Role of intravascular ultrasound for the technical assessment of endovascular reconstruction of the aortic bifurcation.

OBJECTIVE: The aim of this study was to evaluate the role of intravascular ultrasound (IVUS) for the technical assessment of kissing stents (KSs) and covered endovascular reconstruction of the aortic bifurcation (CERAB) in the treatment of aortoiliac obstructive disease involving the aortic bifurcation. METHODS: We conducted a single-center retrospective review of patients undergoing endovascular treatment of severe aorto-iliac obstructive disease (2019-2023). IVUS was performed in patients treated by KSs or CERAB according to preoperative indications, in cases of moderate/severe calcifications, mural thrombus, total occlusions, and lesion extension towards the proximity of renal or hypogastric arteries. Indications for IVUS-guided intraoperative revisions were residual stenosis or compression >30%, incomplete stent-to-wall apposition, or flow-limiting dissection at the landing site. Follow-up assessment was performed at 6 and 12 months, and then yearly. Thirty-day outcomes and 2-year patency rates were evaluated. Logistic regression was used to identify factors associated with significant technical defects detected by IVUS needing intraoperative revision. RESULTS: IVUS was used for the technical assessment of 102 patients treated by KSs (n = 57; 56%) or CERAB (n = 45; 44%) presenting with severe intermittent claudication (39%), rest pain (39%), or ischemic tissue loss (25%). Twenty-nine significant technical defects were identified by IVUS in 25 patients (25%) who then had successful intraoperative correction by additional ballooning (n = 23; 80%) or stenting (n = 6; 20%). Patients with a severely calcified chronic total occlusion (odds ratio, 1.85; 95% confidence interval, 1.01-5.27; P = .044) or severely calcified narrow aortic bifurcation with <12 mm diameter (odds ratio, 2.34; 95% confidence interval, 1.10-8.64; P = .032) were at increased risk for IVUS-guided intraoperative revision. There were no postoperative deaths and no major adverse events. Two-year primary patency was 100%. CONCLUSIONS: IVUS was used for the technical assessment of KSs/CERAB in a selected cohort of patients with severe aorto-iliac obstructive disease. This allowed the identification and intraoperative correction of a significant technical defect not detected by completion angiogram in one-quarter of patients, achieving optimal 2-year results. IVUS assessment of KSs/CERAB may be considered especially in patients with a calcified total occlusion or narrow aortic bifurcation.

[Cost-revenue aspects of endovascular treatment of distal aortic arch pathologies with respect to the introduction of a new thoracic side-branch prosthesis]. / Kosten-Erlös-Aspekte der endovaskulären Versorgung distaler Aortenbogenpathologien im Hinblick auf die Einführung einer neuen thorakalen Seitenarmprothese.

BACKGROUND: The standard vascular surgical procedure (SV) for the treatment of distal aortic arch pathologies involves a hybrid approach using a left carotid-subclavian bypass and thoracic endovascular aortic repair. Considering the introduction of a thoracic side branch prosthesis (TBE), the aim of this study was to analyze the cost-revenue aspects of both procedures. MATERIAL AND METHODS: A retrospective analysis was conducted on cases treated by SV from 2017 to 2022. To draw conclusions regarding the use of TBE, the main diagnoses and procedures of SV were recoded based on current classifications (ICD/OPS 2023) for revenue calculations and regrouped according to aG-DRG 2023. An OPS modification and regrouping were performed for modeling TBE revenues. RESULTS: A total of 13 cases were identified (mean age 62.5 ± 13.8 years; 10 males). After regrouping, the following DRGs were obtained: F42Z in N = 5, F51A in N = 4, F08B in N = 2, and F07A and F36B each in N = 1. The total revenue after regrouping was €â€¯666,514.13, including an additional payment (ZE) of €â€¯132,729.14. With the modeled application of TBE, a total revenue of €â€¯659,212.19 was achieved. Compared to SV, this represents a revenue decrease of €â€¯16,886.71 (changed DRG), but with an increase in ZE revenue by €â€¯65,559.78 (different ZE). The use of TBE resulted in a saving of 74 occupancy days, including 13.5 days in intensive care. CONCLUSION: A cost coverage seems probable with a change in the procedure, despite the yet to be determined pricing of TBE. This is highly dependent on the coding quality and the future development of ZE, given the annually changing DRG relative weights. Precise and transparent performance and cost documentation are essential for determining the pricing.

Seguridad, efectividad y eficiencia del Catéter de Resucitación Endovascular para Oclusión de la Aorta (REBOA) / Safety, effectiveness and efficiency of Resuscitative Endovascular Ballon Occlusión of the Aorta (REBOA)

