A meta-analysis of locoregional anesthesia versus general anesthesia in endovascular repair of ruptured abdominal aortic aneurysm.

OBJECTIVE: To conduct a meta-analytic review of studies investigating the effect of the anesthesia modality on perioperative mortality in endovascular repair of ruptured abdominal aortic aneurysms (REVAR). METHODS: The present meta-analysis was performed in accordance with the PRISMA guidelines. Multiple electronic databases were comprehensively searched from database inception to January 2020. Eligible studies included cohort studies that reported the 30-day/in-hospital mortality rate or the multivariate adjusted odds ratio (OR) or hazard ratio of the mortality risk for patients who underwent emergency REVAR under locoregional anesthesia (LA) vs general anesthesia (GA). A random effects model was used to estimate the ORs by pooling the related data from individual studies. RESULTS: A total of eight studies were included in this analysis. The first meta-analysis of seven studies that reported the 30-day/in-hospital mortality with a total of 3116 patients (867 in the LA group and 2249 in the GA group) revealed that LA was associated with a lower 30-day/in-hospital mortality than GA (16.4% vs 25.4%; unadjusted OR, 0.47; 95% confidence interval [CI], 0.32-0.68). The second meta-analysis of three of these seven studies (including 586 patients in the LA group and 1945 in the GA group) that reported the perioperative variables revealed comparable baseline characteristics but a lower 30-day/in-hospital mortality in the LA group (unadjusted OR, 0.55; 95% CI, 0.42-0.71). The third meta-analysis of the adjusted ORs or hazard ratios that were reported from four studies (including 501 patients in the LA group and 1136 in the GA group) showed a similar trend (adjusted OR,0.37; 95% CI, 0.19-0.75). CONCLUSIONS: REVAR under LA is associated with a lower 30-day/in-hospital mortality than REVAR under GA. However, because the included studies may have had some observation bias, further randomized controlled trials are warranted to validate the present results.

Midterm outcomes for 605 patients receiving Endologix AFX or AFX2 Endovascular AAA Systems in an integrated healthcare system.

BACKGROUND: Endologix issued important safety updates for the AFX Endovascular AAA System in 2016 and 2018 owing to the risk of type III endoleaks. Outcomes with these devices are limited to small case series with short-term follow-up. We describe the midterm outcomes for a large cohort of patients who received an Endologix AFX or AFX2 device. STUDY DESIGN: Data from an integrated healthcare system's implant registry, which prospectively monitors all patients after endovascular aortic repair, was used for this descriptive study. Patients undergoing endovascular aortic repair with three AFX System variations (Strata [AFX-S], Duraply [AFX-D], and AFX2 with Duraply [AFX2]) were identified (2011-2017). Crude cumulative event probabilities for endoleak (types I and III), major reintervention, conversion to open, rupture, and mortality (aneurysm related and all cause) were estimated. RESULTS: Among 605 patients, 375 received AFX-S, 197 received AFX-D, and 33 received AFX2. Median follow-up for the cohort was 3.9 (interquartile range, 2.5-5.1) years. The crude 2-year incidence of overall endoleak, any subsequent reintervention or conversion, and mortality was 8.8% (95% confidence interval [CI], 6.3-12.3), 12.0% (95% CI, 9.1-15.9), and 8.8% (95% CI, 6.3-12.2) for AFX-S. Respective estimates for AFX-D were 7.9% (95% CI, 4.8-13.0), 10.6% (95% CI, 6.9-16.1), and 9.7% (95% CI, 6.3-14.7); for AFX2, they were 14.1% (95% CI, 4.7-38.2), 16.2% (95% CI, 6.4-37.7), and 21.2% (95% CI, 10.7-39.4). CONCLUSIONS: The midterm outcomes of a large U.S. patient cohort with an Endologix AFX or AFX2 System demonstrate a concerning rate of adverse postoperative events. Patients with these devices should receive close clinical surveillance to prevent device-related adverse events.

Decreased mortality with local versus general anesthesia in endovascular aneurysm repair for ruptured abdominal aortic aneurysm in the Vascular Quality Initiative database.

