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| 12. |
- Abdelhalim, Mohamed A., et al.
(författare)
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Multicenter trans-Atlantic experience with fenestrated-branched endovascular aortic repair of chronic post-dissection thoracoabdominal aortic aneurysms
- 2023
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Ingår i: Journal of Vascular Surgery. - : Elsevier. - 0741-5214 .- 1097-6809. ; 78:4, s. 854-862.e1
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: This multicenter international study aimed to describe outcomes of fenestrated-branched endovascular aortic repairs (FB-EVAR) in a cohort of patients treated for chronic post-dissection thoracoabdominal aortic aneurysms (PD-TAAAs).METHODS: We reviewed the clinical data of all consecutive patients treated by FB-EVAR for repair of extent I to III PD-TAAAs in 16 centers from the United States and Europe (2008-2021). Data were extracted from institutional prospectively maintained databases and electronic patient records. All patients received off-the-shelf or patient-specific manufactured fenestrated-branched stent grafts. Endpoints were any cause mortality and major adverse events at 30 days, technical success, target artery (TA) patency, freedom from TA instability, minor (endovascular with <12 Fr sheath) and major (open or ≥12 Fr sheath) secondary interventions, patient survival, and freedom from aortic-related mortality (ARM).RESULTS: A total of 246 patients (76% male; median age, 67 years [interquartile range, 61-73 years]) were treated for extent I (7%), extent II (55%), and extent III (35%) PD-TAAAs by FB-EVAR. The median aneurysm diameter was 65 mm (interquartile range, 59-73 mm). Eighteen patients (7%) were octogenarians, 212 (86%) were American Society of Anesthesiologists class ≥3, and 21 (9%) presented with contained ruptured or symptomatic aneurysms. There were 917 renal-mesenteric vessels targeted by 581 fenestrations (63%) and 336 directional branches (37%), with a mean of 3.7 vessels per patient. Technical success was 96%. Mortality and rate of major adverse events at 30 days was 3% and 28%, including disabling complications such as new onset dialysis in 1%, major stroke in 1%, and permanent paraplegia in 2%. Mean follow-up was 24 months. Kaplan-Meier (KM) estimated patient survival at 3 and 5 years was 79% ± 6% and 65% ± 10%. KM estimated freedom from ARM was 95% ± 3% and 93% ± 5% at the same intervals. Unplanned secondary interventions were needed in 94 patients (38%), including minor procedures in 64 (25%) and major procedures in 30 (12%). There was one conversion to open surgical repair (<1%). KM estimated freedom from any secondary intervention was 44% ± 9% at 5 years. KM estimated primary and secondary TA patency were 93% ± 2% and 96% ± 1% at 5 years, respectively.CONCLUSIONS: FB-EVAR for chronic PD-TAAAs was associated with high technical success and a low rate of mortality (3%) and disabling complications at 30 days. Although the procedure is effective in the prevention of ARM, patient survival was low at 5 years (65%), likely due to the significant comorbidities in this cohort of patients. Freedom from secondary interventions at 5 years was 44%, although most procedures were minor. The significant rate of reinterventions highlights the need for continued patient surveillance.
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| 13. |
- Acosta, Stefan, et al.
