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Aneurysm treatment practice patterns for newly appointed dual-trained cerebrovascular/endovascular neurosurgeons: Comparison of open surgical to neuroendovascular procedures in the first 2 years of academic practice.

ABSTRACT: The practice patterns of a hybrid open cerebrovascular/neuroendovascular (CVNV) neurosurgeon in early academic practice is unknown.We performed a multi-institutional retrospective cohort study of patients with cerebral aneurysms that were treated within the first 24 months of the neurosurgeon's practice.A total of 533 aneurysms were treated by the three senior authors within the first 24 months of their academic practice. Of these aneurysms, 172 were treated with microsurgical clipping, 191 with coiling, and 170 with flow diversion. Treatment in the setting of acute subarachnoid hemorrhage (SAH) occurred in 23% (122/533) of the aneurysms. Majority of the clipped aneurysms (70%, 121/172) were anterior cerebral artery (ACA), anterior communicating artery (ACOM), or middle cerebral artery (MCA) in location. In comparison, only 23% (82/361) of aneurysms treated with coiling or flow diversion therapy were ACA, ACOM, or MCA in location (P < 0.05). Additionally, majority of the flow diverted aneurysm (65%, 111/170) were cavernous or ophthalmic/paraophthalmic in location. During the second year of practice, there appeared to be a trend towards more aneurysms treated with neuroendovascular techniques (22% increase), particularly in flow diversion.Although the CVNV neurosurgeon treats cerebral aneurysms more commonly with neuroendovascular techniques, a third of the cerebral aneurysms are still selected for microsurgical clipping. Aneurysms located along the ACA/ACOM or MCA are the most frequent aneurysms reserved for microsurgical clipping. The CVNV neurosurgeon must be prepared to manage a high percentage of ACA/ACOM or MCA aneurysms microsurgically.

SUBMITTER: Jiang B

PROVIDER: S-EPMC5535564 | biostudies-other | 2017

REPOSITORIES: biostudies-other

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Project description:Concomitant procedures during endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm are performed to facilitate endograft delivery, to simultaneously treat unrelated conditions, or to resolve intraoperative pitfalls. The frequency and perioperative impact of these procedures are not well described. This study aimed to assess the frequency and perioperative impact of various concomitant procedures performed at the time of EVAR.We included all elective EVARs in the Vascular Study Group of New England between January 2003 and November 2014 and identified those with and those without concomitant procedures. Multivariable logistic regression analysis was used to establish the independent association between concomitant procedures and perioperative outcomes.The study included 4033 patients, with 1168 (29.0%) patients undergoing one or more additional procedures. Independent risk factors for 30-day mortality were concomitant femoral endarterectomy (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.1-11.2) and renal angioplasty or stenting (OR, 3.1; 95% CI, 1.2-8.3). Postoperative bowel ischemia was associated with hypogastric embolization (OR, 3.8; 95% CI, 1.1-13.4) and iliac angioplasty or stenting (OR, 3.5; 95% CI, 1.3-9.6). Leg ischemia was associated with unplanned graft extension (OR, 2.3; 95% CI, 1.02-5.0), other artery reconstruction (OR, 5.2; 95% CI, 1.8-15.1), thromboembolectomy (OR, 5.2; 95% CI, 1.3-20.8), and repair of arterial injury (OR, 4.6; 95% CI, 1.2-18.3). Risk factors for deterioration of renal function were iliofemoral bypass (OR, 3.9; 95% CI, 1.3-12.2), other artery reconstruction (OR, 2.7; 95% CI, 1.3-5.8), renal angioplasty or stenting (OR, 2.5; 95% CI, 1.3-4.6), and repair of arterial injury (OR, 4.5; 95% CI, 1.6-12.2). Myocardial infarction was associated with femorofemoral bypass (OR, 3.9; 95% CI, 1.7-8.7), other artery reconstruction (OR, 3.9; 95% CI, 1.6-9.2), and repair of arterial injury (OR, 6.1; 95% CI, 1.8-21.0). Wound complications were predicted by femorofemoral bypass (OR, 13.4; 95% CI, 5.8-31.1).Concomitant procedures during EVAR are associated with increased postoperative morbidity and mortality. The need for performing concomitant procedures should be carefully considered. The morbidity associated with intraoperative complications highlights the importance of avoidance of arterial injury and thromboembolic events where possible.

