Outcomes of Nonagenarian Patients in Vascular Surgery Service in a Tertiary Institution.

INTRODUCTION: With the world population growing and aging, nonagenarians have become a distinct patient cohort with specific characteristics that render the prediction of outcomes essential. We aimed to investigate the specific characteristics of this patient's cohort in a tertiary vascular center. MATERIALS AND METHODS: Retrospective analysis was conducted for all consecutive patients 90 years and above referred or treated in the Department of Vascular Surgery between January 2017 and December 2022 for vascular pathologies. The main endpoint was to analyze the type of vascular services required for nonagenarians. Additional endpoints involved evaluation of treatment outcomes during the study period based on medical records. The analysis was patient-based. RESULTS: A total of 148 nonagenarians were included in the study. In all, 71 (48%) of the patients underwent surgery, whereas 77 (52%) had conservative treatment. Most of the patients were referred for peripheral arterial (PAD; 56, 37.8%) and aortic-related (39, 26.4%) diseases. Other pathologies encountered involved acute limb ischemia (ALI; 25, 16.9%), carotid diseases (12, 8.1%), renal/dialysis-related consultations (8, 5.4%), and referrals from other departments (12, 5.4%). Urgent interventions were performed in 27% of the cases. Indications for surgery included PAD Rutherford Stages IV, V, and VI; symptomatic and ruptured aortic aneurysms; ALI Rutherford Stages I, IIa, and IIb; symptomatic and near total occlusion asymptomatic carotid disease; and dialysis-related procedures for patients with chronic renal failure on regular hemodialysis. Perioperative complications were experienced in 22 patients (14.9%), the 30-day reintervention rate was 7.4%, and 30-day mortality was 4.7%. The overall length of hospital stay for operated patients was a median of 8 nights. CONCLUSION: The proportion of nonagenarians in the population is growing and so is their referral to vascular surgery. Satisfactory short-term treatment outcomes can be achieved in this highly selected cohort of patients. Thirty-day mortality is higher in patients undergoing urgent procedures. Follow-up mortality was higher in the operated nonagenarians as compared with those who were treated conservatively. Careful patient selection and thorough preparation are crucial to enhance clinical outcomes. Further research on therapy outcomes of nonagenarians will enable physicians to make better evidence-based approaches to individual patients and should be encouraged. CLINICAL IMPACT: The study highlights the growing need to manage vascular diseases in nonagenarians, emphasizing that age alone should not exclude patients from surgical interventions. By demonstrating acceptable short-term outcomes with careful patient selection, this research challenges the traditional bias against operating on the elderly. Clinicians should refine risk assessment and treatment plans, particularly when balancing surgical and conservative options. Comorbidities, rather than age, are key determinants of patient suitability, encouraging more individualized, evidence-based approaches in this expanding demographic.

The Impact of Target Vessel Anatomy and Bridging Stent Geometry on Branched Endovascular Aortic Repair Outcomes.

OBJECTIVE: This study aimed to evaluate the impact of target vessel anatomy and bridging stent geometry on target vessel instability in branched endovascular aortic repair (B-EVAR). METHODS: This retrospective, single centre cohort study included all consecutive B-EVARs performed between September 2018 and December 2022 for thoraco-abdominal aortic aneurysm (TAAA) or complex abdominal aortic aneurysm (CAAA). The primary endpoints were target vessel instability and related re-interventions at 12 months. Secondary endpoints were 30 day results, including target vessel instability and re-interventions. Target vessel instability analysis consisted of assessment of target vessel anatomy, including diameter, aortic trunk to branch angle, and tortuosity. Post-operative parameters included change of clock position/horizontal misalignment, bridging length (gap), sealing length, tortuosity, post-stenting angle, and oversizing ratio. RESULTS: A total of 69 patients (TAAA: n = 56, 81%; CAAA: n = 13, 19%) and 271 (133 visceral and 138 renal) target vessels were included. The cumulative incidence of target vessel instability was 4.8%, 6.4%, and 7.9% at one, two, and three years, respectively. In the renal target vessel group, vessel diameter ≤ 4 mm (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.116 - 2.54; p = .022) and a bridging length ≥ 25 mm (HR 1.320, 95% CI 1.066 - 1.636; p = .011) were associated with increased target vessel instability. In visceral vessels, a change in clock position/horizontal misalignment ≥ 70 minutes (HR 1.072, 95% CI 1.026 - 1.121; p = .002) showed a significant association with target vessel instability. CONCLUSION: Target vessel diameter, bridging length (gap), and horizontal misalignment seemed to be associated with adverse target vessel outcomes. This may be solved with more customised endograft solutions to reduce the negative impact of the latter parameter.

