What is the best option for elective repair of an abdominal aortic aneurysm in a young fit patient?

OBJECTIVE: The lower procedural risk associated with endovascular aneurysm repair (EVAR) compared with open aneurysm repair (OAR) is well known. Younger patients are likely to represent a group at low perioperative risk. The long-term durability and late complications following EVAR may have more significance when considering the optimal treatment for young patients with a longer life expectancy. This study examined perioperative and long-term outcomes of young patients undergoing aneurysm repair by either open surgical or endovascular means. METHODS: A retrospective review of a prospectively collated database was performed. Patients undergoing elective aneurysm repair at the age of 65 years or younger between January 2000 and September 2010 were included. All EVAR patients were followed up in a nurse-led clinic. Data regarding long-term outcomes for patients undergoing open repair were gathered from case note review. RESULTS: There were 99 patients who underwent open repair and 59 patients who underwent endovascular repair. Groups were well matched in terms of demographics and co-morbidities. 30-day mortality was 1% after open repair. There were no perioperative deaths after endovascular repair. Overall, 30-day complication rates were 15% after open repair and 12% after EVAR. The nature of complications differed between the two groups with the EVAR group experiencing endoleaks and the OAR group demonstrating more cardiorespiratory complications. Mean follow-up was 75.5 months and there was a 14% reintervention rate after EVAR compared with 7% after OAR. CONCLUSION: Young patients are likely to have a lower procedural risk for EVAR and OAR than described in published figures. Although mortality and complication rates in these two groups were similar, the nature of complications occurring following open surgery were often more significant than those occurring after EVAR. There remains a risk of late reintervention following either form of repair.

Is there an association between angiotensin converting enzyme (ACE) genotypes and abdominal aortic aneurysm?

OBJECTIVES: There is strong evidence of a genetic predisposition to abdominal aortic aneurysm (AAA), however the genes involved remain largely elusive. Recently, two large studies have suggested an association between the angiotensin converting enzyme gene and AAA. This study aimed to investigate the possible association between the ACE insertion/deletion polymorphism and abdominal aortic aneurysm (AAA) in order to replicate the findings of other authors. DESIGN AND METHODS: A case-control study was performed including 1155 patients with aneurysms and 996 screened control subjects. DNA was extracted from whole blood and genotypes determined in 1155 AAAs and 996 controls using a two stage polymerase chain reaction (PCR) technique. RESULTS: The groups were reasonably matched in terms of risk factors for AAA. No association was found between the ACE gene insertion/deletion polymorphism and AAA in this study. CONCLUSIONS: This study cannot support the findings of previous authors and provides evidence against a link between the ACE gene insertion/deletion polymorphism and AAA.

Conservative management of type 2 endoleaks is not associated with increased risk of aneurysm rupture.

OBJECTIVE: Endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs) has led to a reduction in the perioperative mortality when compared with open repair. However, re-intervention for complications, such as endoleak, may be required in up to 20% of the cases. Controversy exists over the management of type 2 endoleaks. This study examined the outcomes of patients with type 2 endoleaks treated conservatively to inform the ongoing management debate. METHODS: All patients with a confirmed type 2 endoleak after EVAR for an infrarenal AAA were included in the study. Data regarding device details, endoleak and time point, aneurysm sac growth, intervention and outcome were collected retrospectively from case notes and the vascular research database. RESULTS: Forty-one type 2 endoleaks were seen in 369 EVARs performed for infrarenal AAA between March 1994 and June 2006. Twenty-five were isolated type 2 endoleaks and 16 occurred in conjunction with other endoleaks. Of the 25 isolated type 2 endoleaks, 18 (72%) patients demonstrated no increase in sac size, six (24%) patients showed an enlargement of the sac and one patient was lost to follow-up. Only one patient underwent intervention for an isolated type 2 endoleak. After a mean follow-up period of 4 years, approximately half of the patients (48%) remain under observation (with an enlarging or stable sac), whilst the others (48%) have spontaneously sealed. Only five patients under surveillance (20%) have an enlarging sac. There were no ruptured aneurysms or aneurysm-related deaths and no patients required conversion to open repair. CONCLUSIONS: In this study, a policy of regular surveillance for type 2 endoleaks was not associated with any adverse events. We therefore advocate the conservative approach for type 2 endoleaks.

Endovascular abdominal aortic aneurysm repair: 5-year follow-up results.

Endovascular aneurysm repair (EVAR) offers a minimally invasive alternative to open repair and has the benefits of reduced perioperative morbidity and mortality. There are potential complications specific to EVAR, including device failure, graft migration, and endoleak, which necessitate long-term follow-up. This remains a relatively novel technique, and therefore, little long-term data exist. This study reports 5-year EVAR outcome data from a single center. Five-year follow-up data for 58 patients at a single center who underwent EVAR using a variety of different commercial devices was reviewed. All patients were followed up with 6-monthly duplex ultrasound scanning and clinical assessment in a nurse-led clinic, in addition to yearly computed tomographic (CT) scans for those participating in the EVAR trial. All patients in this series were male, with a median age of 72 years (range 58-81). Mean preoperative aortic diameter was 5.95 cm, and this reduced following EVAR to 5.2 cm (mean diameter) at 5 years. Mean hospital stay was 7 days, and there were no perioperative deaths. There were 20 (34%) early and 15 (26%) late complications. There were 13 endoleaks confirmed on CT; four (31%) were type I and nine (69%) were type II. All-cause mortality was 26%. There were no late aneurysm-related deaths. EVAR has the advantages of shorter hospital stay and reduced perioperative morbidity and mortality. Long-term follow-up remains a priority following aortic stenting in order to detect late complications such as endoleak.

