Increasing Use of Prophylactic Open Abdomen Therapy With Vacuum Assisted Wound Closure and Mesh Mediated Fascial Traction After Repair of Ruptured Abdominal Aortic Aneurysm.

OBJECTIVE: Open abdomen therapy (OAT) is commonly used to prevent or treat abdominal compartment syndrome (ACS) in patients with ruptured abdominal aortic aneurysms (rAAAs). This study aimed to evaluate the incidence, treatment, and outcomes of OAT after rAAA from 2006 to 2021. Investigating data on resuscitation fluid, weight gain, and cumulative fluid balance could provide a more systematic approach to determining the timing of safe abdominal closure. METHODS: This was a single centre observational cohort study. The study included all patients treated for rAAA followed by OAT from October 2006 to December 2021. RESULTS: Seventy-two of the 244 patients who underwent surgery for rAAA received OAT. The mean age was 72 ± 7.85 years, and most were male (n = 61, 85%). The most frequent comorbidities were cardiac disease (n = 31, 43%) and hypertension (n = 31, 43%). Fifty-two patients (72%) received prophylactic OAT, and 20 received OAT for ACS (28%). There was a 25% mortality rate in the prophylactic OAT group compared with the 50% mortality in those who received OAT for ACS (p = .042). The 58 (81%) patients who survived until closure had a median of 12 (interquartile range [IQR] 9, 16.5) days of OAT and 5 (IQR 4, 7) dressing changes. There was one case of colocutaneous fistula and two cases of graft infection. All 58 patients underwent successful abdominal closure, with 55 (95%) undergoing delayed primary closure. In hospital survival was 85%. Treatment trends over time showed the increased use of prophylactic OAT (p ≤ .001) and fewer ACS cases (p = .03) assessed by Fisher's exact test. In multivariable regression analysis fluid overload and weight reduction predicted 26% of variability in time to closure. CONCLUSION: Prophylactic OAT after rAAA can be performed safely, with a high rate of delayed primary closure even after long term treatment.

Staged repair of a ruptured thoracoabdominal aortic aneurysm: a case report.

BACKGROUND: A ruptured thoracoabdominal aortic aneurysm (rTAAA) represents a considerable challenge for surgeons. To date, endovascular procedures have not been able to completely replace open repair when debranching is required. CASE PRESENTATION: A 73-year-old man was admitted to our hospital after complaining of left lateral abdominal pain. Enhanced computed tomography revealed a left retroperitoneal hematoma and a large, ruptured Crawford type IV TAAA. We first performed emergency resuscitative surgery to close the lacerated foramen. A graft replacement was performed 1 month after the initial surgery when the patient had stabilized. At 5 years postoperatively, neither occlusion nor anastomotic pseudoaneurysm was noted on computed tomography. CONCLUSIONS: We provide an update on the perioperative management of patients undergoing open rTAAA repair. This procedure can be considered to ensure complete repair of an rTAAA.

Aneurysms of Aortic Sinus of Valsalva Dissecting through the Interventricular Septum With Rupture into the Left Ventricle: Case Series and Literature Review.

Aneurysm of Aortic sinus of Valsalva (ASOV) dissecting into the interventricular septum (IVS) and rupturing into the left ventricle (LV) is a rare clinical diagnosis. Systemic inflammatory diseases like tuberculosis can aggravate this condition. We describe three cases of ASOV dissecting into the IVS and rupturing into the LV. All three patients underwent surgical intervention; two had a successful outcome. A literature review was conducted and19 previously reported cases were studied. The extent and direction of septal dissection determined the associated cardiac valvular and rhythm problems. Patch closure of the mouth of the aneurysm is the surgical method of choice. In the presence of multiple sinus tracts or if there is recurrence after surgical closure, aortic sinus or root replacement techniques have better outcomes.

[Surgical Treatment for Ruptured Thoracoabdominal Aneurysm Following Descending Aortic Replacement with Double Barrel Anastomosis].

