| 1. |
- Bath, Jonathan, et al.
(författare)
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Contemporary outcomes after treatment of aberrant subclavian artery and Kommerell's diverticulum
- 2023
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Ingår i: Journal of Vascular Surgery. - : Elsevier BV. - 0741-5214 .- 1097-6809. ; 77:5, s. 1339-1348.e6
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Aberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset.Methods: Patients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak.Results: Overall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms.Conclusions: Treatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate.
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| 2. |
- Bissacco, Daniele, et al.
(författare)
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Comparison of the Reproducibility of Ultrasound Calliper Placement Methods in Abdominal Aortic Diameter Measurements : A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies
- 2023
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier. - 1078-5884 .- 1532-2165. ; 66:5, s. 620-631
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To assess which ultrasound (US) method of maximum anteroposterior (AP) abdominal aortic diameter measurement can be considered most reproducible.DATA SOURCES: MEDLINE, Scopus, and Web of Science were searched (PROSPERO ID: 276694). Eligible studies reported intra- and or interobserver agreement according to Bland-Altman analysis (mean ± standard deviation [SD]) for abdominal aortic diameter AP US evaluations with an outer to outer (OTO), inner to inner (ITI), and or leading edge to leading edge (LELE) calliper placement.REVIEW METHODS: The Preferred Reporting Items for a Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies statement was followed. The QUADAS-2 tool and QUADAS-C extension were used for risk of bias assessment and the GRADE framework to rate the certainty of evidence. Pooled estimates (fixed effects meta-analysis, after a test of homogeneity of means) for each US method were compared with pairwise one sided t tests. Sensitivity analyses (for studies published in 2010 or later) and meta-regression were also performed.RESULTS: 21 studies were included in the qualitative analysis. Twelve were eligible for quantitative analysis. Studies showed heterogeneity in the US model and transducer used, sex of participants, and observer professions, expertise, and training. Included studies shared a common mean for each US method (OTO: p = 1.0, ITI: p = 1.0, and LELE: p = 1.0). A pooled estimate of interobserver reproducibility for each US method was obtained, combining the mean ± SD (Bland-Altman analysis) from each study: OTO: 0.182 ± 0.440; ITI: 0.170 ± 0.554; and LELE: 0.437 ± 0.419. There were no statistically significant differences between the methods (OTO vs. ITI: p = .52, OTO vs. LELE: p = .069, ITI vs. LELE: p = .17). Considering studies published in 2010 and later, the pooled estimate for LELE was the smallest, without statistically significant differences between the methods. Despite the low risk of bias, the certainty of the evidence for both meta-analysed outcomes remained low.CONCLUSION: The interobserver reproducibility for OTO and ITI was 2.5 times smaller (indicating better reproducibility) than LELE; however, without statistically significant differences between the methods and low GRADE evidence certainty. Additional data are needed to validate these findings, while inherent differences between the methods need to be emphasised.
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| 3. |
- Budtz-Lilly, Jacob, et al.
(författare)
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European Multicentric Experience With Fenestrated-branched ENDOvascular Stent Grafting After Previous FAILed Infrarenal Aortic Repair The EU-FBENDO-FAIL Registry
- 2023
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Ingår i: Annals of Surgery. - : Ovid Technologies (Wolters Kluwer Health). - 0003-4932 .- 1528-1140. ; 278:2, s. E389-E395
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Tidskriftsartikel (refereegranskat)abstract
- Objective:To report the mid-term outcomes of fenestrated-branched endovascular aneurysm repair (F-BEVAR) following a failed previous endovascular aneurysm repair (pEVAR) or previous open aneurysm repair (pOAR).Methods:Data from consecutive patients who underwent F-BEVAR for pEVAR or pOAR from 2006 to 2021 from 17 European vascular centers were analyzed. Endpoints included technical success, major adverse events, 30-day mortality, and 5-year estimates of survival, target vessel primary patency, freedom from reinterventions, type I/III endoleaks, and sac growth >5 mm.Background:Treatment of a failed previous abdominal aortic aneurysm repair is a complex undertaking. F-BEVAR is becoming an increasingly attractive option, although comparative data are limited regarding associated risk factors, indications for treatment, and various outcomes.Results:There were 526 patients included, 268 pOAR and 258 pEVAR. The median time from previous repair to F-BEVAR was 7 (interquartile range, 4-12) years, 5 (3-8) for pEVAR, and 10 (6-14) for pOAR, P<0.001. Predominant indication for treatment was type Ia endoleak for pEVAR and progression of the disease for pOAR. Technical success was 92.8%, pOAR (92.2%), and pEVAR (93.4%), P=0.58. The 30-day mortality was 6.5% overall, 6.7% for pOAR, and 6.2% for pEVAR, P=0.81. There were 1853 treated target vessels with 5-year estimates of primary patency of 94.4%, pEVAR (95.2%), and pOAR (94.4%), P=0.03. Five-year estimates for freedom from type I/III endoleaks were similar between groups; freedom from reintervention was lower for pEVAR (38.3%) than for pOAR (56.0%), P=0.004. The most common indication for reinterventions was for type I/III endoleaks (37.5%).Conclusions:Repair of a failed pEVAR or pOARis safe and feasible with comparable technical success and survival rates. While successful treatment can be achieved, significant rates of reintervention should be anticipated, particularly for issues related to instability of target vessels/bridging stents.
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| 4. |
- Burdess, Anne, et al.
