Left atrial appendage morphology and risk of stroke following pulmonary vein isolation for drug-refractory atrial fibrillation in low CHA2DS2Vasc risk patients.

BACKGROUND: Cardiac CT angiography (CCTA) has become an important adjunct in the structural assessment of the pulmonary veins (PV) prior to pulmonary vein isolation (PVI). Published data is conflicting regarding a relationship between left atrial appendage (LAA) and the risk of ischemic stroke (CVA) following PVI. We investigated the associations of volumetric and morphologic left atrial (LA) and LAA measurements for CVA following PVI. METHODS: We retrospectively reviewed 332 consecutive patients with drug refractory atrial fibrillation who obtained cardiac CT angiogram (CCTA) prior to PVI. Baseline demographic data, procedural and lab details, and outcomes were obtained from abstraction of an electronic medical records system. LA, LAA, and PV volumes were measured using CCTA datasets utilizing a semi-automated 3D workstation application. LAA morphology was assigned utilizing volume rendered images as previously described. RESULTS: The study cohort was 55 ± 13 years-old, 83.7% male, low CVA risk (median CHA2DS2Vasc 1; IQR 1, 3), and 30.4% were treated with novel oral anticoagulants. Chicken wing (CW) was the most common morphology (52%), followed by windsock (WS), cauliflower (CF), and cactus (CS) at 18, 9, and 2%, respectively. CVAs occurred in 4 patients following PVI with median time to CVA of 170.5 days. All CVAs were observed in CW morphology patients. When comparing CW morphology with non-CW morphology, CVAs occurred more frequently with the CW morphology (2.1% vs 0%, p = 0.03). This difference was not significant, though, after adjusting for CHA2DS2Vasc risk factors (p = 0.14). CONCLUSION: The CW morphology was observed more commonly in patients who experienced post-PVI CVA. After adjusting for CHA2DS2Vasc risk factors, CW morphology was not an independent predictor of post-PVI CVA. These findings should be interpreted in the setting of a low CVA event rate amongst a low risk population that was highly compliant with indicated anticoagulation therapy.

Open versus endovascular repair of abdominal aortic aneurysm: Incidence of cardiovascular events in 632 patients in a department of defense cohort over 6-year follow-up.

BACKGROUND: Abdominal aortic aneurysm (AAA) is common with unacceptably high rates of mortality and morbidity with unknown rates of complications after repair in the Department of Defense (DoD). METHODS: All patients treated at a DOD or VA clinic or medical facility with a diagnosis of AAA identified by ICD-9 code search were identified by Patient Administration Systems and Biostatistics Activity (PASBA) using the Standard Inpatient Data Record (SIDR) and Composite Ambulatory Patient Encounter Record (CAPER) from January 2006 till December 2011. The primary outcome was death, myocardial infarction (MI), stroke, and cardiac arrhythmia between subjects who underwent endovascular aortic repair (EVAR) or open aortic repair (OAR). RESULTS: A total of 8314 patients were screened to identify 632 patients who underwent surgical repair of non-ruptured AAA. EVAR was performed in 497 patients (78.6%) and OAR in 135 patients (21.4%). Mortality at 30 days was less common in EVAR patients (1.6% vs. 6.7%, p = 0.004), but was not sustained (16.9% vs. 17.8%, p = 0.797). Mean survival free from mortality was not different between the two groups (EVAR vs. OAR: 6.14 ± 0.13 years vs. 6.11 ± 0.22 years, p = 0.378). The composite endpoint of MI, stroke, arrhythmia, or death was not different between groups at 30 days (EVAR vs. OAR: 12.9% vs. 14.1%, p = 0.774) or in long-term follow-up population (EVAR vs. OAR: 40.6% vs. 31.9%, p = 0.073) though there was a trend toward higher event rates in the EVAR. The composite endpoint of MI, stroke, and arrhythmia occurred in 198 patients (31%). CONCLUSION: EVAR was associated with lower 30-day mortality rates; however, this benefit was not sustained in longer-term follow-up. There is no difference in the rates of stroke, myocardial infarction, or cardiac arrhythmia at 30 days or in long-term follow-up.

Rest-Only Myocardial CT Perfusion in Acute Chest Pain.