INTRODUCCIÓN: La patología traumática se encuentra entre las 5 principales causas de mortalidad, de ellas la hemorragia crítica traumática (HECTRA) es la principal causa de muerte evitable después de un traumatismo, suponiendo el 50% de las muertes en las primeras 24 horas. Según la base de datos RETRAUCI, aproximadamente un 6% de los pacientes ingresados en las UCI de Hospitales españoles por traumatismo presentan HECTRA, con una mortalidad hospitalaria del 35%. Teniendo en cuenta que esa mortalidad se refiere solo a los pacientes que ingresan en UCI, es muy probable que la mortalidad real de las HECTRA sea mucho mayor, si se incorporan los datos de muertes extrahospilatarias o en urgencias. El espectro de acretismo placentario (EAP) es una complicación obstétrica compleja asociada a una elevada morbilidad materna. Es un trastorno relativamente nuevo de la placentación, y es consecuencia de daños en la interfase endometrio-miometrio de la pared uterina. El EAP se produce en aproximadamente 1 de cada 1.000 partos. Estas cifras presentan variaciones importantes, probablemente debidas a la definición de la población de estudio, en función de la cual pueden oscilar entre el 0,04 al 0,9%. El EAP supone el 23% de las histerectomías periparto. El dispositivo REBOA (Balón endovascular resucitativo de oclusión aórtica) está compuesto por un catéter con un globo y la vaina de colocación. La colocación se realiza por inserción en arteria femoral. Una vez se ha inflado el globo del catéter REBOA de forma proximal a la lesión, se genera una obstrucción arterial que pretende evitar la hemorragia y mantener la irrigación mínima del cerebro, corazón y pulmones durante el tiempo necesario para que el paciente reciba atención sanitaria adecuada. Cuando REBOA es utilizada adecuadamente por profesionales con experiencia puede mejorar los resultados del subgrupo de pacientes con las lesiones más graves y las hemorragias más extensas. Los riesgos de REBOA incluyen la isquemia visceral total, la pérdida de miembros inferiores, la exacerbación de lesiones cerebrales traumáticas, la isquemia de la médula espinal, la pérdida rápida de sangre proximal y el efecto de lesión por reperfusión. En el caso del EAP, REBOA es una técnica preventiva alternativa y proporciona una oclusión más proximal. Esta técnica también se ha utilizado como complemento de la cirugía conservadora y tiene la ventaja de realizar un bloqueo adicional del riego de la placenta desde las arterias ilíacas externas, así como de detener el flujo en la arteria sacra media, lumbar baja y, en algunos casos, la arteria mesentérica inferior. REBOA se inserta con guía fluoroscópica antes del parto. Suele colocarse por debajo del origen de las arterias renales para evitar la isquemia de los riñones o las vísceras abdominales. El balón se inflaría tras el alumbramiento para prevenir la hemorragia. En España, la técnica REBOA se está utilizando cada vez más en hospitales especializados en cirugía traumática y en el tratamiento de pacientes con lesiones graves, del mismo modo que ha comenzado a utilizarse de modo preventivo en partos de mujeres con placenta acreta. OBJETIVO: Conocer la seguridad, efectividad y eficiencia de la técnica REBOA en pacientes con hemorragias abdominales, retroperitoneales y pélvicas o con espectro de acretismo placentario (EAP). METODOLOGÍA: Se ha realizado una revisión sistemática de la literatura científica disponible sobre efectividad, seguridad y eficiencia de REBOA en pacientes con hemorragia abdomino-pélvica traumática (REBOA terapéutica) o con EAP (REBOA preventiva). RESULTADOS: La RS llevada a cabo arrojó un resultado de 219 referencias de estudios, sin contar duplicados. De entre ellas se seleccionaron como fuente de partida 4 RS que permitieron restringir la búsqueda a aquellos estudios posteriores a las fechas de búsqueda de las mismas: febrero 2017 para REBOA preventiva en casos de EAP y mayo 2021 para REBOA terapéutica. Aplicando todos los criterios de cribado se seleccionaron, 6 estudios individuales posteriores a las revisiones mencionadas y uno más con análisis coste-utilidad. CONCLUSIONES: Reboa Terapéutica: La REBOA terapéutica resulta efectiva en la reducción de mortalidad a las 24 horas cuando se compara con toracotomía resucitativa (OR= 0,26; IC95%: 0,20 ­ 0,34). La certeza de la evidencia se valoró como baja. En general REBOA permite reducir la mortalidad hospitalaria respecto a cualquier comparador (OR= 0,90; IC95%: 0,81 ­ 0,99) (certeza de la evidencia muy baja). Especialmente en la comparación con TR (OR= 0,30; IC95%: 0,26 ­ 0,35), la certeza de la evidencia se valoró como moderada. REBOA también mejora la presión arterial sistólica tras la oclusión más que cualquier comparador (DM= 41,03 mmHg; IC95%: 36,77 ­ 45,29). La certeza de la evidencia se valoró como baja. REBOA es menos segura que sus comparadores en cuanto a amputación de extremidades inferiores, daño renal agudo, paraplejia, con una certeza de la evidencia baja y daño pulmonar agudo con una certeza de la evidencia calificada como muy baja. REBOA no resultaría eficiente según el único estudio identificado que se enmarca en el contexto del Reino Unido y que compara con toracotomía resucitativa. Reboa Preventiva: REBOA reduce el número de histerectomías cuando se utiliza como medida preventiva en partos de mujeres con espectro de acretismo placentario (EAP) (OR= 0,21; IC95%: 0,08 ­ 0,53). La certeza de la evidencia fue calificada como baja. La Reboa: preventiva también permite reducir el número de mujeres ingresadas en UCI (OR= 0,18; IC95%: 0,08 ­ 0,42) (certeza de la evidencia muy baja). Del mismo modo REBOA preventiva permite reducir las necesidades de transfusión y la duración de las intervenciones quirúrgicas de mujeres con EAP (certeza de la evidencia muy baja). REBOA preventiva no presenta más efectos adversos o complicaciones que sus comparadores (certeza de la evidencia muy baja).