(författare)
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Early Experience With a Novel Dissection-Specific Stent-Graft to Prevent Distal Stent-Graft-Induced New Entry Tears After Thoracic Endovascular Repair of Chronic Type B Aortic Dissections
- 2022
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Ingår i: Annals of Vascular Surgery. - : Elsevier. - 0890-5096 .- 1615-5947. ; 81, s. 36-47
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Tidskriftsartikel (refereegranskat)abstract
- Background: The aim was to report short and mid-term outcomes of a novel, investigational, dissection-specific stent-graft (DSSG), specifically designed to address the features of chronic type B aortic dissection (CTBAD) and reduce the risk of distal stent-graft-induced new entry tears (dSINE).Materials and Methods: A retrospective single center cohort study of all patients undergoing TEVAR with the DSSG for CTBAD from January 1, 2017 to January 31, 2020. The DSSG, which is a modified stent-graft based on the Cook Zenith Alpha Thoracic platform, has no proximal barbs, and a customized longer body length with substantial taper. The second and third distal Z-stents are sited internally to avoid any contact of the metal skeleton with the dissection membrane and have reduced radial force, while the most distal stent was removed creating a distal 30 mm unsupported Dacron graft.Results: Sixteen patients (13 males, 3 females) with a median age of 66 years (range 31–79 years) underwent elective TEVAR of CTBAD using the DSSG. Six patients (38%) had an underlying connective tissue disorder. The median tapering was 10 mm (range 4 mm–21 mm) and median length 270 mm (range 210–380 mm). Technical success was achieved in all but one case (96%). One patient died within 30 days, due to retrograde type A dissection with cardiac tamponade. The 30-day rate of stroke, spinal cord ischemia, and re-interventions was 0%. After median imaging follow-up time of 17 months (range 1–31 months), one patient developed a dSINE 4 months after the index procedure. After median survival follow-up of 23 months (range 2–35 months), one late death occurred due to traumatic brain injury, while no aortic-related death occurred during follow-up. Complete false lumen (FL) thrombosis was achieved in 9 patients while the remaining 6 showed partial FL thrombosis. No instances of diameter increase at the level oftreated aortic segment were noted with serial measurements showing either stable (n = 7) or decreased (n = 8) maximal transverse diameter.Conclusions: Use of a novel DSSG with low radial force for TEVAR in the setting of CTBAD is safe and feasible. This early real-world experience shows promising mid-term effectiveness with low rates of dSINE or unplanned re-interventions and satisfactory aortic remodeling during follow-up. Longer follow-up is needed, however, before any firm conclusions can be drawn.
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| 5. |
- D'Oria, Mario, et al.
(författare)
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A scoping review of the rationale and evidence for cost-effectiveness analysis of fenestrated-branched endovascular repair for intact complex aortic aneurysms
- 2020
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Ingår i: Journal of Vascular Surgery. - : MOSBY-ELSEVIER. - 0741-5214 .- 1097-6809. ; 72:5, s. 1772-1782
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Forskningsöversikt (refereegranskat)abstract
- Background: Cost-effectiveness analysis of new interventions is increasingly required by policymakers. For intact complex aortic aneurysms (CAAs), fenestrated-branched endovascular aneurysm repair (F/B-EVAR) offers a minimally invasive alternative option for patients who are physically ineligible for open surgical repair (OSR). Thus, F/B-EVAR is increasingly used, but whether it represents a cost-effective treatment option remains unknown.Methods: A scoping review of the literature was conducted from the PubMed, Ovid Embase, and Scopus databases. They were searched to identify relevant English-language articles published from inception to December 31, 2019. All costs in the identified literature were transformed to U.S. dollar values by the following exchange rate: 1 GBP = 1.3 USD; 1 EUR = 1.1 USD.Results: At this literature search, no randomized clinical trials assessing cost-effectiveness of F/B-EVAR vs OSR for intact CAAs were found. Also, no health economic evaluation studies were found regarding use of F/B-EVAR in patients unfit for OSR. A Markov model analysis based on seven observational center- or registry-based studies published from 2006 to 2014 found that the incremental cost-effectiveness ratio for F/B-EVAR vs OSR was $96,954/quality-adjusted life-year. In the multicenter French Medical and Economical Evaluation of Fenestrated and Branched Stent-grafts to Treat Complex Aortic Aneurysms (WINDOW) registry (2010-2012), F/B-EVAR had a higher cost than OSR for a similar clinical outcome and was therefore economically dominated. At 2 years, costs were higher with F/B-EVAR for juxtarenal/pararenal aneurysms and infradiaphragmatic thoracoabdominal aneurysms but similar for supradiaphragmatic thoracoabdominal aneurysms. The higher costs were related to a $24,278 cost difference of the initial admission (95% of the difference at 2 years) due to stent graft costs. Both these studies, however, included a highly varying center experience with complex endovascular aortic repair, and their retrospective design is subject to selection bias for chosen treatment, which could affect the studied outcome. In contrast, in amore recent U.S. database analysis (879 thoracoabdominal aortic aneurysm repairs, 45% OSRs), the unadjusted total hospitalization cost of OSR was significantly higher compared with F/B-EVAR (median, $44,355 vs $36,612; P = .004). In-hospital mortality as well as major complications were two to three times higher after OSR, indicating that endovascular repair might be the economically dominant strategy.Conclusions: The literature regarding cost-effectiveness analysis of F/B-EVAR for intact CAAs is scarce and ambiguous. Based on the limited nonrandomized available evidence, stent grafts are the main driver for F/B-EVAR expenses, whereas cost-effectiveness in relation to OSR may vary by health care setting and selection of patients.
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| 6. |
- D'Oria, Mario, et al.
(författare)
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An International Expert-Based CONsensus on Indications and Techniques for aoRtic balloOn occLusion in the Management of Ruptured Abdominal Aortic Aneurysms (CONTROL-RAAA)
- 2023
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Ingår i: Journal of Endovascular Therapy. - : Sage Publications. - 1526-6028 .- 1545-1550.
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To report on the recommendations of an expert-based consensus on the indications, timing, and techniques of aortic balloon occlusion (ABO) in the management of ruptured abdominal aortic aneurysms (rAAA).METHODS: Eleven facilitators created appropriate statements regarding the study issues that were voted on using a 4-point Likert scale with open-comment fields, by a selected panel of international experts (vascular surgeons and interventional radiologists) using a 3-round modified Delphi consensus procedure (study period: January-April 2023). Based on the experts' responses, only the statements reaching grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement <5%) were included in the final study report. The consistency of each round's answers was also graded using Cohen's kappa, the intraclass correlation coefficient, and, in case of double resubmission, Fleiss kappa.RESULTS: Sixty-three experts were included in the final analysis and voted on 25 statements related to indication and timing (n=6), and techniques (n=19) of ABO in the setting of rAAA. Femoral sheath or ABO should be preferably placed in the operating room, via a percutaneous transfemoral access, on a stiff wire (grade B, consistency I), ABO placement should be suprarenal and last less than 30 minutes (grade B, consistency II), postoperative peripheral vascular status (grade A, consistency II) and laboratory testing every 6 to 12 hours (grade B, consistency) should be assessed to detect complications. Formal training for ABO should be implemented (grade B, consistency I). Most of the statements in this international expert-based Delphi consensus study might guide current choices for indications, timing, and techniques of ABO in the management of rAAA. Clinical practice guidelines should incorporate dedicated statements that can guide clinicians in decision-making.CONCLUSIONS: At arrival and during both open or endovascular procedures for rAAA, selective use of intra-aortic balloon occlusion is recommended, and it should be performed preferably by the treating physician in aortic pathology.CLINICAL IMPACT: This is the first consensus study of international vascular experts aimed at defining the indications, timing, and techniques of optimal use of ABO in the clinical setting of rAAA. Aortic occlusion by endovascular means (or ABO) is a quick procedure in properly trained hands that may play an important role as a temporizing measure until the definitive aortic repair is achieved, whether by endovascular or open means. Since data on its use in hemodynamically unstable patients are limited in the literature, owing to practical challenges in the performance of well-conducted prospective studies, understanding real-world use by experts is of importance in addressing critical issues and identifying main gaps in knowledge.
