Fast-Track Management of Concurrent Percutaneous Coronary Intervention in Patients Scheduled for Endovascular Abdominal Aortic Aneurysm Repair.

PURPOSE: To investigate the safety and efficacy of fast-track management of concurrent percutaneous coronary intervention (PCI) in patients with abdominal aortic aneurysm scheduled for endovascular aortic aneurysm repair (EVAR). MATERIALS AND METHODS: Eligible patients with abdominal aortic aneurysm who received EVAR from January 2011 to December 2019 were included in this retrospective cohort study. Propensity score (PS)-matched analysis was used to balance the baseline between the fast-track and standard control (EVAR without significant coronary artery disease) groups. Effects of fast-track management on short-term and midterm outcomes were evaluated via Cox proportional hazard regression and logistic regression analyses with corresponding hazard ratio (HR) or odds ratio (OR) and associated 95% confidence intervals (95% CIs), respectively. RESULTS: The study included 669 patients (73 fast-track and 596 standard control). Compared with the standard control group, no significant difference was found regarding major adverse cardiac events (HR 0.78, 95% CI [0.36, 1.68], p=0.519), overall mortality (HR 0.63, 95% CI [0.25, 1.55], p=0.315), and 30-day major hemorrhage events (OR 1.01, 95% CI [0.99, 1.03], p=0.514). The results were consistent in the PS-matched cohorts regarding major adverse cardiac events (HR 0.57, 95% CI [0.25, 1.29], p=0.176), overall mortality (HR 0.43, 95% CI [0.17, 1.11], p=0.820), and 30-day major hemorrhage events (OR 1.00, 95% CI [0.05, 10.61], p=0.999). Similar results were found in the subgroup analyses concerning fast-track management of 2-week intervals and patients with high age-adjusted Charlson comorbidity index. CONCLUSIONS: Under appropriate perioperative care, shortening the time interval between PCI and EVAR to 1 month, or even 2 weeks, seemed to be safe and effective. Short-term and midterm cardiovascular and survival outcomes were comparable with patients who underwent standard EVAR without significant coronary artery disease.

Ultrasound-guided proximal external aortic compression in a vascular trauma patient.

OBJECTIVES: Emergency treatment of patients with severe subphrenic vascular trauma often adopts resuscitative thoracotomy or endovascular balloon. This case report proposes a non-invasive method to treat patients with vascular trauma, mainly through ultrasound-guided positioning of the proximal aorta and applying pressure to occlude the aorta and limit the distal blood flow, using bedside ultrasound to achieve accurate compression, continuous monitoring of its efficacy, and early detection of the recovery of autonomic circulation in patients with cardiac arrest. METHODS: We introduced a case of left iliac artery injury caused by a knife wound and subsequent cardiac arrest.Results We tried to externally compress the proximal aorta under bedside US guidance to achieve and maintain the recovery of the autonomic circulation. This allowed the patient to be transferred from the emergency department to the operating room. CONCLUSION: This case demonstrated that ultrasound-guided proximal external aortic compression can be used as a bridge for further treatment of patients with vascular trauma, such as resuscitative thoracotomy or endoaortic balloon or covered stent occlusion.

No Benefit of Wearing Compression Stockings after Endovenous Thermal Ablation of Varicose Veins: A Systematic Review and Meta-Analysis.

OBJECTIVE: This meta-analysis was conducted to investigate whether compression stockings were necessary after endovenous thermal ablation of varicose veins. DATA SOURCES: Electronic databases, including MEDLINE, EMBASE, and the Cochrane Library database, were searched from inception to 10 March 2021 to identify all the related trials. METHODS: Random or fixed effects models were used to generate pooled mean difference (MD) or standardised mean difference (SMD) for continuous data, risk ratios (RRs) for dichotomous data, and related 95% confidence intervals (95% CIs). The quality of evidence was graded with a specific tool (GRADEpro GDT) from the GRADE working group. RESULTS: A total of seven randomised controlled trials (RCTs) comprising 1 146 patients were included in this meta-analysis. Wearing compression stockings was correlated with lower post-operative pain scores from a 0 to 100 mm visual analogue scale (MD -8.00; 95% CI -12.01 - -3.99; p < .001). No difference was observed between wearing compression stockings or not in quality of life (SMD 0.45; 95% CI 0.14 - 1.04), major complications (RR 0.64; 95% CI 0.26 -1.59), target vein occlusion rates (RR 0.99; 95% CI 0.96 - 1.02), or time to return to work (MD -0.43; 95% CI 1.06 - 0.19). CONCLUSION: After endovenous thermal ablation of varicose veins, wearing compression stockings was not associated with a better outcome except for mild pain relief. Post-operative compression stockings may be unnecessary after endovenous thermal ablation.

Systematic Review and Meta-Analysis of Outcomes Following Endovascular and Open Repair for Infective Native Aortic Aneurysms.

