A new approach for the pre-clinical optimization of a spatial configuration of bifurcated endovascular prosthesis placed in abdominal aortic aneurysms.
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ABSTRACT:
SUBMITTER: Polanczyk A
PROVIDER: S-EPMC5549977 | biostudies-other | 2017
REPOSITORIES: biostudies-other
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Project description:IntroductionEndovascular aneurysm repair has improved outcomes for ruptured abdominal aortic aneurysms (rAAA) compared with open repair. We examined the impact of aorto-uni-iliac (AUI) vs standard bifurcated endograft configuration on outcomes in rAAA.MethodsPatients 18 years or older in the Vascular Quality Initiative database who underwent endovascular aneurysm repair for rAAA from January 2011 to April 2020 were included. Patient characteristics were analyzed by graft configuration: AUI or standard bifurcated. Primary and secondary outcomes included 30-day mortality, postoperative major adverse events (myocardial infarction, stroke, heart failure, mesenteric ischemia, lower extremity embolization, dialysis requirement, reoperation, pneumonia, or reintubation), and 1-year mortality. A subset propensity-score matched cohort was also analyzed.ResultsWe included 2717 patients: 151 had AUI and 2566 had standard bifurcated repair. There was no significant difference between the groups in terms of age, major medical comorbidities, anatomic aortic neck characteristics, or rates of conversion to open repair. Patients who underwent AUI were more commonly female (30% vs 22%, P = .011) and had a history of congestive heart failure (19% vs 12%, P = .013). Perioperatively, patients who underwent AUI had a significantly higher incidence of cardiac arrest (15% vs 7%, P < .001), greater intraoperative blood loss (1.3 L vs 0.6 L, P < .001), longer operative duration (218 minutes vs 138 minutes, P < .0001), higher incidence of major adverse events (46.3% vs 33.3%, P = .001), and prolonged intensive care unit (7 vs 4.7 days, P = .0006) and overall hospital length of stay (11.4 vs 8.1 days, P = .0003). Kaplan-Meier survival analyses demonstrated significant differences in 30-day (31.1% vs 20.2%, log-rank P = .001) and 1-year mortality (41.7% vs 27.7%, log-rank P = .001). The propensity-score matched cohort demonstrated similar results.ConclusionsThe AUI configuration for rAAA appears to be implemented in a sicker cohort of patients and is associated with worse perioperative and 1-year outcomes compared with a bifurcated graft configuration, which was also seen on propensity-matched analysis. Standard bifurcated graft configuration may be the preferred approach in the management of rAAA unless AUI configuration is mandated by patient anatomy or other extenuating circumstances.
| S-EPMC10038827 | biostudies-literature
Project description:Importance:Knowledge regarding the long-term outcomes of elective treatment of abdominal aortic aneurysm (AAA) using endovascular aortic repair (EVAR) is increasing. However, data with greater than 10 years' follow-up remain sparse and are lacking from population-based studies. Objective:To determine the long-term outcomes of EVAR compared with open surgical repair (OSR) for elective treatment of AAA. Design, Setting, and Participants:This retrospective, population-based cohort study used linked administrative health data from Ontario, Canada, to identify all patients 40 years and older who underwent elective EVAR or OSR for AAA repair from April 1, 2003, to March 31, 2016, with follow-up terminating on March 31, 2017. A total of 17 683 patients were identified using validated procedure and billing codes and were propensity score matched. Analysis was conducted from June 26, 2018, to January 16, 2019. Exposures:Elective EVAR or OSR for AAA. Main Outcomes and Measures:The primary outcome was overall survival. Secondary outcomes were major adverse cardiovascular event-free survival, defined as being free of death, myocardial infarction, or stroke; reintervention; and secondary rupture. Results:Among 17 683 patients who received elective AAA repairs (mean [SD] age, 72.6 [7.8] years; 14 286 [80.8%] men), 6100 (34.5%) underwent EVAR and 11 583 (65.5%) underwent OSR. From these patients, 4010 well-balanced propensity score-matched pairs of patients were defined, with a mean (SD) age of 73.0 (7.6) years and 6583 (82.1%) men. In the matched cohort, the mean (SD) follow-up was 4.4 (2.7) years, and maximum follow-up was 13.8 years. The overall median survival was 8.9 years. Compared with OSR, EVAR was associated with a higher survival rate up to 1 year after repair (91.0% [95% CI, 90.1%-91.9%] vs 94.0% [95% CI, 93.3%-94.7%]) and a higher major adverse cardiovascular event-free survival rate up to 4 years after repair (69.9% [95% CI, 68.3%-71.3%] vs 72.9% [95% CI, 71.4%-74.4%]). Cumulative incidence of reintervention was higher among patients who underwent EVAR compared with those who underwent OSR at the 7-year follow-up (45.9% [95% CI, 44.1%-47.8%] vs 42.2% [95% CI, 40.4%-44.0%]). Survival analyses demonstrated no statistically significant differences in long-term survival, reintervention, and secondary rupture for patients who underwent EVAR compared with those who underwent OSR. Kaplan-Meier analysis suggested superior long-term major adverse cardiovascular event-free survival among patients who underwent EVAR compared with those who underwent OSR (32.6% [95% CI, 26.9%-38.4%] vs 14.1% [95% CI, 4.0%-30.4%]; stratified log-rank P < .001) during a maximum follow-up of 13.8 years. Conclusions and Relevance:Endovascular aortic repair was not associated with a difference in long-term survival during more than 13 years' maximum follow-up. The reasons for these findings will require studies to consider specific graft makes and models, adherence to instructions for use, and types and reasons for reintervention.
