Comparison of different intensive care scoring systems and Glasgow Aneurysm score for aortic aneurysm in predicting 28-day mortality: a retrospective cohort study from MIMIC-IV database.

OBJECTIVE: This study aims to assess the performance of various scoring systems in predicting the 28-day mortality of patients with aortic aneurysms (AA) admitted to the intensive care unit (ICU). METHODS: We utilized data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) to perform a comparative analysis of various predictive systems, including the Glasgow Aneurysm Score (GAS), Simplified Acute Physiology Score (SAPS) III, SAPS II, Logical Organ Dysfunction System (LODS), Sequential Organ Failure Assessment (SOFA), Systemic Inflammatory Response Syndrome (SIRS), and The Oxford Acute Illness Severity Score (OASIS). The discrimination abilities of these systems were compared using the area under the receiver operating characteristic curve (AUROC). Additionally, a 4-knotted restricted cubic spline regression was employed to evaluate the association between the different scoring systems and the risk of 28-day mortality. Finally, we conducted a subgroup analysis focusing on patients with abdominal aortic aneurysms (AAA). RESULTS: This study enrolled 586 patients with AA (68.39% male). Among them, 26 patients (4.4%) died within 28 days. Comparative analysis revealed higher SAPS II, SAPS III, SOFA, LODS, OASIS, and SIRS scores in the deceased group, while no statistically significant difference was observed in GAS scores between the survivor and deceased groups (P = 0.148). The SAPS III system exhibited superior predictive value for the 28-day mortality rate (AUROC 0.805) compared to the LODS system (AUROC 0.771), SOFA (AUROC 0.757), SAPS II (AUROC 0.759), OASIS (AUROC 0.742), SIRS (AUROC 0.638), and GAS (AUROC 0.586) systems. The results of the univariate and multivariate logistic analyses showed that SAPS III was statistically significant for both 28-day and 1-year mortality. Subgroup analyses yielded results consistent with the overall findings. No nonlinear relationship was identified between these scoring systems and 28-day all-cause mortality (P for nonlinear > 0.05). CONCLUSION: The SAPS III system demonstrated superior discriminatory ability for both 28-day and 1-year mortality compared to the GAS, SAPS II SIRS, SOFA, and OASIS systems among patients with AA.

High proportion of undiagnosed diabetes in patients surgically treated for infrarenal abdominal aortic aneurysm: findings from the multicentre Norwegian Aortic Aneurysm and Diabetes (ABANDIA) Study.

BACKGROUND: The aim was to investigate the total prevalence of known and undiagnosed diabetes mellitus (DM), and the association of DM with perioperative complications following elective, infrarenal, open surgical (OSR) or endovascular (EVAR), Abdominal Aortic Aneurysm (AAA) repair. METHODS: In this Norwegian prospective multicentre study, 877 patients underwent preoperative screening for DM by HbA1c measurements from November 2017 to December 2020. Diabetes was defined as screening detected HbA1c ≥ 48 mmol/mol (6.5%) or previously diagnosed diabetes. The association of DM with in-hospital complications, length of stay, and 30-day mortality rate were evaluated using adjusted and unadjusted logistic regression models. RESULTS: The total prevalence of DM was 15% (95% CI 13%,17%), of which 25% of the DM cases (95% CI 18%,33%) were undiagnosed upon admission for AAA surgery. The OSR to EVAR ratio was 52% versus 48%, with similar distribution among DM patients, and no differences in the prevalence of known and undiagnosed DM in the EVAR versus the OSR group. Total 30-day mortality rate was 0.6% (5/877). Sixty-six organ-related complications occurred in 58 (7%) of the patients. DM was not statistically significantly associated with a higher risk of in-hospital organ-related complications (OR 1.23, 95% CI 0.57,2.39, p = 0.57), procedure-related complications (OR 1.48, 95% CI 0.79,2.63, p = 0.20), 30-day mortality (p = 0.09) or length of stay (HR 1.06, 95% CI 0.88,1.28, p = 0.54). According to post-hoc-analyses, organ-related complications were more frequent in patients with newly diagnosed DM (n = 32) than in non-DM patients (OR 4.92; 95% CI 1.53,14.3, p = 0.005). CONCLUSION: Twenty-five percent of all DM cases were undiagnosed at the time of AAA surgery. Based on post-hoc analyses, undiagnosed DM seems to be associated with an increased risk of organ related complications following AAA surgery. This study suggests universal DM screening in AAA patients to reduce the number of DM patients being undiagnosed and to improve proactive diabetes care in this population. The results from post-hoc analyses should be confirmed in future studies.