A 75-year-old woman was diagnosed with type B acute aortic dissection 14 years ago and 3-channeled aortic dissection 7 years ago. She received total arch replacement 6 years ago and descending aortic replacement with double barrel anastomosis technique for distal anastomosis 5 years ago. Computed tomography( CT) revealed giant thyroid tumor and thoracoabdominal aortic aneurysm( 58 mm in diameter). She suffered from back pain during her follow-up period. CT revealed ruptured thoracoabdominal aortic aneurysm. First, the false lumen of descending aorta was closed by thoracic endovascular aortic repair, and then thoracoabdominal aortic replacement was performed uneventfully.

Aortic rupture following acute aortitis in a patient with head and neck carcinoma treated with nivolumab: a rare but severe immune-related adverse event.

INTRODUCTION: Immune-related adverse events (irAEs) due to immune checkpoint inhibitors may lead to discontinuation and treatment-related death. Acute aortitis is a rare but severe irAE. CASE PRESENTATION: A 67-year-old man with recurrent lower gingival carcinoma received nivolumab therapy. Twenty-three months later, he experienced chest compression, which resulted in syncope. Following a whole-body computed tomography (CT) scanning, which revealed diffuse thickening of the aorta, and systemic assessments of the causes of aortitis, he was diagnosed with acute aortitis due to irAE. Nivolumab discontinuation and oral steroids improved CT findings. However, 11 months after nivolumab discontinuation, he developed an aortic aneurysmal rupture. Endovascular aortic repair rescued him. A durable anti-cancer response was still observed 4 months after the aortic rupture. CONCLUSION: Although severe irAE, such as acute aortitis, occurred, the patient may still achieve a durable response. A broad examination and prompt treatment of irAE can help improve the patient's survival.

Prehospital point-of-care ultrasound in ruptured abdominal aortic aneurysms-a retrospective cohort study.

BACKGROUND: Patients with ruptured abdominal aortic aneurysm (rAAA) require immediate vascular treatment to survive. The use of prehospital point-of-care ultrasound (POCUS) may support clinical assessment, correct diagnosis, appropriate triage and reduce system delay. The aim was to study the process of care and outcome in patients receiving prehospital POCUS versus patients not receiving prehospital POCUS in patients with rAAA, ruptured iliac aneurysm or impending aortic rupture. METHODS: We performed a retrospective cohort study in patients diagnosed with rAAA in the Central Denmark Region treated by a prehospital critical care physician from 1 January 2017 to 31 December 2021. Performance of prehospital POCUS was extracted from the prehospital electronic health records. System delay was defined as the time from the emergency phone call to the emergency medical service dispatch centre until the start of surgery. Data on patients primary hospital admission to a centre with/without vascular treatment expertise, treatments and complications including death were extracted from electronic health records. RESULTS: We included 169 patients; prehospital POCUS was performed in 124 patients (73%). Emergency surgical treatment was performed in 71 patients. The overall survival in the POCUS group was 39% versus 16% in the NO POCUS group (hazard ratio (HR) (95% 0.60, 95% CI: 0.41-0.89, p = .011). In the POCUS group 99/124 (80%) were directly admitted to a vascular surgical centre versus 25/45 (56%) in the NO POCUS, RD 24% (95% CI: 8-40)), (p = .002). In the POCUS group, system delay was a median of 142 minutes (interquartile range (IQR) 121-189) and a median of 232 minutes (IQR 166-305) in the NO POCUS group (p = .006). In a multivariable analysis incorporating age, sex, previously known rAAA, and typical clinical symptoms of rAAA, the HR for death was 0.57, 95% CI 0.38-0.86 (p = .008) favouring prehospital POCUS. CONCLUSIONS: Prehospital POCUS was associated with reduced time to treatment, higher chance of operability and significantly higher 30-day survival in patients with rAAA, ruptured iliac aneurysm or impending rupture of an AAA in this retrospective study. Residual confounding cannot be excluded. This study supports the clinical relevance of prehospital POCUS of the abdominal aorta.

A 20-Year Analysis of Ruptured Abdominal Aortic Aneurysm Outcomes and Associated Factors in Korea.

