| 1. |
- Ohrlander, Tomas
(författare)
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Aspects on preoperative evaluation prior to EVAR of AAA
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Abdominal Aortic Aneurysms, AAA, is mainly a silent disease that mainly affects elderly males with a history of tobacco use, but when rupture occur most affected dies. Endovascular aneurysm repair (EVAR) has made it possible to treat more fragile and elderly patients with advanced co-morbidities. The benefit of EVAR might be questionable in relation to all cause mortality in some patients. Hence, the need for a proper preoperative evaluation in relation to long term mortality is warranted and the indication for operation should be balanced against the risk of rupture during the patients expected remaining lifetime. The aims of this thesis were to assess (I) cardiovascular predictors, (II) preoperative echocardiographic findings, (III) lung function determinants for all cause long term mortality, and to (IV) compare preoperative evaluation by a vascular physician with a standardized workup protocol. Data from patients undergoing elective standard EVAR for AAA between 1998–2011 at Vascular Center, Malmö, Skåne University Hospital, form the basis of this thesis. Paper I showed that myocardial ischemia on electrocardiogram, ECG, (HR 1.6 [95% CI 1.1–2.4]) and anemia,(HR 1.5 [95% CI 1.0–2.1]), were found to be independent predictors for long-term mortality. Paper II showed that severe heart valve disease measured with echocardiography, was prevalent in 8.7% among the EVAR patients and was an independent predictor for 1-year mortality (OR 3.5 [95% CI 1.2–10.7]). Paper III showed that chronic obstructive pulmonary disease, COPD, grade ≥3 measured with spirometry, or blood gas levels of PaO2 < 8.0 kPa (HR 2.1 [95% CI 1.2–3.4]), chronic kidney disease, stage ≥3 (HR 1.6 [95% CI 1.1–2.2]) and age ≥80 years (HR 1.6 [95% CI 1.0–2.3]), were found to be independently associated with long-term mortality. Paper IV showed that preoperative evaluation by a vascular physician between 2007 and 2011, versus the standardized evaluation protocol between 1998 and 2006, resulted in increased dosage of antihypertensive, platelet aggregation inhibitors and lipid lowering agents with 40%, 24% and 31%, respectively, reduced costs in preoperative patient evaluation (p<0.001), but there was no change in long-term mortality (p=0.24). In conclusion, assessment with preoperative ECG, echocardiography, spirometry, hemoglobin and GFR predicts long term mortality, and strengthens the need of formal evaluation for a better patient selection for elective EVAR of AAA. A preoperative assessment by a vascular physician did not affect mortality but a better pharmacological control of cardiovascular risk factors was obtained.
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| 2. |
- Ohrlander, Tomas, et al.
(författare)
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Cardiovascular predictors for long-term mortality after EVAR for AAA
- 2011
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Ingår i: Vascular Medicine. - 1477-0377. ; 16:6, s. 422-427
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this study was to assess cardiovascular predictors for all-cause long-term mortality in patients undergoing standard endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA). Consecutive patients treated with EVAR (Zenith (R) stent grafts; Cook) between May 1998 and February 2006 were prospectively enrolled in a computerized database, together with retrospectively collected data on medication, and electrocardiographic and echocardiographic variables. Mortality was assessed on 1 December 2010. The median follow-up time was 68 months and the median age was 74 years (range 53-89) for the 304 patients. Mortality at the end of follow-up was 54.3% (165/304). The proportion of deaths caused by vascular diseases was 61% (101/165). In the univariate analysis, low preoperative ejection fraction (EF) (p = 0.004), absence of statin medication (p = 0.007), and medication with diuretics (p = 0.028) or digitalis (p = 0.016) were associated with an increased long-term mortality rate. Myocardial ischemia on electrocardiogram (ECG) (hazard ratio (HR) 1.6 [95% CI 1.1-2.4]) and anemia (HR 1.5 [95% CI 1.0-2.1]) were found to be independent predictors for long-term mortality after Cox regression analysis. There was a trend that chronic kidney disease, stage >= 3 (HR 1.5 [95% CI 1.0-2.2]), and age 80 years and above (HR 1.5 [95% CI 1.0-2.4]) were independently associated with long-term mortality. In conclusion, ischemia on ECG and anemia were independently related to an increased long-term mortality rate after EVAR, and these predictive factors seem to be most important for critical assessment in the preoperative medical work-up.