Preoperative Congestive Heart Failure Is Associated with Higher 30-Day Myocardial Infarction and Pneumonia after Endovascular Repair of Abdominal Aortic Aneurysm.

INTRODUCTION: Preoperative congestive heart failure (CHF) is associated with higher postoperative mortality and complications in noncardiac surgery. However, postoperative outcomes for patients with preoperative CHF undergoing endovascular aneurysm repair (EVAR) have not been thoroughly established. This study evaluated the effect of preoperative CHF on 30-day outcomes following nonemergent intact EVAR using a large-scale national registry. METHODS: Patients who had infrarenal EVAR were identified in the ACS-NSQIP database from 2012 to 2022. A 1:5 propensity-score matching was used to match demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures between patients with and without preoperative CHF. Thirty-day postoperative outcomes were examined. RESULTS: 467 (2.84%) CHF patients underwent intact EVAR. Meanwhile, 15,996 non-CHF patients underwent EVAR, where 2,248 of them were matched to all CHF patients. Patients with and without preoperative CHF had comparable 30-day mortality (3.02% vs. 2.62%, p = 0.64). However, CHF patients had higher myocardial infarction (3.02% vs. 1.47%, p = 0.03), pneumonia (3.23% vs. 1.73%, p = 0.04), 30-day readmission (p = 0.01), and longer length of stay (p < 0.01). CONCLUSION: While patients with and without preoperative CHF had comparable 30-day mortality rates, those with CHF faced higher risks of cardiopulmonary complications. Effective management of preoperative CHF may help prevent postoperative complications in these patients.

Differences in mortality and risk factors, two years after endovascular repair of ruptured abdominal aortic aneurysms - Reassessment analysis.

OBJECTIVE: The prevalence of abdominal aortic aneurysms (AAA) increases with age. Elective intervention for AAA is critical to prevent rupture associated with very high mortality among older males. METHODS: The aim of this study was to address the impact of post-contrast acute kidney-PC-AKI injury among patients treated with endovascular repair of ruptured AAA-EVAR on outcomes such as new onset chronic kidney disease-CKD and mortality among patients within a two-year trial. RESULTS: The same study group (of n = 192 patients) underwent reassessment, two years after EVAR treatment. The overall mortality rate was 16.67%, and it was higher in the AKI group - 38.89%. CKD patients had a mortality rate of 23.88% (n = 16). Among patients with an aneurysm diameter >67 mm mortality rate reached 20% (n = 6), while in the previously reported diabetes mellitus group 37.93% (n = 11). New onset of CKD was diagnosed in 23% of cases. Preexisting CKD patients with PC- AKI contributed to a 33.33% mortality rate (n = 8). CONCLUSION: This study concludes that PC-AKI impacts outcomes and survival in endovascularly treated AAAs. Type 2 diabetes and preexisting chronic kidney disease are associated with higher mortality within a 2-year follow-up, however gender factor was not significant. A larger aneurysm diameter is related with a higher prevalence of PC-AKI. These factors should be taken into account during screening, qualifying patients for the treatment and treating patients with AAA. It may help to identify high-risk individuals and tailor preventive measurements and treatment options accordingly, improving treatment results and reducing mortality.

Preoperative clinical characteristics and 12-month outcomes following operative or non-operative management of asymptomatic aortic aneurysms.