OBJECTIVE: The aim of our systematic review and meta-analysis was to demonstrate the clinical outcomes of open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infective native aortic aneurysms (INAAs). METHODS: MEDLINE, Embase, and Cochrane Databases were searched for articles reporting OSR and/or EVAR repair of INAA. The methodological quality of included studies was assessed by the Newcastle-Ottawa scale and Moga-Score. Random-effects models were used to calculate the pooled measures. RESULTS: A total of 34 studies were included, with 22 studies reporting OSR alone, 6 studies reporting EVAR alone and 6 comparative studies for INAAs. The pooled estimates of infection-related complications (IRCs) were 8.2% (95% CI 4.9%-12.2%) in OSR cohort and 23.2% (95% CI 16.1%-31.0%) in EVAR cohort. EVAR was associated with a significantly increased risk of IRCs compared with OSR during follow-up (OR 1.9, 95% CI 1.0-3.7). As for survival outcomes, the summary estimate rate of all cause 30-day, 3-month and 1-year mortality in OSR cohort were 11.7% (95% CI 7.7%-16.1%), 21.6% (95%CI 16.3%-27.4%) and 28.3% (95% CI 20.5%-36.7%; I2=50.47%), respectively. For EVAR cohort, the summary estimate rate of all cause 30-day, 3-month and 1-year mortality were 4.9% (95% CI 1.1%-10.4%), 9.4% (95% CI 2.7%-18.7%) and 22.2% (95% CI 12.4%-33.7%), respectively. EVAR was associated with a significantly decreased of 30-day mortality (OR 0.2, 95% CI 0.1-0.6). However, no difference was found between EVAR and OSR in 3-month (OR 0.2, 95% CI 0-1.1), 1-year all-cause mortality (OR 0.4, 95% CI 0.1-1.1) or aneurysm-related mortality (OR 1.4, 95% CI 0.5-3.9). Moreover, no difference of incidence of reintervention was observed (OR 2.6, 95% CI 0.9-7.7; I2=53.7%) between two groups. CONCLUSIONS: EVAR could provide better short-term survival than OSR in patients with INAAs. However, patients undergoing EVAR suffered from higher risks of IRCs. EVAR could be considered as an alternative for low-risk patients with well-controlled infections or patients considered high-risk for open reconstruction.

Meta-analysis of outcomes after intentional coverage of celiac artery in thoracic endovascular aortic repair.

OBJECTIVE: The aim of the present study was to demonstrate the clinical outcomes of intentional coverage of the celiac artery (CA) during thoracic endovascular aneurysm repair (TEVAR). METHODS: The MEDLINE, EMBASE, and Cochrane Library databases were searched for studies reporting coverage of CA during TEVAR. The methodologic quality of the included studies was assessed using the Moga score and Newcastle-Ottawa scale. A random effects model was used to pool the estimates. A meta-analysis was performed with investigation of the following outcomes: visceral ischemia, spinal cord ischemia (SCI), stroke, endoleak, reintervention, 30-day mortality, and 1-year mortality. RESULTS: A total of 10 studies with 171 patients were included. The summary estimate rate of visceral ischemia events was 4.2% (95% confidence interval [CI], 0.9-8.9%; I2 = 4.1%). The incidence of stroke and SCI was 0.2% (95% CI, 0%-3.4%; I2 = 0%) and 3% (95% CI, 0.3%-7.4%; I2 = 6.1%). The rate of endoleak during the follow-up period was 24.1% (95% CI, 14.3%-35.1%; I2 = 20.0%). The reintervention rate was 13.6% (95% CI, 4.4%-25.7%; I2 = 66.0%). The 30-day and 1-year mortality were 2.9% (95% CI, 0.3%-7.2%; I2 = 6.2%) and 15.2% (95% CI, 7.8%-23.9%; I2 = 0%). CONCLUSIONS: Among the patients with complex thoracic aortic pathologies deemed at high risk for open reconstruction, TEVAR with intentional coverage of the CA is a safe and feasible option to extend the distal sealing zone with acceptable rates of visceral ischemia, SCI, type II endoleak from the CA, and 30-day mortality.

Effect of limb oversizing on the risk of type Ib endoleak in patients after endovascular aortic repair.