BACKGROUND: Unlike western countries, which have reported distinct decreases in incidence of ruptured abdominal aortic aneurysm (rAAA) over the last few decades, epidemiologic studies in Korea have not shown significant changes in incidence or mortality of rAAA. The purpose of this study was to analyze the changes in rAAA treatment outcomes and various associated risk factors over the past 2 decades. METHODS: A 20-year retrospective multicenter review for rAAA cases from the period of January 2000 to December 2020 was undertaken. Preoperative, intraoperative and postoperative clinical data were extracted for patients diagnosed with rAAA. For analysis, outcomes from the early era, defined as patients treated between January 1, 2000, and December 31, 2010, were compared with outcomes from the late era, defined as patients treated between January 1, 2011, and December 31, 2020. RESULTS: The total in-hospital mortality was 34.1% in the early era compared to 44.8% in the late era. Patients in the late era were older than those in the early era (75.2 ± 10.3 years vs. 70.3 ± 8.9 years; P = 0.009). Treatment with rAAA endovascular aneurysm repair increased from 2.3% in early to 13.8% in late era (P = 0.031). In the early era, more patients were operated by experienced surgeons than the late era (78.1% vs. 45.9%; P = 0.002). The emergency room to operating room time did not show improvement over the 20 years. CONCLUSIONS: The results indicate that mortality rate of rAAA in Korea has not changed over the last 2 decades. The study suggests the need for national preventive strategies, improved systemic coordination, and potential centralization of vascular services to enhance survival rates for rAAA.

Five-year outcomes for bell bottom, iliac branch endoprosthesis, and coil and cover approaches from the GREAT registry.

OBJECTIVE: There are a variety of methods used today to treat common iliac aneurysms with endovascular techniques. Of these approaches, little is known about whether a particular limb strategy influences endoleak, reintervention, or aneurysm regression rates. We present 5-year data comparing endoleak, stent graft migration, fracture, aneurysm sac dynamics, and aortic rupture rates among patients treated with bell bottom limbs (BB), iliac branch endoprosthesis (IBE), and coil and cover (CC) approaches from the Global Registry for Endovascular Aortic Treatment registry. Secondary end points were all-cause mortality, stroke, reintervention, and paraplegia. METHODS: Subjects from the GORE Global Registry for Endovascular Aortic Treatment were enrolled over a 5-year period from October 2017 to August 2022. We included 924 subjects in this study. Statistical data was generated on R software and limb groups were compared using the Pearson's χ2 test and the Kruskal-Wallis rank-sum test. RESULTS: We found no statistical difference in endoleak rates, stent graft migration, fracture, or aortic rupture when stratified by limb strategy. There was no difference between limb approaches with regard to aneurysm sac dynamics among those with abdominal aortic aneurysms and common iliac aneurysms. Similarly, no statistical difference between limb strategies was found in all-cause mortality, stroke, paraplegia, or reintervention rates. Among patients that required an additional graft during reintervention, the highest rates were found within the IBE group 8.6%, compared with BB group 2.2% and CC group 1.3% (P = .006). CONCLUSIONS: Overall, there was no difference among limb strategies in endoleak rates, stent graft migration, aneurysm sac dynamics, aortic rupture rates, or our secondary end points. Increased rates of reintervention requiring an additional graft within the IBE group is noteworthy and must be weighed against the adverse effects of hypogastric sacrifice with the CC approach or potentially less advantageous seal zones in the BB approach. This finding suggests that all limb approaches have equivalent effectiveness in managing the aneurysmal common iliac artery; thus, the choice of limb strategy should be individualized and remain at physician discretion. Future research should include a more robust sample size to reproduce these findings.

A Multidisciplinary Protocolized Approach for Ruptured Abdominal Aortic Aneurysm Management: A Retrospective Before-After Study.

