| 1. |
- Bogdanovic, Marko, et al.
(författare)
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Limb Graft Occlusion Following Endovascular Aneurysm Repair for Infrarenal Abdominal Aortic Aneurysm with the Zenith Alpha, Excluder, and Endurant Devices : a Multicentre Cohort Study
- 2021
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier. - 1078-5884 .- 1532-2165. ; 62:4, s. 532-539
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Limb graft occlusion (LGO) is a serious complication after endovascular aneurysm repair (EVAR) and while device development enables treatment of increasingly complex aortic anatomy, little is known about how endograft type affects the risk of occlusion. This observational study aimed to explore the incidence of LGO after EVAR for three major endograft systems.Methods: All patients with standard EVAR as the primary intervention for infrarenal abdominal aortic aneurysm (AAA), between January 2012 and December 2018, at five Swedish vascular surgery centres, were included in this multicentre retrospective cohort study. LGO was defined as a total limb occlusion regardless of symptoms, or a treated significant stenosis. A nested case control (NCC) design with incidence density sampling of 1:3 was used for analysis of potential per-operative and morphological risk factors. Conditional logistic regression was used to estimate multivariable odds ratios (OR) with 95% confidence intervals (CI)Results: A total of 924 patients were included. The majority were male (84%), the mean age was 76 years (+/- 7.5 SD), and median AAA diameter was 59 mm (IQR 55, 67). Patients were treated with Zenith Alpha (n = 315, ZISL limbs), Excluder (n = 152, PLC/PXC limbs), and Endurant (n = 457, ETLW/ ETEW limbs). During median follow up of 37 months (IQR 21, 62), 55 occlusions occurred (5.9%); 39 with Zenith Alpha (12.4%), one with Excluder (0.7%), and 15 with Endurant (3.3%). In the NCC analysis, the Zenith Alpha device (OR 5.31, 95% CI 1.97 - 14.3), external iliac artery (EIA) landing (OR 5.91, 95% CI 1.30 - 26.7), and EIA diameter < 10 mm (OR 4.99, 95% CI 1.46 - 16.9) were associated with an increased risk of LGO.Conclusion: Endograft device type is an independent risk factor for LGO after EVAR. Specifically, the Zenith Alpha demonstrated an increased risk of LGO compared with the Endurant and Excluder devices. In addition, a narrow EIA and landing zone in EIA are also risk factors for LGO.
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| 2. |
- Ersryd, Samuel
(författare)
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Abdominal compartment syndrome and colonic ischaemia after abdominal aortic aneurysm repair in the endovascular era
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Abdominal Compartment Syndrome (ACS) and colonic ischaemia (CI) are serious and potentially lethal complications after open (OSR) and endovascular repair (EVAR) of ruptured (rAAA) and intact (iAAA) abdominal aortic aneurysms. The aims of this thesis were to investigate the incidence, outcome, and risk factors associated with ACS (Papers I-III) and to evaluate extraluminal colonic tonometry for postoperative surveillance of colonic perfusion (Paper IV).Papers I-III combined data from the nationwide Swedish vascular registry (Swedvasc) (2008-2015) with case records and radiologic imaging. Paper I investigated incidence and outcome of ACS. The incidence was approximately 7% for both EVAR and OSR after rAAA and 1.6% after OSR and 0.5% after EVAR for iAAA. ACS was associated with a more than two-fold (59% vs 27%) 90-day mortality after rAAA and six-fold (19% vs 3%) after iAAA. Paper II investigated risk factors and outcome among subgroups. Risk of death could not be attributed to a specific main pathology of ACS: CI, postoperative bleeding and general oedema, nor to timing of decompressive laparotomy in relation to AAA surgery. However, the duration of intra-abdominal hypertension (IAH) predicted the need for renal replacement therapy. Paper III investigated risk factors after EVAR for rAAA. ACS was rare without pronounced pre- or intraoperative physiologic derangement associated with circulatory instability. Aortic morphology did not impact ACS development, nor did presence of a patent inferior mesenteric and lumbar arteries, known risk factors for type II endoleak. Paper IV studied patients operated on for iAAA/rAAA (n=27), and demonstrated extraluminal colonic tonometry safe, reliable and indicative of CI among all affected patients (n=4).In conclusion, ACS was common after rAAA repair, with poor outcome irrespective of AAA repair technique and indication for repair. Outcome did not differ depending on the main pathophysiological finding associated with ACS development, while a longer duration of IAH increased the risk of renal replacement therapy. ACS after EVAR for rAAA was largely associated with pre- and intraoperative physiologic factors. These findings highlight the importance of vigilant intra-abdominal pressure measurement after rAAA repair and in case of haemodynamic instability, as well as timely interventions to treat IAH. Extraluminal colonic tonometry appears promising for surveillance of postoperative colonic perfusion.