OBJECTIVE: We assessed the association between the degree of limb oversizing and the risk of type Ib endoleak (TIBEL) in different types of iliac landing zones after endovascular aortic aneurysm repair. METHODS: We performed a retrospective cohort study of patients who had undergone endovascular aortic aneurysm repair with bifurcated and limb endografts in an academic center. The main exposure was the degree of limb oversizing. The primary outcome was the occurrence of TIBELs. The secondary outcomes included limb occlusion, reintervention, and overall survival. Subgroup analyses stratified by ectatic and normal iliac landing zones were performed. Multivariate Cox regression analysis and sensitivity analyses using marginal structure model were conducted to adjust for potential confounders. RESULTS: A total of 750 patients with 1500 iliac limb endografts were included in our study (817 limbs with oversizing of ≤10% and 683 with oversizing >10%). The median 1-year freedom from TIBEL was 98.9% (interquartile range [IQR], 98.0%-99.8%) for limbs with oversizing of ≤10% and 99.6% (IQR, 99.0%-100%) for limbs with oversizing >10%. The median 3-year freedom from TIBEL was 95.6% (IQR, 93.1%-98.1%) and 98.2% (IQR, 96.5%-99.9%) for oversizing ≤10% and >10%, respectively. We found that limb oversizing >10% was associated with a significantly decreased risk of TIBEL (adjusted hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.19-0.76) in the overall population. After stratification by ectatic iliac landing zone, we found that limb oversizing >10% was associated with a significantly decreased risk of TIBEL in the ectatic iliac landing zones (adjusted HR, 0.38; 95% CI, 0.16-0.88). However, no significant difference was found in the limb endografts landing in normal iliac arteries (adjusted HR, 0.44; 95% CI, 0.13-1.45). In the subgroup of normal iliac arteries, we observed a significantly increased risk of limb occlusion in the limbs with distal oversizing >15% compared with the limbs with distal oversizing of ≤15% (adjusted HR, 4.66; 95% CI, 1.68-12.91). CONCLUSIONS: Adequate limb oversizing >10% was associated with a significantly decreased risk of TIBEL in limbs with ectatic iliac landing zones. However, no additional benefit was observed for oversizing >10% in limb grafts landing in normal iliac arteries. Furthermore, excessive limb oversizing (>15%) in normal iliac landing zones can be associated with an increased risk of limb occlusion.

Frailty as a predictor of major adverse cardiac and cerebrovascular events after endovascular aortic aneurysm repair.

OBJECTIVE: To evaluate the effect of frailty assessed by the modified Frailty Index (mFI) on major adverse cardiac and cerebrovascular events (MACCE) in the elderly patients after endovascular aortic aneurysm repair (EVAR). METHODS: This was a retrospective cohort study of elderly patients who underwent EVAR in a tertiary hospital. The main exposure was frailty status assessed by the mFI. The primary outcomes were 30-day and long-term MACCE. The predictive ability of the mFI was compared with the Revised Cardiac Risk Index (RCRI) using net reclassification improvement (NRI) and integrated discrimination improvement (IDI) statistics. RESULTS: Of 749 participants, 134 (17.89%) were identified as frail and 185 (24.70%) as prefrail. Thirteen patients (1.74%) were lost in follow-up after surgery, and the median length of follow-up was 32.00 months (range, 15.00-59.25 months). Frailty was associated with a significantly increased risk of 30-day MACCE (adjusted odds ratio OR, 14.53; 95% confidence interval [CI], 4.59-46.04; P < .0001) and longer intensive care unit stay (adjusted odds ratio, 2.43; 95% CI, 1.17-5.07; P = .0176). As for long-term outcomes, both frailty and prefrailty were associated significantly increased risks of MACCE after EVAR (prefrail: adjusted hazard ratio [HR] 1.71; 95% CI, 1.12-2.61; frail: adjusted HR, 3.37; 95% CI, 1.86-6.10). When considering death as a competing risk, we also observed a significant association between frailty and cardiac and cerebrovascular events (adjusted HR, 2.95; 95% CI, 1.06-8.15). In addition, frailty was associated with a significantly increased risk of all-cause mortality (adjusted HR, 1.93; 95% CI, 1.28-2.90). Compared with the RCRI, the mFI had better discrimination in predicting 30-day MACCE (IDI: 0.225; 95% CI, 0.018-0.431; P = .033; NRI: 0.225; 95% CI, 0.023-0.427; P = .029) and long-term MACCE (IDI: 0.056; 95% CI, 0.018-0.128; P = .013; NRI: 0.237; 95% CI, 0.136-0.359; P < .001). CONCLUSIONS: Frailty assessed by the mFI may serve as a useful predictor of both short-term and long-term MACCE in elderly patients after EVAR, with improved discrimination and reclassification abilities compared with the RCRI.

Comparison of Clinical Outcomes Following One versus Two Stage Hybrid Repair of Thoraco-Abdominal Aortic Aneurysms: A Comprehensive Meta-Analysis.