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| 7. |
- D'Oria, Mario, et al.
(författare)
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Association Between Hospital Volume and Failure to Rescue After Open or Endovascular Repair of Intact Abdominal Aortic Aneurysms in the VASCUNET and International Consortium of Vascular Registries
- 2021
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Ingår i: Annals of Surgery. - : Wolters Kluwer. - 0003-4932 .- 1528-1140. ; 274:5, s. 452-459
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To investigate the association between hospital volume and failure to rescue (FtR), after open repair (OAR), and endovascular repair (EVAR) of intact abdominal aortic aneurysms (AAA) among centers participating in the VASCUNET and International Consortium of Vascular Registries.Summary of Background Data: FtR (ie, in-hospital death following major complications) is a composite end-point representing the inability to treat complications effectively and prevent death.Methods: Using data from 8 vascular registries, complication and mortality rates after intact AAA repair were examined (n = 60,273; EVAR-43,668; OAR-16,605). A restricted analysis using pooled data from 4 countries (Australia, Hungary, New Zealand, and USA) reporting data on all postoperative complications (bleeding, stroke, cardiac, respiratory, renal, colonic ischemia) was performed to identify risk-adjusted association between hospital volume and FtR.Results: The most frequently reported complications were cardiac (EVAR-3.0%, OAR-8.9%) and respiratory (EVAR-1.0%, OAR-5.7%). In adjusted analysis, 4.3% of EVARs and 18.5% of OARs had at least 1 complication. The overall FtR rate was 10.3% after EVAR and 15.7% after OAR. Subjects treated in the highest volume centers (Q4) had 46% and 80% lower odds of FtR after EVAR (OR = 0.54; 95% CI = 0.34-0.87; P = 0.04) and OAR (OR = 0.22; 95% CI = 0.11-0.44; P < 0.001) when compared to lowest volume centers (Q1), respectively. Colonic ischemia had the highest risk of FtR for both procedures (adjusted predicted risks, EVAR: 27%, 95% CI 14%-45%; OAR: 30%, 95% CI 17%-46%).Conclusions: In this multi-national dataset, FtR rate after intact AAA repair with EVAR and OAR is significantly associated with hospital volume. Hospitals in the top volume quartiles achieve the lowest mortality after a complication has occurred.
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| 8. |
- D'Oria, Mario, et al.
(författare)
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Center volume and failure to rescue after open or endovascular repair of ruptured abdominal aortic aneurysms
- 2022
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Ingår i: Journal of Vascular Surgery. - : Elsevier BV. - 0741-5214 .- 1097-6809. ; 76:6, s. 1565-
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Tidskriftsartikel (refereegranskat)abstract
- Background: The correlation between center volume and elective abdominal aortic aneurysm (AAA) repair outcomes is well established; however, these effects for either endovascular aneurysm repair (EVAR) or open aneurysm repair (OAR) of ruptured AAA (rAAA) remains unclear. Notably, the capacity to either avert or manage complications associated with postoperative mortality is an important cause of outcome disparities after elective procedures; however, there is a paucity of data surrounding nonelective presentations. Therefore, the purpose of this analysis was to describe the association between annual center volume, complications, and failure to rescue (FtR) after EVAR and OAR of rAAA.Methods: All consecutive endovascular and open rAAA repairs from 2010 to 2020 in the Vascular Quality Initiative were examined. Annual center volume (procedures/year per center) was grouped into quartiles: EVAR-Q1 (<14), 3.4%; Q2 (14-23), 12.8%; Q3 (24-37), 24.7%; and Q4 (>38), 59.1%; OAR-Q1 (<3), 5.4%; Q2 (4-6), 12.8%; Q3 (7-10), 22.7%; and Q4 (>10), 59.1%. The primary end point was FtR, defined as in-hospital death after experiencing one of six major complications (cardiac, renal, respiratory, stroke, bleeding, colonic ischemia). Risk-adjusted analyses for intergroup comparisons were completed using multivariable logistic regression.Results: The unadjusted in-hospital death rate was 16.5% and 28.9% for EVAR and OAR, respectively. Complications occurred in 45% of EVAR (n = 1439/3188) and 70% of OAR (n = 1366/1961) patients with corresponding FtR rates of 14% (EVAR) and 26% (OAR). For OAR, Q4-centers had a 43% lower FtR risk (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.4-0.9; P =.017) compared with Q1 centers. Centers performing fewer than five OARs/year had a 43% lower risk (OR, 0.57; 95% CI, 0.4-0.7; P <.001) of FtR and this decreased 4% for each additional five procedures performed annually (95% CI, 0.93-0.991; P =.013). However, there was no significant relationship between center volume and FtR after EVAR. The risk of FtR was strongly associated with a greater number of complications for both procedures (OR multiplied by 6.5 for EVAR and 1.5 for OAR for each additional complication; P <.0001). Among OAR patients with a single recorded complication, return to the operating room for bleeding had highest risk of in-hospital mortality (OR, 4.1; 95% CI, 1.1-4.8; P =.034), whereas no specific type of complication increased FtR risk after EVAR.Conclusions: FtR occurs commonly after EVAR and OAR of rAAA within Vascular Quality Initiative centers. Importantly, increasing center volume was associated with decreased FtR risk after OAR, but not EVAR. Complication pattern and frequency predicted FtR after either repair strategy. For stable patients, especially those deemed anatomically ineligible for EVAR, these findings emphasize the need to improve the coordination of regional referral networks that centralize rAAAs to high-volume centers. Moreover, hospitals that treat rAAA should invest in resources that develop protocols targeting specific complications to mitigate risk of preventable postoperative death.