DESIGN: An observational cohort study conducted at a tertiary referral center for aortic surgery to describe the medical and surgical characteristics of patients assessed for abdominal aortic aneurysm repair and examine associations with 12-month outcome. METHODS: Patients with aortic aneurysms referred for discussion at the aortic multidisciplinary meeting (MDM). Data were collected via a prospectively maintained clinical database and included aneurysm characteristics, patient demographics, co-morbidities, geriatric syndromes, including frailty, management decision and 12-month mortality, both aneurysm-related and all-cause including cause of death. The operative and non-operative groups were compared statistically. RESULTS: 621 patients referred to aortic MDM; 292 patients listed for operative management, 141 patients continued on surveillance, 138 patients for non-operative management. There was a higher 12-month mortality rate in the non-operative group compared to the operative group (41% vs 7%, P = <0.001). In the non-operative group, 16 patients (29%) died of aneurysm rupture within 12 months, with 39 patients (71%) dying from other medical causes. Non-operatively managed patients were older, more likely to have cardiac and respiratory disease and more likely to be living with frailty, cognitive impairment and functional limitation, compared to the operative group. CONCLUSION: This study shows that preoperative geriatric syndromes and increased comorbidity lead to shared decision to non-operatively manage asymptomatic aortic aneurysms. Twelve-month mortality is higher in the non-operative group with the majority of deaths occurring due to cause other than aneurysm rupture. These findings support the need for preoperative comprehensive geriatric assessment followed by multispecialty discussion and shared decision making.

Outcome analysis of the surgical team in open surgical repair of intact abdominal aortic aneurysm surgery.

OBJECTIVES: To analyze how the experience of the surgical team went to impact the outcomes after open surgical repair (OSR) of intact abdominal aortic aneurysms (AAAs). METHODS: This is a single-center, observational cohort study with retrospective analysis of all OR for intact AAA performed between 1 January 2010 and 31 December 2022. The primary outcome was survival at 30 days and in follow-up, and a composite outcome of mortality and major complication. The secondary outcome was freedom from aorta-related reintervention. All outcomes were stratified according to the experience of the operating team (surgeons and anesthesiology). RESULTS: We analyzed 103 (7.2%) patients: 97 (94.2%) males and 6 (5.8%) females. The mean age was 76 ± 8 years (range, 55-93). The best possible team composition was present in 52 (50.5%) interventions. The follow-up index was 0.82 ± 0.18 (range, 0.6-1.0). Mean follow-up duration was 59 ± 43 months (range, 0-158). We observed no differences between teams in major complications (best, 17.3% vs mixed, 21.6%; OR: 0.4, P = 0.622), 30 days mortality (best, 0% vs mixed, 5.9%; OR: 7.6, P = 0.118) and composite outcome (best, 11.5% vs mixed, 17.6%; OR: 0.8, P = 0.416). Cox regression analysis identified the best possible team as a protective factor against the need for reintervention (hazard ratio: 0.2; 95% confidence interval: 0.06-0.88, P = 0.032). CONCLUSIONS: In our experience, OR of AAA yielded satisfactory results in terms of safety and efficacy independently of the team's experience. A more experienced team may protect against aorta-related reintervention.

Isolated Abdominal Aortic Dissection With and Without Abdominal Aortic Aneurysm.

OBJECTIVE: The aim of this study was to report the clinical presentation and treatment outcomes of patients treated for IAAD with and without abdominal aortic aneurysm (AAA) in a single academic institution in South America. MATERIALS AND METHODS: A retrospective review of all patients with IAAD with or without concomitant AAA between January 2002 and December 2023 from a single academic hospital was performed. RESULTS: Eighteen patients with IAAD were diagnosed of whom 13 (72.2%) were males. Median age was 63 years (range: 43-88 years). Sixteen (88.8%) patients presented with symptoms, and in two (11.1%) asymptomatic patients IAAD was an incidental finding. Ten (55.5%) patients had concomitant abdominal aortic aneurysm (AAA), with a median size of the aneurysm of 49.5 mm (range: 44-66 mm). No statistical differences in baseline characteristics were seen between patients with concomitant IAAD and AAA and patients with only IAAD. Seven (38.8%) patients presented chronic dissection, and 11 (61.1%) patients had acute dissection. Five (27.7%) patients were treated conservatively with blood pressure, pain control, and antiplatelets; endovascular surgery was performed in eight (44.4%) patients and open surgery in five (27.7%) patients. The complication rate was 22.2% (n = 4), and the mortality rate was 0%. Median follow-up was 36 months (range: 6-240 months). Complete remodeling was seen in all patients except two patients who underwent conservative treatment. Of those, one had partial remodeling, and the other no changed. CONCLUSION: Isolated aortic dissection of the abdominal aorta is an uncommon condition, with acceptable different treatment strategies, from conservative to invasive treatments. Sometimes IAAD can concur with AAA, and when so, invasive treatment might be considered. More studies describing the natural history of AAA and its association with IAAD are warranted, as well as further research reporting long-term outcomes on aortic remodeling after different treatment modalities.

