Influence of Operative Time in the Results of Elective Endovascular Repair of Abdominal Aortic Aneurysms.

BACKGROUND: A prolonged operative time (OT) is a well-recognized risk factor of postoperative complications after many open surgical procedures, although little is known about its impact in less-invasive endovascular procedures. We aimed to define the characteristics related to a prolonged OT in the endovascular treatment of aorto-iliac aneurysms (EVAR) and to evaluate the influence of OT on postoperative outcomes. METHODS: Retrospective analysis of 284 consecutive patients (mean age 75 years, 95% male) who underwent an elective EVAR between 2000 and 2019. Operative characteristics related to OT and the impact of OT in postoperative results was studied using multiple lineal and logistic regression analyses, respectively. RESULTS: The mean surgical time was 200 min. OT was associated (regression model) with the implantation of straight endografts (-38 min, P = 0.007), femoral artery surgery (+80 min, P < 0.001), hypogastric preservation procedures (+70 min, P < 0.001), associated peripheral arterial disease (+22 min, P = 0.013), general anesthesia (+34 min, P < 0.001), and aneurysm diameter (+9 min/cm, P = 0.002). During the postoperative period (<30 days or at discharge), 21% presented a complication and 2.8% died. OT was independently associated with a higher incidence of postoperative complications (odds ratio [OR] for each additional 30' of surgery = 1.34, P < 0.001), such as immediate (OR = 1.48, P = 0.003) and 6-month mortality (OR = 1.28, P = 0.025). CONCLUSIONS: A prolonged OT is an independent risk factor for complications and mortality after EVAR. Surgeons must take this factor into consideration when defining the best therapeutic strategy for abdominal aortic aneurysms.

A cost-effectiveness analysis of the introduction of a specialised consultation with duplex ultrasound assessment prior to vascular access surgery for haemodialysis.

INTRODUCTION: Duplex ultrasound (DUS) is increasingly used before vascular access (VA) surgery for haemodialysis. However, the cost-effectiveness of this approach is unknown. Our objective was to assess whether the introduction of a specialised consultation with DUS assessment modifies the cost and the time delay to achieve a first VA valid for haemodialysis. PATIENTS AND METHODS: Prospective cohort of patients undergoing a first VA (June 2014-July 2017) after a specialised consultation with DUS (ECO group). They were compared with a historical cohort (January 2012-May 2014) where VA was indicated exclusively by clinical evaluation (CLN group). We analysed the cost related to visits, DUS assessments, interventions, hospital admissions and graft materials to achieve a first VA valid for haemodialysis at least during 1 month. RESULTS: 86 patients in the CLN group were compared with 92 in the ECO group. Patients in the ECO group were younger (68.4 vs. 64.0 years; P=.038) but no other differences were seen among groups. The average cost to achieve a first AV valid for haemodialysis was significantly lower in the ECO group (2707 vs. 3347€; P=.024). There was a higher cost associated with DUS assessments in the ECO group yet the CLN group had a higher cost related to follow-up visits, successive surgical interventions, prosthetic material, days of hospital admission and catheters. The mean time needed to achieve a first AV valid for haemodialysis was also shorter in the ECO group (49.9 vs. 82.9 days, P=.002). CONCLUSION: The introduction of a specialised vascular access consultation with DUS prior to VA surgery has reduced the cost necessary to achieve a first VA valid for haemodialysis. From the patient's point of view this has meant less interventions and hospital admissions and a shortening of the time delay.

A cost-effectiveness analysis of the introduction of a specialised consultation with duplex ultrasound assessment prior to vascular access surgery for haemodialysis. / Impacto de la introducción de una consulta específica con valoración eco-doppler en el costo asociado a la obtención de un primer acceso vascular para hemodiálisis.