BACKGROUND: Endovascular aneurysm repair (EVAR) is an accepted approach for patients presenting with ruptured abdominal aortic aneurysm (rAAA) and suitable anatomy. The effect of anesthesia modality on mortality outcomes in rAAA has not been well described. Using the Vascular Quality Initiative database, this study compares local anesthesia (LA) vs general anesthesia (GA) in EVAR for rAAA. METHODS: The Vascular Quality Initiative database was queried for patients presenting with rAAA managed with open surgical repair, EVAR under LA (rEVAR-LA), and EVAR under GA (rEVAR-GA) between 2003 and 2017. Patients were observed until the earlier end point of either death or 1-year follow-up. Kaplan-Meier event rates are presented at 30 days and 1 year. Cox proportional hazards regression was used to model risk of death, with adjustment for demographic and clinical factors. Additional multivariate Cox hazards analyses were used to assess effect modifiers for 1-year mortality for the different repair methods. RESULTS: A total of 3330 patients (77.4% male) met the inclusion criteria (1594 [47.9%] open surgical repair, 226 [6.8%] rEVAR-LA, and 1510 [45.3%] rEVAR-GA). Patients treated with rEVAR-LA compared with rEVAR-GA had decreased intraoperative time, number of intraoperative blood transfusions, intraoperative crystalloid administration, intensive care unit length of stay, and postoperative pulmonary complications. Mortality rates with rEVAR-LA were lower compared with rEVAR-GA at 30 days (15.5% vs 23.3%; adjusted hazard ratio [AHR], 0.70; 95% confidence interval [CI], 0.49-0.99; P = .04) and at 1 year (22.5% vs 32.3%; AHR, 0.71; 95% CI, 0.53-0.96; P = .02). Patients undergoing EVAR who were <75 years old and those without preoperative hypotension had the greatest survival benefit from LA compared with GA (both factors: AHR, 0.14 [95% CI, 0.03-0.57]; single factor: AHR, 0.57 [95% CI, 0.36-0.91]). CONCLUSIONS: This study demonstrates that rEVAR-LA for rAAA may be a safe alternative to rEVAR-GA for certain patients, with lower morbidity and improved mortality. Further prospective study is warranted to confirm mortality benefit in rEVAR-LA for rAAA.

Local anaesthesia for endovascular repair of ruptured abdominal aortic aneurysm.

BACKGROUND: Case series and a post hoc subgroup analysis of a large randomized trial have suggested a potential benefit in treating ruptured abdominal aortic aneurysms (rAAAs) using endovascular aneurysm repair (EVAR) with local anaesthesia (LA) rather than general anaesthesia (GA). The uptake and outcomes of LA in clinical practice remain unknown. METHODS: The UK National Vascular Registry was interrogated for patients presenting with rAAA managed with EVAR under different modes of anaesthesia between 1 January 2014 and 31 December 2016. The primary outcome was in-hospital mortality. Secondary outcomes included: the number of centres performing EVAR under LA; the proportion of patients receiving this technique; duration of hospital stay; and postoperative complications. RESULTS: Some 3101 patients with rAAA were treated in 72 hospitals during the study: 2306 underwent on open procedure and 795 had EVAR (LA, 319; GA, 435; regional anaesthesia, 41). Overall, 56 of 72 hospitals (78 per cent) offered LA for EVAR of rAAA. Baseline characteristics and morphology were similar across the three EVAR subgroups. Patients who had surgery under LA had a lower in-hospital mortality rate than patients who received GA (59 of 319 (18·5 per cent) versus 122 of 435 (28·0 per cent)), and this was unchanged after adjustment for factors known to influence survival (adjusted hazard ratio 0·62, 95 per cent c.i. 0·45 to 0·85; P = 0·003). Median hospital stay and postoperative morbidity from other complications were similar. CONCLUSION: The use of LA for EVAR of rAAA has been adopted widely in the UK. Mortality rates appear lower than in patients undergoing EVAR with GA.

Western Vascular Society guidelines for transfer of patients with ruptured abdominal aortic aneurysm.