Project description:BackgroundEndovascular aneurysm sealing (EVAS), using the Nellix endovascular aneurysm sealing system, has been associated with high reintervention and migration rates. However, prior reports have suggested that EVAS might be related to a lower all-cause mortality compared with endovascular aneurysm repair (EVAR). In the present study, we examined the 5-year all-cause mortality trends after EVAS and EVAR.MethodsWe compared the 333 EVAS patients in the EVAS-1 Nellix U.S. investigational device exemption trial with 16,497 infrarenal EVAR controls from the Vascular Quality Initiative, treated between 2014 and 2016, after applying the exclusion criteria from the investigational device exemption trial (ie, hemodialysis, creatinine >2.0 mg/dL, rupture). As a secondary analysis, we stratified the patients by aneurysm diameter (<5.5 cm and ≥5.5 cm). We calculated propensity scores after adjusting for demographics, comorbidities, and anatomic characteristics and applied inverse probability weighting to compare the risk-adjusted long-term mortality using Kaplan-Meier and Cox regression analyses.ResultsAfter weighting, the EVAS group had experienced similar 5-year mortality compared with the controls from the Vascular Quality Initiative (EVAS vs EVAR, 18% vs 14%; hazard ratio [HR], 1.1; 95% confidence interval [CI], 0.71-1.7; P = .70). The subgroup analysis demonstrated that for patients with an aneurysm diameter of <5.5 cm, EVAS was associated with higher 5-year mortality compared with EVAR (19% vs 11%; HR, 2.4; 95% CI, 1.7-4.7; P = .013). In patients with an aneurysm diameter of ≥5.5 cm, EVAS was associated with lower mortality within the first 2 years (2-year mortality: HR, 0.29; 95% CI, 0.13-0.62; P = .002). However, compared with EVAR, EVAS was associated with higher mortality between 2 and 5 years (HR, 1.9; 95% CI, 1.2-3.0; P = .005), with no mortality difference at 5 years (18% vs 17%; HR, 0.82; 95% CI, 0.4-1.4; P = .46).ConclusionsWithin the overall population, EVAS was associated with similar 5-year mortality compared with EVAR. EVAS was associated with higher mortality for those with small aneurysms (<5.5 cm). For those with larger aneurysms (≥5.5 cm), EVAS was initially associated with lower mortality within the first 2 years, although this advantage was lost thereafter, with higher mortality after 2 years. Future studies are required to evaluate the specific causes of death and to elucidate the potential beneficial mechanism behind sac obliteration that leads to this potential initial survival benefit. This could help guide the development of future grafts with better proximal fixation and sealing that also incorporate sac obliteration.

Project description:ObjectiveEndovascular aneurysm repair (EVAR) is a widely used option for patients with suitable vascular anatomy who have a large infrarenal abdominal aortic aneurysm (AAA). Patients with small AAAs are managed with careful surveillance and it is a common concern that their anatomy may change with AAA growth, and their option for EVAR may become limited. Device innovation has resulted in expanded ranges of anatomy that may be eligible for EVAR. This study sought to identify changes in anatomic eligibility for repair with contemporary endovascular devices in AAA patients, monitored by computed tomography scan over the course of 2 years.MethodsPatients from the Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA3CT, NCT01756833) were included in this analysis. Females had baseline AAA maximum transverse diameter between 3.5 and 4.5 cm, and males had baseline maximum transverse diameter between 3.5 and 5.0 cm. Patients were included in this analysis if they completed pre-enrollment and 2-year follow-up computed tomography imaging. Pertinent anatomic measurements were performed on a postprocessing workstation in a centralized imaging core laboratory. EVAR candidacy was determined by measuring proximal aortic neck diameter, AAA length, and infrarenal neck angulation. Patients were considered to be eligible for EVAR if they qualified for at least one of the seven studied devices' instructions for use at baseline and at 2 years. A paired t test analysis was used to detect differences in aortic measurements over 2 years, and the McNemar test was used to compare eligibility over 2 years.ResultsWe included 192 patients in this analysis-168 male and 24 female. Of these patients, 85% were eligible for EVAR at baseline and 85% after 2 years of follow-up (P = 1.00; 95% confidence interval -0.034 to 0.034). Of the 164 EVAR candidates at baseline, 160 (98%) remained eligible over 2 years of surveillance. Insufficient neck length was the most common reason for both ineligibility at baseline (18 of 28 patients) as well as loss of candidacy over 2 years (3 of 4 patients).ConclusionsThe majority of patients eligible for EVAR when entering a surveillance program for small AAA remain eligible after 2 years. Substantial changes in AAA neck anatomy resulting in loss of EVAR treatment options are infrequent. Patients with anatomic AAA progression beyond EVAR eligibility remain candidates for complex EVAR and open repair.

Project description:BackgroundJuxtarenal abdominal aortic aneurysms pose a significant challenge whether managed endovascularly or by open surgery. Fenestrated endovascular aneurysm repair (FEVAR) is now well established, but few studies have compared it with open surgical repair (OSR). The aim of this systematic review was to compare short- and long-term outcomes of FEVAR and OSR for the management of juxtarenal aortic aneurysms.MethodsA literature search was conducted of the Ovid Medline, EMBASE and PubMed databases. Reasons for exclusion were series with fewer than 20 patients, studies published before 2007 and those concerning ruptured aneurysms. Owing to variance in definitions, the terms 'juxta/para/suprarenal' were used; thoracoabdominal aortic aneurysms were excluded. Primary outcomes were 30-day/in-hospital mortality and renal insufficiency. Secondary outcomes included major complication rates, rate of reintervention and rates of endoleak.ResultsTwenty-seven studies were identified, involving 2974 patients. Study designs included 11 case series, 14 series within retrospective cohort studies, one case-control study and a single prospective non-randomized trial. The pooled early postoperative mortality rate following FEVAR was 3·3 (95 per cent c.i. 2·0 to 5·0) per cent, compared with 4·2 (2·9 to 5·7) per cent after OSR. After FEVAR, the rate of postoperative renal insufficiency was 16·2 (10·4 to 23·0) per cent, compared with 23·8 (15·2 to 33·6) per cent after OSR. The major early complication rate following FEVAR was 23·1 (16·8 to 30·1) per cent versus 43·5 (34·4 to 52·8) per cent after OSR. The rate of late reintervention after FEVAR was higher than that after OSR: 11·1 (6·7 to 16·4) versus 2·0 (0·6 to 4·3) per cent respectively.ConclusionNo significant difference was noted in 30-day mortality; however, FEVAR was associated with significantly lower morbidity than OSR. Long-term durability is a concern, with far higher reintervention rates after FEVAR.

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Aneurysm treatment practice patterns for newly appointed dual-trained cerebrovascular/endovascular neurosurgeons: Comparison of open surgical to neuroendovascular procedures in the first 2 years of academic practice.

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