INTRODUCTION: Traumatic pathology is among the 5 leading causes of mortality, of which traumatic critical haemorrhage (TCH) is the main cause of avoidable death after trauma, accounting for 50% of deaths in the first 24 hours. According to the RETRAUCI database, approximately 6% of the patients admitted to the ICU of Spanish hospitals for trauma present TCH, with a hospital mortality of 35%. Bearing in mind that this mortality refers only to patients admitted to the ICU, it is very likely that the real mortality of TCH is much higher if the data on deaths outside the hospital or in the emergency department are included. Placental accreta spectrum disorder (PAD) is a complex obstetric complication associated with high maternal morbidity. It is a relatively new disorder of placentation, resulting from damage to the endometrial-myometrial interface of the uterine wall. PAD occurs in approximately 1 in 1000 deliveries. These figures vary widely, probably due to the definition of the study population, depending on which may range from 0.04 to 0.9%. PAP accounts for 23% of peripartum hysterectomies. The REBOA device (Resuscitative Endovascular Balloon Aortic Occlusion) consists of a catheter with a balloon and delivery sheath. Placement is by insertion into the femoral artery. Once the balloon of the REBOA catheter is inflated proximal to the lesion, an arterial blockage is created to prevent bleeding and maintain minimal blood supply to the brain, heart and lungs for the time necessary for the patient to receive adequate care. When used properly by experienced professionals, REBOA can improve outcomes for the subgroup of patients with the most severe injuries and extensive bleeding. Risks of REBOA include total visceral ischaemia, lower limb loss, exacerbation of traumatic brain injury, spinal cord ischaemia, rapid proximal blood loss and reperfusion injury effect. In the case of PAD, REBOA is an alternative preventive technique and provides a more proximal occlusion. This technique has also been used as an adjunct to conservative surgery and has the advantage of additional blockage of the placental supply from the external iliac arteries, as well as stopping flow in the middle sacral, lower lumbar and, in some cases, the inferior mesenteric artery. REBOA is inserted under fluoroscopic guidance prior to delivery. It is usually placed below the origin of the renal arteries to avoid ischaemia of the kidneys or abdominal viscera. The balloon would be inflated after delivery to prevent haemorrhage. In Spain, the REBOA technique is increasingly being used in hospitals specialising in trauma surgery and in the treatment of patients with severe injuries, and has also begun to be used preventively in the delivery of women with PAD. OBJECTIVE: To determine the safety, effectiveness and efficiency of the REBOA technique in patients with abdominal, retroperitoneal and pelvic haemorrhage or with PAD. METHODOLOGY: A systematic review of the available scientific literature on the effectiveness, safety and cost-effectiveness of REBOA in patients with traumatic abdomino-pelvic haemorrhage (therapeutic REBOA) or with PAD (preventive REBOA) was carried out. RESULTS: The SR carried out yielded 219 study references, excluding duplicates. Of these, 4 SR were selected as a starting source, which allowed us to restrict the search to those studies after their search dates: February 2017 for preventive REBOA in cases of PAD and May 2021 for therapeutic REBOA. Applying all the screening criteria, 6 individual studies were selected after the aforementioned reviews and one more with cost-utility analysis. CONCLUSIONS: Therapeutic Reboa: Therapeutic REBOA is effective in reducing 24-hour mortality when compared to resuscitative thoracotomy (OR= 0.26; 95%CI: 0.20 ­ 0.34). The certainty of the evidence was assessed as low. Overall, REBOA reduces in-hospital mortality compared to any comparator (OR= 0.90; 95%CI: 0.81 ­ 0.99) (very low certainty of evidence). Especially in the comparison with TR (OR= 0.30; 95%CI: 0.26 ­ 0.35), the certainty of evidence was assessed as moderate. REBOA also improves systolic blood pressure after occlusion more than any comparator (MD= 41.03 mmHg; 95% CI: 36.77 ­ 45.29). The certainty of the evidence was assessed as low. REBOA is less safe than its comparators in terms of lower limb amputation, acute kidney damage, paraplegia with a certainty of evidence rated as low. and acute lung damage, with a certainty of evidence rated as very low. REBOA wouldn't be efficient according to the only identified study in the UK context comparing with TR. Preventive Reboa: REBOA reduces the number of hysterectomies when used as a preventive measure in deliveries of women with PAD (OR= 0.21; 95%CI: 0.08 ­ 0.53). Certainty of evidence rated as low. Preventive REBOA also reduces the number of women admitted to the ICU (OR= 0.18; 95%CI: 0.08 ­ 0.42) (certainty of evidence very low). Similarly, preventive REBOA reduces transfusion requirements and the duration of surgery for women with PAD (certainty of evidence very low). Preventive REBOA has no more adverse effects or complications than its comparators (certainty of evidence very low).

Assessment of Thoracic Endovascular Aortic Repair Using Relay Proximal Scallop: Results of a French Prospective Multicentre Study.