Is infrainguinal bypass grafting successful following failed angioplasty?

OBJECTIVES: Angioplasty is often used in the management of lower limb ischaemia and can reduce the need for infrainguinal bypass in some patients. There is an associated failure rate with this technique and bypass surgery is often used in this situation as a secondary limb salvage procedure. We aimed to evaluate the outcome of infrainguinal bypass grafting following failed attempt at angioplasty. METHODS: All cases of infrainguinal bypass at a single centre over a seven year period were identified and notes reviewed. Cases were divided into four groups according to their indication for surgery; acute ischaemia, chronic critical ischaemia, failed angioplasty and an 'other' group including aneurysmal disease and claudicants. The failed angioplasty group was compared with the other three groups. Survival analysis was performed using Kaplan Meier curves and groups compared in terms of long term patency and survival. RESULTS: Primary patency was 61.2% in the failed angioplasty group at 12 months compared with 60.6% in the other groups (P=1.11). There was also no significant difference in primary patency at 60 months (50% vs 40.6%, P=0.26). Survival at 12 months was also comparable between the groups (failed angioplasty group 74.2% compared with 77.3% in the other groups, P=0.662) as was 60 months survival (33.3% and 35.4% respectively, P=0.166). DISCUSSION: In this study, outcome of infrainguinal bypass following failed angioplasty was comparable to outcome of surgery performed for another indication. This paper supports the use of distal bypass surgery for limb salvage in cases where minimal access techniques have failed.

The genetic basis of abdominal aortic aneurysms: a review.

INTRODUCTION: The pathogenesis of abdominal aortic aneurysm (AAA) remains poorly understood, however significant evidence has emerged in recent years to suggest a chronic inflammatory process. Observational studies have highlighted a familial trend towards AAA development among relatives of affected individuals and it is thought that inflammatory genes may influence an individual's susceptibility. Conflicting reports exist over single gene versus multiple gene inheritance patterns in addition to a collection of studies examining individual inflammatory genes. This paper reviews the evidence for a genetic predisposition to aneurysm formation including familial and segregation studies in addition to experimental evidence investigating specific candidate genes. METHOD: Medline and Pubmed database searches were conducted using the search terms abdominal aortic aneurysm and gene. Papers were reviewed and references manually searched for further relevant publications which were added to the data. Papers were categorised under the headings familial, segregation and candidate gene studies. RESULTS: A review of 58 papers is presented under sub-headings as above. In the case of the candidate gene section, a brief report of the functional relevance of each gene is included. CONCLUSION: A summary of the evidence presented is given and the direction of future work in this field is briefly considered.

Duplex ultrasound scanning is reliable in the detection of endoleak following endovascular aneurysm repair.

OBJECTIVE: To investigate the value of duplex ultrasound scanning (DUSS) in the routine follow up of patients following EVAR. METHODS: Imaging was reviewed for 310 consecutive patients undergoing EVAR at a single centre. Concurrent ultrasound and CT scans were defined as having occurred within 6 months of each other. There were 244 paired concurrent DUSS and CT scans which were used for further analysis. These modalities were compared with respect to sensitivity, specificity, positive and negative predictive values and level of agreement (by Kappa statistics) using CT as the 'gold standard'. RESULTS: DUSS failed to detect a number of endoleaks which were seen on CT and the sensitivity of this test was therefore poor (67%). However, the specificity of DUSS compared more favourably with a value of 91%. Positive predictive values ranged from 33-100% but negative predictive values were more reliable with values of 91-100% at all time points post operatively. There were no type I leaks, or endoleaks requiring intervention which were missed on DUSS. Overall, there was a 'fair' level of agreement between the two imaging modalities using Kappa statistics. CONCLUSION: Although DUSS is not as sensitive as CT scanning in the detection of endoleak, no leaks requiring intervention were missed on DUSS in this study. DUSS is much cheaper than CT and avoids high doses of radiation. DUSS therefore remains a valuable method of follow up after EVAR and can reduce the need for repeated CT scans.

Comparison of renal allograft fibrosis after transplantation from heart-beating and non-heart-beating donors.

BACKGROUND: Renal transplants from non-heart-beating donors (NHBDs) yield acceptable function and allograft survival rates in the medium term. However, the long-term results are less certain and there is a paucity of information relating to the development of chronic allograft nephropathy. The aim of this study was to compare allograft fibrosis in kidneys transplanted from NHBDs and conventional heart-beating donors (HBDs). METHODS: A series of 37 NHBD and 75 HBD renal transplants were studied. Protocol renal transplant biopsies were performed at 6 and 12 months after transplantation. Biopsy sections were stained with Sirius red to demonstrate interstitial extracellular matrix. Renal allograft fibrosis was quantified using a computerized image analysis system. RESULTS: The mean first warm ischaemia time for kidneys from NHBDs was 24 min. A significant delay in graft function occurred in eight of 75 recipients in the HBD group and 31 of 37 in the NHBD group (P < 0.001). There were no significant differences in the level of allograft fibrosis between the two groups at any time point. CONCLUSION: Despite high rates of delayed graft function secondary to a prolonged warm ischaemia time, NHBD kidneys do not appear to be more susceptible to the development of renal allograft fibrosis. This study supports the growing body of evidence that kidneys from NHBDs are an acceptable alternative to those from HBDs.