Effect of Chronic Kidney Disease on 30-Day Outcomes in Endovascular Repair of Complex Abdominal Aortic Aneurysm.

BACKGROUND: Chronic kidney disease (CKD) has been identified as an independent predictor of poorer long-term prognosis after endovascular aneurysm repair (EVAR) for complex abdominal aortic aneurysm (AAA). However, its impact on short-term perioperative outcomes is conflicting, which can be important for preoperative risk stratification. This study aimed to evaluate the 30-day outcomes of patients with CKD following non-ruptured complex EVAR in a national registry. METHODS: Patients who had EVAR for complex AAA were identified in ACS-NSQIP targeted database from 2012-2022. Complex AAA included juxtarenal, suprarenal, or pararenal proximal extent, Type IV thoracoabdominal aneurysm, and/or aneurysms treated with Zenith Fenestrated endograft. Exclusion criteria included age<18 years, ruptured AAA, acute intraoperative conversion to open, emergency presentation, and dialysis. Multivariable logistic regression was used to compare 30-day postoperative outcomes of CKD and non-CKD patients, where demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, anesthesia, and concomitant procedures were adjusted. RESULTS: There were 695 (39.33%) and 1072 (60.67%) patients with and without CKD, respectively, who underwent EVAR for complex AAA. Patients with and without CKD have comparable 30-day mortality (aOR = 1.165, 95 CI = 0.646-2.099, P = 0.61). However, CKD patients had a higher risk of renal complications (aOR = 2.647, 95 CI = 1.399-5.009, P < 0.01) including higher progressive renal insufficiency (aOR = 3.707, 95 CI = 1.329-10.338, P = 0.01) and acute renal failure requiring renal replacement therapy (aOR = 2.533, 95 CI = 1.139-5.633, P = 0.02). All other 30-day outcomes were comparable between CKD and non-CKD patients. CONCLUSION: Patients with CKD had similar 30-day mortality and morbidity rates but a higher risk of postoperative renal complications. Therefore, meticulous preoperative planning and postoperative management, which may include optimal hydration, appropriate contrast use, and close renal function monitoring, are essential for patients with CKD after complex EVAR.

A Comparison of Outcome in Patient With and Without Undergoing Cardiopulmonary Exercise Testing (CPET).

BACKGROUND: Cardiopulmonary exercise testing (CPET) is a preoperative risk stratification tool providing an objective measure of fitness and functional capacity. There is however little evidence on the use of this compared to non-physiological test in vascular surgery despite its current use. This study investigates whether CPET perioperatively has value alongside non-physiological testing for patients undergoing elective open abdominal aortic aneurysm (AAA) repair. METHOD: Retrospective data was collected at 2 vascular centres between 2015-2019 in a CPET centre vs non-CPET centre in patients undergoing elective AAA repair. Outcomes measured included: length of stay in an intensive care unit (ICU); total length of stay; post-operative complications and acute kidney injury (AKI). Statistical analysis was performed using IBM SPSS software. RESULTS: There were 38 patients at each centre. The mean duration of stay in ICU for patients in CPET centre was 2.5 ± 2.13 days whilst in non-CPET centre it was 3.68 ± 4.08 days (P = 0.05). The mean duration of stay in ICU and total length of stay was significantly shorter in CPET centre (P = 0.05 and P = 0.015 respectively). Mortality in CPET centre was 2.63% and 5.26% in non-CPET centre (not significant). The number of patients developing AKI post-operatively was 13.61% in CPET vs 28.95% in non-CPET centre. CONCLUSION: CPET tested patients have statistically significant lower length of total and ICU stay compared to non-CPET patients. CPET is therefore a useful adjunct in selecting patients for open surgery compared to non-physiological testing. This study provides some evidence on the use of this routinely but not validated assessment tool in aortic aneurysm repair.

Safety Evaluation of Unibody Endografts for Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis.