OBJECTIVES: Cardiac computed tomography perfusion (CTP) using stress testing is an emerging application in the field of cardiac computed tomography. We evaluated patients with acute chest pain (CP) in the emergency department (ED) with evidence of obstructive coronary artery disease (CAD), defined as >70% stenosis on coronary computed tomography angiography (CCTA) and confirmed by invasive coronary angiography (ICA), to evaluate the applicability of resting CTP in the acute CP setting. METHODS: From January to December 2013, 183 low-intermediate risk symptomatic patients with negative cardiac biomarkers and no known CAD underwent a rapid CCTA protocol in the ED. Of these, 4 patients (1.4%) had obstructive CAD (≥70% stenosis) on CCTA confirmed by ICA. All 183 CCTA studies were evaluated retrospectively with CTP software by a transmural perfusion ratio (TPR) method with a superimposed 17-segment model. A TPR value <0.99 was considered abnormal based on previously published data. RESULTS: A total of four patients were included in this pilot analysis. The duration from resolution of CP to performance of CCTA ranged from 1.6 to 5.0 hours. Three patients underwent revascularization, two with percutaneous coronary intervention (PCI) and one with coronary artery bypass grafting. The fourth patient was managed with aggressive medical therapy. Two patients had multivessel obstructive CAD and two patients had single-vessel CAD. The first patient underwent CCTA 5 hours after resolution of CP symptoms. CCTA demonstrated noncalcified obstructive CAD in the mid-LAD and mid-right coronary artery. ICA showed good correlation by quantitative coronary assessment (QCA) in both vessels and the patient underwent PCI. CTP analysis demonstrated perfusion defects in the LAD and right coronary artery territories. The second patient underwent CCTA 1.6 hours after resolution of CP symptoms with findings of obstructive ostial left main CAD. ICA confirmed obstructive left main CAD by QCA and intravascular ultrasound. The patient underwent revascularization with coronary artery bypass grafting. CTP demonstrated perfusion defects in the anterior and lateral wall segments. The third patient was evaluated for CP in the ED with CCTA demonstrating single-vessel CAD 10 hours after resolution of symptoms with findings of a noncalcified obstructive stenosis in the mid-LAD. The patient subsequently underwent ICA demonstrating good correlation to the CCTA findings in the LAD by QCA. CTP analysis revealed perfusion defects in LAD territory. He was successful treated with PCI. The final patient underwent CCTA 5.4 hours following resolution of CP with the finding of an intermediate partially calcified stenosis in the distal LAD. ICA was performed, with fractional flow reserve demonstrating a hemodynamically insignificant distal LAD at 0.86. CTP detected a perfusion defect in the LAD territory. CONCLUSIONS: When positive, rest CTP may have value in the risk stratification of patients presenting to the ED with nontraumatic acute CP.

Application of the principles of evidence-based medicine to patient care.

Evidence-based medicine (EBM) is the conscientious and judicious use of the best evidence available collected from clinical trials, guidelines, and consensus statements. This article provides simple ways to practice EBM using five steps (assess the patient, ask a clearly focused clinical question, acquire the best evidence available from the medical literature, appraise the evidence, and apply the evidence to patient care) and how to execute each step properly, multiple examples of how to apply EBM to patient care, and examples of how to apply the PICO mnemonic (patient, intervention, comparison, and outcome) to the process of EBM.

Marathon running as a cause of troponin elevation: a systematic review and meta-analysis.

BACKGROUND: Cardiac troponin (cTn) has high sensitivity and specificity for myocardial injury in acute coronary syndrome. Our objective was to review the published literature regarding the incidence of cTn elevations in marathon runners. METHODS: Systematic review and meta-analysis of observational studies published before September 2009. We included studies of patients who had completed a marathon and had serum cTn levels within 24 hours. The primary outcome was the odds ratio for conversion of a normal pre-marathon cTn to an elevated post-marathon cTn. Secondary outcomes included the pooled prevalence of cTn elevation and comparison of the odds ratio for post-marathon elevation of cTnI versus cTnT. RESULTS: Sixteen studies of 939 participants met criteria for inclusion. The mean age was 39 ± 4 years and patients were 74 ± 14% male. There were 6 pre-marathon cTn elevations and 579 post-race elevations. The pooled odds ratio for converting from a normal pre-race to an elevated post-race cTn was 51.84 (95% CI 16-168, I² = 66%, P < 0.001). The pooled incidence of a post-marathon cTn elevation was 51% (95% CI 33-69, I² = 98%, P < 0.001) of all runners. For the primary outcome there was no significant publication bias. Age and gender were not associated, but publication date and assay sensitivity was associated with cTn elevation. cTnI was less commonly elevated versus cTnT. CONCLUSIONS: The available data demonstrate that cTn levels are frequently elevated after a marathon with unclear cardiovascular significance. This elevation of cTn appears to be consistent among a diverse patient population.