OBJECTIVE: For thoraco-abdominal aortic aneurysms (TAAA), it is unclear whether it is better to perform hybrid repair in one (single) or two stages (staged). This study aimed to compare the clinical outcomes of single vs. staged hybrid repair of TAAA. METHODS: The Medline, Embase, and Cochrane Databases (1 January 1994 to 11 May 2020) were searched for studies on hybrid repair of TAAA. Cohort studies and case series reporting outcomes of single and staged hybrid repair of TAAA were eligible for inclusion. The Newcastle-Ottawa scale and an 18 item tool were used to assess the risk of bias. The primary outcome was 30 day mortality, and the secondary outcomes included post-operative complications, overall survival, and other mid term events. A random effects model was used to calculate pooled estimates. RESULTS: A total of 37 studies was included in the meta-analysis. The quality assessment of the included studies suggested low or moderate risk of bias. The pooled estimates for aneurysm rupture and death during stage interval were 2% (95% CI 0%-4%, I2 = 0%) and 4% (95% CI 2%-7%, I2 = 0%), respectively. Single repair was associated with a significantly higher 30 day risk of death when compared with patients who completed staged procedures successfully (OR 2.64, 95% CI 1.36-5.12, I2 = 0%). Staged repair also had lower incidence of major adverse cardiac events (MACE) (single: 10%, 95% CI 5%-16%; staged: 2%, 95% CI 0%-5%) and intestinal complications (single: 15%, 95% CI 8%-25%; staged: 3%, 95% CI 1%-6%). For mid term outcomes, single and staged repair had comparable 12 month overall survival, aneurysm related mortality, rate of re-intervention, and graft patency. CONCLUSION: Two stage hybrid repair may represent a better choice for patients with controlled risk of aneurysm rupture, because it can provide lower 30 day mortality risks, MACE, and intestinal complications, as well as comparable mid term outcomes. Randomised controlled trials are needed to ascertain the effect of repair staging in patients for elective TAAA.

Editor's Choice - Mid Term Outcomes of Crossed Limb vs. Standard Limb Configuration in Endovascular Abdominal Aortic Aneurysm Repair: A Propensity Score Analysis.

OBJECTIVE: The aim was to compare mid term outcomes between crossed limb (CL) and standard limb (SL) configuration in patients who underwent endovascular aortic aneurysm repair (EVAR). METHODS: This was a comparative cohort study. Eligible patients who underwent EVAR between September 2011 and March 2019 in a tertiary academic centre were included. Inverse probability of treatment weighting (IPTW) was used to balance the demographic, anatomical and operative baseline characteristics between the two groups. The primary outcome was adverse limb events including type IB endoleak (T1BEL), type III endoleak, and limb occlusion. Cox proportional hazards regression and marginal structural model were performed to compare time to event outcomes. RESULTS: The study included 729 patients (194 CL and 535 SL) with a median follow up of 34 months (interquartile range 16 - 62 months). The weighted analyses revealed no significant difference between CL and SL EVAR in terms of adverse limb events, type IA endoleak (T1AEL), type II endoleak (T2EL), re-intervention, and overall survival. In the subgroup analysis of large aneurysm sac, the CL configuration was associated with a significantly decreased risk of T1BEL (hazard ratio [HR] 0.31, 95% confidence interval [CI] 0.12 - 0.78, p = .014). Similar results were also observed in the subgroup of tortuous iliac arteries (HR 0.30, 95% CI 0.11 - 0.81, p = .017). After stratification by severe neck angulation, no significant difference was found between CL and SL EVAR for T1AEL, but the CL configuration was associated with a significantly increased risk of re-intervention (HR 2.69, 95% CI 1.31 - 5.51, p = .007). In addition, a trend towards a higher risk of adverse limb events in the CL group with severely angulated proximal neck was observed. CONCLUSION: CL configuration in EVAR is safe and may be associated with a lower risk of T1BEL in patients with a large aneurysm sac or tortuous iliac arteries. However, it should be applied cautiously to aneurysms with a severely angulated neck due to the potentially higher risk of re-intervention.

Influence of Anesthetic Techniques on Perioperative Outcomes after Endovascular Aneurysm Repair.

BACKGROUND: The purpose of the study was to explore the influence of anesthetic techniques on perioperative outcomes after endovascular aneurysm repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) in a Chinese population. METHODS: A retrospective review was performed in patients after elective EVAR for infrarenal AAA at our single center. Patients were classified into general anesthesia (GA), regional anesthesia (RA), and local anesthesia (LA) groups. The primary outcomes (30-day mortality and morbidity) and secondary outcomes [procedure time, mean arterial pressure (MAP), and length of hospital stay (LOS)] were collected and analyzed. RESULTS: From January 2006 to December 2015, 486 consecutive patients underwent elective EVAR at our center. GA was used in 155 patients (31.9%), RA in 56 (11.5%), and LA in 275 (56.6%). The GA patients had fewer respiratory comorbidities, shorter and more angulated proximal necks, and more concomitant iliac aneurysms. LA during EVAR was significantly associated with a shorter procedure time (GA, P < 0.001; RA, P < 0.001) and shorter LOS (GA, P = 0.002; RA, P = 0.001), but a higher MAP (GA, P < 0.001; RA, P < 0.001) compared with GA and RA. LA was associated with a significantly lower risk of cardiac (odds ratio (OR) 4.27, 95% confidence interval (CI) 1.21-15.04), pulmonary (OR 5.37, 95% CI 1.58-18.23), and systemic complications (OR 4.15, 95% CI 1.85-9.33) compared with GA. RA was also associated with a decreased risk of systemic complications (OR 4.74, 95% CI 1.19-18.92) compared with GA. There was no difference in the 30-day mortality, neurologic complications, renal complications, and intraoperative extra procedures among the 3 groups. CONCLUSIONS: Anesthetic techniques for EVAR have no influence on the 30-day mortality. LA for EVAR appears to be beneficial concerning the procedure time, LOS, and 30-day systemic complications for patients after elective EVAR for infrarenal AAA in the Chinese population.