BACKGROUND: The unibody bifurcated aortic endograft (AFX/AFX2) has emerged as a treatment option for abdominal aortic aneurysms (AAAs). This systematic review and meta-analysis aimed to evaluate the safety of the unibody endograft. METHODS: A literature search was conducted in Cochrane Library, Scopus, Web of Science, and PubMed. Studies assessing the unibody endograft for AAA repair between 2014 and 2023 were included. The defined primary outcomes were the incidences of type I, II, and III endoleaks. The secondary outcomes were access site problems, aneurysm-related mortality, aneurysm rupture, all-cause mortality, aneurysm sac growth, limb occlusion, stent graft migration, and technical success rate. RESULTS: Fourteen studies including 12 observational studies and 2 randomized controlled trials were included in the systematic review. The meta-analysis included 10 studies with 12,690 patients that reported the measured outcomes, and excluded 4 studies that did not. Type II endoleaks had the highest incidence of 12% (95% confidence interval [CI]: 4-20%), followed by type III endoleaks with an incidence of 3% (95% CI: 1-5%). The incidence of type I endoleaks was 1% (95% CI: 0-2%). A subgroup analysis by follow-up duration showed that type II endoleak incidence was higher after 1 to 2 years of follow-up than 3 to 4 years of follow-up. The incidence of aneurysmal mortality was 2% (95% CI: 0-7%), limb occlusion was 1% (95% CI: 0-1%), stent graft migration was 1% (95% CI: 0-2%), aneurysmal rupture was 6% (95% CI: 2-11%), access site problems were 7% (95% CI: 2-13%), aneurysm sac growth was 2% (95% CI: 0-4%), all-cause mortality was 21% (95% CI: 4-38%), and technical success rate was 100% (95% CI: 98-100%). CONCLUSIONS: The unibody endograft is a safe and minimally invasive approach for AAA repair. However, potential complications necessitate close patient follow-up after the intervention.

Complications and Technical Success on Upper Limb Vascular Access for Endovascular Repair of Complex Abdominal and Thoraco-abdominal Aortic Aneurysms: A Systematic Review and Meta-Analysis.

BACKGROUND: Catheterization of target vessels (TV) represented by renal visceral vessels are the crucial aspect during fenestrated and branched endovascular repair. This study aims to assess the efficacy and complications associated with upper limb catheterization during complex aneurysm endovascular surgery repair. METHODS: A systematic review was conducted after Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines, involving a search across PubMed, Cochrane CENTRAL, and Web of Science. Primary endpoint was represented by 30-day stroke. Secondary endpoints were target vessels' (TVs) technical success, 30-day mortality, and local access-related complications. Meta-analyses were performed using a random-effects model. RESULTS: Sixteen observational studies encompassing 4,137 patients were included. The 30-day stroke incidence for upper limb access was 1.4% (95% CI 1.0-1.8%), which was slightly higher than lower limb, despite not statistically significant. Mortality varied between 0 and 6.8%, and local access-related complications occurred in 3.2% (95% CI 1.9-4.4%). Technical success in TV catheterization was 99.2% (95% CI 98.4-100.0%). CONCLUSIONS: This systematic review and meta-analysis demonstrate the safety and efficacy of upper limb access for Fenestrated and Branched Endovascular Aortic Repair (f/b-EVAR), with low stroke risk, mortality rates, and minimal local complications. Despite the risk of bias, the findings suggest that upper limb access may be beneficial, especially in bailout situations when femoral access fails, offering valuable insights for clinical decision-making.

Clinical value identification of RDW on in-hospital death in unruptured abdominal aortic aneurysm.