| S-EPMC6624804 | biostudies-other
Project description:ObjectivesTo systematically review studies comparing peri-operative mortality and length of hospital stay in patients with ruptured abdominal aortic aneurysms (rAAAs) who underwent endovascular aneurysm repair (EVAR) to patients who underwent open surgical repair (OSR).MethodsThe Medline, Cochrane, EMBASE, and Google Scholar databases were searched until Apr 30, 2013 using keywords such as abdominal aortic aneurysm, emergent, emergency, rupture, leaking, acute, endovascular, stent, graft, and endoscopic. The primary outcome was peri-operative mortality and the secondary outcome was length of hospital stay.ResultsA total of 18 studies (2 randomized controlled trials, 5 prospective studies, and 11 retrospective studies) with a total of 135,734 rAAA patients were included. rAAA patients who underwent EVAR had significantly lower peri-operative mortality compared to those who underwent OSR (overall OR = 0.62, 95% CI = 0.58 to 0.67, P<0.001). rAAA patients with EVAR also had a significantly shorter mean length of hospital stay compared to those with OSR (difference in mean length of stay ranged from -2.00 to -19.10 days, with the overall estimate being -5.25 days (95% CI = -9.23 to -1.26, P = 0.010). There was no publication bias and sensitivity analysis showed good reliability.ConclusionsEVAR confers significant benefits in terms of peri-operative mortality and length of hospital stay. There is a need for more randomized controlled trials to compare outcomes of EVAR and OSR for rAAA.
| S-EPMC3909181 | biostudies-literature
Project description:ObjectiveThere is a growing body of literature raising concerns about the long-term durability of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs), suggesting that long-term outcomes may be better after open AAA repair. However, the data investigating these long-term outcomes largely originate from early in the endovascular era and therefore do not account for increasing clinical experience and technologic improvements. We investigated whether 4-year outcomes after EVAR and open repair have improved over time.MethodsWe identified all EVARs and open repairs for intact infrarenal AAA within the Vascular Quality Initiative database (2003-2018). We then stratified patients by procedure year into treatment cohorts of four years: 2003-2006, 2007-2010, 2011-2014, and 2015-2018. We used Kaplan-Meier analysis and Cox proportional hazards models to assess whether the survival after EVAR or open repair changed over time. In addition, we propensity matched EVAR and open repairs for each time cohort to investigate whether the relative survival benefit of EVAR over open repair changed over time.ResultsWe included 42,293 EVARs (increasing from 549 performed between 2003 and 2006 to 25,433 between 2015 and 2018) and 5189 open AAA repairs (increasing from 561 to 2306). Four-year survival increased for the periods 2003-2006, 2007-2010, 2011-2014, and 2015-2018 after both EVAR (76.6% vs 79.7% vs 83.5% vs 87.3%; P < .001) and open repair (82.2% vs 85.8% vs 87.7% vs 88.9%; P = .026). After risk adjustment, compared with 2003-2006, hazard of mortality up to 4 years after EVAR was lower for those performed between 2011 and 2014 (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.59-0.87; P = .001) and for those performed between 2015 and 2018 (HR, 0.56; 95% CI, 0.46-0.68; P < .001). In contrast, the risk-adjusted hazard of mortality was similar between open repair cohorts (2011-2014: HR, 0.81 [95% CI, 0.61-1.08; P = .15]; and 2015-2018: HR, 0.86 [95% CI, 0.64-1.17; P = .34]). Finally, in matched EVAR and open repairs, there was no difference in mortality in the first three cohorts, whereas the hazard of mortality was lower for the 2015-2018 cohort (HR, 0.65; 95% CI, 0.51-0.84; P = .001).ConclusionsFour-year survival improved in more recent years after EVAR but not after open repair. This finding suggests that midterm outcomes after EVAR are improving, perhaps because of technologic improvements and increased experience, information that should be considered by surgeons and policymakers alike in evaluating the value of contemporary EVAR and open AAA repair.