Medical management in peripheral arterial disease: a systematic approach to medical therapy.

The American College of Cardiology/American Heart Association 2005 Guidelines for the Management of Patients with Peripheral Arterial Disease (PAD) emphasize the importance of cardiovascular risk reduction in all patients with PAD as a result of the high likelihood of coexisting atherosclerotic disease of the peripheral, coronary, and cerebral circulations. The guidelines outline the clear and definite role for antiplatelet, lipid-lowering, and antihypertensive drugs as well as adequate diabetic control. All practicing interventional radiologists should be familiar with these practical and useful guidelines, as well as the rationale for use of each of these medications.

Treatment in a preventive cardiology clinic utilizing advanced practice providers effectively closes atherosclerotic cardiovascular disease risk-management gaps among a primary-prevention population compared with a propensity-matched primary-care cohort: A team-based care model and its impact on lipid and blood pressure management.

BACKGROUND: Advanced practice providers (APPs) can fill care gaps created by physician shortages and improve adherence/compliance with preventive ASCVD interventions. HYPOTHESIS: APPs utilizing guideline-based algorithms will more frequently escalate ASCVD risk factor therapies. METHODS: We retrospectively reviewed data on 595 patients enrolled in a preventive cardiology clinic (PCC) utilizing APPs compared with a propensity-matched cohort (PMC) of 595 patients enrolled in primary-care clinics alone. PCC patients were risk-stratified using Framingham Risk Score (FRS) and coronary artery calcium scoring (CACS). RESULTS: Baseline demographics were balanced between the groups. CACS was more commonly obtained in PCC patients (P < 0.001), resulting in reclassification of 30.6% patients to a higher risk category, including statin therapy in 26.6% of low-FRS PCC patients with CACS ≥75th MESA percentile. Aspirin initiation was higher for high and intermediate FRS patients in the PCC (P < 0.001). Post-intervention mean LDL-C, non-HDL-C, and triglycerides (all P < 0.05) were lower in the PCC group. Compliance with appropriate lipid treatment was higher in intermediate to high FRS patients (P = 0.004) in the PCC group. Aggressive LDL-C and non-HDL-C treatment goals (<70 mg/dL, P = 0.005 and < 130 mg/dL, P < 0.001, respectively), were more commonly achieved in high-FRS PCC patients. Median post-intervention SBP was lower among intermediate and low FRS patients (P = 0.001 and P < 0.001, respectively). Cumulatively, this resulted in a reduction in median post-intervention PCC FRS across all initial FRS risk categories (P < 0.001 for all). CONCLUSIONS: APPs within a PCC effectively risk-stratify and aggressively manage ASCVD risk factors, resulting in a reduction in post-intervention FRS.

Conversion of atrial fibrillation to sinus rhythm during treatment with intravenous esmolol or diltiazem: a prospective, randomized comparison.

Prior studies have suggested that intravenous diltiazem reduces the probability of spontaneous conversion of atrial fibrillation (AF) to sinus rhythm in the electrophysiology laboratory and in patients with postoperative AF. Whether diltiazem exerts the same effect in patients presenting to the emergency department (ED) with spontaneous AF is unclear. Fifty patients presenting to the ED with new-onset or paroxysmal AF and a rapid ventricular rate (>100 beats per minute) were randomly assigned to receive intravenous diltiazem or esmolol during the first 24 hours of presentation. Conversion to sinus rhythm occurred in 10 patients (42%) in the diltiazem group compared with 10 patients (39%) in the esmolol group (P = 1.0). Diltiazem does not decrease the likelihood of spontaneous conversion of AF to sinus rhythm in the ED setting.

The incidence of phlebitis with intravenous amiodarone at guideline dose recommendations.