This study aimed to identify highly valuable blood indicators for predicting the clinical outcomes of patients with aortic aneurysms (AA). Baseline data of 1180 patients and 16 blood indicators were obtained from the public Medical Information Mart for Intensive Care-IV (MIMIC-IV) database. The association of blood indicators with 4 types of clinical outcomes was analyzed, and the prediction performance of core indicators on different outcomes was next evaluated. Then, we explored the detailed association between core indicators and key outcomes among subgroups. Finally, a machine learning model was established to improve the prediction performance. Generalized linear regression analysis indicated that only red cell volume distribution width (RDW) was commonly associated with 4 end-points including surgery requirement, ICU stay requirement, length of hospital stay, and in-hospital death (all P < .05). Further, RDW showed the best performance for predicting in-hospital death by receiver operating characteristic (ROC) analysis. The significant association between RDW and in-hospital death was then determined by 3 logistic regression models adjusting for different variables (all P < .05). Stratification analysis showed that their association was mainly observed in unruptured AA and abdominal AA (AAA, all P < .05). We subsequently established an RDW-based model for predicting the in-hospital death only in patients with unruptured AAA. The favorable prediction performance of the RDW-based model was verified in training, validation, and test sets. RDW was found to make the greatest contribution to in-hospital death within the model. RDW had favorable clinical value for predicting the in-hospital death of patients, especially in unruptured AAA.

Aneurysm sac shrinkage at 1 year after fenestrated-branched endovascular aortic repair of complex aortic aneurysms offers mid-term survival advantage.

OBJECTIVES: To investigate the impact of 1-year changes in aneurysm sac diameter on patient survival after fenestrated-branched endovascular aortic repair (FB-EVAR) of complex abdominal aortic aneurysms or thoracoabdominal aortic aneurysms. METHODS: We reviewed the clinical data of patients enrolled in a prospective nonrandomized study investigating FB-EVAR (2013-2022). Patients with sequential follow up computed tomography scans at baseline and 6 to 18 months after FB-EVAR were included in the analysis. Aneurysm sac diameter change was defined as the difference in maximum aortic diameter from baseline measurements obtained in centerline of flow. Patients were classified as those with sac shrinkage (≥5 mm) or failure to regress (<5 mm or expansion) according to sac diameter change. The primary end point was all-cause mortality. Secondary end points were aortic-related mortality (ARM), aortic aneurysm rupture (AAR), and aorta-related secondary intervention. RESULTS: There were 549 patients treated by FB-EVAR. Of these, 463 patients (71% male, mean age, 74 ± 8 years) with sequential computed tomography imaging were investigated. Aneurysm extent was thoracoabdominal aortic aneurysms in 328 patients (71%) and abdominal aortic aneurysms in 135 (29%). Sac shrinkage occurred in 270 patients (58%) and failure to regress in 193 patients (42%), including 19 patients (4%) with sac expansion at 1 year. Patients from both groups had similar cardiovascular risk factors, except for younger age among patients with sac shrinkage (73 ± 8 years vs 75 ± 8 years; P < .001). The median follow-up was 38 months (interquartile range, 18-51 months). The 5-year survival estimate was 69% ± 4.1% for the sac shrinkage group and 46% ± 6.2% for the failure to regress group. Survival estimates adjusted for confounders (age, chronic pulmonary obstructive disease, chronic kidney disease, congestive heart failure, and aneurysm extent) revealed a higher hazard of late mortality in patients with failure to regress (adjusted hazard ratio, 1.72; 95% confidence interval, 1.18-2.52; P = .005). The 5-year cumulative incidences of ARM (1.1% vs 3.1%; P = .30), AAR (0.6% vs 2.6%; P = .20), and aorta-related secondary intervention (17.0% ± 2.8% vs 19.0% ± 3.8%) were both comparable between the groups. CONCLUSIONS: Aneurysm sac shrinkage at 1 year is common after FB-EVAR and is associated with improved patient survival, whereas sac enlargement affects only a minority of patients. The low incidences of ARM and AAR indicate that failure to regress may serve as a surrogate marker for nonaortic-related death.

Correlation Between Calcium Scoring and Abdominal Aortic Aneurysm Endovascular Repair Outcomes.

OBJECTIVES: Endovascular aneurysm repair, though minimally invasive and has the benefit of relatively low perioperative complication rates, it is associated with significant long term reintervention rates related to endoleaks. Several variables have been studied to predict the outcomes of endovascular aneurysm repair, 1 of which is the calcium burden of the vasculature. This prompted us to study the association between calcium burden measured by the standardized Agatston scoring system and the outcomes of Endovascular aneurysm repair. METHODS: This is a retrospective study of patients who underwent Endovascular aneurysm repair from 2008 to 2020 at our institution and who had a non-contrast computerized tomography scan preoperatively, accounting for 87 patients. The calcium burden of the vasculature was measured by the Agatston scoring system allowing for better reproducibility, and the outcome variables included mortality and endoleaks. RESULTS: Patients with higher median total calcium scores (≥12966.9) had significantly lesser survival (79.8% vs 52.3% (P = .002) at five years compared to patients with lower median total calcium score (<12966.9). Also, patients with type 2 endoleaks had higher calcium scores in above the aneurysm level ((1591.2 vs 688.2), P = .05)) compared to patients with no type 2 endoleaks. CONCLUSION: Calcium score assigned using a standardized Agatston scoring system can be used as a predictor of mortality risk assisting in deciding the treatment of choice for patients.