INTRODUCTION: When a patient with ruptured abdominal aortic aneurysm (rAAA) presents at a facility ill-equipped to provide care, transfer may provide the best chance for survival. Large distances and long travel times provide challenging barriers to prompt and appropriate care in the western United States. METHODS: The Western Vascular Society (WVS) adopted a set of guidelines in considering transfer of a patient with an rAAA using published literature, membership survey and input, and existing recommendations. This article reports the guidelines and describes the process and rationale behind their development. RESULTS: Fifteen guidelines for transfer and care of rAAAs were endorsed by the WVS. CONCLUSIONS: When local care cannot be provided, transfer guidelines may standardize care for rAAAs and may be applicable across may practice settings.

Investigation of long chain omega-3 PUFAs on arterial blood pressure, vascular reactivity and survival in angiotensin II-infused Apolipoprotein E-knockout mice.

Abdominal aortic aneurysm (AAA) is an inflammatory vascular disease. Long chain omega-3 polyunsaturated fatty acids (LC n-3 PUFAs) decrease inflammation and oxidative stress in an angiotensin II-infused apolipoprotein E-knockout (ApoE(-/-)) mouse model of AAA. This study investigated the effects of LC n-3 PUFAs on blood pressure and vascular reactivity in fourteen angiotensin II-infused ApoE(-/-) male mice. Blood pressure was obtained using a non-invasive tail cuff method and whole blood was collected by cardiac puncture. Vascular reactivity of the thoracic aorta was assessed using wire myography and activation of endothelial nitric oxide synthase (eNOS) was determined by immunohistochemistry. A high LC n-3 PUFA diet increased the omega-3 index and reduced the n-6 to n-3 PUFA ratio. At day 10 post-infusion with angiotensin II, there was no difference in systolic blood pressure or diastolic blood pressure in mice fed the high or low n-3 PUFA diets. The high LC n-3 PUFA diet resulted in a non-significant trend for delay in time to death from abdominal aortic rupture. Vascular reactivity and eNOS activation remained unchanged in mice fed the high compared to the low LC n-3 PUFA diet. This study argues against direct improvement in vascular reactivity in ApoE(-/-) mice that were supplemented with n-3 PUFA for 8 weeks prior to infusion with angiotensin II.

Integration of endovascular therapy of ruptured abdominal and iliac aneurysms in the treatment algorithm: a single-center experience in a medium-volume vascular center.

PURPOSE: To evaluate the influence of endovascular therapy of ruptured abdominal or iliac aneurysms on total mortality. MATERIALS AND METHODS: We analyzed the mortality of 40 patients from 2005 to 2009, when only surgical treatment was available. These results were compared with the period 2010 to 2013, when endovascular aneurysm repair (EVAR) was assessed as the first option in selected patients. RESULTS: During 2005 to 2009, the mortality was 37.5%. From 2010 to 2013, 45 patients were treated with mortality 28.9%. Open repair was performed in 35 (77.8%) patients and EVAR in 10 (22.2%) patients. The 30-day and 1-year mortality rates of the EVAR group were 0% and 20%, respectively, and the total mortality rate was 30% during follow-up (median 11 months, range 1-42 months). The 30-day mortality in the surgical group remained unchanged, at 37.1%, and 1-year and total mortality rates were 45.7% and 51.4%, respectively. CONCLUSION: Following integration in the treatment algorithm, EVAR decreased total mortality in our center by 8.6%.

Early and delayed rupture after endovascular abdominal aortic aneurysm repair in a 10-year multicenter registry.