| S-EPMC8025309 | biostudies-literature
Project description:Several reports suggest unexpectedly high rates of late abdominal aortic aneurysm (AAA) rupture occur after endovascular AAA repair (EVAR). However, a population-based study examining causes of late death after EVAR vs open surgical repair has not been performed.We performed a retrospective cohort study of patients undergoing infrarenal AAA repair using information from the Medicare inpatient hospital discharge records (MedPAR files), physician claim files (Part B files, 20% sample), and Medicare Denominator Files for the years 2001 to 2004. Using the Social Security Death Index, we identified all "late" deaths, defined as deaths occurring >30 days and after hospital discharge. We used the National Death Index to identify cause of death information; in particular, those deaths that were likely caused by late rupture. We compared causes of late death and survival between EVAR and open repair using Wilcoxon log-rank and rank-sum tests.Between 2001 and 2004, 13,971 patients underwent AAA repair (6119 EVAR, 7852 open repair). After a mean follow-up of 1.6 years in the EVAR cohort and 1.9 years in the open cohort, mortality rates were similar across repair type (15.4% EVAR, 15.9% open repair), with an adjusted odds ratio for death after open repair of 0.98 (95% confidence interval, 0.90-1.07). Of the 2194 documented deaths, 523 occurred before discharge or <or=30 days, and 1671 occurred >30 days and after hospital discharge. Cause of death information for the 1671 late deaths was available from the National Death Index for 1515 (91%). The 15 most common codes for causes of late death were dominated by cardiac disease (atherosclerotic heart disease, acute myocardial infarction) and pulmonary disease (lung cancer, respiratory failure). Causes of late death with specific mention of aneurysm were identified in 37 patients (2.4% of all deaths), but this event was not more common in EVAR or open repair (15 [0.3%] in the EVAR group, 22 [0.3%], in the open repair group; P = .71).Late deaths from aneurysm rupture after EVAR or open repair appear to be relatively infrequent and similarly distributed across procedure type. Our results emphasize that the effectiveness of EVAR is comparable to open AAA repair in preventing aneurysm-related death.
| S-EPMC5292250 | biostudies-literature
Project description:PurposeThis study aimed to examine the sac changes after endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysms.Materials and methodsWe examined the aneurysm sac size initially and regularly after surgery in 157 consecutive patients who underwent EVAR in 2009-2019. Contrast-enhanced computed tomography (CT) scans were used as well as ultrasound images with non-enhanced CT scans in the patients with renal insufficiency. Sac expansion (SE) at 3 years was divided into two categories: progressive SE (PSE) defined as continuous sac enlargement of ≥5 mm on serial follow-up images at 1 and 3 years compared with the initial sac and delayed SE (DSE) defined as re-expansion of ≥5 mm compared with the regressed or stable sac at 1 year. The SE rate at 1 and 3 years and the risk factors for SE at 3 years were analyzed using logistic regression.ResultsDuring a median follow-up of 32.5 months, nine reinterventions in six patients were performed with open conversion (n=5) and endovascular repair (n=4). At 1 year, 112 patients underwent follow-up imaging. SE and sac regression were noted in 4 (3.6%) and 57 (50.9%) patients, respectively. Of the 64 patients with 3-year follow-up images, 16 (25%) exhibited SE (PSE [n=6] and DSE [n=10]). In the multivariable analysis, the risk factors for overall SE at 3 years were endoleaks at 1 year (P=0.006) and renal insufficiency (P=0.003).ConclusionDuring post-EVAR follow-up, patients with any endoleak at 1 year or renal insufficiency must be strictly monitored for SE development.