Postoperative atrial fibrillation following cardiothoracic surgery is common and frequently managed with intravenous (IV) amiodarone. Phlebitis is the most common complication with peripheral infusion of this agent. Current practice guidelines for peripheral IV administration of <2 mg/mL amiodarone were established to reduce the risk of phlebitis. The present study examines the incidence of phlebitis in a postoperative patient population given current dose recommendations. A total of 273 patient charts were reviewed. The incidence of phlebitis in patients given IV amiodarone (n = 36) was 13.9% (95% confidence interval, 2.6-25.2%; p = 0.001). Logistic regression analysis with backward elimination of other therapeutic risk factors suggests that the odds ratio for phlebitis using current dose regimens without IV filters is 19-fold greater than baseline risk in this population. Phlebitis remains a significant complication associated with peripheral infusion of amiodarone within recommended dosing limits.

Healthcare Policy Statement on the Utility of Coronary Computed Tomography for Evaluation of Cardiovascular Conditions and Preventive Healthcare: From the Health Policy Working Group of the Society of Cardiovascular Computed Tomography.

The rising cost of healthcare is prompting numerous policy and advocacy discussions regarding strategies for constraining growth and creating a more efficient and effective healthcare system. Cardiovascular imaging is central to the care of patients at risk of, and living with, heart disease. Estimates are that utilization of cardiovascular imaging exceeds 20 million studies per year. The Society of Cardiovascular CT (SCCT), alongside Rush University Medical Center, and in collaboration with government agencies, regional payers, and industry healthcare experts met in November 2016 in Chicago, IL to evaluate obstacles and hurdles facing the cardiovascular imaging community and how they can contribute to efficacy while maintaining or even improving outcomes and quality. The summit incorporated inputs from payers, providers, and patients' perspectives, providing a platform for all voices to be heard, allowing for a constructive dialogue with potential solutions moving forward. This article outlines the proceedings from the summit, with a detailed review of past hurdles, current status, and potential solutions as we move forward in an ever-changing healthcare landscape.

Use of carbonated water in reduction of adjacent gastric activity in 456 consecutive technetium-99m myocardial perfusion imaging studies.

BACKGROUND: Small, observational trials have suggested a reduction in adjacent gastric activity with ingestion of soda water in myocardial perfusion imaging (MPI). We report our findings prior to and after implementation of soda water in 467 consecutive MPI studies. METHODS: Consecutive MPI studies performed at a high-volume facility referred for vasodilator (VD) or exercise treadmill testing (ETT) were retrospectively reviewed before and after implementation of the soda water protocol. Patients undergoing the soda water protocol received 100 ml of soda water administered 30 min prior to image acquisition and after stress. Studies were performed using a same day rest/stress protocol. Incidence of adjacent gastric activity, diaphragmatic attenuation, stress and rest perfusion defects, and major adverse cardiovascular events (MACE) outcomes defined as death, myocardial infarction, stroke, reevaluation for chest pain, and late revascularization (>90 days from MPI) were abstracted using International Classification of Diseases, Ninth Revision (ICD-9) search. RESULTS: Two hundred and eighteen studies were performed prior to implementation of the soda water protocol and 249 studies were performed with the use of soda water. Baseline demographic data were equal between the groups with the exception of more patients undergoing VD stress receiving soda water (p < 0.001). Soda water was not associated with a decreased incidence of adjacent gastric activity with stress (54.7% versus 61.9% with no soda water, p = 0.129) or rest (68.6% versus 69.5% with no soda water, p = 0.919) imaging. Less adjacent gastric activity was observed with patients undergoing ETT who received soda water (42.5% versus 56.9% with no soda water, p = 0.031), but no difference was observed between the groups with VD stress (69.0% versus 68.1% with no soda water, p = 1.000). CONCLUSION: The use of soda water prior to technetium-99m MPI was associated with lower rates of adjacent gastric activity only in patients undergoing ETT stress but not rest or VD stress. This differs from previously published data.

Management of Coronary Artery Calcium and Coronary CTA Findings.