OBJECTIVES: To investigate whether implementation of a multidisciplinary protocol for ruptured abdominal aortic aneurysm (rAAA) management reduces rates of adverse complications. DESIGN: A retrospective before-after study. SETTING: A tertiary-care academic hospital. PARTICIPANTS: Adult patients who underwent open or endovascular rAAA repair; data were stratified into before-protocol implementation (group 1: 2015-2018) and after-protocol implementation (group 2: 2019-2022) groups. INTERVENTION: The protocol details the workflow for vascular surgery, anesthesia, emergency department, and operating room staff for a rAAA case; training was accomplished through yearly workshops. MEASUREMENTS AND MAIN RESULTS: The primary outcome was in-hospital mortality. Secondary outcomes included all-cause morbidity and other major complications. Differences in postoperative complication rates between groups were assessed using Pearson's χ2 test. Of the 77 patients included undergoing rAAA repair, 41 (53.2%) patients were in group 1, and 36 (46.8%) patients were in group 2. Patients in group 2 had a significantly shorter median time to incision (1.0 v 0.7 hours, p = 0.022) and total procedure time (180.0 v 160.5 minutes, p = 0.039) for both endovascular and open repair. After protocol implementation, patients undergoing endovascular repair exhibited significantly lower rates of mortality (46.2% v 20.0%, p = 0.048), all-cause morbidity (65.4% v 44.0%, p = 0.050), and renal complications (15.4% v 0.0%, p = 0.036); patients undergoing open repair for a rAAA exhibited significantly lower rates of mortality (53.3% v 27.3%, p = 0.018) and bowel ischemia (26.7% v 0.0%, p = 0.035). CONCLUSIONS: Implementation of a multidisciplinary protocol for the management of a rAAA may reduce rates of adverse complications and improve the quality of care.

Modified Harborview Risk Score accurately predicts mortality for patients with ruptured abdominal aortic aneurysm.

OBJECTIVE: The modified Harborview Risk Score (HRS) is a simple measure initially derived from a single institutional dataset used to predict ruptured abdominal aortic aneurysm (rAAA) repair survival preoperatively using basic labs and vital signs collected upon presentation. However, validation of this widely applicable scoring system has not been performed. This study aims to validate this scoring system using a large multi-institutional database. METHODS: All patients who underwent repair of an rAAA from 2011 to 2018 in the National Surgical Quality Improvement Program (NSQIP) and at a single academic medical center were included. The modified HRS was calculated by assigning 1 point for each of the following: age >76 years, creatinine >2 mg/dL, international normalized ratio >1.8, and any systolic blood pressure less than 70 mmHg. Assessment of the prediction model was then completed. Using a primary outcome measure of 30-day mortality, the receiver operating characteristic area under the curve was calculated. The discrimination between datasets was compared using a Delong test. Mortality rates for each score were compared between datasets using the Pearson χ2 test. Comparative analysis for patients with a score of 4 was limited due to a small sample size. RESULTS: A total of 1536 patients were identified using NSQIP, and 163 patients were assessed in the institutional dataset. There were 518 patients with a score of 0 (455 NSQIP, 63 institutional), 676 patients with a score of 1 (617 NSQIP, 59 institutional), 391 patients with a score of 2 (364 NSQIP, 27 institutional), 106 with a score of 3 (93 NSQIP, 13 institutional), and 8 patients with a score of 4 (7 NSQIP, 1 institutional). No difference was found in the receiver operating characteristic area under the curves between datasets (P = .78). Thirty-day mortality was 10% NSQIP vs 22% institutional for a score of 0; 28% NSQIP vs 36% institutional for a score of 1; 41% NSQIP vs 44% institutional for a score of 2; 45% NSQIP vs 69% institutional for a score of 3; and 57% NSQIP vs 100% institutional for a score of 4. Score 0 was the only score with a significant mortality rate difference between datasets (P = .01). CONCLUSIONS: The modified HRS is confirmed to be broadly applicable as a clinical decision-making tool for patients presenting with rAAAs. Therefore, this easily applicable model should be applied for all patients presenting with rAAAs to assist with provider and patient decision-making prior to proceeding with repair.

The open-first strategy is acceptable for ruptured abdominal aortic aneurysm even in the endovascular era.

