Ultrasound Surveillance is Feasible After Endovascular Aneurysm Repair.

BACKGROUND: Surveillance after endovascular aneurysm repair (EVAR) is traditionally done with computed tomography angiography (CTA) scans that exposes patient to radiation, nephrotoxic contrast media, and potentially increased risk for cancer. Ultrasound (US) is less labor intensive and expensive and might thus provide a good alternative for CTA surveillance. The aim of this study was to evaluate in real-life patient cohorts whether US is able to detect post-EVAR aneurysm-related complications similarly to CTA. METHODS: This retrospective study compared the outcome of consecutive patients who underwent EVAR for intact abdominal aortic aneurysm and were surveilled solely by CTA (CTA-only cohort, n = 168) in 2000-2010 or by combined CTA and US (CTA/US cohort, n = 300) in 2011-2016, as a standard surveillance protocol in the department of vascular surgery, Helsinki University Hospital. The CTA-only patients were imaged at 1, 3, and 12 months and annually thereafter. The CTA/US patients were imaged with CTA at 3 and 12 months, US at 6 months and annually thereafter. If there were suspicion of >5 mm aneurysm growth, CTA scan was performed. The patients were reviewed for imaging data, reinterventions, aneurysm ruptures, and death until December 2018. The 2 groups were compared for secondary rupture, aneurysm-related and cancer-related death, reintervention related to abdominal aortic aneurysm, and maximum aneurysm diameter increase ≥5 mm. The mean follow-up in the CTA-only cohort was 67 months and in CTA/US cohort 43 months. RESULTS: The 2 cohorts were alike for basic characteristics and for the mean aneurysm diameter. The total number of CT scans for detecting aneurysm was 84.1/100 patient years in the CTA-only cohort compared to 74.5/100 patient years for US/CTA cohort. Forty percent of patients under combined CTA/US surveillance received 1 or more additional CTA scans. The 2 cohorts did not differ for 1-year, 5-year and 8-year freedom from aneurysm related death, secondary sac rupture, nor the incidence of rupture preventing interventions. CONCLUSIONS: Based on the follow-up data of this real-life cohort of 468 patients, combined surveillance with US and additional CTA either per protocol or due to suspicion of aneurysm-related complications had comparable outcome with sole CTA-surveillance. Thus, US can be considered a reasonable alternative for the CTA. However, our study showed also that the need of additional CTAs due to suspicion of endoleak or aneurysm nonrelated reasons is substantial.

A Population-Based Study of Abdominal Aortic Aneurysm Treatment in Finland 2000 to 2014.

BACKGROUND: In the event of rupture of an abdominal aortic aneurysm (AAA), mortality is very high. AAA prevalence and incidence of ruptures have been reported to be decreasing. The treatment of AAA has also undergone a change in recent decades with a shift toward endovascular aneurysm repair (EVAR). Our aim was to evaluate how these changes have affected the elective and emergency treatment of AAA and their results in Finland. METHODS: All patients treated for AAA in Finland, a country with a population of 5.5 million, during 2000 to 2014 were searched from the registry of the Finnish Institute for Health and Welfare. Data on all patients who had died of AAA during the same time period were obtained from Statistics Finland. The data were combined and analyzed. RESULTS: The annual incidence of ruptured AAA was 16.4 per 100 000 population over 50 years and decreased significantly during the study period. Over half of the 4949 patients who had a ruptured AAA died outside the hospital. Thirty-day mortality after emergency repair was 39.4%. Intact AAA repairs numbered 4956. The absolute number of annual repairs increased during the study period, and the use of EVAR became the dominant method of elective repair. Thirty-day mortality in elective AAA repair dropped significantly from 6.3% in 2000 to 2004 to 2.7% in 2010 to 2014 mostly because of the increased number of EVAR procedures with lower mortality. Long-term mortality in patients treated with EVAR was higher than in patients treated with open repair. Mortality after elective AAA repair was primarily attributable to cardiovascular causes, but there was a slightly higher proportion of AAA-related late deaths in patients treated with EVAR. CONCLUSIONS: Ruptured AAA incidence for men >65 years has declined by nearly 30% in Finland, likely because of the decrease in AAA prevalence. The treatment results have improved as well for both elective and emergency repair. Increased use of EVAR has resulted in a decrease of mortality after elective AAA repair, but results of open repair have improved as well. However, late mortality from elective EVAR is surprisingly high in comparison with open repair, which may have been exaggerated by patient selection.

Few internal iliac artery aneurysms rupture under 4 cm.