Impact of Isolated Type 2 Endoleak on Subsequent Cardiovascular Events and Mortality.

BACKGROUND: Assess subsequent cardiovascular events and all-cause mortality in patients with intact abdominal aortic aneurysm (AAA) treated by endovascular aneurysm repair (EVAR) according to the existence of isolated endoleak type 2 (EL2) at 1 year after EVAR implantation. METHODS: This retrospective, single-center study included patients treated with EVAR between 2010 and 2017 in the vascular surgery department of the University Hospital of Lyon with an infrarenal AAA > 50 mm. The baseline clinical characteristics collected just before EVAR were retrieved from electronic patient records of our institution. AAA characteristics, procedure, and the 1-year postoperative computed tomography angiography (CTA) were reported. Study end points, major adverse cardiovascular events (MACE), major adverse lower-extremity events (MALE), and all-cause mortality were recorded during follow-up. Patients were divided into 2 groups according to the presence of isolated EL2 (EL2 +) or absence (EL2 -) of any endoleak on CTA at 1 year. MACE, MALE, and all-cause mortality were compared between both groups. RESULTS: During the study period, 589 patients were treated by endovascular surgery and 207 were included. According to the CTA results at 1 year, 60 patients (29%) were included in the EL2 + group and 147 patients (71%) in the EL2 - group. A total of 109 patients (53%) experienced a MACE or MALE; significantly fewer patients in the EL2 + than in the EL2 - group did so (P = 0.009). There were 47 patients (23%) who experienced at least 1 MALE, and the frequency was significantly lower in the EL2 + group (P = 0.017). CONCLUSIONS: Patients with AAA treated by EVAR who did not develop EL2 at 1 year were at higher risk of MALE during follow-up. This might be explained by more frequent symptomatic lower extremity peripheral arterial disease at baseline in this group. These patients therefore require a closer follow-up and strict control of cardiovascular risk factors to prevent cardiovascular morbi-mortality.

Retrospective Cohort Study on EVAR Open Surgical Conversion: Focus on Endoleaks With Wrong Preoperative Categorization.

BACKGROUND: Late open conversion (LOC) following endovascular aneurysm repair (EVAR) is a rare complication with a high morbidity and mortality and is often proposed as the last line of treatment after failure of endovascular reintervention of any type. This study aimed to highlights the limitations of EVAR follow-up imaging in characterizing endoleaks, which may contribute to the failure of endovascular reinterventions and lead to LOC. METHODS: This retrospective cohort study recruited all EVAR implanted in Amiens University Hospital (France) between January 2008 and December 2022. Elective LOC was defined as surgical conversion >1 month after EVAR. The primary endpoint was the rate of wrong categorization of endoleaks by follow-up exams before LOC. Secondary endpoints were the morbidity and the mortality associated with LOC. RESULTS: Seven hundred eight EVARs were performed in our institution, 30 required elective LOC. Twenty-five of them were treated for sac enlargement due to an endoleak (83.3%) (all types). Wrong categorization of the endoleak was noted in 13 patients (52.2%). Twelve of these recategorizations involved the preoperative diagnosis of a type II endoleaks (92.3%). The change in categorization in 7 out of 12 cases (58%) was in favor of a type I endoleak, other recategorization included 1 type III (8%) and 4 type IV (33%). One patient died during the 30-day postoperative period and 7 patients (28%) presented a major complication; the median length of stay was 13 days (interquartile range 9-21). CONCLUSIONS: Routine follow-up examinations such as angioscanner and contrast Doppler ultrasound appear to be limited in their ability to categorize the type of persistent endoleak, which may increase the number of patients requiring LOC. New precision diagnostic imaging techniques, such as dynamic examinations, need to be developed to limit the need for LOC.