Coronary artery calcium (CAC) testing and coronary computed tomography angiography (CTA) have significant data supporting their ability to identify coronary artery disease (CAD) and classify patient risk for atherosclerotic cardiovascular disease (ASCVD). Evidence regarding CAC use for screening has established an excellent prognosis in patients with no detectable CAC, and the ability to risk re-classify the majority of asymptomatic patients considered intermediate risk by traditional risk scores. While data regarding the ideal management of CAC findings are limited, evidence supports statin consideration in patients with CAC > 0 and individualized aspirin therapy accounting for CAD risk factors, CAC severity, and factors which increase a patient's risk of bleeding. In patients with stable or acute symptoms undergoing coronary CTA, a normal CTA predicts excellent prognosis, allowing reassurance and disposition without further testing. When CTA identifies nonobstructive CAD (<50 % stenosis), observational data support consideration of statin use/intensification in patients with extensive plaque (at least four coronary segments involved) and patients with high-risk plaque features. In patients with both nonobstructive and obstructive CAD, multiple studies have now demonstrated an ability of CTA to guide management and improve CAD risk factor control. Still, significant under-treatment of cardiovascular risk factors and high-risk image findings remain, among concerns that CTA may increase invasive angiography and revascularization. To fully realize the impact of atherosclerosis imaging for ASCVD prevention, patient engagement in lifestyle changes and the modification of ASCVD risk factors remain the foundation of care. This review provides an overview of available data and recommendations in the management of CAC and CTA findings.

The lack of obstructive coronary artery disease on coronary CT angiography safely reduces downstream cost and resource utilization during subsequent chest pain presentations.

OBJECTIVE: The purpose of this study is to investigate the cost and resource use due to chest pain (CP) evaluations after initial coronary CT angiography (CCTA) stratified by coronary artery disease (CAD) burden. METHODS: We examined 1518 patients referred for CCTA from January 2005 to July 2012 for downstream evaluation after CCTA during a median follow-up of 351 days. Results were stratified by CAD burden as quantified on CCTA into no CAD, nonobstructive CAD (<50% stenosis), or obstructive CAD (≥50% stenosis). The incidence of ischemic testing at the time of recurrent evaluation (defined as a composite of clinic visit, emergency department encounter, or ischemic testing after the index CCTA for CP, atypical CP, or angina defined by ICD-9 code), the testing modality used, and frequency of testing were abstracted and used to calculate the direct costs of downstream utilization. Major adverse cardiovascular events defined as all-cause mortality, nonfatal myocardial infarction, stroke, or revascularization >90 days from CCTA were abstracted using ICD-9 codes and Social Security Death Index query. RESULTS: A total of 174 patients (11.5%) underwent evaluation for CP after index CCTA with a higher rate of subsequent clinical visits among obstructive CAD patients compared to those with nonobstructive CAD and no CAD (17.8% vs 13.9% vs. 7.5%; P < .001). A significant reduction in the incidence of repeat ischemic testing was observed in patients with no CAD and nonobstructive CAD (P = .002). This resulted in a lower per-patient cost in the nonobstructive CAD and no CAD patients (median [interquartile range 25-75]: $2952 [$307-2952] and $235 [$0-2880]) when compared with patients with obstructive CAD (median [interquartile range 25-75]: $5832 [$5498-17,459]; P < .001). Major adverse cardiovascular events were not different in the 90 patients that underwent repeat testing at the time of CP evaluation when compared with the 84 patients for whom testing was deferred. CONCLUSION: Absence of CAD on initial CCTA was associated with lower costs and decreased downstream utilization compared to the presence of nonobstructive and obstructive CAD on CCTA during median follow-up of 351 days.

Anomalous left anterior descending artery to coronary sinus fistula with associated localized ischemia: A clinical dilemma.

PATIENT: Female, 57 FINAL DIAGNOSIS: Coronary sinus - venous fistula Symptoms: Dispnoea Medication: - Clinical Procedure: - Specialty: Cardiology. OBJECTIVE: Rare disease. BACKGROUND: Coronary arterial fistula, or arteriovenous malformation (AVM), is a connection between the coronary tree and a cardiac chamber or great vessel, having bypassed the myocardial capillary bed. Known complications from coronary artery fistulas may include "steal" from the adjacent myocardium, resulting in myocardial ischemia. CASE REPORT: We report the case of a 57-year-old Hispanic woman with abnormal preoperative electrocardiogram (ECG) and symptoms of dyspnea on exertion, who underwent a stress echocardiography demonstrating inferior distribution hypokinesis at peak exercise. Coronary computed tomography angiography (CCTA) demonstrated a venous fistula connecting the coronary sinus (CS) with the distal portion of the left anterior descending artery (LAD), occupying the territory of a left posterior descending artery (L-PDA) and corresponding in distribution with the patient's stress-induced wall motion abnormalities. CONCLUSIONS: Anomalous left anterior descending artery to coronary sinus fistula with associated ischemia is a rare clinical dilemma with limited experience of success with either surgical or medical options.