A meta-analysis of translumbar embolization versus transarterial embolization for type II endoleak after endovascular repair of abdominal aortic aneurysm.

OBJECTIVE: This systematic review and meta-analysis aimed to compare the clinical outcomes between transarterial and translumbar (direct aneurysm sac puncture) approaches for persistent type II endoleak after endovascular repair of abdominal aortic aneurysm. METHODS: We searched multiple electronic databases (up to October 31, 2018) for eligible trials in patients with type II endoleaks after endovascular abdominal aortic aneurysm repairs that evaluated the outcomes of translumbar embolization vs transarterial embolization. The primary outcome was clinical success (absence of the endoleak on the last examination); the secondary outcomes were technical success and complication rate. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. RESULTS: Among the 904 studies screened, 9 studies with 354 participants were included in this review. None of the studies reported rupture or mortality. The translumbar group had a relatively higher clinical success rate than the transarterial group, but this difference was not statistically significant (OR, 2.29; 95% CI, 1.00-5.25; P = .05; I2 = 52%). The technical success rate was significantly higher in the translumbar group than in the transarterial group (OR, 13.32; 95% CI, 3.41-52.07; P = .0002; I2 = 0%). No significant difference was found in the complication rate of the two groups (OR, 1.15; 95% CI, 0.26-4.96; P = .85; I2 = 0%). We also included five studies that reported the clinical outcomes of open repair. All patients were technically treated by open repair, and 58 of 60 patients owned clinical success during the follow-up period. CONCLUSIONS: The translumbar route was more successful in obliterating the endoleak on follow-up imaging. When repeated endovascular embolizations fail, a laparotomy should follow.

Systematic review and meta-analysis of sex differences in outcomes after endovascular aneurysm repair for infrarenal abdominal aortic aneurysm.

OBJECTIVE: Women face distinctive challenges when they receive endovascular aneurysm repair (EVAR) treatment, and according to the previous studies, sex differences in outcomes after EVAR for infrarenal abdominal aortic aneurysm (AAA) remains controversial. This study aimed to compare the short-term and long-term outcomes between women and men after EVAR for infrarenal AAA. METHODS: We conducted a comprehensive systematic review and meta-analysis of all available studies reporting sex differences after EVAR for infrarenal AAA, which were retrieved from the MEDICINE, Embase, and Cochrane Database. The pooled results were presented as odds ratios (ORs) for dichotomous data and hazard ratios for time-to-event data using a random effect model. RESULTS: Thirty-six cohorts were included in this meta-analysis. The pooled results showed that women were associated with a significantly increased risk of 30-day mortality (crude OR, 1.67; 95% confidence interval [CI], 1.50-1.87; P < .001; adjusted OR, 1.73; 95% CI, 1.32-2.26; P < .001), in-hospital mortality (OR, 1.90; 95% CI, 1.43-2.53; P < .001), limb ischemia (OR, 2.44; 95% CI, 1.73-2.43; P < .001), renal complications (OR, 1.73; 95% CI, 1.12-2.67; P = .028), cardiac complications (OR, 1.68; 95% CI, 1.01-2.80; P = .046), and long-term all-cause mortality (hazard ratio, 1.23; 95% CI, 1.09-1.38; P = .001) compared with men; however, no significant sex difference was observed for visceral/mesenteric ischemia (OR, 1.62; 95% CI, 0.91-2.88; P = .098), 30-day reinterventions (OR, 1.37; 95% CI, 0.95-1.98; P = .095), late endoleaks (OR, 1.18; 95% CI, 0.88-1.56; P = .264), and late reinterventions (OR, 1.05; 95% CI, 0.78-1.41; P = .741). In the intact AAA subgroup, women had a significantly increased risk of visceral/mesenteric ischemia (OR, 1.85; 95% CI, 1.01-3.39; P = .046) and an equivalent risk of cardiac complications (OR, 1.64; 95% CI, 0.85-3.17; P = .138) compared with men. CONCLUSIONS: Compared with male sex, female sex is associated with an increased risk of 30-day mortality, in-hospital mortality, limb ischemia, renal complications, cardiac complications, and long-term all-cause mortality after EVAR for infrarenal AAA. Women should be enrolled in a strict and regular long-term surveillance after EVAR.

Systematic Review and Meta-analysis of Current Literature on Isolated Abdominal Aortic Dissection.