| S-EPMC8580744 | biostudies-literature
Project description:Current clinical practice for the assessment of abdominal aortic aneurysms (AAA) is based on vessel diameter and does not account for the multifactorial, heterogeneous remodeling that results in the regional weakening of the aortic wall leading to aortic growth and rupture. This study was conducted to determine correlation between a novel non-invasive surrogate measure of regional aortic weakening and the results from invasive analyses performed on corresponding ex vivo aortic samples. Tissue samples were evaluated to classify local wall weakening and likelihood of further degeneration based on non-invasive indices. A combined, image-based fluid dynamic and in-vivo strain analysis approach was used to estimate the Regional Aortic Weakness (RAW) index and assess individual aortas of AAA patients prior to elective surgery. Nine patients were treated with complete aortic resection allowing the systematic collection of tissue samples that were used to determine regional aortic mechanics, microstructure and gene expression by means of mechanical testing, microscopy and transcriptomic analyses. The RAW index was significantly higher for samples exhibiting lower mechanical strength (p = 0.035) and samples classified with low elastin content (p = 0.020). Samples with higher RAW index had the greatest number of genes differentially expressed compared to any constitutive metric. High RAW samples showed a decrease in gene expression for elastin and a down-regulation of pathways responsible for cell movement, reorganization of cytoskeleton, and angiogenesis. Please note that the sample 'characteristisc: strain' represents the in-vivo strain corresponding to each section of aorta, which is measured from dynamic CT images of patient AAA using a proprietary software.
2021-01-26 | GSE165470 | GEO
Project description:Degenerative aneurysms of the thoracic aorta are increasing in prevalence; open repair of descending thoracic aortic aneurysms is associated with high rates of morbidity and mortality. Repair of isolated descending thoracic aortic aneurysms using stent grafts was introduced in 1995, and in an anatomically suitable subgroup of patients with thoracic aortic aneurysm, repair with endovascular stent graft provides favorable outcomes, with decreased perioperative morbidity and mortality relative to open repair. The cornerstones of successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough preprocedural planning, and cautious procedural execution, the elements of which are discussed here.
| S-EPMC3140248 | biostudies-other
Project description:Abdominal aortic aneurysm (AAA) is a localized enlargement of the abdominal aorta. Once ruptured AAA (rAAA) happens, repairing procedures need to be applied immediately, for which there are two main options: open aortic repair (OAR) and endovascular aortic repair (EVAR). It is of great clinical significance to objectively compare the survival outcomes of OAR versus EVAR using randomized clinical trials; however, this has serious feasibility issues. In this study, with the Medicare data, we conduct an emulation analysis and explicitly "assemble" a clinical trial with rigorously defined inclusion/exclusion criteria. A total of 7826 patients are "recruited", with 3866 and 3960 in the OAR and EVAR arms, respectively. Mimicking but significantly advancing from the regression-based literature, we adopt a deep learning-based analysis strategy, which consists of a propensity score step, a weighted survival analysis step, and a bootstrap step. The key finding is that for both short- and long-term mortality, EVAR has survival advantages. This study delivers a new big data strategy for addressing critical clinical problems and provides valuable insights into treating rAAA using OAR and EVAR.
| S-EPMC7759828 | biostudies-literature
Project description:ObjectivesTo report our early experience using endografts with inner branches for the treatment of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs).MethodsA retrospective analysis of all patients treated in our institution for complex abdominal aortic aneurysms and TAAAs with custom-made stent grafts consisting of one or more inner branches. Data collected included patients demographics, aortic aneurysm morphology, stent grafts features, perioperative morbidity and mortality and short-term reintervention and mortality rates.ResultsTwenty-seven patients (18 males, mean age 70 ± 7.1) were included. Indications for surgery included TAAAs (12, 41%) juxtarenal abdominal aortic aneurysms (10, 37%), type 1A endoleaks (4, 15%) and paraanastamotic aneurysms (1, 4%). A total of 90 inner branches were used. Twenty-one (78%) of the stent grafts consisted only of inner branches and six (22%) had a combination of inner branches with either fenestrations or outer branches. Technical success was achieved in 26/27 (96%) of the patients. There was one perioperative mortality. Six patients suffered from major perioperative adverse events. Mean follow-up was seven months (range 1-23). During the follow-up period, four patients (15%) required reinterventions. Branch-related reinterventions were performed in two (7%) patients. No occlusions of inner branches occurred during the follow-up.ConclusionsInner branches in branched endovascular aneurysm repairs offer a feasible option for the treatment of complex abdominal aortic aneurysms and TAAAs. The procedures can be completed with high technical success and with acceptable short-term branch-related reintervention rates. Further follow-up is required to determine the long-term durability of this technology.
| S-EPMC8564222 | biostudies-literature