PURPOSE: To examine the surgical findings of ruptured abdominal aortic aneurysm (RAAA) based on the open-first strategy in the last decade, and to analyze the predictors of in-hospital mortality for RAAA in the endovascular era. METHODS: The subjects of this retrospective study were 116 patients who underwent RAAA repair, for whom sufficient data were available [25% female, median age 76 (70-85) years]. Sixteen (13.8%) patients were managed with endovascular aneurysm repair (EVAR) and 100 patients (86.2%) were managed with open surgical repair (OSR). RESULTS: Univariate analysis identified base excess (BE) (odds ratio [OR] 0.88; 95% confidence interval [CI] 0.79-0.96; p = 0.006), and preoperative cardiopulmonary arrest (CPA) [OR] 15.4; 95% [CI] 1.30-181; p = 0.030), BE (OR 0.88; 95% CI 0.79-0.96; p = 0.006), shock index (OR 2.44; 95% CI 1.01-5.94; p = 0.050), lactic acid (Lac) (OR 1.18; 95% CI 1.02-1.36; p = 0.026), and blood sugar (BS) > 215 (OR 3.46; 95% CI 1.10-10.9; p = 0.034) as positive predictors of hospital mortality. CONCLUSIONS: The findings of this study suggest that a first-line strategy of OSR for ruptured AAAs is acceptable. Poor preoperative conditions, including a high shock index, CPA, low BE, high Lac, and a BS level > 215 mg/dl, were identified as predictors of hospital mortality, rather than the procedures themselves.

Congestive Heart Failure in an Adolescent With a Ruptured Sinus of Valsalva Aneurysm.

Sinus of Valsalva aneurysm (SVA) is an abnormal dilatation of the aortic root located between the aortic valve annulus and the sinotubular junction and is rare in the pediatric population. This case report describes a unique case of a 16-year-old adolescent patient admitted with progressive heart failure symptoms and diagnosed with a ruptured noncoronary SVA. He underwent surgical repair of the SVA with autologous pericardial patches and had an uncomplicated postoperative course. A genetic workup revealed an underlying 22q11.2 deletion that is infrequently associated with SVA.

Peri-Operative Mortality and Survival After Repair of Abdominal Aortic Aneurysm in Advanced Age Patients: A National Study from the Norwegian Registry for Vascular Surgery Focused on Nonagenarians.

OBJECTIVE: Treatment of abdominal aortic aneurysm (AAA) in nonagenarians has become more frequent. This national observational cohort study aimed to investigate peri-operative mortality and survival after AAA surgery in nonagenarians in Norway. METHODS: All AAA repairs registered in the Norwegian Registry for Vascular Surgery from 2015 to 2021 were identified and stratified into nonagenarians > 90 years old (n = 77), octogenarians 80 - 89 years old (n = 1 362), and patients < 80 years old (n = 4 590). The patient characteristics and comorbidities were recorded, and the 30 and 90 day mortality rates were calculated. Kaplan-Meier analysis was performed to obtain the estimated median survival and survival curves. RESULTS: In the nonagenarians, the 30 day mortality rates were 2.5% in asymptomatic patients, 33.3% in symptomatic patients, and 59.1% in the patients with a ruptured AAA (rAAA). The estimated median survival (years) were 3.3 (95% confidence interval [CI] 1.95 - 4.59) for asymptomatic AAA, 2.9 (interquartile range [IQR] 2.82, 5.80) for symptomatic AAA, and 0.1 for rAAA (IQR 0.01, 3.04). For nonagenarians surviving the first 90 days, the estimated median survival (years) were 4.2 (95% CI 2.56 - 5.88) for asymptomatic AAA, 3.4 (IQR 2.86, 5.80) for symptomatic AAA, and 3.8 (IQR 1.49, 4.85) for rAAA. The 90 day mortality rates were 100.0%, 80.0%, and 62.5% for asymptomatic, symptomatic, and rAAA, respectively, after open surgical repair (OSR), and 5.1%, 10.0%, and 50.0%, respectively, after endovascular aortic repair (EVAR). CONCLUSION: Peri-operative mortality and survival results after AAA surgery in nonagenarians support treatment of selected asymptomatic patients. The 90 day survivors had an expected survival of more than three years, enabling balanced decision making regarding surgical vs. conservative treatment options in this challenging cohort. EVAR is the treatment method of choice for AAA in nonagenarians because most of them would probably live longer untreated than if treated by OSR.