OBJECTIVE: A proximal scallop design allows aortic arch repair without complex endovascular manipulation in the aortic arch. The aim was to assess the safety and efficacy at one year of the Relay proximal scallop stent graft. METHODS: A prospective multicentre study evaluated consecutive patients treated with the Relay proximal scallop stent graft in 10 French aortic centres. All consecutive patients eligible for elective thoracic endovascular repair with proximal scallop in the 10 participating centres between January 2015 and July 2018 were included. Primary endpoints were 30 day mortality, stroke, and spinal cord ischaemia (SCI) rates. Outcomes including safety and efficacy, technical and clinical success, all cause death, neurological events, vessel patency, and device specific complications were analysed. Survival and survival without severe complications were estimated using Kaplan-Meier estimates. RESULTS: Ten aortic centres treated 40 patients for thoracic aortic aneurysm (45%), penetrating atherosclerotic aneurysm (30%), and dissection (25%). Half of the procedures (50%) targeted zone 0 of the aortic arch (zone 0 in 17.5% and zones 0/1 in 32.5%), 37.5% targeted zone 2 (35% zone 2 alone; 2.5% zones 1/2), and 15% targeted zone 1 (12.5% zone 1 alone). Median follow up was one year. Thirty day mortality, stroke, and SCI rates were 10%, 5%, and 0% respectively. Primary technical success was 95%. Type Ia, Ib, and III endoleaks rates were 5.4%, 0%, and 0% respectively at one month. The overall mortality rate at one year was 17.5%. Aneurysm expansion was > 5 mm in one case at one year associated with type Ia endoleak (3%). There was no supra-aortic trunk thrombosis, one (2%) graft kink, and no migration. CONCLUSION: One year outcomes showed that the Relay proximal scallop stent graft is an acceptable answer to thoracic aortic disease to deal with short proximal landing zones.

Open Versus Endovascular Repair With Covered Stents for Complex Aortoiliac Occlusive Disease: Cost Analysis Results.

BACKGROUND: The aim of this work is to value cost-effectiveness of complex aortoiliac occlusive disease (AIOD) revascularization, by comparing in-hospital clinical outcomes and detailed costs of hospitalization of open and endovascular techniques. METHODS: This observational single-center retrospective cohort study included all patients who underwent AIOD revascularization from May 2008 to February 2018 and met inclusion and exclusion criteria. Patients were divided into 2 groups: open surgical repair and endovascular repair. Inclusion criteria were type C and D AIOD, and type of intervention: aorto-bifemoral bypass and covered kissing stenting. Costs were directly compared between the 2 groups, and subsequently a multivariate logistic regression model was performed to define which group most influenced major in-hospital costs. Cox proportional hazard models were used to identify predictors of long-term mortality and primary patency (PP). RESULTS: The 2 groups included 50 patients each, and all patients had a bilateral iliac axis revascularization. Mean age was 67 ± 9 years and 71% of patients were males. The open surgical repair group had a significantly longer length of hospitalization (P < 0.001) and in-hospital medical complications rate (22%, P = 0.003). No differences were found in the total cumulative cost of hospitalization, including ward, intensive care unit, and operating room. In a multivariate logistic model, higher total hospitalization costs were not significantly associated with either one or the other type of treatment. We did not find any statistically significant differences in overall medium-term survival (P = 0.298) and PP (P = 0.188), which were not influenced by the type of revascularization on Cox proportional hazard models (overall survival: hazard ratio 2.09 confidence interval 95% [0.90-4.84] P = 0.082; PP: hazard ratio 1.82 confidence interval 95% [0.56-6.16] P = 0.302). CONCLUSIONS: Total in-hospital stay cost analysis did not reveal significant differences between aorto-bifemoral bypasses and covered kissing stentings for AIOD revascularization.

Association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery.

OBJECTIVE: To examine whether there is an association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery. METHODS: A retrospective cohort study using a national clinical database in Japan was conducted. Patients who underwent emergency thoracic aortic surgery from January 1, 2014, to December 31, 2016, were included. Patients with type B dissection were excluded. A multilevel logistic regression analysis was performed to examine the association between prehospital transfer distance and surgical mortality. In addition, an instrumental variable analysis was performed to address unmeasured confounding. RESULTS: A total of 12,004 patients underwent emergency thoracic aortic surgeries at 495 hospitals. Surgical mortality was 13.8%. The risk-adjusted mortality odds ratio for standardized distance (mean 12.8 km, standard deviation 15.2 km) was 0.94 (95% confidence interval, 0.87-1.01; P = .09). Instrumental variable analysis did not reveal a significant association between transfer distance and surgical mortality as well. CONCLUSIONS: No significant association was found between surgical mortality and prehospital transfer distance in emergency thoracic aortic surgery cases. Suspected cases of acute thoracic aortic syndrome may be transferred safely to distant high-volume hospitals.

The impact of hospital size on national trends and outcomes in isolated open proximal aortic surgery.

