| 1. |
- Baderkhan, Hassan, et al.
(författare)
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Celiprolol Treatment in Patients with Vascular Ehlers-Danlos Synurome
- 2021
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier. - 1078-5884 .- 1532-2165. ; 61:2, s. 326-331
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Tidskriftsartikel (refereegranskat)abstract
- Objecti_ Vascular Ehlers-Danlos syndrome (vEDS) is a rare monogenetic disease caused by pathogenic variants in procollagen 3A1. Arterial rupture is the most serious clinical manifestation. A randomised controlled trial, the Beta-Blockers in Ehlers-Danlos Syndrome Treatment (BBEST) trial, reported a significant protective effect of the beta blocker celiprolol. The aim was to study the outcome of celiprolol treatment in a cohort of Swedish patients with vEDS. Methods: Uppsala is a national referral centre for patients with vEDS. They are assessed by vascular surgeons, angiologists, and clinical geneticists. Family history, previous and future clinical events, medication, and side effects are registered. Celiprolol was administered twice daily and titrated up to a maximum dose of 400 mg daily. Logistic regression was used to analyse predictors of vascular events. Results: Forty patients with pathogenic sequence variants in COL3A1 were offered treatment with celiprolol in the period 2011-2019. The median follow up was 22 months (range 1-98 months); total follow up was 106 patient years. In two patients, uptitration of the dose is ongoing. Of the remaining 38, 26 (65%) patients reached the target dose of 400 mg daily. Dose uptitration was unsuccessful in six patients because of side effects; one died before reaching the maximum dose, and five terminated the treatment. Five major vascular events occurred; four were fatal (ruptured ascending aorta; aortic rupture after type B dissection; ruptured cerebral aneurysm; and ruptured pulmonary artery). One bled from a branch of the internal iliac artery, which was successfully coiled endovascularly. The annual risk of a major vascular event was 4.7% (n = 5/106), similar to the treatment arm of the BBEST trial (5%) and lower than in the control arm of the same trial (12%). No significant predictor of vascular events was identified. Conclusion: Treatment with celiprolol is tolerated in most patients with vEDS. Despite fatal vascular events, these observations suggest that celiprolol may have a protective effect in vEDS.
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| 2. |
- Baderkhan, Hassan, et al.
(författare)
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Challenging Anatomy Predicts Mortality and Complications After Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm
- 2016
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Ingår i: Journal of Endovascular Therapy. - : SAGE Publications. - 1526-6028 .- 1545-1550. ; 23:6, s. 919-927
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: To analyze the effects of aortic anatomy and endovascular aneurysm repair (EVAR) inside and outside the instructions for use (IFU) on outcomes in patients treated for ruptured abdominal aortic aneurysms (rAAA).METHODS: All 112 patients (mean age 73 years; 102 men) treated with standard EVAR for rAAA between 2000 and 2012 in 3 European centers were included in the retrospective analysis. Patients were grouped based on aortic anatomy and whether EVAR was performed inside or outside the IFU. Data on complications, secondary interventions, and mortality were extracted from the patient records. Cox regression analysis was performed to assess predictors of mortality and complications; results are presented as the hazard ratio (HR) with 95% confidence interval (CI). Survival was analyzed using the Kaplan-Meier method.RESULTS: Of the 112 patients examined, 61 (54%) were treated inside the IFU, 43 (38%) outside the IFU, and 8 patients lacked adequate preoperative computed tomography scans for determination. Median follow-up of those surviving 30 days was 2.5 years. Mortality at 30 days was 15% (95% CI 6% to 24%) inside the IFU vs 30% (95% CI 16% to 45%) outside (p=0.087). Three-year mortality estimates were 33.8% (95% CI 20.0% to 47.5%) inside the IFU vs 56% (95% CI 39.7% to 72.2%) outside (p=0.016). At 5 years, mortality was 48% (95% CI 30% to 66%) inside the IFU vs 74% (95% CI 54% to 93%) outside (p=0.015). Graft-related complications occurred in 6% (95% CI 0% to 13%) inside the IFU and 30% (95% CI 14% to 42%) outside (p=0.015). The rate of graft-related secondary interventions was 14% (95% CI 4% to 22%) inside the IFU vs 35% (95% CI 14% to 42%) outside (p=0.072). In the multivariate analysis, neck length <15 mm (HR 8.1, 95% CI 3.0 to 21.9, p<0.001) and angulation >60° (HR 3.1, 95% CI 1.0 to 9.3, p=0.045) were independent predictors of late graft-related complications. Aneurysm neck diameter >29 mm (HR 2.5, 95% CI 1.1 to 5.9, p=0.035) was an independent predictor of overall mortality.CONCLUSION: Long-term mortality and complications after rEVAR are associated with aneurysm anatomy. The role of adjunct endovascular techniques and the outcome of open repair in cases with challenging anatomy warrant further study.
