeding episodes more complex. The treatment of unusual metachronous ruptured aneurysms in a patient with hemophilia A with factor VIII inhibitor is presented, and the outcomes of endovascular and open operations are discussed.

INTRODUCTION Successful endovascular aneurysm repair (EVAR) requires detailed pre-operative imaging to allow device planning. This process may delay surgery and some aneurysms may rupture prior to intervention. The aim of this study was to quantify these delays. PATIENTS AND METHODS Data were collected prospectively on all patients presenting with non-ruptured abdominal aortic aneurysms (AAAs) between January 2003 and October 2005. The delay between referral, the first out-patient visit, CT-scan, follow-up appointment and surgery were quantified in all patients and compared between two groups undergoing open repair and EVAR. RESULTS A total of 146 patients underwent AAA repair during the study (48 EVAR versus 98 open repair). There was no significant differences in the wait for CT scans between the groups (median 42 days for EVAR versus 47 days for open repairs [P = 0.48]) or the median interval between decision to operate and surgery (56 days versus 42 days [P = 0.075]). However, the median delay between referral and surgery was significantly longer in those patients undergoing EVAR at 129 days versus 77 days for open repair (P = 0.02). CONCLUSIONS Patients presenting electively with AAAs experienced significant delay from referral to surgery. This delay was significantly greater in those patients undergoing endovascular repair. Inevitably, some patients will rupture whilst waiting and strategies aimed at reducing delay should be pursued.

BACKGROUND and OBJECTIVES: The aim of this study was to apply three simple risk - scoring systems to prospectively collected data on all elective open Abdominal Aortic Aneurysm (AAA) operations in the Cambridge Academic Vascular Unit over a 6 - year period (January 1998 to January 2004), to compare their predictive values and to evaluate their validity with respect to prediction of mortality and post-operative complications. METHODS: 204 patients underwent elective open infra-renal AAA repair. Data were prospectively collected and risk assessment scores were calculated for mortality and morbidity according to the Glasgow Aneurysm Score (GAS), VBHOM (Vascular Biochemistry and Haematology Outcome Models) and Estimation of Physiologic Ability and Surgical Stress (E-PASS). RESULTS: The mortality rate was 6.3% (13/204) and 59% (121/204) experienced a post-operative complication (30-day outcome). For GAS, VBHOM and E-PASS the receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.84 (95% confidence interval [CI], 0.76 to 0.92; p

OBJECTIVE: Strategies to improve outcomes for patients with ruptured abdominal aortic aneurysm (rAAA) are becoming more evident. The aging population, however, continues to make the decision to intervene often difficult, especially given that traditional risk models do not reflect issues of aging and frailty. This study aimed to integrate measures of function alongside comorbidity- and frailty-specific factors to determine outcome.METHODS: Patients treated for a rAAA between January 2006 and April 2014 were assessed. Demographics, mortality, and requirement for care after discharge as well as a variety of measures of function (physical, social, and psychological) and comorbidity were recorded. The primary outcome was 1-year mortality. Outcome models were generated using multivariate logistic regression and were compared with models of vascular frailty and AAA-related outcome.RESULTS: Of 184 patients treated, 108 (59%) underwent an open surgical repair. The overall 30-day and 1-year mortality were 21.5% and 31.4%, respectively, with an overall median hospital length of stay of 13 days (interquartile range, 6-27 days). An optimal logistic regression model for 12-month mortality used Katz score, Charlson score, number of admission medicines, visual impairment, hearing impairment, hemoglobin level, and statin use as predictors, achieving an area under the receiver operating characteristic curve of 0.84.CONCLUSIONS: This novel rAAA model incorporating function and comorbidity offers good predictive power for mortality. It is quick to calculate and may ultimately become helpful for both counseling and selection of patients and comparative audit at a time when outcome in patients with rAAA increasingly comes under the spotlight.