OBJECTIVE: This study investigated the diameter of internal iliac artery (IIA) aneurysms (IIAAs) at the time of rupture to evaluate whether the current threshold diameter for elective repair of 3 cm is reasonable. The prevalence of concomitant aneurysms and results of surgical treatment were also investigated. METHODS: This was a retrospective analysis of patients with ruptured IIAA from seven countries. The patients were collected from vascular registries and patient records of 28 vascular centers. Computed tomography images taken at the time of rupture were analyzed, and maximal diameters of the ruptured IIA and other aortoiliac arteries were measured. Data on the type of surgical treatment, mortality at 30 days, and follow-up were collected. RESULTS: Sixty-three patients (55 men and 8 women) were identified, operated on from 2002 to 2015. The patients were a mean age of 76.6 years (standard deviation, 9.0; range 48-93 years). A concomitant common iliac artery aneurysm was present in 65.0%, 41.7% had a concomitant abdominal aortic aneurysm, and 36.7% had both. IIAA was isolated in 30.0%. The mean maximal diameter of the ruptured artery was 68.4 mm (standard deviation, 20.5 mm; median, 67.0 mm; range, 25-116 mm). One rupture occurred at <3 cm and four at <4 cm (6.3% of all ruptures). All patients were treated, 73.0% by open repair and 27.0% by endovascular repair. The 30-day mortality was 12.7%. Median follow-up was 18.3 months (interquartile range, 2.0-48.3 months). The 1-year Kaplan-Meier estimate for survival was 74.5% (standard error, 5.7%). CONCLUSIONS: IIAA is an uncommon condition and mostly coexists with other aortoiliac aneurysms. Follow-up until a diameter of 4 cm seems justified, at least in elderly men, although lack of surveillance data precludes firm conclusions. The mortality was low compared with previously published figures and lower than mortality in patients with ruptured abdominal aortic aneurysm.

The Outcome after Endovascular and Open Repair of Abdominal Aortic Aneurysms-A Binational Study Conducted between 1998 and 2017.

Objective: We aimed to analyse patient outcomes following open (OAR) or endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) in Finland and Sweden from 1998 to 2017. Both intact and ruptured AAAs (rAAAs) were included in the analysis. Methods: Patient-level data from national registries in Finland and Sweden were analysed, pairing operations for intact and ruptured AAA repair with mortality data (date of death). All-cause mortality was the primary endpoint. Anonymized patient data from both countries were pooled, comprising a total of 32,324 operations. Ruptured and intact AAAs were considered separately. In total, EVAR was performed on 9619 intact AAAs and 1470 rAAAs, while OAR was performed on 13,241 intact AAAs and 7994 rAAAs. The patient's age, sex and the date of operation were obtained as demographic information. Cox regression and Kaplan-Meier analyses were used to evaluate long-term (10-year) survival after the treatment of AAA or rAAA with either modality. Kaplan-Meier analysis was performed in three different age groups (<65 years, 65-79 years and ≥80 years). Results: Considering all age groups together, the 1-, 3- and 10-year Kaplan-Meier survival rates after EVAR were 93.4%, 80.5% and 35.3%, respectively, for intact AAA repair and 67.2%, 55.9% and 22.2%, respectively, for rAAA repair. For OAR of intact AAAs, the 1-, 3- and 10-year Kaplan-Meier survival rates were 92.1%, 84.8% and 48.7%, respectively. The respective rates for OAR of rAAAs were 55.4%, 49.3% and 24.6%. In a Cox regression analysis, a more recent year of operation was associated with improved survival, and older age affected survival negatively for both intact and ruptured AAA repair. If patients survived the first 90 days after the operation, the survival after intact AAA repair was 13.5 years for those <65 years (general population: 18.0 years), and 7.3 years for those ≥80 years (general population: 7.9 years). After rAAA repair, the mean survival was 13.1 years for patients <65 years and 5.5 years for patients ≥80 years, respectively. Conclusions: The long-term survival of patients undergoing intact AAA treatment at the age of 80 or older is close to that of the general population, provided they survive the operation. Conversely, for patients younger than 65, the long-term survival is markedly worse. The long-term survival of AAA patients has improved over time. Open surgery is still a safe and effective option for young patients undergoing intact AAA repair. Our results support the ESVS guidelines recommendation of EVAR being the first-line treatment for patients with rAAA.

Effect of EVAR on International Ruptured AAA Mortality-Sex and Geographic Disparities.

Background: We sought to investigate the differential impact of EVAR (endovascular aneurysm repair) vis-à-vis OSR (open surgical repair) on ruptured AAA (abdominal aortic aneurysm) mortality by sex and geographically. Methods: We performed a retrospective study of administrative data on EVAR from state statistical agencies, vascular registries, and academic publications, as well as ruptured AAA mortality rates from the World Health Organization for 14 14 states across Australasia, East Asia, Europe, and North America. Results: Between 2011-2016, the proportion of treatment of ruptured AAAs by EVAR increased from 26.1 to 43.8 percent among females, and from 25.7 to 41.2 percent among males, and age-adjusted ruptured AAA mortality rates fell from 12.62 to 9.50 per million among females, and from 34.14 to 26.54 per million among males. The association of EVAR with reduced mortality was more than three times larger (2.2 vis-à-vis 0.6 percent of prevalence per 10 percentage point increase in EVAR) among females than males. The association of EVAR with reduced mortality was substantially larger (1.7 vis-à-vis 1.1 percent of prevalence per 10 percentage point increase in EVAR) among East Asian states than European+ states. Conclusions: The increasing adoption of EVAR coincided with a decrease in ruptured AAA mortality. The relationship between EVAR and mortality was more pronounced among females than males, and in East Asian than European+ states. Sex and ethnic heterogeneity should be further investigated.