OBJECTIVE: To determine the impact of hospital size on national trend estimates of isolated open proximal aortic surgery for benchmarking hospital performance. METHODS: Patients age >18 years who underwent isolated open proximal aortic surgery for aneurysm and dissection from 2002 to 2014 were identified using the National Inpatient Sample. Concomitant valvular, vessel revascularization, re-do procedures, endovascular, and surgery for descending and thoracoabdominal aorta were excluded. Discharges were stratified by hospital size and analyzed using trend, multivariable regression, propensity-score matching analysis. RESULTS: Over a 13-year period, 53,657 isolated open proximal aortic operations were performed nationally. Although the total number of operations/year increased (∼2.9%/year increase) and overall in-hospital mortality decreased (∼4%/year; both P < .001 for trend), these did not differ by hospital size (P > .05). Large hospitals treated more sicker and older patients but had shorter length of stay and lower hospital costs (both P < .001). Even after propensity-score matching, large hospital continued to demonstrate superior in-hospital outcomes, although only statistically for major in-hospital cardiac complications compared with non-large hospitals. In our subgroup analysis of dissection versus non-dissection cohort, in-hospital mortality trends decreased only in the non-dissection cohort (P < .01) versus dissection cohort (P = .39), driven primarily by the impact of large hospitals (P < .01). CONCLUSIONS: This study demonstrates increasing volume and improving outcomes of isolated open proximal aortic surgeries nationally over the last decade regardless of hospital bed size. Moreover, the resource allocation of sicker patients to larger hospital resulted shorter length of stay and hospital costs, while maintaining similar operative mortality to small- and medium-sized hospitals.

Mid-Term Survival after Thoracic Endovascular Aortic Repair by Indication in the Medicare Population.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is indicated for treatment of aneurysms, dissections, and traumatic injury. We describe mid-term mortality and reintervention rates in Medicare beneficiaries undergoing TEVAR. STUDY DESIGN: Patients who underwent TEVAR between 2006 and 2014 were identified by CPT codes in a 20% Medicare sample. Indication for aortic repair (aneurysm, dissection, trauma) was ascertained via ICD-9 codes. Follow-up was evaluated until 2015. Kaplan-Meier survival analysis and Cox regression were used to compare mortality, with reintervention and mortality rates expressed as a composite outcome in a hazard ratio with 95% confidence interval (hazard ratio [HR] 95% CI). RESULTS: There were 3,095 patients who underwent TEVAR during the study period: 1,465 (47%) for aneurysm, 1,448 (47%) for dissection, and 182 (5.9%) for trauma. Mean patient age was 74.4 years, and 44.5% were female. Median follow-up was 2.7 years. The overall 30-day, 1-year, and 5-year, and 8-year survival rates were 93%, 78%, 49%, and 33%, respectively. Thirty-day mortality was highest in traumatic indications, but overall mortality was highest in patients undergoing TEVAR for aneurysm. Freedom from combined reintervention and mortality at 30 days, 1 year, 5 years, and 8 years was 89%, 73%, 43%, and 29%, respectively. Reintervention was highest in patients undergoing TEVAR for dissection (12.8%), followed by aneurysm (10.0%) and trauma (5.5%). Advanced age (HR 1.03 per year, 95% CI 1.02-1.03), congestive heart failure (CHF) (HR 1.48, 95% CI 1.33-1.65), dementia (HR 1.40, 95% CI 1.14-1.28), and rupture (HR 1.38, 95% CI 1.24-1.54) were associated with mortality. CONCLUSIONS: Midterm survival is lower in patients who undergo TEVAR for dissection and aneurysm compared with trauma. Aneurysmal disease, advanced age, CHF, dementia, and aortic rupture are associated with mortality and reintervention in TEVAR.

Persistent Opioid Use After Open Aortic Surgery: Risk Factors, Costs, and Consequences.

BACKGROUND: The incidence and financial impact of persistent opioid use (POU) after open aortic surgery is undefined. METHODS: Insurance claim data from opioid-naïve patients who underwent aortic root replacement, ascending aortic replacement, or transverse arch replacement from 2011 to 2017 were evaluated. POU was defined as filling an opioid prescription in the perioperative period and between 90 and 180 days postoperatively. Postoperative opioid prescriptions, emergency department visits, readmissions, and health care costs were quantified. Multivariable logistic regression identified risk factors for POU, and quantile regression quantified the impact of POU on postoperative health care costs. RESULTS: Among 3240 opioid-naïve patients undergoing open aortic surgery, 169 patients (5.2%) had POU. In the univariate analysis, patients with POU were prescribed more perioperative opioids (375 vs 225 morphine milligram equivalents, P < .001), had more emergency department visits (45.6% vs 25.4%, P < .001), and had significantly higher health care payments in the 6 months postoperatively ($10,947 vs $7223, P < .001). Independent risk factors for POU in the multivariable logistic regression included preoperative nicotine use and more opioids in the first perioperative prescription (all P < .05). After risk adjustment, POU was associated with a $2439 increase in total health care costs in the 6 months postoperatively. CONCLUSIONS: POU is a challenge after open aortic operations and can have longer-term impacts on health care payments and emergency department visits in the 6 months after surgery. Strategies to reduce outpatient opioid use after aortic surgery should be encouraged when feasible.

[Perioperative Risk Management for Extensively Atheromatous Aortic Disease].