The Importance of Cell Saver Usage in Complex Endovascular Repair of Thoraco-Abdominal Aortic Aneurysms.

BACKGROUND: The use of the cell saver is well-established in open aneurysm repair; however, its role in endovascular repair is yet to be determined. The aim of this study was to analyze the effects of cell saver usage in patients undergoing complex endovascular procedures. MATERIALS AND METHODS: Single-center retrospective cohort study, including consecutive patients undergoing fenestrated and/or branched repair for the treatment of thoracoabdominal and complex abdominal aortic aneurysms (CAAAs) between January 2019 and December 2022. The cell saver was a standard part of the intraoperative setup of these procedures, and its use was readily available. The primary endpoint was the percentage of patients, in which autologous blood collected was transfused (cell saver blood transfusion [CSBT]), alongside the useable amount obtained. Secondary endpoints included mean blood loss, postoperative hemoglobin levels, and 30-day mortality. RESULTS: A total of 170 patients (77.1% male, mean age 71.2 ± 9.2 years) were included, with a median blood loss of 700 mL (interquartile range [IQR] 400-1,200 mL). A total of 96 patients received some kind of blood transfusion (BT) (56.5%): 35 patients were (20.6%) allogenic BT, 31 patients were (18.2%) CSBT only, and 30 patients were (17.6%) a combination of both. In total, 61 patients (35.9% or 63.5% of all patients requiring BTs) received CSBT, with a median useable blood volume of 282 mL (IQR, 194.5-508 mL). Thirty-day mortality was similar in both groups. Although the CSBT group had lower intraoperative hemoglobin values (9.25 ± 1.55 vs. 10.36 ± 1.88 mg/dL; P < 0.001), both groups presented similar postoperative hemoglobin (Hb) levels. CONCLUSIONS: Blood loss during complex endovascular repair is not insignificant. In this cohort, over 50% of included patients required some kind of BT, 32.3% of which received exclusively CSBT, while 31.3% had supplementary CSBT alongside allogenic BT. This data showcases its potential role in these repairs, paving the way for its standardization in the intraoperative setup of these complex procedures.

Analysis of Target Vessel Instability in Fenestrated Endovascular Repair (f-EVAR) in Thoraco-Abdominal Aortic Pathologies.

Objective: The aim of this study was to evaluate the influence of target vessel anatomy and post-stenting geometry on the outcome of fenestrated endovascular aortic repair (f-EVAR). Methods: A retrospective review of data from a single center was conducted, including all consecutive fenestrated endovascular aortic repairs (f-EVARs) performed between September 2018 and December 2023 for thoraco-abdominal aortic aneurysms (TAAAs) and complex abdominal aortic aneurysms (cAAAs). The analysis focused on the correlation of target vessel instability to target vessel anatomy and geometry after stenting. The primary endpoint was the cumulative incidence of target vessel instability. Secondary endpoints were the 30-day and follow-up re-interventions. Results: A total of 136 patients underwent f-EVAR with 481 stented target vessels. A total of ten target vessel instabilities occurred including three in visceral and seven instabilities in renal vessels. The cumulative incidence of target vessel instability with death as the competing risk was 1.4%, 1.8% and 3.4% at 1, 2 and 3 years, respectively. In renal target vessels (260/481), a diameter ≤ 4 mm (OR 1.21, 95% CI 1.035-1.274, p = 0.009) and an aortic protrusion ≥ 5.75 mm (OR 8.21, 95% CI 3.150-12-23, p = 0.027) was associated with an increased target vessel instability. In visceral target vessels (221/481), instability was significantly associated with a preoperative tortuosity index ≥ 1.25 (HR 15.19, CI 95% 2.50-17.47, p = 0.045) and an oversizing ratio of ≥1.25 (HR 7.739, CI % 4.756-12.878, p = 0.049). Conclusions: f-EVAR showed favorable mid-term results concerning target vessel instability in the current cohort. A diameter of ≤4 mm and an aortic protrusion of ≥5.75 mm in the renal target vessels as well as a preoperative tortuosity index and an oversizing of the bridging stent of ≥1.25 in the visceral target vessels should be avoided.