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| 9. |
- D'Oria, Mario, et al.
(författare)
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Comparison of early and mid-term outcomes after fenestrated-branched endovascular aortic repair in patients with or without prior infrarenal repair
- 2021
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Ingår i: Journal of Endovascular Therapy. - : Sage Publications. - 1526-6028 .- 1545-1550. ; 29:4, s. 544-554
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Tidskriftsartikel (refereegranskat)abstract
- Objective: The purpose of this study was to compare short- and mid-term outcomes of fenestrated-branched endovascular repair (F-BEVAR) of pararenal (PRAA)/thoracoabdominal (TAAA) aortic aneurysms in patients with or without prior endovascular/open (EVAR/OAR) infrarenal aortic repair.Methods: Data from consecutive F-BEVAR (2010-2019) at two high-volume aortic centers were retrospectively reviewed. Primary endpoints were technical success, 30-day mortality, and overall survival. Secondary endpoints included 30-day major adverse events (MAE), freedom from type I/III endoleaks, reinterventions, sac expansion, and target vessel (TV) primary patency.Results: A total of 222 consecutive patients were included for analysis; of these 58 (26.1%) had prior infrarenal repair (EVAR=33, OAR=25) and 164 (73.9%) had native PRAA/TAAA. At baseline, patients with prior infrarenal repair were older (mean age=75.1 vs 71.6 years, p=.005) and the proportion of females was lower (8.6% vs 29.3%, p=.002). Technical success was 97.8% (n=217) in the entire cohort, without any significant differences between study groups (94.8% vs 98.8%, p=.08). At 30 days, there were no significant differences between patients with prior infrarenal repair as compared with those without in rate of MAE (44.8% vs 54.9%, p=.59). The 5-year estimate of survival for those who underwent native aortic repair was 61.6%, versus 61.3% for those who had a previous repair (p=.67). The 5-year freedom from endoleaks I/III estimates were significantly lower in patients who had prior infrarenal repair as compared with patients undergoing treatment of native aneurysms (57.1% vs 66.1%, p=.03), mainly owing to TV-related endoleaks (ie, type IC and/or IIIC endoleaks). No significant differences were found between study groups in rates of reinterventions and TV primary patency. Five-year estimates of freedom from sac increase >5mm were significantly lower in patients who received F-BEVAR after previous infrarenal repair as compared with those who underwent treatment of native aneurysms (48.6% vs 77.5%, p=.002).Conclusions: F-BEVAR is equally safe and feasible for treatment of patients with prior infrarenal repair as compared with those undergoing treatment for native aneurysms. Increased rates of TV-related endoleaks were observed which could lead to lower freedom from aneurysm sac shrinkage during follow-up. Nevertheless, the 5-year rates of reinterventions and TV patency were similar, thereby indicating that overall effectiveness of treatment remained satisfactory at mid-term.
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| 10. |
- D'Oria, Mario, et al.
(författare)
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Frequency and type of interval adverse events during the waiting time to complex aortic endovascular repair.
- 2022
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Ingår i: Journal of Vascular Surgery. - : Elsevier. - 0741-5214 .- 1097-6809. ; 75:6, s. 1821-1828.e1
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: Aim of the study was to evaluate the frequency and type of adverse events that may occurs during the waiting time to complex aortic endovascular repair.METHODS: This is a retrospective study of all elective patients with complex aortic aneurysms (including pararenal/suprarenal, thoracoabdominal, or aortic arch aneurysms) that required a custom-made device (CMD) from Cook Medical at a tertiary referral vascular center (Nov 2010 - May 2020). The waiting time was defined as interval between date of stent-graft order and date of procedure or cancellation date. Interval adverse events were defined as any event that occurred during waiting time which led to either mortality, aneurysm rupture, or cancellation of the planned procedure.RESULTS: A total of 235 patients (mean age 72 years, 25% females) had a CMD graft ordered (201 planned as single-stage procedures). The median waiting time until surgery was 106 days (IQR:77-146) in the whole cohort and 101 days (IQR:77-140) among single-stage procedures. The planned procedure was carried out electively in 219 (93%), with an overall thirty-day elective mortality of 2% (N=5). There were 16 interval adverse events during waiting time. Of these, 10 were aneurysm ruptures and six were cancellations of the procedure owing to non-aneurysm-related deaths (3% of the entire cohort). A total of 10 interval deaths were registered (4.2%), four were aneurysm-related. Risk of rupture during waiting time (Kaplan-Meier) was 6.1% (SD 2.3) at 180 days. The median time from stent-graft order to aneurysm rupture was 101 days (IQR: 54-200 days). Out of the 10 aneurysm ruptures that occurred, six underwent emergent repair with 0% mortality at thirty-days (one open repair, one T-Branch, one physician-modified endograft, two cases in which the CMD was already available, one case in which a different CMD was available).CONCLUSIONS: The median waiting time from stent-graft order to implantation was about fifteen weeks. During this time, a substantial proportion may suffer from adverse events, either related to aneurysm rupture or underlying comorbidity. Rupture risk during waiting time exceeded the risk of perioperative mortality; efforts to decrease this can therefore significantly improve outcome. A combination of different techniques may play a vital role to reduce the mortality in case of interval ruptures.
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| 11. |
- D'Oria, Mario, et al.
(författare)
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Long-term survival after repair of ruptured abdominal aortic aneurysms is improving over time : Nationwide analysis during twenty-four years in Sweden (1994-2017)
- 2021
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Ingår i: Annals of Surgery. - : Wolters Kluwer. - 0003-4932 .- 1528-1140. ; 277:3, s. 670-677
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To investigate long-term survival after ruptured abdominal aortic aneurysms (rAAA) repair in Sweden during twenty-four years (1994-2017).Summary Background Data: Management of rAAA has seen significant changes in the past decades, with the shifting from open (OAR) to endovascular (EVAR) being the most striking, thereby enabling treatment of elderly patients with multiple comorbidities.Methods: A registry-based nationwide cohort study was performed, and three 8-year periods (1994-2001, 2002-2009, 2010-2017) were compared for crude long-term survival with Kaplan-Meier and multivariable Cox proportional hazards analyses. Relative survival compared to matched general population referents was estimated.Results: Overall, 8,928 rAAA repair subjects were identified (1994-2001 N=3,368; 2002-2009 N=3,405; 2010-2017 N=2,155). The proportion of octogenarians (20.6%; 27.5%; 34.0%; p<.001), women (14.3%; 18.5%; 20.6%; p<.001), and EVAR procedures (1.5%; 14.9%; 35.5%; P<.001) increased over time. The crude 5-year survival was 36%; 44%; 43% (p<.0001). Multivariable Cox proportional hazard analysis displayed a decreasing mortality hazard ratio (HR) over time (1.00; 0.80; 0.72; p<.001). Use of EVAR was associated with reduced hazards of crude long-term mortality (HR=0.80, P<.001). Relative survival for patients surviving the perioperative period (i.e. 90 days) was lower than matched general population referents, and was stable over time (relative 5-year survival: 86% vs 88% , vs 86% p<.001).Conclusions: Nationwide analysis of long-term outcomes after repair of rAAA in Sweden during 24 years (1994-2017) has revealed that, despite changes in the baseline population characteristics as well as in the treatment strategy, long-term survival improved over time.