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| 3. |
- Ersryd, Samuel, et al.
(författare)
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Editor's Choice - Abdominal Compartment Syndrome After Surgery for Abdominal Aortic Aneurysm : A Nationwide Population Based Study
- 2016
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 52:2, s. 158-165
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Tidskriftsartikel (refereegranskat)abstract
- Objective/Background: The understanding of abdominal compartment syndrome (ACS), and its importance for outcome, has increased over time. The aim was to investigate the incidence and clinical consequences of ACS after open (OR) and endovascular repair (EVAR) for ruptured and intact infrarenal abdominal aortic aneurysm (rAAA and iAAA, respectively). Methods: In 2008, ACS and decompression laparotomy (DL) were introduced as variables in the Swedish vascular registry (Swedvasc), offering an opportunity to study this complication in a prospective, population based design. Operations carried out in the period 2008-13 were analysed. Of 6,612 operations, 1,341 (20.3%) were for rAAA (72.0% OR) and 5,271 (79.7%) for iAAA (41.9% OR). In all, 3,171 (48.0%) were operated on by OR and 3,441 by EVAR. Prophylactic open abdomen (OA) treatment was validated through case records. Cross-matching with the national population registry secured valid mortality data. Results: After rAAA repair, ACS developed in 6.8% after OR versus 6.9% after EVAR (p = 1.0). All major complications were more common after ACS (p<.001). Prophylactic OA was performed in 10.7% of patients after OR. For ACS, DL was performed in 77.3% after OR and 84.6% after EVAR (p=.433). The 30 day mortality rate was 42.4% with ACS and 23.5% without ACS (p <.001); at 1 year it was 50.7% versus 31.8% (p <.001). After iAAA repair, ACS developed in 1.6% of patients after OR versus 0.5% after EVAR (p <.001). Among those with ACS, DL was performed in 68.6% after OR and in 25.0% after EVAR (p=.006). Thirty day mortality was 11.5% with ACS versus 1.8% without it (p <.001); at 1 year it was 27.5% versus 6.3% (p <.001). When ACS developed, renal failure, multiple organ failure, intestinal ischaemia, and prolonged intensive care were much more frequent (p <.001). Morbidity and mortality were similar, regardless of primary surgical technique (OR/EVAR/iAAA/rAAA). Conclusion: ACS and OA were common after treatment for rAAA. ACS is a devastating complication after surgery for rAAA and iAAA, irrespective of operative technique, emphasizing the importance of prevention.
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| 4. |
- Ersryd, Samuel, et al.