OBJECTIVE: Rupture after abdominal endovascular aortic aneurysm repair (EVAR) is a function of graft maintenance of the seal and fixation. We describe our 10-year experience with rupture after EVAR. METHODS: From 2000 to 2010, 1736 patients with abdominal aortic aneurysm (AAA) from 17 medical centers underwent EVAR in a large, regional integrated health care system. Preoperative demographic and clinical data of interest were collected and stored in our registry. We retrospectively identified patients with postoperative rupture, characterized as "early" and "delayed" rupture (≤30 days and >30 days after the initial EVAR, respectively), and identified predictors associated with delayed rupture. RESULTS: The overall follow-up rate was 92%, and the median follow-up was 2.7 years (interquartile range, 1.2-4.4 years) in these 1736 EVAR patients. We identified 20 patients with ruptures; 70% were male, the mean age was 79 years, and mean AAA size at the initial EVAR was 6.3 cm. Six patients underwent initial EVAR for rupture (n = 2) or symptomatic presentation (n = 4). Of the 20 post-EVAR ruptures, 25% (five of 20) were early, all occurring within 2 days after the initial EVAR. Of these five patients, four had intraoperative adverse events leading directly to rupture, with one type I and one type III endoleak. Of the five early ruptures, four patients underwent endovascular repair and one received repair with open surgery, resulting in two perioperative deaths. Among the remaining 15 patients, the median time from initial EVAR to rupture was 31.1 months (interquartile range, 13.8-57.3 months). Most of these delayed ruptures (10 of 15) were preceded by AAA sac increases, including three patients with known endoleaks who underwent reintervention. At the time of delayed rupture, nine of 15 patients had new endoleaks. Among all 20 patients, six patients did not undergo repair (all delayed patients) and died, nine underwent repeated EVAR, and five had open repair. For patients who underwent repair for delayed rupture, mortality at 30 days and 1 year were 44.4% and 66.7%, respectively. Multivariable Cox regression analysis identified age 80 to 89 (hazard ratio, 3.3; 95% confidence interval, 1.1-9.4; P = .03), and symptomatic or ruptured initial indication for EVAR (hazard ratio, 7.4; 95% confidence interval, 2.2-24.8; P < .01) as significant predictors of delayed rupture. CONCLUSIONS: Rupture after EVAR is a rare but devastating event, and mortality after repair exceeds 60% at 1 year. Most delayed cases showed late AAA expansion, thereby implicating late loss of seal and increased endoleaks as the cause of rupture in these patients and mandating vigilant surveillance.

Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry.

OBJECTIVE: To assess outcomes after endovascular abdominal aortic aneurysm repair (EVAR) in an integrated health care system. METHODS: Between 2000 and 2010, 1736 patients underwent EVAR at 17 centers. Demographic data, comorbidities, and outcomes of interest were collected. EVAR in patients presenting with ruptured or symptomatic aneurysms was categorized as urgent; otherwise, it was considered elective. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size, endoleak status, major adverse events, and reintervention. RESULTS: Overall, the median age was 76 years (interquartile range, 70-81 years), 86% were male, and 82% were Caucasian. Most cases (93.8%) were elective, but urgent use of EVAR increased from 4% in the first 5 years to 7.3% in the last 5 years of the study period. Mean aneurysm size was 5.8 cm. Patients were followed for an average of 3 years (range, 1-11 years); 8% were lost to follow-up. Intraoperatively, 4.5% of patients required adjunctive maneuvers for endoleak, fixation, or flow-limiting issues. The 30-day mortality rate was 1.2%, and the perioperative morbidity rate was 6.6%. Intraoperative type I and II endoleaks were uncommon (2.3% and 9.3%, respectively). Life-table analysis at 5 years demonstrated excellent overall survival (66%) and freedom from ARM (97%). Postoperative endoleak was seen in 30% of patients and was associated with an increase in sac size over time. Finally, the total reintervention rate was 15%, including 91 instances (5%) of revisional EVAR. The overall major adverse event rate was 7.9% and decreased significantly from 12.3% in the first 5 years to 5.6% in the second 5 years of the study period (P < .001). Overall ARM was worse in patients with postoperative endoleak (4.1% vs 1.8%; P < .01) or in those who underwent reintervention (7.6% vs 1.6%; P < .001). CONCLUSIONS: Results from a contemporary EVAR registry in an integrated health care system demonstrate favorable perioperative outcomes and excellent clinical efficacy. However, postoperative endoleak and the need for reintervention continue to be challenging problems for patients after EVAR.

Intraoperative blood product resuscitation and mortality in ruptured abdominal aortic aneurysm.