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| 3. |
- Ohrlander, Tomas, et al.
(författare)
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Morphological State as a Predictor for Reintervention and Mortality After EVAR for AAA.
- 2011
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Ingår i: Cardiovascular and Interventional Radiology. - : Springer Science and Business Media LLC. - 1432-086X .- 0174-1551.
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: This study was designed to assess aorto-iliac morphological characteristics in relation to reintervention and all-cause long-term mortality in patients undergoing standard EVAR for infrarenal AAA. METHODS: Patients treated with EVAR (Zenith(®) Stentgrafts, Cook) between May 1998 and February 2006 were prospectively enrolled in a computerized database where comorbidities and preoperative aneurysm morphology were entered. Reinterventions and mortality were checked until December 1, 2010. Median follow-up time was 68 months. RESULTS: A total of 304 patients were included, of which 86% were men. Median age was 74 years. The reintervention rate was 23.4% (71/304). A greater diameter of the common iliac artery (p = 0.037; hazard ratio (HR) 1.037 [1.002-1.073]) was an independent factor for an increased number of reinterventions. The 30-day mortality rate was 3.0% (9/304). Aneurysm-related deaths due to AAA occurred in 4.9% (15/304). Five patients died due to a concomitant ruptured thoracic aortic aneurysm. The mortality until end of follow-up was 54.3% (165/304). The proportion of deaths caused by vascular diseases was 61.6%. The severity of angulation of the iliac arteries (p = 0.014; HR 1.018 [95% confidence interval (CI) 1.004-1.033]) and anemia (p = 0.044; HR 2.79 [95% CI 1.029-7.556]) remained as independent factors associated with all-cause long-term mortality. The crude reintervention-free survival rate at 1, 3, and 5 years was 84.5%, 64.8%, and 51.6%, respectively. CONCLUSIONS: The initial aorto-iliac morphological state in patients scheduled for standard EVAR for AAA seems to be strongly related to the need for reinterventions and long-term mortality.
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| 4. |
- Ohrlander, Tomas, et al.
(författare)
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Preoperative echocardiographic predictors for 1-year mortality in patients treated with standard endovascular aneurysm repair for abdominal aortic aneurysm.
- 2013
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Ingår i: World Journal of Cardiovascular Diseases. - : Scientific Research Publishing, Inc.. - 2164-5329 .- 2164-5337. ; 3:3, s. 74-268
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Tidskriftsartikel (refereegranskat)abstract
- Background: Abdominal aortic aneurysm (AAA) and cardiovascular disease are intimately associated, the latter representing the most common cause of death in Sweden. Cardiac complications are held responsible for the majority of perioperative morbidity and mortality in patients undergoing repair of AAA. The importance of preoperative thorough cardiac assessment is therefore obvious. The aim of this study was to evaluate the prognostic significance of preoperative echocardiographic findings for 1-year mortality after elective endovascular aneurysm repair (EVAR) of infrarenal AAA. Design: Retrospective analysis. Methods: The 505 patients were identified in a prospective database for endovascular interventions between 1998 and 2011, and data were retrieved from patient records. Preoperative echocardiography reports in 380 patients were reviewed and findings were notified according to a predefined protocol. Results: The 1-year mortality rate was 6.7%. Severe valve disease was present in 8.7% of the patients, aortic valve stenosis being the leading cause of valve pathology. Severe valve disease (OR 3.5, 95% CI [1.2 - 10.7]; p = 0.025) and chronic kidney disease grade ≥ 3 (OR 7.5, 95% CI [2.1 - 26.1]; p = 0.002) were the only independent risk factors for increased mortality rate at 1-year. Conclusion: Echocardiography should be a part of the preoperative workup in AAA patients. Finding of severe valve disease should be further evaluated by a cardiologist prior to EVAR.
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| 5. |
- Ohrlander, Tomas, et al.
