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In this study of abdominal aortic aneurysm repair, endovascular repair was shown to have an early survival advantage over open repair during the first three years. However, interventions related to aneurysm and ruptures were more common after endovascular repair. The use of endovascular repair of abdominal aortic aneurysms is increasing. By 2010, endovascular repair accounted for 78% of all intact repairs. 1 , 2 Randomized, controlled trials comparing endovascular repair with open repair generally have shown a perioperative benefit of endovascular repair over open repair. 3 – 5 Long-term survival, however, is similar with the two approaches. 6 – 9 As data on long-term outcomes accumulate, concerns have been raised about endovascular repair with respect to the increased rate of late failure leading to rupture and higher rates of reintervention. In our previous analyses performed with the use of Medicare data, which account for more . . .

Hospital and registry data and national statistics showed a lower rate of abdominal aortic aneurysm repair and a larger mean aneurysm diameter at repair in England than in the United States; U.S. rates of aneurysm rupture and aneurysm-related death were lower. The decision about whether to repair an abdominal aortic aneurysm requires consideration of a balance of risks, including aneurysm rupture if surgery is not performed and death due to aneurysm repair itself, as well as consideration of an individual patient’s probable life expectancy. The decision is influenced by patient and clinician preference, medical management of coexisting conditions, and the availability of and access to endovascular procedures as an alternative to open repair. The aneurysm diameter is the best predictor of aneurysm rupture 1 , 2 ; the risk increases exponentially with an increasing diameter. 3 Therefore, the aneurysm diameter is a key determinant . . .

IntroductionSeveral risk factors for adverse events after endovascular aneurysm repair (EVAR) have been described, but there is no consensus on their comparative prognostic significance, use in risk stratification and application in determining postoperative surveillance.Methods and analysisA scoping review of the literature was conducted to identify risk factors for adverse events after EVAR. Main adverse events were considered post-EVAR abdominal aortic aneurysm rupture and reintervention. Risk factors were grouped into four domains: (1) preoperative anatomy, (2) aortic device, (3) procedure performance and (4) postoperative surveillance. The Delphi methodology will be used to steer a group of experts in the field towards consensus organised into three tiers. In tier 1, participants will be asked to independently rate risk factors for adverse events after EVAR. In tier 2, the panel will be asked to independently rate a range of combinations of risk factors across the four domains derived from tier 1. A risk-stratification tool will then be built, which will include algorithms that map responses to signalling questions onto a proposed risk judgement for each domain. Domain-level judgements will in turn provide the basis for an overall risk judgement for the individual patient. In tier 3, risk factor-informed surveillance strategies will be developed. Each tier will typically include three rounds and rating will be conducted using a 4-point Likert scale, with an option for free-text responses.Ethics and disseminationResearch Ethics Committee and Health Research Authority approval has been waived, since this is a professional staff study and no duty of care lies with the National Health Service to any of the participants. The results will be presented at regional, national and international meetings and will be submitted for publication in peer-reviewed journals. The risk stratification tool and surveillance algorithms will be made publicly available for clinical use and validation.

A gender-neutral threshold aneurysm diameter (AD) of more than 5.5 cm for surgical intervention in abdominal aortic aneurysms (AAA) ignores the fact that women have a smaller baseline AD. We hypothesized that women have a greater AD relative to body surface area (BSA) at the time of surgery and that this worsens outcome. The Vascular Study Group of New England database was queried for elective AAA repairs performed from 2003 to 2011 to compare BSA-indexed AD, ie, aortic size index (ASI), between men and women at the time of surgery and the impact of ASI on outcome. Women were older and had higher ASI among both open-repair (n = 1,566) and endovascular repair (n = 2,172) patients (P < .001). Among open-repair patients, mean ASI for men undergoing repair at AD of 5.5 cm (2.75 cm/m²) was used to subdivide women into 2 categories: women with ASI of 2.75 or more were older (P < .001), had a larger aneurysm size (P < .001), and had a higher 1-year mortality (P = .042) than women with ASI less than 2.75. When indexed to BSA, women have a larger aneurysm size than men at the time of AAA repair.