(författare)
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Increasing incidence of ruptured abdominal aortic aneurysm : a population-based study
- 2006
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Ingår i: Journal of Vascular Surgery. - : Elsevier BV. - 0741-5214 .- 1097-6809. ; 44:2, s. 237-243
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Tidskriftsartikel (refereegranskat)abstract
- Objective: The aim of the present population-based study was to assess the trends of age- and gender-specific incidence of ruptured abdominal aortic aneurysm (rAAA). Methods. Patients with rAAA from the city of Malmo, Sweden, were studied between 2000 and 2004. An analysis of trends of incidence and mortality of rAAA in Malmo was possible because of a previous population-based study on patients with rAAA between 1971 and 1986 (autopsy rate 85% compared with 25% for the time period 2000 to 2004). The in-hospital registry of Malmo University Hospital and the databases at the Department of Pathology, Malmo, and the Institution of Forensic Medicine, Lund, identified patients with rAAA, and the in-hospital registry identified all elective repairs for AAA. Results. Compared with the time period 1971 to 1986, the overall incidence of rAAA significantly increased from 5.6 (95 % confidence interval [CI], 4.9 to 6.3) to 10.6 (95% CI, 8.9 to 12.4) per 100,000 person-years (standardized mortality ratio, 1.6; 95% CI, 1.0 to 2.1). In men aged 60 to 69 and 70 to 79 years, the incidence increased significantly from 16 (95% CI, 11 to 21) and 56 (95% Cl, 43 to 69) to 46 (95% Cl, 28 to 63) and 117 (95% CI, 84 to 149) per 100,000 person-years, respectively, whereas no increase in the age-specific incidence in women could be demonstrated. The overall incidence of elective repair of AAA increased significantly from 3.4 (95% CI, 2.8 to 4.0) to 7.0 (95% CI, 5.6 to 8.4) per 100,000 person-years and increased most significantly from 12 (95% CI, 3.4 to 32) to 68 (95% CI, 34 to 102) per 100,000 person-years in men aged 80 to 89 years and from 5.1 (95% CI, 2.4 to 9.3) to 28 (95% CI, 15 to 41) per 100,000 person-years in women aged 70 to 79 years. The elective-acute repair ratio in women increased from 2.4 to 5.6 and decreased in men from 2.1 to 1.0. Conclusions: Between 1971 to 1986 and 2000 to 2004, the incidence of rAAA increased significantly, despite a 100% increase in elective repairs and notwithstanding a potential for bias towards underestimation due to lower autopsy rates in recent years. The reason behind this increase is unclear, and further studies are needed to identify risk groups for direction of effective prevention and screening.
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| 14. |
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| 15. |
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| 16. |
- Acosta, Stefan, et al.
(författare)
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The Hardman index in patients operated on for ruptured abdominal aortic aneurysm: A systematic review.
- 2006
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Ingår i: Journal of Vascular Surgery. - : Elsevier BV. - 1097-6809 .- 0741-5214. ; 44:5, s. 949-954
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Forskningsöversikt (refereegranskat)abstract
- Background. The aims of the present study were to (1) analyze preoperative predictors for outcome suggested by Hardman and surgical mortality after open repair and endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA), and (2) further evaluate the Hardman index in a systematic review. Methods. Patients operated on for rAAA during a 5-year period between 2000 and 2004 were scored according to Hardman-1 point for either age > 76 years, loss of consciousness after presentation, hemoglobin < 90 g/L, serum creatinine > 190 mu mol/L or electrocardiographic (ECG) signs of ischemia-with blinded evaluation of ECGs by a specialist in clinical physiology. The results were included in a systematic review of studies evaluating the Hardman index. Results: In-hospital mortality after operation was 41% (67/162). There was no difference in in-hospital mortality between open repair (n=106) and EVAR (n=56), whereas the Hardman index was associated with operative mortality in our institution and in the systematic review of 970 patients (P <.001). Mortality rate in patients with Hardman index >= 3 was 77% in the pooled analysis. A full data set of all five scoring variables was obtained in 94 (58%) of 162 patients in our study, and potential underscoring was thus possible in 68 patients. Of the available ECGs, 12 (8.7%) of 138 were judged nondiagnostic. Five studies did not state their missing data on ECG and hemoglobin and serum creatinine concentrations, nor did they specify the criteria for ECG ischermia. Conclusions: A strong correlation between the Hardman index and mortality was found. A Hardman index >= 3 cannot be used as an absolute limit for denial of surgery. The utility of the Hardman index seems to be impeded by variability in scoring resulting from missing or nondiagnostic data.
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| 17. |
- Andersson, Mattias, et al.