(författare)
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Preoperative Spirometry Results as a Determinant for Long-term Mortality after EVAR for AAA
- 2012
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1532-2165 .- 1078-5884. ; 43:1, s. 43-47
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: The aim of this study was to analyse lung function test determinants for long-term mortality after standard endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA). Design: Retrospective analysis. Materials: Three-hundred and four consecutive patients treated electively with EVAR (Zenith (R) stent grafts, Cook) between May 1998 and February 2006 were prospectively enrolled in a computerised database. Methods: The Global Initiative for Chronic Obstructive Lung Diseases (GOLD) guideline was used to grade the severity of obstructive lung disease. Mortality was checked until 1 December 2010. Median follow-up time was 68 (interquartile range (IQR) 40-94) months. Results: The percentage of patients with mild, moderate or severe (grade 3) chronic obstructive pulmonary disease (COPD) was 9.9%, 23.2% and 7.7%, respectively. In a combined medical severity assessment, arterial partial pressure of oxygen (PaO2) < 8.0 kPa or COPD, grade >= 3 (hazard ratio (HR) 2.06; 95% confidence interval (CI) (1.24-3.42)), anaemia (HR 1.72; 95% CI (1.21-2.44)), chronic kidney disease, stage >= 3 (HR 1.55; 95% Cl (1.08-2.24)) and age >= 80 years (HR 1.55; 95% Cl (1.04-2.31)) were independently associated with long-term mortality. Lower forced expiratory volume in 1 s (FEV1) (p = 0.002) and lower forced vital capacity (FVC) (p = 0.003) were independently associated with long-term mortality. Conclusions: Our findings strengthen the need for formal evaluation of lung function with spirometry prior to proceeding to AAA repair. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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| 6. |
- Ohrlander, Tomas, et al.
(författare)
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Socioeconomic Position, Comorbidity, and Mortality in Aortic Aneurysms: A 13-Year Prospective Cohort Study.
- 2012
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Ingår i: Annals of Vascular Surgery. - : Elsevier BV. - 1615-5947 .- 0890-5096. ; 26, s. 312-321
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: To evaluate factors associated with incidence and 3-year all-cause mortality in patients with aortic aneurysm (AA). The design is sex and age-stratified (60-79 and 80-90 years) prospective cohort. By using the population register, we constituted a cohort of all men and women born between 1900 and 1930 and living in Scania by 1991, and followed them for 13 years. Identification of AA was based on hospital discharge diagnosis obtained from the Swedish Patient Register or from the information on death certificates from the Cause of Death Register. METHODS: We applied stepwise Cox regression and investigated both AA incidence (1991-2003) as well as 3-year survival after the first hospitalization for AA. RESULTS: We found an inverse relation between AA incidence and previous hospitalization by diabetes mellitus in women (hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.19-0.88) and in men (HR: 0.38; 95% CI: 0.24-0.61) aged 60-79 years. Three-year all-cause mortality after diagnosis of AA was 58.6% in women, 50.2% in men, 72.9% in octogenarians, and 43.7% for nonoctogenarians. Low income, chronic respiratory diseases, cerebrovascular diseases, dementia, systemic connective tissue disorders, renal failure, and malignant neoplasms were independent factors for mortality in 60-79-year-old men with AA. CONCLUSIONS: Inferior socioeconomic position is associated with increased 3-year all-cause mortality in 60-79-year-old men with AA.
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| 7. |
- Ohrlander, Tomas, et al.
(författare)
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The chimney graft: a technique for preserving or rescuing aortic branch vessels in stent-graft sealing zones.
- 2008
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Ingår i: Journal of Endovascular Therapy. - : International Society of Endovascular Specialists. - 1545-1550 .- 1526-6028. ; 15:4, s. 427-432
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: To report an alternative to the fenestrated stent-graft for preserving blood flow to side branches in the sealing zones of aortic stent-grafts. TECHNIQUE: A covered stent is deployed parallel to the main aortic stent-graft, protruding somewhat proximally, like a chimney, to preserve flow to a vital side branch covered by the aortic stent-graft. Use of a chimney graft makes it possible to use standard off-the-shelf stent-grafts to instantly treat lesions with inadequate fixation zones, providing an alternative to fenestrated stent-grafts in urgent cases, in aneurysms with challenging neck morphology, and for reconstituting an aortic side branch unintentionally compromised during endovascular repair. This technique has been used successfully in 10 patients, combining chimney grafts in the renal, superior mesenteric, left subclavian, left common carotid, and innominate arteries with stent-grafts in the abdominal (n=6) or thoracic (n=4) aorta. There has been no late chimney graft-related endoleak on imaging studies up to 8 months. CONCLUSION: The use of chimney grafts is feasible in the renal and superior mesenteric arteries, as well as in the supra-aortic branches, to facilitate stent-graft repair of thoracic or abdominal aortic lesions with inadequate fixation zones.
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