(författare)
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Editor's Choice - Abdominal Compartment Syndrome after Surgery for Abdominal Aortic Aneurysm : Subgroups, Risk Factors, and Outcome
- 2019
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : W B SAUNDERS CO LTD. - 1078-5884 .- 1532-2165. ; 58:5, s. 671-679
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: Abdominal compartment syndrome (ACS) is a serious complication after abdominal aortic aneurysm (AAA) repair. The aim was to investigate outcome among subgroups and factors associated with outcome, with emphasis on the duration of intra-abdominal hypertension before treatment.Methods: Since 2008, ACS and decompressive laparotomy (DL) after AAA repair are registered prospectively in the Swedish vascular registry (Swedvasc). Registry data and case records were reviewed. Subgroups were defined by main pathophysiological finding at DL, timing of DL after AAA repair, and treatment modality.Results: During 2008-2015, 120 of 8765 patients undergoing surgery for infrarenal AAA developed postoperative ACS (1.4%). Eighty-three followed ruptured AAA (rAAA); 45 open surgical repairs (OSR) and 38 endovascular (EVAR), and thirty-seven after intact AAA (iAAA); 30 OSR and seven EVAR. The main pathophysiological findings at DL were bowel ischaemia in 27 (23.3%), post-operative bleeding in 34 (29.3%), and general oedema in 55 (47.4%). DL was performed <24 hours after AAA repair in 56 (48.7%), 24-48 hours in 30 (26.1%), and >48 hours in 29 patients (25.2%). The overall 90 day mortality was 50.0%, neither different depending on main pathophysiological finding, nor on the timing of DL. In multivariable regression analysis, age was a predictor of mortality (p = .017), while duration of intra-abdominal hypertension (IAH) prior to DL predicted the need for renal replacement therapy (RRT) (p = .033). DL was performed earlier after EVAR compared with OSR in rAAA (p < .001).Conclusions: Mortality in ACS was high, irrespective of the main pathophysiological finding and timing of DL. The duration of IAH prior to DL predicted the need for RRT. DL was performed earlier after EVAR than after OSR for rAAA, underlining the importance of monitoring IAP after EVAR for rAAA.
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| 5. |
- Ersryd, Samuel, et al.
(författare)
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Risk Factors for Abdominal Compartment Syndrome After Endovascular Repair for Ruptured Abdominal Aortic Aneurysm : A Case Control Study
- 2021
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier. - 1078-5884 .- 1532-2165. ; 62:3, s. 400-407
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Ruptured abdominal aortic aneurysms (rAAA) are treated by endovascular aneurysm repair (rEVAR) increasingly often. Despite rEVAR being a minimally invasive method, abdominal compartment syndrome (ACS) remains a significant post-operative threat. The aim of this study was to investigate risk factors for ACS after rEVAR, including aortic morphological features. Methods: The Swedish vascular registry (Swedvasc) was assessed for ACS after rEVAR in the period 2008 - 2015. All patients identified were compared with controls (i.e., patients who did not develop ACS after rEVAR), matched by centre and repair date. Case records were reviewed, and radiology images analysed in a core laboratory. Comparisons were performed with respect to physiological and radiological risk factors. Results: The study population consisted of 40 patients with ACS and 68 controls. Pre-operatively, patients with ACS had a lower blood pressure (BP) than controls (median 70 mmHg vs. 97 mmHg; p <.001). Intra-operatively, they had aortic balloon occlusion more often (55.0% vs. 10.3%; p <.001) and received more transfusions than controls (median nine units of packed red blood cells [pRBC] vs. two units; p <.001). Ninety-seven per cent of those who developed ACS had a pre-operative BP < 70 mmHg, aortic balloon occlusion, or received more than five pRBC unit transfusions. Treatment outside the instructions for use did not differ between patients and controls (57.5% vs. 54.4%; p=.84), and neither did the pre-operative patency of the inferior mesenteric artery (57.1% vs. 63.9%; p=.52) nor the number of visible lumbar arteries on pre-operative imaging (2 vs. 4; p=.014). In multivariable logistic regression, the number of intra-operative transfusions were predictive of ACS (p <.001), while pre-operative hypotension (p=.32) and aortic balloon occlusion (p=.018) were not. Conclusion: ACS after rEVAR is mainly associated with physiological factors and is unlikely to develop without the presence of a pre-operative BP < 70 mmHg, the need for an aortic occlusion balloon, or more than five intraoperative pRBC unit transfusions. Treatment outside the IFU or any other morphological factor were not associated with a risk of ACS.
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| 6. |
- Ersryd, Samuel, 1978-, et al.