Extensive atheromatous disease of the thoracic aorta is a significant risk factor of lethal complications and remains an unsolved issue in patients undergoing cardiovascular surgery. The disease condition has been documented to be associated not only with high operative risk but also with relatively poor prognosis especially in patients with aortic replacement, due to the susceptibility to potential embolic events such as neurological deficits. To achieve favorable outcomes after surgical intervention, precise preoperative evaluation and meticulous surgical planning are important. 3-dimensional computed tomography (CT) can reveal detailed aortic lesions, graftable anastomotic sites, suitable cannulation sites, risk score related to thoracic endovascular aortic repair (TEVAR). Despite the tendency that atheromatous lesions are extensive and multiple, a selected treatment would better be targeted only for clinically significant pathologic site to minimize the risks associated with surgical intervention. In addition, realistic anticipation and subsequent preparation for potential second operation should also be planned. As for a representative aortic surgery, total aortic arch replacement has been the most frequently performed procedure in Japan. When extensive atheromatous lesions are encountered around the arch and supra-aortic branches, rapid switching over to isolation of neck vessels and selective cerebral perfusion is recommended rather than solely relying on the right axillar artery perfusion. Retrograde cerebral perfusion may also be employed in a case with hostile cervical arterial lesions. Besides surgical strategy, peri-operative managements including preservation of renal and gastrointestinal functions are of paramount importance, and definitely influence the post-operative quality of life in patients with extensive atheromatous disease.

Trends of vascular surgery procedures in Marfan syndrome and Ehlers-Danlos syndrome.

OBJECTIVES: Marfan syndrome and Ehlers-Danlos syndrome represent two connective tissue vascular diseases requiring unique consideration in their vascular surgical care. A comprehensive national review encompassing all hospitalizations for the Marfan Syndrome and Ehlers-Danlos syndrome patient population is lacking. METHODS: The National (Nationwide) Inpatient Sample from 2010 to 2014 was reviewed for all inpatient vascular surgery procedures including those with a diagnosis of Marfan syndrome and Ehlers-Danlos syndrome. National estimates of vascular surgery rates were generated from provided weights. Patient demographics, procedure type, and outcomes were assessed. RESULTS: There were 3103 Marfan syndrome and 476 Ehlers-Danlos syndrome vascular procedures identified as well as 3,895,381 vascular procedures in the remainder of population (control group). The percent of aortic procedures from all vascular procedures in Marfan syndrome (23.5%) and Ehlers-Danlos syndrome (23.5%) were 2.5-fold higher than controls (9.1%), p < 0.0001. Open aortic aneurysm repair was also significantly greater in both Marfan syndrome (16.8%) and Ehlers-Danlos syndrome (11.2%) compared to controls (4.4%), p < 0.0001. Endovascular aortic repair (p < 0.2302) was similar among the groups. Marfan syndrome (7.7%) and Ehlers-Danlos syndrome (5.1%) had more thoracic endovascular aortic repair performed than controls (0.7%), p < 0.0001. Percutaneous procedures were fewer in Marfan syndrome (6.3%) than controls (31.3%) and Ehlers-Danlos syndrome (26.3%), p < 0.0001, while repair of peripheral arteries was greater in Marfan syndrome (5.9%) and Ehlers-Danlos syndrome (4.1%) than controls (1.5%), p < 0.0001. For total aortic procedures, the mean age of aortic procedures was 68.2 years in controls vs 45.8 years in Marfan syndrome and 55.3 years in Ehlers-Danlos syndrome, p < 0.0001. Marfan syndrome and Ehlers-Danlos syndrome had fewer comorbidities overall, while controls had significantly higher rates of coronary artery disease (controls 39.9% vs Marfan syndrome 8.3% and Ehlers-Danlos syndrome 13.0%, p < 0.0001), peripheral vascular disease (controls 34.5% vs Marfan syndrome 4.2% and Ehlers-Danlos syndrome 8.7%, p < 0.0001), and diabetes (controls 20.6% vs Marfan syndrome 6.6 and Ehlers-Danlos syndrome 4.4%, p < 0.0001). Marfan syndrome and Ehlers-Danlos syndrome had higher overall complication rate (65.5% and 52.2%) compared to controls (44.6%), p < 0.0001. Postoperative hemorrhage was more likely in Marfan syndrome (42.9%) and Ehlers-Danlos syndrome (39.1%) than controls (22.2%), p < 0.0001. Increased respiratory failure was noted in Marfan syndrome (20.2%) vs controls (10.7%) and Ehlers-Danlos syndrome (8.7%), p = .0003. Finally, length of stay was increased in Marfan syndrome 12.5 days vs Ehlers-Danlos syndrome 7.4 days and controls 7.2 days (p < 0.0001) as well as a higher median costs of index hospitalization in Marfan syndrome ($57,084 vs Ehlers-Danlos syndrome $22,032 and controls $26,520, p < 0.0001). CONCLUSIONS: Patients with Marfan syndrome and Ehlers-Danlos syndrome differ from other patients undergoing vascular surgical procedures, with a significantly higher proportion of aortic procedures including open aneurysm repair and thoracic endovascular aortic repair. While they are younger with fewer comorbidities, due to the unique pathogenesis of their underlying connective tissue disorder, there is an overall higher rate of procedural complications and increased length of stay and cost for Marfan syndrome patients undergoing aortic surgery.

[Type A acute aortic syndromes: Assessment of the management delays in an emergency medicine network]. / Syndromes aortiques aigus de type A : évaluation des délais de prise en charge dans un réseau de médecine d'urgence.