OBJECTIVE: To present the pooled quantitative evidence of basic profiles, initial treatment strategies, and clinical outcomes in patients with isolated abdominal aortic dissection (IAAD). METHODS: A comprehensive systematic review and meta-analysis was performed of all available studies reporting IAAD, retrieved from the MEDLINE, Embase, and Cochrane Databases. The logistic normal random effect model was fitted using the generalised linear mixed model with random intercepts to calculate the pooled proportion estimates. RESULTS: Seventeen studies with 482 patients were included in this meta-analysis. Male smokers with hyperlipidaemia and hypertension were the most prominent basic profile. IAADs were predominantly spontaneous and infrarenal, and roughly half were acute and symptomatic. Approximately 67% [95% confidence interval (CI) 42-86%] of patients were managed initially conservatively. In the overall population, the 30 day all cause mortality was 3% (95% CI 1-5%) and the long term mortality during follow up was 8% (95% CI 5-14%). Re-intervention during follow up occurred in 8% (95% CI 5-15%) of patients. In the subgroup analysis, patients with conservative treatment had a 30 day mortality of 1% (95% CI 0-8%), a long term mortality of 5% (95% CI 1-29%), and a re-intervention rate of 18% (95% CI 10-29%). Patients with open surgery had a 30 day mortality of 9% (95% CI 0-82%), a long term mortality of 12% (95% CI 4-31%), and a re-intervention rate of 9% (95% CI 1-44%). Patients with endovascular repair had a 30 day mortality of 2% (95% CI 0-10%), a long term mortality of 5% (95% CI 2-13%), a re-intervention rate of 6% (95% CI 3-13%), and a persistent endoleak rate of 4% (95% CI 2-10%). CONCLUSION: Appropriate initial treatment strategies can be used to obtain acceptable clinical outcomes in patients with IAAD. Invasive intervention is necessary if patients match certain indications for intervention. Regular imaging surveillance should be provided for all patients, especially those treated conservatively.

Endovascular and Surgical Management of Intact Splenic Artery Aneurysm.

OBJECTIVE: This study aims to reveal the experience with endovascular and surgical management of intact splenic artery aneurysms in our single center. METHOD: Between January 2011 and June 2017, 42 patients with intact splenic artery aneurysm were enrolled in this study. Twenty patients undergoing surgical intervention were classified as the surgical group, and 22 patients who received endovascular repair were categorized as the endovascular group. Demographic data, preoperative comorbidities, and anatomical characteristics of aneurysms were collected and analyzed. Details of interventions, perioperative outcomes, and follow-up results were evaluated and compared between the 2 groups. RESULTS: Forty-two patients with a mean age of 53.4 ± 11.6 years were enrolled in this study, and 44 aneurysms were repaired. Thirty-nine (92.9%) patients were asymptomatic, and 3 (7.1%) patients were symptomatic. The diameter of splenic artery aneurysms was 3.3 ± 1.6 cm, and the shape was mostly saccular. In the surgical group, the common methods used were splenic artery aneurysm resection (9 patients), followed by splenic artery aneurysms resection and splenectomy (6 patients), splenic artery aneurysm resection and arterial reconstruction with end-to-end anastomosis (3 patients), and laparoscopic splenic artery aneurysm resection coexisting with splenectomy (2 patients). In the endovascular group, the exclusive means was embolization with coils. The technical success rates in both open repair and endovascular repair were 100%. The 30-day mortality was nil, and no severe complication was found in the early time except that 1 patient suffered multiple splenic abscess in the endovascular group after embolization. Endovascular repair had significantly shorter surgery time (82.5 ± 27.6 vs 191.9 ± 62.7 min, P < 0.001) and hospital stay (5.6 ± 3.1 vs 10.8 ± 5.2 days, P < 0.001) compared with open repair. The median follow-up period in this study was 34.5 (interquartile range 16.8-60.8) months. Two sac reperfusions were detected during the follow-up in the endovascular group, and patients needed new embolization. No late deaths were found in the follow-up period, and the freedom from reintervention in the endovascular group at 1 and 3 years postoperatively was 95.5% and 82.4%, respectively. In addition, the freedom from reintervention in the surgical group at both 1 year and 3 years postoperatively were 100%. No significant differences were observed in late survival and reintervention between open repair and endovascular repair. CONCLUSIONS: Open repair and endovascular repair were equally feasible, safe, and effective for intact splenic artery aneurysm. Endovascular repair is less invasive accompanied with an obvious decrease in surgery time and rapid recovery with a short hospital time.

Percutaneous Vascular Interventions Versus Bypass Surgeries in Patients With Critical Limb Ischemia: A Comprehensive Meta-analysis.