Purpose: To evaluate national outcomes after endovascular and open surgical repair of ruptured abdominal aortic aneurysms (rAAA). Methods: The Nationwide Inpatient Sample was interrogated to identify all repairs between 2000 and 2005 for rAAA based on ICD-9 codes. In the study period, 2323 patients (1794 men; median age 75 years, range 45–98) with rAAAs had endovascular repair, while 26,106 patients (20,311 men; median age 73 years, range 22–99) had an open procedure. Outcomes included in-hospital mortality, length of stay (LOS), complications, and hospitalization charge. A secondary analysis was performed to compare outcomes from low-, medium-, and high-volume institutions based on annual rAAA repair volume. Results: Patients in the endovascular group were significantly older (p<0.05). Mortality was 41% overall: 33% and 41% for endovascular versus open repair, respectively (p<0.001). Mortality after endovascular repair was lower than open surgery for patients ≥70 years (36% versus 47%, p<0.001), but not for those <70 years (24% versus 30%, p=0.15). LOS was shorter after endovascular repair (7 versus 9 days, p<0.001). Respiratory complications (8% versus 4%, p<0.05) and acute renal failure were more common following open repair (30% versus 23%, p<0.01). Costs were similar (endo $73,590 versus open $67,287, p=0.15). Mortality decreased as hospital surgical volume increased (low 44%, medium 39%, high 38%; p<0.001). Over time, endovascular repair utilization increased more rapidly at high-volume centers, and a lower mortality was seen with endovascular repair at high-volume compared to low-volume hospitals (22% versus 44%, p<0.001). Multivariate predictors of mortality were age, female gender, lower hospital surgical volume, open repair, and year of surgery. Conclusion: This population-based study found that mortality associated with rAAAs may be improved by the performance of endovascular repair, especially in older patients. Mortality after rAAA for both endovascular and open repairs was also lower at high-volume institutions.

Acute aortic syndromes (AAS) represent a spectrum of disorders with a common theme of disruption in aortic integrity. AAS are associated with high morbidity and mortality and warrant emergent medical or surgical intervention as delayed treatment is associated with worse outcomes. There are multiple advanced imaging modalities for the diagnosis and complimentary assessment of AAS, each with advantages and limitations. CT angiography remains the imaging modality of choice for diagnosis in the overwhelming majority of patients as it is rapidly acquired and widely available; however, transoesophageal echocardiogram also offers excellent diagnostic accuracy in addition to complimentary data for surgical repair in those with type A dissection. Transthoracic echocardiography and magnetic resonance angiography can also be valuable in select patients. Imaging is increasingly important for risk stratification in the subacute and chronic phases of AAS. Additionally, imaging is vital for planning of interventions in both acute and delayed intervention. Endovascular treatment options are used with increasing frequency—multimodality imaging during the procedure allows for optimisation of these increasingly complex procedures.

Key Points Endovascular aneurysm repair (EVAR), rather than open repair, is currently the treatment of choice for most patients with an anatomically suitable infrarenal abdominal aortic aneurysm (AAA) Clinical evidence-based research shows a lower perioperative morbidity and mortality, and similar long-term survival, for EVAR compared with open repair of suitable infrarenal AAAs The indications for endovascular management of AAA are expanding to include increasingly complex and anatomically challenging aneurysms Challenging anatomy might require the use of fenestrated and branched stent grafts, chimney grafts, or the sandwich technique Future directions for stent grafts include fenestrated and branched off-the-shelf stent grafts, multilayer stents, endoanchor systems, and sac-anchoring endoprostheses Stent graft technology for infrarenal AAA continues to evolve, with profile downsizing, optimization of sealing and fixation, and the use of fabrics with reduced porosity Endovascular aneurysm repair has become the standard of care in many hospitals for patients with abdominal aortic aneurysms (AAAs) who have anatomy deemed suitable for the procedure. In this Review, Dominique Buck and colleagues discuss evidence-based practice and evaluate promising new strategies for endovascular repair of AAAs. The role of imaging in the management of AAAs is also highlighted. Patients with abdominal aortic aneurysms (AAAs) are usually treated with endovascular aneurysm repair (EVAR), which has become the standard of care in many hospitals for patients with suitable anatomy. Clinical evidence indicates that EVAR is associated with superior perioperative outcomes and similar long-term survival compared with open repair. Since the randomized, controlled trials that provided this evidence were conducted, however, the stent graft technology for infrarenal AAA has been further developed. Improvements include profile downsizing, optimization of sealing and fixation, and the use of low porosity fabrics. In addition, imaging techniques have improved, enabling better preoperative planning, stent graft placement, and postoperative surveillance. Also in the past few years, fenestrated and branched stent grafts have increasingly been used to manage anatomically challenging aneurysms, and experiments with off-label use of stent grafts have been performed to treat patients deemed unfit or unsuitable for other treatment strategies. Overall, the indications for endovascular management of AAA are expanding to include increasingly complex and anatomically challenging aneurysms. Ongoing studies and optimization of imaging, in addition to technological refinement of stent grafts, will hopefully continue to broaden the utilization of EVAR.