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| 3. |
- Baderkhan, Hassan, et al.
(författare)
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Detection of Late Complications After Endovascular Abdominal Aortic Aneurysm Repair and Implications for Follow up Based on Retrospective Assessment of a Two Centre Cohort
- 2020
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : W B SAUNDERS CO LTD. - 1078-5884 .- 1532-2165. ; 60:2, s. 171-179
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Tidskriftsartikel (refereegranskat)abstract
- Objective. Endovascular aortic aneurysm repair (EVAR) is associated with the risk of late complications and mandates follow up. This retrospective study assessed post-EVAR complications in a two centre cohort. The study evaluated the rate of complications presenting with symptoms vs. those detected by imaging follow up. Additionally, the agreement between DUS and CTA in detecting complications was assessed in patients with both. Methods: All EVAR patients from 1998 to 2012 in two centres were included. Complications were classified based on whether they were symptomatic or detected by imaging, as well as based on imaging detection modality (DUS or CTA). For patients who had undergone DUS and CTA within three months of each other, the kappa coefficient of agreement was assessed. Results: Four hundred and fifty-four patients treated by EVAR were identified. The median follow up time was 5.2 (IQR 2.8-7.6) years. One hundred and eighteen patients (26%) developed 176 complications. One hundred and six (60.2%) of the complications were asymptomatic, and 70 (39.8%) were symptomatic. Two hundred and fifty-three patients had imaging with both modalities within three months of each other; the kappa coefficient for agreement between CTA and DUS for detecting clinically significant complications was 0.91. Regarding CTA as the standard modality, DUS had a sensitivity of 88.8% (95% CI 77.3-95.8%) and a specificity of 99.4% (95% CI 97.1-99.9%). Three of the complications missed by DUS were related to loss of proximal and distal seal, all occurring in patients with short sealing length on first post-operative CT scan. Conclusion: Approximately a quarter of the patients developed complications, the majority of which were asymptomatic, underlining the importance of adequate surveillance. There was good agreement between CTA and DUS in detecting complications. Clinically significant complications related to inadequate seal were missed by DUS, suggesting that CTA still plays an important role in EVAR surveillance.
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| 4. |
- Baderkhan, Hassan, et al.
(författare)
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Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging
- 2018
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Ingår i: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 05:6, s. 709-718
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundLifelong postoperative surveillance is recommended following endovascular aneurysm repair (EVAR). Although the purpose is to prevent and/or identify complications early, it also results in increased cost and workload. This study was designed to examine whether it may be possible to identify patients at low risk of complications based on their first postoperative CT angiogram (CTA).MethodsAll patients undergoing EVAR in two Swedish centres between 2001 and 2012 were identified retrospectively and categorized based on the first postoperative CTA as at low risk (proximal and distal sealing zone at least 10 mm and no endoleak) or high risk (sealing zone less than 10 mm and/or presence of any endoleak) of complications.ResultsSome 326 patients (273 men) with a CTA performed less than 1 year after EVAR were included (low risk 212, 65·0 per cent; high risk 114, 35·0 per cent). There was no difference between the groups in terms of sex, age, co‐morbidities, abdominal aortic aneurysm (AAA) diameter, preoperative AAA neck anatomy, stent‐graft type or duration of follow‐up (mean(s.d.) 4·8(3·2) years). Five‐year freedom from AAA‐related adverse events was 97·1 and 47·7 per cent in the low‐ and high‐risk groups respectively (P < 0·001). The corresponding freedom from AAA‐related reintervention was 96·2 and 54·1 per cent (P < 0·001). The method had a sensitivity of 88·3 per cent, specificity of 77·0 per cent and negative predictive value of 96·6 per cent to detect AAA‐related adverse events. The number of surveillance imaging per AAA‐related adverse event was 168 versus 11 for the low‐risk versus high‐risk group.ConclusionTwo‐thirds of patients undergoing EVAR have an adequate seal and no endoleak on the first postoperative CTA, and a very low risk of AAA‐related events up to 5 years. Less vigilant follow‐up after EVAR may be considered for these patients.