OBJECTIVE: The aim of our study was to compare percutaneous vascular interventions (PVI) versus bypass surgeries (BSX) in patients with critical limb ischemia (CLI). BACKGROUND: Previous relevant reviews with limited numbers of included studies did not strictly confine the inclusion criteria to CLI, also involving patients with severe claudication, which may introduce bias in the decision-making of CLI revascularization. Current treatment strategies for CLI still remain controversial. METHODS: We performed a meta-analysis of all available randomized controlled trials and observational clinical studies comparing PVI with BSX in CLI patients. Primary endpoints included overall survival, amputation-free survival, 30-day mortality, and major adverse cardiovascular and cerebrovascular events. RESULTS: We identified 45 cohorts and 1 RCT in over 20,903 patients. In overall population, PVI reduced the risks of 30-day mortality [odds ratio (OR) 0.69, 95% confidence interval (CI) 0.51-0.95), major adverse cardiovascular and cerebrovascular events (OR 0.42, 95% CI 0.29-0.61), and surgical site infection (OR 0.31, 95% CI 0.19-0.51), but increased the risks of long-term all-cause mortality [hazard ratio (HR) 1.16, 95% CI 1.05-1.27) and primary patency failure (HR 1.31, 95% CI 1.08-1.58). When compared with autogenous BSX, PVI was also associated with additional increased risks of long-term death or amputation (HR 1.41, 95% CI 1.02-1.94) and secondary patency failure (HR 1.51, 95% CI 1.17-1.95). In patients with infrapopliteal lesions, we found PVI had inferior primary patency (HR 1.39, 95% CI 1.10-1.75) compared with BSX. CONCLUSION: For patients in good physical condition with long life-expectancy, BSX may represent a better choice compared with PVI, particularly when autogenous bypass is available. While enhanced perioperative care for cardiovascular events and surgical site should be considered in patients underwent BSX to achieve comparable short-term outcomes provided by PVI.

Systematic review and meta-analysis of current evidence in spontaneous isolated celiac and superior mesenteric artery dissection.

OBJECTIVE: Spontaneous isolated celiac artery dissection (SICAD) and spontaneous isolated superior mesenteric artery dissection (SISMAD) represent the major types of spontaneous visceral artery dissection. However, no quantitative meta-analysis of SICAD and SISMAD is available. The aim of our study was to pool current evidence concerning basic profiles, treatment strategies, long-term adverse events, and morphologic changes of lesioned vessels in SICAD and SISMAD patients. METHODS: We searched the MEDLINE, Embase, Scopus, and Cochrane Databases (January 1, 1946-September 21, 2017) for studies of SICAD and SISMAD. Related cohort studies or case series with sample size larger than 10 were included. Two reviewers independently extracted and summarized the data. A random-effects model was used to calculate pooled estimates. RESULTS: In total, 43 studies were included. An estimated 8% (95% confidence interval [CI], 0.01-0.21) symptomatic SICAD and 12% (95% CI, 0.06-0.19) symptomatic SISMAD patients with initial conservative management required secondary intervention during follow-up, whereas none of the asymptomatic patients treated conservatively required secondary intervention. As for morphologic changes during follow-up, a higher proportion of SICAD patients (64%; 95% CI, 0.47-0.80) achieved complete remodeling compared with SISMAD patients (25%; 95% CI, 0.19-0.32), and an estimated 6% (95% CI, 0.00-0.16) of SICAD and 12% (95% CI, 0.05-0.20) of SISMAD patients had morphologic progression. Overall, the pooled estimate of long-term all-cause mortality was 0% (95% CI, 0.00-0.03) in SICAD and 1% (95% CI, 0.00-0.02) in SISMAD. When stratified by symptoms, symptomatic patients were associated with a significantly increased probability of accomplishing complete remodeling (odds ratio, 3.95; 95% CI, 1.31-11.85) compared with asymptomatic patients. CONCLUSIONS: Initial conservative treatment is safe for asymptomatic SICAD or SISMAD patients. Symptomatic patients managed conservatively have relatively high occurrence of late secondary intervention, which may require closer surveillance, especially in SISMAD because of a lower rate of remodeling.