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| 12. |
- D'Oria, Mario, et al.
(författare)
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Microsurgical Salvage of Acute Lower Limb Ischemia after Iatrogenic Femoral Injury during Orthopedic Surgery in a Pediatric Patient
- 2020
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Ingår i: Annals of Vascular Surgery. - : Elsevier BV. - 0890-5096 .- 1615-5947. ; 69, s. 452.e5-452.e11
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Tidskriftsartikel (refereegranskat)abstract
- Acute lower limb ischemia (ALLI) in the pediatric population is rare but may lead to limb loss and life-long complications. We report the technique and outcomes of microsurgical salvage of ALLI in a preterm newborn after open reduction of congenital hip dysplasia. A 2-month-old girl was born premature at week 36 with congenital bilateral hip dysplasia. The initial management attempted was conservative and entailed placement of bilateral Von Rosen splints. The treatment was successful on the left side, but the patient had recurrent unstable hip dislocation on the right side. Subsequently, 2 attempts at close reduction under general anesthesia were done and both were unsuccessful in maintaining the right hip in the acetabulum. Therefore, an open reduction of the right hip was planned through a medial/obturator approach. During the surgical procedure, the neurovascular femoral bundle (including the superficial femoral artery [SFA], femoral vein [FV], and femoral nerve) was accidently transected with subsequent development of ALLI. Therefore, the FV was harvested distally to the injury site and a 4-cm long healthy segment was obtained. It was reversed, flushed with heparin, spatulated at both extremities, and interposed to the SFA in end-to-end fashion using two 9/0 polypropylene interrupted sutures under microscope. Reperfusion of the limb was noted immediately after releasing the vascular clamps. The final ischemia time at completion of the surgical procedure was 6 hr. Thereby, prophylactic 4-compartment fasciotomies were performed in the right leg. The patient tolerated the procedure well and the postoperative clinical course was free from adverse events. Duplex ultrasound examination at 6 weeks after the intervention confirmed sustained clinical success and showed no signs of venous thromboembolism. At the same time, X-ray examination of the right hip confirmed adequate and stable reduction of the joint in the acetabulum. ALLI due to accidental arterial injury during orthopedic surgical procedures for congenital defects in newborns is a rare but potentially devastating complication. Microsurgical salvage is a safe, feasible, and effective option to restore limb flow. Multidisciplinary expertise and meticulous technique are mandatory in order to achieve satisfactory and durable outcomes.
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| 13. |
- D'Oria, Mario, et al.
(författare)
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Narrative review on endovascular techniques for left subclavian artery revascularization during thoracic endovascular aortic repair and risk factors for postoperative stroke
- 2021
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Ingår i: Interactive Cardiovascular and Thoracic Surgery. - : Oxford University Press (OUP). - 1569-9293 .- 1569-9285. ; 32:5, s. 764-772
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Forskningsöversikt (refereegranskat)abstract
- OBJECTIVESThe aim of this study was to present a narrative review on endovascular techniques (ET) for revascularization of the left subclavian artery (LSA) during zone 2 thoracic endovascular aortic repair (TEVAR) and on risk factors for postoperative stroke following TEVAR procedures.METHODSNon-systematic search of the literature from the PubMed, Ovid and Scopus databases to identify relevant English-language articles fully published in the period 1 January 2010–1 August 2020.RESULTSCurrent general agreement is that LSA revascularization should be always attempted in the elective setting. Under urgent circumstances, it can be delayed but might be considered during the same session on a case-by-case basis. Three ET are currently available: (i) chimney/snorkels (also known as parallel grafts), (ii) fenestrations or branches and (iii) proximal scallops. The main issue with ET is the potential for increased peri-operative stroke risk owing to increased manipulation within the aortic arch. Also, they are relatively novel and further assessment of their long-term durability is needed. Intra-operative embolism and loss of left vertebral artery perfusion are hypothesized as the main causes of stroke in patients undergoing TEVAR.CONCLUSIONSThe overall risk of stroke seems higher without LSA revascularization during zone 2 TEVAR. As LSA revascularization might have a direct effect in preventing posterior stroke, it should be routinely performed in elective cases, while a case-by-case evaluation can be made under urgent circumstances. While ET can provide effective options for LSA revascularization during zone 2 TEVAR, they are novel and need further durability assessment. Stroke after TEVAR is a multifactorial pathological process and preventing TEVAR-related cerebral injury remains a significant unmet clinical need.
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| 14. |
- D’Oria, Mario, et al.
(författare)
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Novel insights into thoracic endografts technology for prevention of distal stent-graft induced new entry (dSINE) following endovascular repair of type B aortic dissections : from bench to bedside
- 2024
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Ingår i: Expert Review of Medical Devices. - : Taylor & Francis. - 1743-4440 .- 1745-2422. ; 21:5, s. 391-398
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Forskningsöversikt (refereegranskat)abstract
- Introduction: Endovascular treatment of type B aortic dissections (TBAD) has currently acquired a primary therapeutic role when anatomically feasible. The main issue with thoracic endovascular aortic repair (TEVAR) for aortic dissection is the actual nature of the aortic wall, which is structurally compromised and more fragile. Indeed, a wealth of data have shown that TEVAR for TBAD will lead, in a substantial proportion of cases, to a device-related adverse event named distal stent-graft induced new entry (dSINE).Areas Covered: Currently available aortic stent-grafts have not been specifically devised for the treatment of aortic dissection. A novel dissection specific stent-graft (DSSG) was developed, which is a custom-made device based on the Zenith Alpha Thoracic platform (Cook Medical). The DSSG has several unique properties that, in principle, make its use optimal in TBAD patients.Expert Opinion: TEVAR in the setting of aortic dissections remains technically challenging. The occurrence of dSINE represents a unique complication in this scenario and may lead to high rates of aortic-related adverse events and need for secondary interventions. The use of a novel custom-made DSSG in the setting of chronic TBAD has been proven to be safe, feasible and effective. However, even this approach may fail to completely prevent dSINE formation.