(författare)
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Risk factors for abdominal compartment syndrome after endovascular repair for ruptured abdominal aortic aneurysm: A case-control study
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Objectives: Ruptured abdominal aortic aneurysms (rAAA) are increasingly often treated by endovascular aneurysm repair (rEVAR). Despite rEVAR being a minimal invasive method, abdominal compartment syndrome (ACS) remains a significant postoperative threat. The aim was to investigate risk factors for ACS after rEVAR, including aortic morphological features.Methods: The Swedish vascular registry (Swedvasc) was assessed for ACS after rEVAR during 2008-2015. All patients identified were compared with controls, i.e. patients who did not develop ACS after rEVAR, matched by centre and repair date. Case records were reviewed, and radiologic images were analysed in a core-lab. Comparisons were performed with respect to physiological and radiological risk factors.Results: After data validation the final study population consisted of 40 patients with ACS after rEVAR and 68 controls. Preoperatively, ACS patients had lower blood pressure (BP) than controls (median 70mmHg vs 97mmHg, p<.001). Intraoperatively, they had aortic balloon occlusion more often (55.0% vs 10.3%, p<.001) and received more transfusions than controls (median 9 packed red blood cells (pRBC) vs 2 pRBC, p<.001). Postoperatively, they received more transfusions than controls (5 pRBC vs 0 pRBC, p<.001). Ninety-seven percent of those who developed ACS had either preoperative BP <70mmHg, aortic balloon occlusion or received >5 intraoperative pRBC transfusions. Neither treatment outside instructions for use (IFU) nor preoperative patency of the inferior mesenteric artery differed between cases and controls (57.5% vs 54.4%, p=.842 and 57.1% vs 63.9%, p=.522 respectively), while the number of visible lumbar arteries on preoperative imaging were fewer among ACS patients (2 vs 4, p=.014).Conclusions: ACS after rEVAR is mainly associated with physiologic factors and is unlikely to develop without the presence of either preoperative BP <70mmHg, need for aortic occlusion balloon, or >5 intraoperative pRBC transfusions. Neither treatment outside IFU nor any other morphological factor could be associated with risk for ACS.
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| 7. |
- Ersryd, Samuel, et al.
(författare)
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Surveillance to detect colonic ischemia with extraluminal pH measurement after open surgery for abdominal aortic aneurysm
- 2021
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Ingår i: Journal of Vascular Surgery. - : Elsevier. - 0741-5214 .- 1097-6809. ; 74:1, s. 97-104
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Colonic ischemia (CI) is a life-threatening complication after aortic surgery. Postoperative surveillance of colonic perfusion may be warranted. The aim was to evaluate the safety and feasibility of postoperative extraluminal pH measurement (pHe) using colonic tonometry after open abdominal aortic aneurysm (AAA) repair.Methods: Before closing the abdomen after open AAA repair, a tonometric catheter was placed transabdominally in contact with the sigmoid colon serosa, similar to a drainage catheter. Extraluminal partial pressure of carbon dioxide was measured postoperatively and combined with arterial blood gas analysis, the pHe was calculated. The measurements were repeated every four hours alongside simultaneous intra-abdominal pressure measurements. The threshold for colonic malperfusion was set at pHe<7.2.Results: Twenty-seven patients were monitored, twelve operated on for ruptured AAA and fifteen for intact AAA. Four patients developed clinically significant CI requiring surgical treatment, all of which were preceded by prolonged (>5h) pHe<7.2 indicating malperfusion. A fifth patient, who during monitoring had a lowest pHe of 7.21, developed mild colonic ischemia with onset after completion of monitoring, which was successfully managed conservatively. Seven patients who had brief durations (<5h) of pHe<7.2 did not develop clinical signs of CI or any related adverse events.Conclusions: Measurements of pHe using colonic tonometry indicated malperfusion in all patients who developed clinically significant CI. Shorter duration of low pHe was well tolerated without any signs of CI. Measurement of pHe was safe and reliable for surveillance of colonic perfusion after open aortic surgery, indicating a promising technique, but larger studies are needed.
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