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| 5. |
- Dellagrammaticas, Demos, et al.
(författare)
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Management of Aortic Sac Enlargement Following Successful EVAR in a Frail Patient
- 2016
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 51:2, s. 302-308
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: An enlarging aneurysm after endovascular aneurysm repair (EVAR) without clear endoleak is a clinical challenge. Management of this problem is guided by the current evidence for adequate EVAR follow up and recommended thresholds for re-intervention. In a frail patient, careful risk assessment of aneurysm related mortality against the risks associated with examinations and interventions is required.METHODS: The literature was reviewed for imaging modalities for EVAR follow up and their advantages and disadvantages. The current evidence and guideline recommendations regarding follow up and re-intervention after EVAR were assessed in relation to the presented case.RESULTS: To detect sac expansion after EVAR, repeated examinations with the same imaging modality are needed. Verified expansion must be above the inter-observer variation of the method used. Although duplex ultrasound is an excellent modality for EVAR follow up, the finding of a significant expansion on duplex requires further examination, primarily with computed tomography angiography to assess sealing, stent graft integrity, and presence of endoleak. A frail patient should be assessed thoroughly before any kind of surgical intervention, the extent of which is related to the identified or suspected cause of expansion.CONCLUSION: Failure to totally exclude the aneurysm from continuing circulation, pressure and endoleak remains a potential shortcoming of EVAR. Significant sac expansion is an indication of EVAR failure. Decisions regarding further examinations or intervention are guided by the stability of the initial EVAR performed, the cause and extent of expansion, and the patient's comorbidities.
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| 6. |
- 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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| 7. |
- 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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| 8. |
- Goncalves, F. Bastos, et al.
(författare)
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Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair
- 2014
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Ingår i: British Journal of Surgery. - : Oxford University Press (OUP). - 0007-1323 .- 1365-2168. ; 101:7, s. 802-810
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Tidskriftsartikel (refereegranskat)abstract
- Background: Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance. Methods: Patients undergoing EVAR from 2000 to 2011 at three vascular centres (in 2 countries), who had two imaging examinations (postoperative and after 6-18 months), were included. Maximum diameter, complications and secondary interventions during follow-up were registered. Patients were categorized according to early sac dynamics. The primary endpoint was freedom from late complications. Secondary endpoints were freedom from secondary intervention, postimplant rupture and direct (type I/III) endoleaks. Results: Some 597 EVARs (71.1 per cent of all EVARs) were included. No shrinkage was observed in 284 patients (47.6 per cent), moderate shrinkage (5-9mm) in 142 (23.8 per cent) and major shrinkage (at least 10mm) in 171 patients (28.6 per cent). Four years after the index imaging, the rate of freedom from complications was 84.3 (95 per cent confidence interval 78.7 to 89.8), 88.1 (80.6 to 95.5) and 94.4 (90.1 to 98.7) per cent respectively. No shrinkage was an independent risk factor for late complications compared with major shrinkage (hazard ratio (HR) 3.11; P < 0.001). Moderate compared with major shrinkage (HR 2.10; P = 0.022), early postoperative complications (HR 3.34; P < 0.001) and increasing abdominal aortic aneurysm baseline diameter (HR 1.02; P = 0.001) were also risk factors for late complications. Freedom from secondary interventions and direct endoleaks was greater for patients with major sac shrinkage. Conclusion: Early change in aneurysm sac diameter is a strong predictor of late complications after EVAR. Patients with major sac shrinkage have a very low risk of complications for up to 5 years. This parameter may be used to tailor postoperative surveillance.