OBJECTIVE: To assess the diagnostic delay (between first hospital medical contact and diagnosis) and the surgical delay (between diagnosis and incision) of type A acute aortic syndromes (AAAS) within the RENAU (REseau Nord Alpin des Urgences), organizing the management of emergency medicine care in the French North Alpine Arc. PROCEDURE: Multicenter retrospective study between 2012 and 2016 on the AAAS operated in the RENAU heart surgical centers (Annecy, Grenoble). Post-traumatic, iatrogenic or chronic lesions, incidental discoveries and deaths before surgery were excluded. RESULTS: One hundred and ninety-seven patients were included with a median age [IQR] of 65 years [58; 73] of which 67% were men. The median diagnosis delay was 88min [46;241] and the median surgical delay was 193min [146;249]. Initial management was performed by the SMUR for 102 patients (52%), 7% of whom received a pre-hospital transthoracic ultrasound. 52 patients (26%) presented themselves spontaneously to the emergency department. Patients were initially admitted in a center without cardiac surgery in 65% of cases. The CT scan was the diagnostic test in 81% of cases. The postoperative hospital mortality was 16%. CONCLUSION: Referring to IRAD data reporting a median diagnostic and surgical delay of 258min each, our study suggests that the RENAU organization may be associated with reduced diagnostic and surgical delays for patients with SAAA.

National Study of Index and Readmission Mortality and Costs for Thoracic Endovascular Aortic Repair in Patients With Renal Disease.

BACKGROUND: In the current era of value-based health care delivery, an understanding of patient populations at greatest risk for mortality, complications, and readmissions after thoracic endovascular aortic repair (TEVAR) is warranted. Thus, the present study aimed to evaluate outcomes after TEVAR for patients with varying degrees of renal dysfunction. METHODS: All patients who underwent TEVAR from 2010 to 2015 in the Nationwide Readmissions Database were identified. These patients were further stratified into four groups: no chronic kidney disease (NCKD), chronic kidney disease (CKD) stages 1 to 3 (CKD1-3), CKD 4 to 5 (CKD4-5), and end-stage renal disease (ESRD) requiring dialysis. Multivariable regression analysis was used to study index mortality, early (30 days) and intermediate (31-90 days) readmissions, costs, and length of stay. Kaplan-Meier analyses were performed to compare readmission performance among all four groups. RESULTS: An estimated 121,046 patients underwent TEVAR with 26,653 (22.1%) being elective. Patients with ESRD comprised 2.7% of elective and 5.4% of nonelective TEVAR operations. Patients with CKD4-5 (17.8%; P = .01) and with ESRD (21.1%; P < .001), but not with CKD1-3 (14.1%; P = .12), had remarkably higher early readmission rate than the NCKD cohort (9.2%). Patients with ESRD had remarkably higher hospitalization costs than the NCKD group ($7456; 95% confidence interval, $2629-$12,283). Cardiovascular, infectious, and vascular complications were the most prevalent diagnoses on readmission, with no remarkable difference among the NCKD and CKD4-5/ESRD groups. CONCLUSIONS: Nearly 10% of all patients with TEVAR have evidence of chronic kidney disease of varying severity. Only patients with ESRD are at risk of substantially higher odds of mortality, readmissions, index length of stay, and costs compared with the non-CKD cohort.

Endovascular Approach Versus Aortobifemoral Bypass Grafting: Outcomes in Extensive Aortoiliac Occlusive Disease.

OBJECTIVE: Compare technical, clinical, and economic outcomes between endovascular and open approaches in patients with type D aortoiliac occlusive disease according to the TransAtlantic Inter-Society Consensus. METHODS: Patients undergoing revascularization for type D aortoiliac lesions, either endovascular or open surgery approach, from 2 Portuguese institutions between January 2011 and October 2017 were included. The surgical technique was left to the surgeon discretion. Patients with common femoral artery affection, both obstructive and aneurysmatic, were excluded. RESULTS: Twenty-seven patients underwent aortobifemoral bypass and 32 patients were submitted to endovascular repair. The patients undergoing endovascular procedure were more likely to present with chronic heart failure (P = .001) and chronic kidney disease (P = .022) and less likely to have a history of smoking (P = .05). The mean follow-up period was 67.84 (95% confidence interval = 61.85-73.83) months. The open surgery approach resulted in a higher technical success (P = .001); however, limb salvage and patency rates were not different between groups. Endovascular approach was associated with a shorter length-of-stay, both inpatient (6 vs 9 days; P = .041) and patients admitted in the intensive care unit (0 vs 3.81 days; P = .001) as well as lower hospital expenses (US$9281 vs US$23 038; P = .001) with a similar procedure cost (US$2316 vs US$1173; P = .6). No differences were found in the postsurgical quality of life. CONCLUSION: Endovascular approach is, at least, clinically equivalent to open surgery approach and is more cost-efficient. The "endovascular-first" approach should be considered for type D occlusive aortoiliac lesions.

The Consequences of Negligence Claims in Arterial Surgery - An Analysis of Two Periods with an Increasing Use of Endovascular Treatment.