Hypertension during transfer is associated with poor outcomes in unstable patients with ruptured abdominal aortic aneurysm.

OBJECTIVE: Limited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock. METHODS: We performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality. RESULTS: Detailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality. CONCLUSIONS: Hypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible.

The association of ruptured abdominal aortic aneurysm diameter with mortality in the International Consortium of Vascular Registries.

BACKGROUND: The mortality after ruptured abdominal aortic aneurysm (rAAA) repair is high, despite improvements in perioperative care, centralization of emergency vascular surgical services, and the introduction of endovascular aneurysm repair (EVAR). The diameter of intact AAA has been shown to be a predictor of short- and long-term survival. The aim of this study was to analyze the impact of AAA diameter on mortality for rAAA repair using contemporary data collected from the International Consortium of Vascular Registries and compare outcomes by sex and the type of repair patients received. METHODS: Prospective registry data on repair of rAAA from seven countries were collected from 2010 to 2016. The primary outcome was perioperative mortality after EVAR and open surgical repair (OSR). Data were stratified by type of repair and sex. Logistic regression models were used to estimate odds ratio (OR) for the association between AAA diameter and perioperative mortality and the association between type of repair and mortality. Multivariable logistic regression models were used to adjust for differences in patient characteristics. RESULTS: The study population consisted of 6428 patients with a mean age ranging from 70.2 to 75.4 years; the mean AAA diameter was 7.7 ± 1.8 cm. Females had a significantly smaller AAA diameter at presentation compared with males (6.9 ± 1.6 cm vs 7.9 ± 1.8 cm; P < .001). who underwent OSR had larger AAA diameters compared with those who underwent EVAR (P < .001). Females who underwent repair were significantly older (P < .001). Males were more likely to have cardiac disease, diabetes mellitus, and renal impairment. Overall, AAA diameter was a predictor of mortality in univariate and multivariate analysis. When analyzing EVAR and OSR separately, the impact of AAA diameter per cm increase on mortality was apparent in both males and females undergoing EVAR, but not OSR (EVAR: male OR, 1.09 [95% confidence interval, 1.03-1.16] and EVAR: female OR, 1.17 [95% confidence interval, 1.02-1.35]). The early mortality rate for males and females who underwent EVAR was 18.9% and 25.9% (P < .001), respectively. The corresponding mortality for males and females who underwent OSR was 30.2% and 38.6% (P < .001), respectively. CONCLUSIONS: In these real-world international data, there is a significant association between rAAA diameters and early mortality in males and females. This association was more evident in patients undergoing EVAR, but not shown in OSR. Despite improvements in overall AAA repair outcomes, the risk of mortality after rAAA repair is consistently higher for females.

[Management of Stent-graft migration with obstruction of supra-aortic vessel during an endovascular procedure for aortic isthmus rupture]. / Migration d'endoprothèse thoracique avec occlusion des troncs supra-aortiques en per-procédure pour rupture isthmique ; prise en charge.

The endovascular approach is widely used in the management of aortic isthmic rupture. Even if it remains less invasive than conventional surgery, a life-threatening complications are possible. We report the case of a young female patient presenting a stent-graft migration during the deployment with total obstruction of the supra-aortic vessels. We describe the therapeutic management with a cerebral rescue procedure followed by a delayed surgical repair.

Modified Harborview Risk Score improves ease in predicting mortality after ruptured abdominal aortic aneurysm repair.