The Impact of Frailty on Outcomes of Elderly Patients After Major Vascular Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the quality of published evidence of all frailty tools in major vascular surgery and to determine the effect of frailty on short and long-term outcomes after vascular procedures. METHODS: MEDLINE, Embase, Cochrane Database and Scopus (updated on May 12, 2018) were searched for studies evaluating the effect of frailty in vascular surgery and data were extracted from the included studies. A modified Newcastle-Ottawa scale was used to assess the quality of the included studies. The impact of frailty on outcomes was expressed as odds ratios (OR) or hazard ratios (HR) using a random effects model. RESULTS: A total of 22 cohort studies and one RCT were included. Overall frailty was found to be associated with a significantly increased risk of 30 day mortality in patients who underwent vascular surgery (OR 3.83, 95% CI 3.08-4.76), with similar effects in both patients who underwent abdominal aortic aneurysm (AAA) repair (OR 5.15, 95% CI 3.91-6.77) and lower extremity revascularisation (OR 3.29, 95% CI 2.53-4.28). Functional status remained the only tool with high quality of evidence predicting 30 day mortality after vascular surgery (OR 4.49, 95% CI 3.81-5.30). As for long-term outcomes, frailty was associated with a significantly increased risk of long-term all cause mortality in the overall studied population (HR 2.22, 95% CI 1.81-2.73), as well as in patients with AAA repair (HR 2.10, 95% CI 1.59-2.79) and lower extremity revascularisation (HR 2.46, 95% CI 1.73-3.49). Central muscle mass was found to be the only tool with moderate quality of evidence predicting long-term survival after major vascular surgery (HR 2.48, 95% CI 1.76-3.49). Other single domain tools were generally scored as low quality, and the modified Frailty Index was the only multi-domain tool with moderate quality while others were scored as low or very low. CONCLUSION: Frailty, assessed by functional status, can predict short-term mortality in elderly patients after vascular surgery; while central muscle mass may help determine long-term survival in abdominal aortic repair. As frailty is associated with both worse short and long-term outcomes, frailty assessment may be considered in patients scheduled for vascular surgery.

Bilateral Axillary Artery Aneurysms in a Six-Year-Old Child.

True axillary artery aneurysms in children are rare and mostly caused by blunt trauma. Idiopathic bilateral axillary aneurysms in children are even more infrequent, and evidence for optimal management is scarce. Moreover, the maximum follow-up time of interventions reported in pediatric axillary artery aneurysms was less than 1 year, and long-term outcomes remained unknown. In this report, we presented a 6-year-old child with bilateral axillary artery aneurysms treated by saphenous vein reconstruction with a 5-year follow-up. Meanwhile, we reviewed the etiology and treatment of true axillary artery aneurysm in children, which we hope would add information to the scarce evidence of management of true axillary artery aneurysms in children.

Aneurysmal Degeneration of an Aortorenal Bypass for Takayasu Renal Artery Stenosis: A Novel Endovascular Intervention.

We report an aneurysm degeneration of a vein graft in a previous aortorenal bypass performed 5 years earlier for severe right renal artery stenosis due to Takayasu arteritis. The patient was a 31-year-old woman who suffered from refractory hypertension. The autogenous bypass adopting great saphenous vein was performed from her infrarenal abdominal aorta to her right renal artery. Five years after the operation, the patient complained vague discomfort in her abdomen. Three-dimensional computed tomography angiography reconstruction demonstrated the existence of an aneurysm with a maximum diameter of 1.5 cm at the distal portion of a previous aortorenal vein graft, and >75% stenosis of the right renal artery. The replacement of a previous vein graft bypass with autograft or artificial graft is reported in literature. In this case, we attempted endovascular procedures by embolization of the aneurysm and revascularization of the right renal artery using coils and Viabahn stents.

Perioperative Pharmacological Thromboprophylaxis in Patients With Cancer: A Systematic Review and Meta-analysis.

OBJECTIVE: To compare the relative effects between pharmacological thromboprophylaxis and no anticoagulation. BACKGROUND: The efficacy and safety of pharmacological thromboprophylaxis in cancer patients undergoing surgery need to be quantified to guide management. METHODS: We searched multiple electronic databases (up to March 31, 2016) for trials of cancer patients undergoing surgery that assessed the relative benefits and harms of perioperative pharmacological thromboprophylaxis. Relative risks (RRs) with 95% confidence intervals (CI) were estimated. RESULTS: A total of 39 studies were enrolled in this review. Patients with pharmacological thromboprophylaxis had a relatively reduced incidence of deep venous thrombosis (DVT) compared with those without (0.5% vs 1.2%, RR 0.51, 95% CI 0.27-0.94; P = 0.03) but a significantly increased incidence of bleeding events (RR 2.51, 95% CI 1.79-3.51; P < 0.0001). The incidence of pulmonary embolism (PE) (RR 1.77, 95% CI 0.76-4.14; P = 0.19) and mortality related to venous thromboembolism (VTE) (1/2,811 vs 2/3,380) were similar between the pharmacological thromboprophylaxis group and the no pharmacological thromboprophylaxis group. Low-molecular-weight heparin (LMWH) reduced the incidence of DVT compared with unfractionated heparin (UFH) (RR 0.81, 95% CI 0.66-1.00; P = 0.05), and standard extended thromboprophylaxis after cancer surgery significant decreased the incidence of DVT as compared with conventional thromboprophylaxis (RR 0.57, 95% CI 0.39-0.83; P = 0.003). CONCLUSIONS: Routine pharmacological thromboprophylaxis for cancer patients undergoing surgery needs to be carefully considered, because although thromboprophylaxis is associated with lower VTE events, there is a higher incidence of clinically significant bleeding events. If pharmacological thromboprophylaxis is to be used, extended thromboprophylaxis started preoperatively with LWMH might be the most effective strategy.