INTRODUCTION: Duplex ultrasound (DUS) is increasingly used before vascular access (VA) surgery for haemodialysis. However, the cost-effectiveness of this approach is unknown. Our objective was to assess whether the introduction of a specialised consultation with DUS assessment modifies the cost and the time delay to achieve a first VA valid for haemodialysis. PATIENTS AND METHODS: Prospective cohort of patients undergoing a first VA (June 2014-July 2017) after a specialised consultation with DUS (ECO group). They were compared with a historical cohort (January 2012-May 2014) where VA was indicated exclusively by clinical evaluation (CLN group). We analysed the cost related to visits, DUS assessments, interventions, hospital admissions and graft materials to achieve a first VA valid for haemodialysis at least during 1 month. RESULTS: Eighty-six patients in the CLN group were compared with 92 in the ECO group. Patients in the ECO group were younger (68.4 vs. 64.0 years; P=.038) but no other differences were seen among groups. The average cost to achieve a first AV valid for haemodialysis was significantly lower in the ECO group (2707 vs. 3347€; P=.024). There was a higher cost associated with DUS assessments in the ECO group yet the CLN group had a higher cost related to follow-up visits, successive surgical interventions, prosthetic material, days of hospital admission and catheters. The mean time needed to achieve a first AV valid for haemodialysis was also shorter in the ECO group (49.9 vs. 82.9 days, P=.002). CONCLUSION: The introduction of a specialised vascular access consultation with DUS prior to VA surgery has reduced the cost necessary to achieve a first VA valid for haemodialysis. From the patient's point of view this has meant less interventions and hospital admissions and a shortening of the time delay.

Outcome of elective endovascular repair of abdominal aortic aneurysms in octogenarians.

AIM: The need to adjust the indications of elective abdominal aortic aneurysm (AAA) repair among patients with a limited life-span deserves a specific evaluation for octogenarians. The aim of this study was to compare the postoperative results and the long-term survival after endovascular repair of abdominal aortic and/or iliac aneurysms (EVAR) in octogenarians compared with patients under 80 years of age. METHODS: Retrospective analysis of 241 consecutive patients who underwent an elective EVAR between 2000 and 2017. EVAR was not considered among patients with clear life-limiting conditions. Patients receiving other than commercially standard infra-renal endoprostheses were excluded. RESULTS: Seventy patients (29.0%) were octogenarians. They had a lower rate of active smoking (10.0% vs. 30.4%, P < 0.001) and a higher prevalence of previous cerebrovascular disease (21.4% vs. 11.7%, P = 0.055) than younger patients. Thirty-day/in-hospital complication and mortality rates were not significantly higher among octogenarians when compared with younger patients (24.3% vs. 16.9% and 2.9% vs. 2.4%, respectively). Octogenarians had a lower long-term survival at 1, 3 and 5 years (92.6% vs. 93.3%, 67.7% vs. 78.0% and 39.3% vs. 60.6%, P = 0.039) in the bivariate analysis. However, an age ≥ 80 years per se was not an independent predictor of survival after adjustment for confounding factors. CONCLUSION: An age above 80 years was not associated with an increased risk of postoperative complications or long-term mortality. Our results suggest that EVAR can be considered in elderly patients without a clear life-limiting condition and with a suitable aneurysm anatomy. Geriatr Gerontol Int 2021; 21: 392-397.

Natural History After Below-knee Amputation: Analysis of Survival and Prosthetic Fitting Over 2 Decades. / Historia natural del paciente sometido a una amputación infracondílea: análisis de la supervivencia y protetización durante 2 décadas.

INTRODUCTION: This study sought to evaluate the natural history of patients undergoing below-knee amputation (BKA) and compare their evolution over 2 decades, as well as survival predictors, prosthetic fitting, and contralateral amputation. METHODS: Retrospective study of 209 consecutive patients (mean age 72.9 years; 68% males) who underwent BKA in 2 periods: 1996-2005 and 2006-2015. The fitting of prostheses, risk of contralateral amputation and survival, as well as their predictive factors, were assessed by survival analysis. RESULTS: 133 BKA were performed from 1996-2005 and 106 from 2006-2015. The etiology that motivated the BKA was acute ischemia (4.3%), chronic ischemia (34.0%), infection (9.1%) or mixed (chronic+infection, 52.6%), with no differences found between periods. Survival: mortality within one month=9.2%, one year=31.9%, 2 years=43.8% and 5 years=63.9%, with no significant differences between the 2 periods. Prosthetic: the fitting rate was 44.5% throughout the follow-up, with no significant differences between the two periods. 41.1% patients managed to walk. Contralateral amputation: 20.1% of the patients later required a major contralateral amputation, with no significant differences between the two periods. CONCLUSIONS: In the last decade, fewer BKA have been performed probably, due to higher previous interventional revascularization. Despite this, the results of fitting, contralateral amputation or survival were not modified. In any case, the number of patients who are able to achieve ambulation is modest, so it emphasizes the need for an optimal selection of patients with BKA with the goal of prosthetic fitting.