OBJECTIVES: The resuscitation of patients with ruptured abdominal aortic aneurysms (RAAAs) has not been well studied, and the potential benefit of autotransfusion (AT) is unknown. The increased use of fresh-frozen plasma (FFP) has been associated with decreased mortality rates in trauma patients and may also improve RAAA survival. We explored the influence of intraoperative AT and FFP resuscitation on mortality rates in massively transfused RAAA patients. METHODS: A single-center review of RAAA patient records from April 1989 to October 2009 was undertaken. Clinical data and outcomes were studied. Operative and anesthesia records were queried for intraoperative transfusion totals. Massive transfusion was defined as ≥10 units of red blood cells (RBCs) inclusive of AT units. RESULTS: We identified 151 RAAA patients, of which 89 (60%) received a massive transfusion and comprised the study population. These 89 patients had an in-hospital mortality rate of 44%. Univariate predictors of mortality included increased age, preoperative hypotension, operative blood loss, and crystalloid, RBCs, and FFP volume. AT was used in 85 patients, with an increased ratio of AT:RBC units associated with survival. Mortality was 34% with AT:packed RBCs (PRBC) ≥1 (high AT) and 55% with AT:PRBC of <1 (low AT; P = .04). On multivariate analysis, age > 74 years (P = .03), lowest preoperative systolic blood pressure (SBP) <90 mm Hg (P = .06), blood loss >6 liters (P = .06), and low AT (P = .02) independently predicted mortality. The mean RBC:FFP ratio was similar in those that died (2.7) and in those that lived (2.9; P = .66). RBC:FFP ≤2 (high FFP) was present in 38 (43%) patients, with mortality of 49%. RBC:FFP >2 (low FFP) had 40% mortality (P = .39). RBC:FFP ratios decreased over time from 3.6 (years 1989 to 1999) to 2.2 (years 2000 to 2009; P < .001), but more liberal use of FFP was not associated with decreased mortality (47% vs 41%; P = .56). AT:PRBC ratios were stable over time (range, 1.4-1.2; P = .18). CONCLUSIONS: Greater use of AT but not of FFP was associated with survival in massively transfused RAAA patients. No mortality benefit was seen with increased FFP, but few patients had high FFP transfusion ratios. Further study to identify RAAA patients at risk for massive transfusion should be undertaken and a potentially greater role for AT in RAAA resuscitation investigated.

Early outcome of endovascular treatment of acute traumatic aortic injuries: the talent thoracic retrospective registry.

BACKGROUND: Acute traumatic injury of the thoracic aorta (TAI) is a life-threatening complication in patients who sustain deceleration or crush injuries. This study was conducted to examine the results in patients who underwent endovascular repair with the Talent (Medtronic/AVE, Santa Rosa, CA) thoracic stent graft for acute traumatic injury. METHODS: Out of 457 consecutive endograft patients, 41 (9%) were treated for traumatic aortic conditions. There were 36 males with a mean age of 36 +/- 14 years. Mean aortic diameter at the time of intervention was 34 mm +/- 9 (range, 20 to 70 mm). The mean length of covered aorta was 106 mm (range, 5 to 130 mm) with only one stent graft used in 98% (40) of all cases. Median follow-up period for hospital survivors was 13 months (1.0 to 69.0 months). RESULTS: Stent graft implantation was technically successful in all cases (100%). One patient died during hospitalization, yielding an overall in-hospital mortality rate of 2.4%. Procedural-related paraplegia was zero and a primary endoleak was observed in 1 patient. Postoperative complications occurred in 4 patients (3 respiratory failures, 1 multiorgan failure). No patient required conversion to open surgical repair. CONCLUSIONS: The treatment of acute traumatic injuries of the descending thoracic aorta with the Talent stent graft is a feasible and safe technique; it provides low morbidity and mortality rates in the early postoperative period, and early results are encouraging. However, long-term studies are worthwhile to evaluate the effectiveness and the durability of this procedure.

Endovascular repair of acute AAAs under local anesthesia with bifurcated endografts: a feasibility study.