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| 15. |
- D'Oria, Mario, et al.
(författare)
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Outcomes of "Anterior Versus Posterior Divisional Branches of the Hypogastric Artery as Distal Landing Zone for Iliac Branch Devices" : The International Multicentric R3OYAL Registry
- 2024
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Ingår i: Journal of Endovascular Therapy. - : Sage Publications. - 1526-6028 .- 1545-1550. ; 31:2, s. 282-294
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Tidskriftsartikel (refereegranskat)abstract
- Objective: The aim of this multicentric registry was to assess the outcomes of "anteRior versus posteRior divisional bRanches Of the hYpogastric artery as distAl landing zone for iLiac branch devices (R3OYAL)."Methods: The main exposure of interest for the purpose of this study was the internal iliac artery (IIA) divisional branch (anterior vs posterior) that was used as distal landing zone. Early endpoints included technical success and adverse events. Late endpoints included survival, primary/secondary IIA patency, and IIA branch instability.Results: A total of 171 patients were included in the study, of which 50 received bilateral implantation of iliac branch devices (IBDs). This resulted in a total of 221 incorporated IIAs included in the final analysis, of which 40 were anterior divisional branches and 181 were posterior divisional branches. Technical success was high in both groups (anterior division: 98% vs posterior division: 100%, P = .18). Occurrence of any adverse event was noted in 14% of patients in both groups (P = 1.0). The overall rate of freedom from the composite IBD branch instability did not show significant differences between patients receiving distal landing in the anterior or posterior division of the IIA at 3 years (79% vs 87%, log-rank test = .215). The 3-year estimates of IBD patency were significantly lower in patients who received distal landing in the anterior divisional branch than those who received distal landing in the posterior divisional branch (primary patency: 81% vs 96%, log-rank test = .009; secondary patency: 81% vs 97%, log-rank test < .001).Conclusions: The use of the anterior or posterior divisional branches of the IIA as distal landing zone for IBD implantation shows comparable profiles in terms of immediate technical success, perioperative safety, and side-branch instability up to 3 years. However, IBD patency at 3 years was higher when the distal landing zone was achieved within the posterior divisional branch of the IIA.Clinical Impact: The results from this large multicentric registry confirm that use of the anterior or posterior divisional branches of the internal iliac artery (IIA) as distal landing zone for implantation of iliac branch devices (IBD) shows comparable profiles of safety and feasibility, thereby allowing to extend the indications for endovascular repair of aorto-iliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Although mid-term rates of device durability and branch instability seem to be similar, the rates of primary and secondary IBD patency at three years was favored when the distal landing zone was achieved in the posterior divisional branch of the IIA.
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| 16. |
- D'Oria, Mario, et al.
(författare)
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Pre-Operative Moderate to Severe Chronic Kidney Disease is Associated with Worse Short-Term and Mid-Term Outcomes in Patients Undergoing Fenestrated-Branched Endovascular Aortic Repair
- 2021
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier. - 1078-5884 .- 1532-2165. ; 62:6, s. 859-868
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To review experience of fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal/thoraco-abdominal aortic aneurysms (PRAA/TAAA) and to assess the association between pre-operative moderate to severe chronic kidney disease (CKD) and post-operative outcomes.METHODS: All consecutive patients undergoing (elective and non-elective) F-BEVAR at a single centre (1 January 2011 - 1 July 2019) were identified. Renal function was calculated as the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula. Accordingly, presence of moderate to severe CKD was defined as eGFR < 60 mL/min/1.73m2.RESULTS: Overall, 202 consecutive patients (mean age 72 ± 8 years; 25% women) underwent F-BEVAR for the treatment of PRAA/TAAA during the study period. Of these, 51 had a history of moderate to severe CKD (none on chronic haemodialysis). No statistically significant differences were found in demographics and major comorbidities between patients with or without a history of CKD. The overall peri-operative mortality rate was 2%, without statistically significant differences between study groups (p = .26). Patients with prior CKD had statistically significantly higher rates of acute kidney injury (AKI) (37% vs. 12%, p < .001). At three years, overall survival was statistically significantly lower in patients with history of CKD compared with those without pre-operative CKD (57% vs. 82%, p = .010). Similarly, freedom from renal function decline at three years was statistically significantly poorer in patients with prior history of CKD compared with those without pre-operative CKD (43% vs. 80%, p = .020). In a multivariable analysis CKD was independently associated with higher odds of peri-operative AKI (OR 2.8, 95% CI 1.9 - 5.8, p = .030), renal function decline (OR 4.9, 95% CI 1.7 - 9.2, p = .003), and all cause mortality (HR 3.2, 95% CI 1.2 - 8.6, p = .020).CONCLUSION: Despite low peri-operative mortality rates that are comparable to patients with unimpaired renal function, occurrence of AKI was statistically significantly higher in subjects with pre-existing moderate to severe CKD. History of CKD was independently associated to renal function decline and poorer midterm survival.
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| 17. |
- D'Oria, Mario, et al.