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| 9. |
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| 10. |
- Hassan, Baderkhan, 1970-
(författare)
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Endovascular aortic aneurysm repair: Aspects of follow-up and complications
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Endovascular aortic aneurysm repair (EVAR) is the procedure of choice in most patients with abdominal aortic aneurysm. The drawbacks of EVAR are a higher rate of complications and frequent need for reinterventions, requiring regular postoperative follow-up. Non-stratified follow-up may have a deleterious effect on patients and the health care system. The aim of this thesis is to develop strategies that can stratify the EVAR follow-up programme according to an individual patient´s risk profile.Study I, an international multicentre study of all abdominal aortic aneurysm (AAA) patients with EVAR in three centres (2000 to 2011) demonstrated a lower rate of late complications and reinterventions in patients with sac shrinkage during the first postoperative year, compared to the non-shrinkage group.Study II, an international multicentre study of patients treated for a ruptured aortic aneurysm with EVAR in three centres (2000 to 2012) demonstrated that ruptured EVAR (rEVAR) in patients with hostile anatomy is associated with a high rate of graft-related complications, reinterventions and increased overall mortality.Study III, a two-centre cohort study of 326 patients with EVAR (2001 to 2012), with first postoperative computerised tomographic angiography (CTA) within one year of the operation. Patients with adequate proximal and distal sealing zones and no endoleak in the first postoperative CTA had significantly lower risk for AAA-related complications and reinterventions up to five years postoperatively.Study IV, studied all complications and reinterventions in a two-centre cohort study of all EVAR patients (1998 to 2012), One-fourth of the patients in the study developed complications during a mean follow-up of five years. Most complications were asymptomatic imaging-detected. Ultrasound could detect most of the clinically significant complications.
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| 11. |
- Yu, Hok Yee Harry, et al.
(författare)
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Systematic review and meta-analysis of prophylactic aortic side branch embolization to prevent type II endoleaks
- 2020
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Ingår i: Journal of Vascular Surgery. - : MOSBY-ELSEVIER. - 0741-5214 .- 1097-6809. ; 72:5, s. 1783-
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Forskningsöversikt (refereegranskat)abstract
- Objective: Type II endoleaks are the most common type of endoleak after endovascular aneurysm repair (EVAR) and may cause late sac expansion and rupture. To prevent this, prophylactic embolization of aortic side branches has been suggested. The aim of this review was to assess the current evidence for this prophylactic treatment and its association with sac size enlargement as well as rate of and reintervention for type II endoleak. Methods: This was a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE and Scopus databases were used to search for related articles until March 2019. After screening, original studies reporting outcome comparing patients having prophylactic embolization with those undergoing EVAR without prophylactic embolization were included. An assessment of the quality of the included studies as well as data extraction was performed by two independent observers. Statistical analysis was performed using Review Manager 5.3 (The Nordic Cochrane Center, Copenhagen, Denmark). Results: There were 3777 publications identified. After elimination of duplicate entries and review of titles and abstracts, 13 retrospective cohort studies including 1427 patients comparing prophylactic embolization with standard EVAR therapy were identified. No randomized trials were available. Five of these 13 studies reported sac growth, with a frequency of 7.4%(14/90) in the embolization group vs 13.4% in controls (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.29-1). The rate of type II endoleak was 18.5% (100/540) in the embolization group vs 38.6% in the control group (342/887; OR, 0.34; 95% CI, 0.26-0.44). Based on 10 studies, the rate of reinterventionwas 1.5%(7/468) in the embolization group vs 12.4%(80/646) in the control group (OR, 0.12; 95% CI, 0.06-0.24). Nine of these 13 studies showed that technical success of inferior mesenteric artery and lumbar artery embolization was 82.3% and 69.1%, respectively. Regarding complications, 10 of 108 patients (9.3%) in one study reported nonspecific abdominal pain after embolization, and all resolved with overnight rehydration. Only one patient, who previously had right hemicolectomy, died after inferior mesenteric artery embolization of ischemic colitis. Conclusions: This systematic review and meta-analysis suggests that prophylactic aortic side branch embolization may be associated with lower rate of sac enlargement, incidence of type II endoleaks, and reinterventions. However, high-quality unbiased studies are lacking in this field, and this review and meta-analysis may be affected by selection bias and residual confounders remaining in the retrospective studies. To conclude whether prophylactic embolization should be routinely performed, a prospective, randomized trial is required.
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