Purpose: To compare endovascular (EVAR) and open surgical repair (OSR) for ruptured abdominal aortic aneurysms (RAAA) in terms of preoperative hemodynamic status and comorbidities. Methods: The 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated to find all patients undergoing repair for RAAA. Of the 567 RAAA repairs identified, 121 (21%) were endovascular and 446 (79%) were open. Demographics, comorbidities, and preoperative hemodynamic status were compared by repair method. Results: Age, sex, and race were similar between repair cohorts. EVAR patients had greater incidences of recent myocardial infarction (7% versus 2%, p<0.05), revascularization or amputation for peripheral vascular disease (8% versus 3%, p<0.05), and cerebrovascular disease (22% versus 11%, p<0.01). Preoperative hemodynamic status was similar based on need for >4 units of blood (3% versus 6%, p=0.31), intubation (12% versus 17%, p=0.18), impaired sensorium (7% versus 11%, p=0.25), coma (4% versus 5%, p=0.65), acute renal failure (2% versus 2%, p=0.60), and ASA class 5 (29% versus 34%, p=0.29). Open repair was associated with greater operative time (3.3 versus 2.6 hours, p<0.01) and intraoperative blood transfusions (8 versus 2 units, p<0.001). Overall mortality was 33.5% (EVAR 24% versus OSR 36%; OR 1.8, 95% CI 1.1 to 2.8, p<0.05). After adjusting for preoperative comorbidities and all preoperative hemodynamic variables, mortality after open repair was greater than after EVAR (OR 1.9, 95% CI 1.1 to 3.2, p<0.05). Overall postoperative complications were greater after open repair (62% versus 47%, p<0.01). Graft failure requiring reintervention was higher after EVAR (4% versus 1%, p<0.05), while rates of return to the operating room for a major operation were similar (21% versus 24%, p=0.43). Conclusion: For RAAA within NSQIP hospitals in recent years, preoperative hemodynamic status was similar between EVAR and OSR, but EVAR patients had greater comorbidities. Despite this and after accounting for minor differences in hemodynamic status, EVAR mortality was lower than OSR mortality. Institutions with adequate experience and resources should attempt endovascular repair for RAAA when anatomy allows.

BackgroundPreoperative type and screen are currently recommended for all patients undergoing colectomy. We aimed to identify risk factors for transfusion and define a low-risk cohort of patients undergoing colectomy in whom type and screen may be safely avoided.MethodsWe identified all patients undergoing elective colectomy in the National Surgical Quality Improvement Project-Targeted Colectomy files from 2012 to 2016. Patients transfused preoperatively and those undergoing other concurrent major abdominal procedures were excluded. We compared patients who received blood transfusion on the day of surgery to those who did not. Half of the cohort was randomly selected for development of a points-based model predicting blood transfusion on the day of surgery. This model was then validated using the remaining patients.ResultsOf 61,964 patients undergoing colectomy, 3128 (5%) patients were transfused with 1290 (2.1%) occurring on the day of surgery. Preoperative anemia was the strongest predictor of blood transfusion on the day of surgery. Among patients with hematocrit > 35%, day of surgery transfusion risk was 0.8%; 99% of patients with hematocrit > 35% had a score 20 or less. Selective type and screen for patients with score ≤ 20 or hematocrit > 35% would avoid type and screen in 91% and 81% of patients, respectively.ConclusionTransfusion following elective colectomy is rare and can be accurately predicted by preoperative patient characteristics. Selective type and screen based on these parameters have the potential to prevent operative delays and lower cost.

An Abdominal Aortic Aneurysm (AAA) is a dilation of the aorta at the level of the abdomen. To reduce the risk of rupture, an endograft is often implanted inside the aneurysm to decrease pressure on the aneurysm sac. To maintain blood flow to major abdominal vessels, a fenestrated endograft can be used, whereby physicians modify commercial endografts by creating fenestrations based on preoperative computed tomography imaging. The manual process of aligning patient-specific visceral anatomy onto endografts can be tedious and subject to human error. Here we developed a computational program, ‘FenFit’, for automated fitting of fenestrations onto commercially available endografts. A pilot clinical study was conducted to evaluate the efficiency of FenFit compared to physician manual planning, showing FenFit can reduce planning time by 62-fold on average. Our program has potential to improve clinical outcomes by providing a user interface that is expeditious and far less susceptible to human error. Tom Dillon and colleagues introduce ‘FenFit’, a new computational program designed for automatically fitting fenestrations onto commercially available endografts. This innovation offers promising opportunities to enhance clinical outcomes by providing a user-friendly interface that is quick and significantly less prone to human error.