(författare)
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PRINciples of optimal antithrombotiC therapy and coagulation managEment during elective fenestrated and branched EndovaScular aortic repairS (PRINCE2SS) : An International Expert Based Delphi Consensus Study
- 2022
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier. - 1078-5884 .- 1532-2165. ; 63:6, s. 838-850
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Tidskriftsartikel (refereegranskat)abstract
- ObjectiveManagement of antithrombotic therapy in patients undergoing elective fenestrated branched endovascular aortic repair (F-BEVAR) is not standardised, nor are there any recommendations from current guidelines. By designing an international expert based Delphi consensus, the study aimed to create recommendations on the pre-, intra-, and post-operative management of antithrombotic therapy in patients scheduled for elective F-BEVAR in high volume centres.MethodsEight facilitators created appropriate statements regarding the study topic that were voted on, using a four point Likert scale, by a selected panel of international experts using a three round modified Delphi consensus process. Based on the experts’ responses, only those statements reaching Grade A (full agreement ≥ 75%) or B (overall agreement ≥ 80% and full disagreement < 5%) were included in the final document. The round answers’ consistency was graded using Cohen’s k, the intraclass correlation coefficient, and, in case of double re-submission, the Fleiss k.ResultsSixty-seven experts were included in the final analysis and voted the initial 43 statements related to pre- (n = 15), intra- (n = 10), and post-operative (n = 18) management of antithrombotic drugs. At the end of the process, six statements (13%) were rejected, 20 statements (44%) received a Grade B consensus, and 18 statements (40%) reached a Grade A consensus. Most statements (27; 71%) exhibited very high or high consistency grades, and 11 (29%) a fair or poor grading. The intra-operative statements mostly concentrated on threshold for and monitoring of proper heparinisation. The pre- and post-operative statements mainly focused on indications for dual antiplatelet therapy and its management, considering the possible need for cerebrospinal fluid drainage.ConclusionBased on the elevated strength and high consistency of this international expert based Delphi consensus, most of the statements might guide current clinical management of antithrombotic therapy for elective F-BEVAR. Future studies are needed to clarify the debated issues.
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| 18. |
- D'Oria, Mario, et al.
(författare)
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Reply
- 2022
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Ingår i: Journal of Vascular Surgery. - : Elsevier. - 0741-5214 .- 1097-6809. ; 76:6, s. 1759-1759
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
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| 19. |
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| 20. |
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| 21. |
- DOria, Mario, et al.
(författare)
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Robustness of Longitudinal Safety and Efficacy After Paclitaxel-Based Endovascular Therapy for Treatment of Femoro-Popliteal Artery Occlusive Disease : An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials
- 2024
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Ingår i: Annals of Vascular Surgery. - : Elsevier. - 0890-5096 .- 1615-5947. ; 101, s. 164-178
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Tidskriftsartikel (refereegranskat)abstract
- Background:The aims of this study were: i) to assess fragility indices (FIs) of individual randomized controlled trials (RCTs) that compared paclitaxel-based drug-coated balloons (DCBs) or drug-eluting stents (DESs) versus standard endovascular devices, and ii) to meta-analyze mid-term and long-term safety and efficacy outcomes from available RCT data while also estimating the FI of pooled results.Methods:This systematic review has been registered in the PROSPERO public database (CRD42022304326 http://www.crd.york.ac.uk/PROSPERO). A query of PubMed (Medline), EMBASE (Excerpta Medical Database), Scopus, and CENTRAL (Cochrane Central Register of Controlled Trials) databases was performed to identify eligible RCTs. Rates of primary patency (PP) and target lesion revascularization (TLR) were assessed as efficacy outcomes, while lower limb amputation (LLA) consisting of major amputation that is. below or above the knee and all-cause mortality were estimated as safety outcomes. All outcomes were pooled with a random effects model to account for any clinical and study design heterogeneity. The analyses were performed by dividing the RCTs according to their maximal follow-up length (mid-term was defined as results up to 2-3 years, while long-term was defined as results up to 4-5 years). For each individual outcome, the FI and reverse fragility index (RFI) were calculated according to whether the outcome results were statistically significant or not, respectively. The fragility quotient (FQ) and reverse fragility quotient (RFQ), which are the FI or RFI divided by the sample size, were also calculated.Results:A total of 2,337 patients were included in the systematic review and meta -analysis. There were 2 RCTs examining DES devices and 14 RCTs evaluating different DCBs. For efficacy outcomes, there was evidence that paclitaxel-based endovascular therapy increased the PP rate and reduced the TLR rate at mid-term, with a calculated pooled risk ratio (RR) of 1.66 for patency (95% CI, 1.55-1.86; P < 0.001), with a corresponding number needed -totreat (NNT) of 3 patients (95% CI, 2.9-3.8) and RR of 0.44 for TLR (95% CI, 0.35-0.54; P = 0.027), respectively. Similarly, there was evidence that paclitaxel-based endovascular therapy both increased PP and decreased TLR rates at long-term, with calculated pooled RR values of 1.73 (95% CI, 1.12-2.61; P = 0.004) and 0.53 (95% CI, 0.45-0.62; P = 0.82), respectively. For safety outcomes, there was evidence that paclitaxel-based endovascular therapy increased all -cause mortality at mid-term, with a calculated pooled RR of 2.05 (95% CI, 1.21-3.24). However, there was no difference between treatment arms in LLA at mid-term (95% CI, 0.1-2.7; P = 0.68). Similarly, neither all -cause mortality nor LLA at long-term differed between treatment arms, with a calculated pooled RR of 0.66, 1.02 (95% CI, 0.31-3.42) and 1.02 (95% CI, 0.305.21; P = 0.22), respectively. The pooled estimates of PP at mid-term were robust (FI = 28 and FQ = 1.9%) as were pooled rates of TLR (FI = 18 and FQ = 0.9%). However, when safety outcomes were analyzed, the robustness of the meta -analysis decreased significantly. In fact, the relationship between the use of paclitaxel-coated devices and all -cause mortality at mid-term showed very low robustness (FI = 4 and FQ = 0.2%). At 5 years, only the benefit of paclitaxel-based devices to reduce TLR remained robust, with an FI of 32 and an FQ of 3.1%.Conclusions:The data supporting clinical efficacy endpoints of RCTs that examined paclitaxelbased devices in the treatment of femoral-popliteal arterial occlusive disease were robust; however, the pooled safety endpoints were highly fragile and prone to bias due to loss of patient follow-up in the original studies. These findings should be considered in the ongoing debate concerning the safety of paclitaxel-based devices.
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| 22. |
- D'Oria, Mario, et al.