(författare)
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A population-based study of post-endovascular aortic repair rupture during 15 years
- 2021
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Ingår i: Journal of Vascular Surgery. - : Elsevier BV. - 0741-5214 .- 1097-6809. ; 74:3
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Tidskriftsartikel (refereegranskat)abstract
- Objective: The devastating event of a ruptured abdominal aortic aneurysm (rAAA) in patients who have survived a previous AAA repair, either elective or urgent, is a feared and quite uncommon event. It has been suggested to partly explain the loss of the early survival benefit for endovascular aortic repair (EVAR) vs open surgical repair (OSR). The main objective of this study was to report the national incidence rate, risk factors and outcome of post-EVAR ruptures. Secondarily, the national incidence rate of ruptures after OSR (post-OSR ruptures) was investigated. Methods: We conducted a nationwide, population-based, retrospective cohort study using the inpatient and outpatient entries for all patients >40 years of age, receiving their first (index) surgical procedure for AAA, from 2001 to 2015. Only patients surviving their index procedure were included. The primary outcome was rAAA, registered after discharge from the index procedure (EVAR or OSR), identified in the Swedish National Patient Registry and the Cause of Death Registry. Results: In total, 14,859 patients survived their primary (index) AAA procedure. There were 6470 EVAR procedures, 5893 for intact AAA (iAAA) and 577 for rAAA. Of the 6470 EVAR patients, 86 cases of post-EVAR rupture were identified, corresponding with a cumulative incidence of 1.3% over a mean follow-up time of 3.9 years. The incidence rate was 3.4 (95% confidence interval [CI], 2.7-4.2)/1000 person-years. The independent risk factors identified for post-EVAR rupture were rAAA at index surgery HR 2.4 (95% CI, 1.4-4.1, p 0.002) and age (hazard ratio, 1.1; 95% CI, 1.0-1.1; P <.001). Freedom from post-EVAR rupture was 99%, 98%, and 96% at 3, 5, and 10 years, respectively. Total and postoperative mortality after post-EVAR rupture were 42% and 17% (30 days), 45% and 22% (90 days), and 53% and 33% (1 year). The incidence rate of post-OSR rupture was 0.9/1000 person-years (95% CI, 0.7-1.2). Conclusions: Post-EVAR rupture is a rare complication that can occur at any time after the index EVAR procedure. This finding may have implications for the discussion of limited follow-up programs and for the choice of procedure in patients with an AAA with a long life expectancy. An rAAA as the indication for the index surgery and age were identified as risk factors for post-EVAR rupture. The mortality associated with post-EVAR rupture is high, but lower than that of primary rAAA. The much lower risk of post-OSR rupture was confirmed, but must not be neglected as a possible late complication. © 2021 The Authors
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| 18. |
- Apelqvist, Jan, et al.
(författare)
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Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients.
- 2011
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Ingår i: Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. - : Elsevier BV. - 1097-6809. ; 53, s. 1582-1588
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: Peripheral vascular disease (PVD) is an important limiting factor for healing in neuroischemic or ischemic diabetic foot ulcer. The purpose of this study was to identify factors related to healing in patients with diabetes with foot ulcers and severe PVD. METHODS: Patients with diabetes with a foot ulcer, consecutively presenting at a multidisciplinary foot center with a systolic toe pressure <45 mm Hg or an ankle pressure <80 mm Hg were prospectively included, followed according to a preset program, and with the exception of specified exclusions, subjected to angiography offered vascular intervention when applicable. All patients had continuous follow-up until healing or death irrespective of the type of vascular intervention. RESULTS: One thousand one hundred fifty-one patients were included. Eighty-two percent had a toe pressure <45 mm Hg and 49% had an ankle pressure <80 mm Hg. Eight hundred one patients (70%) underwent an angiography. Out of these, 63% had vascular intervention, either percutaneous transluminal angioplasty (PTA; 39%) or reconstructive surgery (24%). Nine percent of the patients had one or more complications after angiography. PTA was multisegmental in 46% and to the crural arteries in 46%. Reconstructive surgery was distal in 51%. Age (P < .001), renal function impairment (P = .005), congestive heart failure (P = .01), number and type of ulcer (P < .001), and severity of PVD (P = .003) affected the outcome of ulcers. PTA and reconstructive vascular surgery increased the probability of healing without amputation (odds ratio [OR], 1.77 and 2.05, respectively). CONCLUSION: Probability of ulcer healing is strongly related to comorbidity, extent of tissue involvement, and severity of PVD in patients with diabetes with severe PVD.
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| 19. |
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| 20. |
- 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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