OBJECTIVES: Patient treatment within the Swedish medical service system can claim negligence injuries to the malpractice insurance review board and request financial compensation. The aim of this paper was to analyse the consequences of a negligence claim after arterial surgery between two periods with increasing use of endovascular treatment. METHODS: This was a retrospective cohort study of the arterial surgery negligence claims from two three year periods 2005-2007 (Period A) and 2012-2014 (Period B) from the County Council's Mutual Insurance Company. The analysis was restricted to aortic, carotid, and lower limb arterial diseases. The magnitude of surgery for vascular diseases was obtained from the Swedish vascular register (Swedvasc). RESULTS: The number of patients undergoing arterial procedures increased from 16 628 to 20 709 (p = .01). There was an increase of 54% in the number of negligence claims between the periods. In Period A, the number of compensated claims was 22 out of 83 (29%) and in Period B 60 out of 151 (41%) (p = .06). Patients treated for aortic disorders and peripheral arterial surgery received compensation with increasing frequency whereas carotid diseases decreased. Claimants treated for aortic disorders were compensated in four out of 23 (17%) and 21 out of 54 (39%) in the two periods (p = .07), and after lower limb arterial surgery in six out of 34 (18%) and in 24 out of 71 (34%) (p = .09). After carotid surgery the corresponding figures were 12 out of 26 (46%) and 14 out of 25 (46%) (p = .48). The increasing use of endovascular procedures (but not in carotid artery surgery) did not seem to influence the pattern of negligence claims. CONCLUSIONS: Between the two three year periods there has been an increase in negligence claims but not in compensated ones. The increased use of endovascular procedures has not influenced the pattern of compensated negligence claims.

An economic analysis of medical and surgical management of aortopathy associated with bicuspid aortic valve.

AIMS: To develop a cost-effectiveness model to address the outcome and economic implications of different thresholds for surgery in the management of aortopathy associated with bicuspid aortic valve disease. METHODS AND RESULTS: A model was created from the perspective of an Australian healthcare funding agency. The index case was a 65-year-old with bicuspid aortic valve (BAV) and ascending aorta diameter of 5.0 cm. Health states were defined as: pre-operative with dilated aorta, post-operative without complications, post-complication, and death. The mean and variance of risks and transition probabilities were taken from a local surgical database and local costs and utilities of elective and urgent thoracic aortic surgery (AoS) with or without aortic valve replacement, with a sensitivity analysis based on a systematic review. Scenario analyses were provided for other aortic dimensions. Implications for survival, quality-adjusted life years (QALYs), and costs were calculated from healthcare delivery and economic perspectives. After 10 000 simulations for the reference case, the utility of watchful waiting (WW) exceeded that of elective AoS (13 ± 4 vs. 10 ± 5 QALY). The net monetary benefit was A$351 063 ± 304 965 with immediate AoS vs. 534 797 ± 198 570 with WW surveillance. The most important variables affecting effectiveness were utility value of survivors, rate of aortic growth, and probability of acute aortic event during WW. CONCLUSIONS: This decision-analytic model informed by our practice, as well as a systematic analysis, shows that AoS in a BAV patient with aorta <5 cm diameter is costlier and less effective than WW.

Left ventricular assist device implantation combined with bentall procedure

Abstract Ventricular assist devices (VADs) are an important technological development for patients with end-stage heart failure, and approximately 50% of these patients require various additional cardiac procedures. Here we presente the case of a patient suffering from severe aortic insufficiency, aortic root dilatation, and an ascending aortic aneurysm with end-stage decompensated heart failure. We performed the Bentall procedure combined with a left VAD implantation during the same session. The postoperative period was uneventful for this patient, and he was discharged on the 32nd postoperative day. The heart failure symptoms of the patient are reasonable, and he is still on the heart transplantation waiting list.

Left Ventricular Assist Device Implantation Combined with Bentall Procedure.

Ventricular assist devices (VADs) are an important technological development for patients with end-stage heart failure, and approximately 50% of these patients require various additional cardiac procedures. Here we presente the case of a patient suffering from severe aortic insufficiency, aortic root dilatation, and an ascending aortic aneurysm with end-stage decompensated heart failure. We performed the Bentall procedure combined with a left VAD implantation during the same session. The postoperative period was uneventful for this patient, and he was discharged on the 32nd postoperative day. The heart failure symptoms of the patient are reasonable, and he is still on the heart transplantation waiting list.

Multimodality imaging assessment of endoleaks post-endovascular aortic repair.

Endoleaks are a common complication of endovascular aortic repair (EVAR). As a result, patients require lifelong imaging surveillance following EVAR. In current clinical practice, evaluation for endoleaks is predominantly performed with CT angiography (CTA). Due to the significant cumulative radiation burden associated with repetitive CTA imaging, as well as the repeated administration of nephrotoxic contrast agent, contrast-enhanced ultrasound (CEUS) and magnetic resonance angiography (MRA) have evolved as potential modalities for lifelong surveillance post-EVAR. In this paper, multimodality imaging, including CTA, CEUS and MRA, for the surveillance of endoleaks is discussed. Further, new CTA techniques for radiation reduction are elaborated. Additionally, imagery for three cases of aortic endoleak detection using CTA and five cases using MRA are presented. Imaging for different types of endoleaks with CTA, MRA and CEUS are presented. For lifelong endoleak surveillance post-EVAR, CTA is still regarded as the imaging modality of choice. However, advancements in CEUS and MRA technique enable partial replacement of CTA in certain patients.