(författare)
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Short-term and Mid-term Outcomes after Use of the Native Infrarenal Aorta as Distal Landing Zone for Fenestrated-Branched Endovascular Aortic Repair
- 2021
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Ingår i: Annals of Vascular Surgery. - : Elsevier. - 0890-5096 .- 1615-5947. ; 72, s. 114-123
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Tidskriftsartikel (refereegranskat)abstract
- Background: This study aimed to examine outcomes after use of the native infrarenal aorta as distal landing zone for fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal-thoracoabdominal aortic aneurysms (PRAA-TAAA). Methods: All F-BEVAR procedures for treatment of PRAA-TAAA (2011-2019) at 2 aortic centers were examined. The outcomes of interest were as follows: i) technical success, ii) perioperative morbidity, iii) preservation of lumbar arteries and the inferior mesenteric artery, iv) type IB endoleaks, v) reinterventions, vi) survival, vii) aneurysm sac behavior, and viii) infrarenal aortic changes. Results: Twenty consecutive patients with distal landing in the native infrarenal aorta were included (median age 71 years; 25% men). The median number of visible lumbar arteries at baseline was 7, and a patent inferior mesenteric artery (IMA) before the operation was present in 19 (95%) of the cases. There were no deaths within 30 days. One patient (5%), operated on with a 4-BEVAR for a type 2 TAAA, experienced spinal cord ischemia (permanent paraplegia). The median decrease in the number of visible lumbar arteries at the first postoperative scan was 3 from the baseline value, whereas a patent IMA was preserved in 12 out of 19 patients. Only in one case (5%), a type IB endoleak was noted for an overall technical success rate of 95%, which required a standard EVAR 20 months after the initial operation. The median follow-up duration for the study cohort was 491 days; all patients were alive at the longest available individual follow-up, and no instances of new-onset type IB endoleaks were observed. Another 3 late reinterventions (in addition to the one mentioned previously) were performed during midterm follow-up, all because of target vessel instability. In patients with >= 12 months of follow-up after the index procedure (n = 12, 60% of the entire cohort), no instances of aneurysm sac increase >5 mm were noted; the median largest aortic diameter was 51 mm with a median difference from baseline of -6 mm. The median distal landing zone diameter increase was 4 mm from baseline but never beyond the nominal stent-graft diameter, whereas the median aortic bifurcation diameter differed 1 mm from baseline. Conclusions: This preliminary experience shows that the use of the native infrarenal aorta as a distal landing zone for F-BEVAR is safe in the short term and midterm in patients with suitable anatomy, allowing the sparing of collateral vessels. Longer follow-up is warranted to assess durability.
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| 23. |
- D'Oria, Mario, et al.
(författare)
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The Association Between Body Mass Index and Death Following Elective Endovascular and Open Repair of Abdominal Aortic Aneurysms in the Vascular Quality Initiative
- 2023
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 66:1, s. 27-36
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Tidskriftsartikel (refereegranskat)abstract
- Objective: The effect of body mass index (BMI) on post-operative outcomes after abdominal aortic aneurysm (AAA) repair remains poorly defined. The association between BMI and death following elective endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR) of AAA in a large national quality registry is investigated.Methods: All elective AAA repairs within the Society for Vascular Surgery Vascular Quality Initiative (VQI; 2010 to September 2021) were reviewed (EVAR, n = 53 426; OAR, n = 9 479). All analyses were conducted separately for EVAR and OAR patients. The primary end points were 30 day mortality and five year survival rates. Study cohorts were divided into World Health Organisation BMI categories (C1 < 18.5, C2 18.5 <= BMI < 25, C3 25 <= BMI < 30, C4, 30 <= BMI < 35, C5 35 <= BMI < 40, C6 >= 40). BMI was examined as both a categorical and continuous variable. Logistic and Cox proportional hazards regression were used for risk adjustment.Results: Among EVAR patients, BMI distribution was C1, 1 216 (2%); C2, 14 687 (28%); C3, 20 516 (38%); C4, 11 352 (21%); C5, 3 947 (7%); C6, 1 708 (3%). Class 1, 2, and 6 BMI patients experienced an increased 30 daymortality rate (C1 2.6%; C2 1.3%; C6 1.4% vs. C3 - 5 0.7%; p < .001) and C1 and C2 had correspondingly inferior long termsurvival (five years: C1 69 +/- 3%; C2 79 +/- 1% vs. C3 - 6 86 - 88 +/- 2%; log rank p <.001). These survival disparities persisted after risk adjustment formultiple confounders. In the OAR cohort, BMI distribution was C1, 280 (3%); C2, 2 862 (30%); C3, 3 587 (38%); C4, 1 940 (21%); C5, 581 (6%); C6, 229 (2%). Crude 30 day mortality rates were increased for both the lowest and highest BMI patients (C1 12%, C6 7% vs. C2 - 5 3 - 4%; p < .001); these differences also persisted in long term survival (five years: C1 71 +/- 6%, C6 82 +/- 6% vs. C2 - 6 85 - 88 +/- 3%; log rank p <.001). In risk adjusted analysis, both low and high BMI OAR patients had an increased 30 day and long term mortality rate.Conclusion: Within the VQI, both the extreme low (< 18.5) and high (>= 40) BMI groups experienced an increased 30 day mortality rate after both elective EVAR and OAR. By comparison, while the lowest BMI cohort was significantly associated with decreased long term survival after both procedures, the highest BMI group only experienced reduced long termsurvival after OAR. Based upon this large real world registry analysis of elective AAA repairs, differential metabolic signatures exist within extreme BMI categories, which may inform peri-operative risk stratification and clinical decision making.
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| 24. |
- D'Oria, Mario, et al.
(författare)
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Use of Fenestrated Stent-Grafts for Preservation of Spinal Artery Flow During Endovascular Repair of Thoracoabdominal Aortic Disease
- 2021
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Ingår i: Annals of Vascular Surgery. - : Elsevier. - 0890-5096 .- 1615-5947. ; 70, s. 566.e15-566.e20
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Tidskriftsartikel (refereegranskat)abstract
- We illustrate the safety and feasibility of the application of fenestrated stent-grafts for the preservation of spinal artery flow during endovascular repair of thoracoabdominal aortic aneurysms (TAAA) in 2 patients deemed high-risk for spinal cord ischemia (SCI). In one case, an unstented fenestration was used in a 78-year-old male treated for distal stent-graft induced new entry tear. In the other case, a fenestration with a bridging stent-graft was used to revascularize a spinal artery in a 66-year-old female with Marfan disease and island patch aneurysm following open TAAA reconstruction. Both procedures were successful without any postoperative neurologic complication. The unstented fenestration led to a type III endoleak that required the relining of the aortic stent-graft 2 years later. The stented spinal fenestration was patent at a 5-year imaging follow-up.
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| 25. |
- Grandi, Alessandro, et al.
(författare)
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Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms : A Scoping Review
- 2023
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Ingår i: Journal of Clinical Medicine. - : MDPI. - 2077-0383. ; 12:17
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Forskningsöversikt (refereegranskat)abstract
- Purpose. The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA). Materials and Methods. A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)? Results. The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies. Conclusions. The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events.
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