Exclusion of left atrial appendage thrombus using single phase coronary computed tomography as compared to transesophageal echocardiography in patients undergoing pulmonary vein isolation.

Background. Transesophageal echocardiography (TEE) is used for the evaluation of the presence of left atrial appendage (LAA) thrombus prior to pulmonary vein isolation (PVI), while coronary computed tomography angiography (CCTA) is used for anatomic mapping during PVI. Methods. We compared the diagnostic performance of single phase CCTA to TEE in excluding the presence of LAA thrombus in patients undergoing PVI in 172 subjects performed during index hospitalization. Results. The mean age was 51 ± 13 years, a median CHADS2 score of 1 [IQR25,75 0,1, range 0-3] and a mean periprocedural INR of 2.1 ± 0.6. The prevalence of an LAA filling defect on single phase CCTA was 9.3% (6/183) and on TEE was 1.2% (2/183). Sensitivity, specificity, positive predictive value, and negative predictive value were 100% (95% CI, 19.8-100%), 91.8% (95% CI, 94-99%), 12.5% (95% CI, 60-76%), and 91.8% (95% CI, 97-100%) for the detection of LAA filling defect, respectively. Conclusion. Given the utility of a preprocedural single phase CCTA for the performance of PVI, the absence of a filling defect negates the need for a subsequent TEE as an adjunct for exclusion of LAA thrombus.

Chamber dimensions and functional assessment with coronary computed tomographic angiography as compared to echocardiography using American Society of Echocardiography guidelines.

BACKGROUND: The correlation between normal cardiac chamber linear dimensions measured during retrospective coronary computed tomographic angiography as compared to transthoracic echocardiography using the American Society of Echocardiography guidelines is not well established. METHODS: We performed a review from January 2005 to July 2011 to identify subjects with retrospective electrocardiogram-gated coronary computed tomographic angiography scans for chest pain and transthoracic echocardiography with normal cardiac structures performed within 90 days. Dimensions were manually calculated in both imaging modalities in accordance with the American Society of Echocardiography published guidelines. Left ventricular ejection fraction was calculated on echocardiography manually using the Simpson's formula and by coronary computed tomographic angiography using the end-systolic and end-diastolic volumes. RESULTS: We reviewed 532 studies, rejected 412 and had 120 cases for review with a median time between studies of 7 days (interquartile range (IQR25,75) = 0-22 days) with no correlation between the measurements made by coronary computed tomographic angiography and transthoracic echocardiography using Bland-Altman analysis. We generated coronary computed tomographic angiography cardiac dimension reference ranges for both genders for our population. CONCLUSION: Our findings represent a step towards generating cardiac chamber dimensions' reference ranges for coronary computed tomographic angiography as compared to transthoracic echocardiography in patients with normal cardiac morphology and function using the American Society of Echocardiography guideline measurements that are commonly used by cardiologists.

Open versus Endovascular Repair of Abdominal Aortic Aneurysm in the Elective and Emergent Setting in a Pooled Population of 37,781 Patients: A Systematic Review and Meta-Analysis.

Background. We evaluated the incidence of mortality and myocardial infarction (MI) in endovascular repair (EVAR) as compared to open aneurysm repair (OAR) in both elective and ruptured abdominal aortic aneurysm (AAA ) setting. Methods. We analyzed the rates of 30-day mortality, 30-day MI, and hospital length of stay (LOS) based on comparative observation and randomized control trials involving EVAR and OAR. Results. 41 trials compared EVAR to OAR with a total pooled population of 37,781 patients. Analysis of elective and ruptured AAA repair favored EVAR with respect to 30-day mortality with a pooled odds ratio of 0.19 (95% CI 0.17-0.20; I (2) = 88.9%; P < 0.001). There were a total of 1,835 30-day MI events reported in the EVAR group as compared to 2,483 events in the OAR group. The pooled odds ratio for elective AAA was 0.74 (95% CI 0.58-0.96; P = 0.02) in favor of EVAR. The average LOS was reduced by 296.75 hrs (95% CI 156.68-436.82 hrs; P < 0.001) in the EVAR population. Conclusions. EVAR has lower rates of 30-day mortality, 30-day MI, and LOS in both elective and ruptured AAA repair.