OBJECTIVE: The Harborview Risk Score (HRS) is a simple, accurate 4-point preoperative risk scoring system used to predict 30-day mortality following ruptured abdominal aortic aneurysm (rAAA) repair. The HRS assigns 1 point for each of the following: age >76 years, pH <7.2, creatinine >2 mg/dL, and any episode of severe hypotension (systolic blood pressure <70 mmHg). One potential limitation of this risk scoring system is that arterial blood gas (ABG) analysis is required to determine arterial pH. Because ABG analysis is not routinely performed prior to patient transfer or rAAA repair, we sought to determine if the HRS could be modified by replacing pH with the international normalized ratio (INR), a factor that has been previously shown to have a strong and independent association with 30-day death after rAAA repair. METHODS: A retrospective review of all rAAA repairs done at a single academic medical center between January 2002 and December 2018 was performed. Our traditional HRS was compared with a modified score, in which pH <7.2 was replaced with INR >1.8. Patients were included if they underwent rAAA repair (open or endovascular), and if they had preoperative laboratory values available to calculate both the traditional and modified HRS. RESULTS: During the 17-year study period, 360 of 391 repairs met inclusion criteria. Observed 30-day mortality using the modified scoring system was 17% (18/106) for a score of 0 points, 43% (53/122) for 1 point, 54% (52/96) for 2 points, 84% (27/32) for 3 points, and 100% (4/4) for 4 points. Receiver operating characteristic analysis revealed similar ability of the two scoring systems to predict 30-day death: there was no significant difference in the area under the curve (AUC) comparing the traditional (AUC = 0.74) and modified (AUC = 0.72) HRS (P = .3). CONCLUSIONS: Although previously validated among a modern cohort of patients with rAAA, our traditional 4-point risk score is limited in real-world use by the need for an ABG. Substituting INR for pH improves the usefulness of our risk scoring system without compromising accuracy in predicting 30-day mortality after rAAA repair.

Endovascular treatment for thoracic aortic disease from the Global Registry for Endovascular Aortic Treatment.

OBJECTIVE: Global Registry for Endovascular Aortic Treatment (GREAT) is an international prospective multicenter registry collecting real-world data on performance of W. L. Gore thoracic and abdominal aortic endografts. This analysis evaluated the long-term differences in patient survival and device performance in patients undergoing thoracic endovascular aortic repair (TEVAR) for any thoracic aortic pathology. METHODS: From August 2010 to October 2016, 5014 patients were enrolled in GREAT. The population of interest was comprised of only patients treated for thoracic aortic pathologies. Through 5 years, primary outcomes were all-cause and aortic-related mortality, stroke, aortic rupture, endoleaks, migration, fracture, compression, paraplegia, and any reintervention through 5 years, grouped by pathology. Secondary outcomes were reintervention rate and freedom from serious device- and aortic-related events. RESULTS: The 578 patients with thoracic aortic pathologies enrolled in GREAT and identified for this analysis were categorized by common pathologies: thoracic aneurysm (n = 239), thoracic dissection (n = 203), arch (n = 26), and other (n = 110). The mean age of this population was 66.1 ± 12.8 years, and 64.7% were male. Procedure survival was 99.7%. In the overall group, at index procedure to 30 days and 31 days to 5 years, Kaplan-Meier estimates of freedom from all-cause mortality were 99.6% and 66.4%, respectively, and for aortic-related mortality were 97.7% and 94.6%, respectively. Aortic rupture rate was 0.5% (n = 3) at 30 days and 1.4% (n = 8) through 5 years. Stroke and spinal cord ischemic events were 1.9% (n = 11) and 1.6% (n = 9) at 30 days and at 5 years were 3.6% (n = 20), 0.5% (n = 3), respectively. Reinterventions were required in 7.3% (n = 42) at 30 days and 12.4% (n = 69) through 5 years. The number of patients with endoleaks at 30 days was 2.1% (n = 12): n = 3 (1.1%) for each of types IA, 1B, and II; n = 2 (0.3%) for type III; and n = 4 (0.7%) for unspecified. Through 5 years, the percentage of patients was 8.3% (n = 40): n = 15 (3.1%) for type IA; n = 10 (2.1%) for type IB; n = 11 (2.3%) for type II; and n = 9 (1.9%) for unspecified. One patient (0.2%) had stent migration at 30 days (aneurysm group); none were reported through 5 years. There were no incidents of stent compression or fracture from index procedure through 5 years. CONCLUSIONS: Data herein demonstrates durability and support for treatment of thoracic aortic disease with the GORE TAG conformable thoracic stent graft, including no incidents of stent compression/fracture and high freedom from aortic-related mortality. The planned analysis of follow-up to 10 years in GREAT will be beneficial.