PURPOSE: To evaluate endovascular repair of abdominal aortic aneurysms (AAA) under local anesthesia in the acute setting. METHODS: Between 1998 and 2001, 47 patients with an acute AAA were evaluated for endovascular repair after informed consent, provided they were in a stable, albeit hypotensive condition. The patients underwent urgent computed tomography to assess suitability for endovascular repair; 16 were eligible for stent-graft repair: 9 were frank ruptures and 7 were symptomatic aneurysms. Complications and outcome of endovascular repair were evaluated; mortality was compared to a contemporaneous surgical cohort. RESULTS: Seven (23%) of 31 patients having a standard surgical procedure died in the study period compared to 1 (6%) of 16 patients undergoing endovascular repair (following conversion to surgery because of calcified access vessels). Twelve (75%) of the endovascular repairs were performed under local anesthesia; no complications with this mode of anesthesia were encountered. The median duration of the endovascular procedures was 110 minutes (range 75-240); median blood loss was 250 mL (range 100-2800 mL). Only 4 patients required blood transfusion, and only 8 patients required admission to the intensive care unit. There were 3 postoperative complications (1 ischemic colitis, 1 renal failure, 1 groin hematoma). During follow-up, 3 endograft patients received stent-graft extensions in uneventful procedures. Two patients died at 9 and 16 months from cardiac causes. CONCLUSIONS: This study demonstrates the feasibility and possible advantages of endovascular repair under local anesthesia in selected acute AAA patients. Further studies are needed to prove the advantages over open repair.

Ruptured abdominal aortic aneurysm: influence of intraoperative management on surgical outcome.

PURPOSE: This study was designed to determine the influence of changes in intraoperative management on the outcome of ruptured abdominal aortic aneurysm (RAAA). METHODS: Retrospective review of our surgical experience of RAAA identified 61 patients and was separated into two periods: 1986 to 1988 (group 1 [n = 21 patients]) and 1989 to 1994 (group 2 [n = 40 patients]). Since 1989 operations have been conducted by two vascular surgeons without systemic administration of heparin and with control of suprarenal aorta if extensive hematoma is present, use of collagen-impregnated grafts, preferential repair with aortoaortic grafting, and routine use of intraoperative autotransfusion. RESULTS: Factors differing between the groups were use of intraoperative autotransfusion (4.76% in group 1 vs 80% in group 2, p < 0.00001), repair with tube grafting (42.8% in group 1 vs 80% in group 2, p = 0.003), number of packed homologous red blood cells (7.5 +/- 5.2 units in group 1 vs 3.1 +/- 3.6 units in group 2, p = 0.008), postoperative blood loss (365 +/- 705 ml in group 1 vs 133 +/- 351 ml in group 2, p = 0.01). The intraoperative mortality rate was significantly lower in group 2 (5% vs 28.6%, p = 0.016). The only predictive factor was the use of intraoperative autotransfusion with a lower mortality rate in patients undergoing autotransfusion (p = 0.029). The postoperative mortality rate was significantly lower in group 2 (20% vs 52.4%, p = 0.009). Predictive factors were use of intraoperative autotransfusion (p = 0.0009), age of the patients (p = 0.0039), and repair with tube graft (p = 0.039). The odds ratio of postoperative death was 25 times higher without intraoperative autotransfusion and seven times lower when a tube graft was used. CONCLUSION: Continuing efforts to achieve improvement in surgical technique and use of intraoperative autotransfusion were important determinants in lowering the postoperative mortality rate of RAAA to 20%.

[Surgical consideration of ruptured abdominal aortic aneurysms].

During the recent 18 and a half years, 30 cases of ruptured abdominal aortic aneurysm (including four cases of A-V fistula) were operated at Saiseikai Utsunomiya Hospital. In 26 cases, a conventional graft replacement was performed. In other four cases, axillo-bifemoral bypass (in the cases ruptured into the colon) or other methods were used. Overall operative mortality rate was 26.7%. However, during the last 9 years, operative results were improved (21.7%, 5 deaths out of 23 cases). Amount of intraoperative blood loss influenced the operative results greatly. Other operative risk factors included preoperative shock, preoperative severe cerebrovascular or cardiovascular complications, and postoperative thromboembolism. Factors of recent improvement in mortality included; establishment of emergency system which resulted in earlier operation after the patient's arrival at the hospital, use of occlusive balloon for bleeding control, heparin administration before the aortic clamp for preventing peripheral thromboembolism and introduction of autotransfusion system for reducing the amount of blood transfusion.