Thirty-Nine Percent of Patients with a Ruptured Abdominal Aortic Aneurysm (AAA) Have an Incidentally Detected AAA Prior to Rupture.

BACKGROUND: Abdominal aortic aneurysm (AAA) screening has been offered to 65-year-old men living in Oslo, Norway, since May 2011. A significant number of AAA-related deaths occurred in individuals who are not eligible for screening. The primary aim of this study was to describe the group of patients admitted to Oslo University Hospital with a ruptured AAA after the implementation of the local AAA screening project. The following parameters were investigated: AAA detection before rupture, surveillance status, eligibility for screening, and comorbidities. We also sought to compare outcomes (repair rates and 30-day mortality) between patients with and without an incidentally detected AAA prior to rupture. METHODS: This cohort study included patients admitted acutely to Oslo University Hospital due to a symptomatic or ruptured AAA in the period January 2011 to December 2022. Data on demographics, prior AAA detection, surveillance status, treatment, and mortality were collected retrospectively through electronic medical records. RESULTS: We identified 200 patients with a symptomatic or ruptured AAA, among which 79 (40%) had an AAA detected before rupture-one (1%) through screening and 78 (39%) incidentally. Up to 30% of the incidentally detected AAAs were not under any surveillance. Six patients were found eligible for screening: one had attended, three were non-attenders, and two had not been invited. Patients with an incidentally detected AAA before rupture had a more advanced age and a significantly higher degree of comorbidities than patients without a previously detected AAA, and the repair rates in these groups were 56% and 84%, respectively (P < 0.001). Adjusted for comorbidities and risk factors, the odds ratio for repair among patients with incidentally detected AAA was 0.56 (P = 0.292). The 30-day mortality was not significantly different between the two groups (P = 0.097). CONCLUSIONS: Most patients with a ruptured AAA were not eligible for screening, but 39% of the patients had an incidentally detected AAA prior to rupture. Standardized reporting and follow-up of incidentally detected AAAs is thus identified as an additional measure to organized screening in the effort to reduce AAA-related mortality.

Endograft Thrombosis as an Indication for Open Conversion after Endovascular Aneurysm Repair in a Multicenter Experience over 25 Years.

BACKGROUND: To describe the outcomes of aortic endograft thrombosis (AET) as an indication for open conversion (OC) after endovascular aortic aneurysm repair (EVAR) in a multicenter experience. METHODS: This study retrospectively analyzed cases of OC for AET following EVAR across 12 Italian Vascular Surgery centers from 1997 to September 2022. The end points were as follows: 30-day mortality and major postoperative complications. Follow-up data included survival and aortic-related complications. RESULTS: Sixteen patients (mean age: 68.6 ± 8.5 years) were included. The median elapsed time between EVAR and OC was 26.46 months (interquartile range: 13.8-45.9). Proximal aortic cross-clamping site was supraceliac in 8 out of 16 (50%) patients, and complete removal of the stentgraft was achieved in 75% of cases (12/16 patients). Reconstructions were aorto-bi-iliac grafts in 8 cases (50%), 7 aortobifemoral bypass grafts (43.8%), and 1 aortoaortic tube graft (6.3%). All patients were symptomatic at presentation (68.7% unilateral acute limb ischemia, 25% bilateral acute limb ischemia, 1 patient had chronic severe claudication). Thirty-day mortality was 12.5% (2/16 patients). The overall morbidity rate was 43.8% (7 of 16 patients). No specific risk factors for early mortality were found. The overall estimated survival rate was 80.4% at 1 year, 62.5% at 2 years, and 41.7% at 3 years. CONCLUSIONS: OC for AET is typically reserved for complex cases that are not amenable to endovascular solutions. The frequent need for suprarenal clamping and complete endograft removal seems to be associated with high short-term mortality.

The Effect of One Year Aneurysm Sac Dynamics on Five Year Mortality and Continued Aneurysm Sac Evolution.

OBJECTIVE: One year aneurysm sac dynamics after endovascular abdominal aortic aneurysm repair (EVAR) were independently associated with a greater all cause mortality risk in prior registry studies but were limited in completeness and granularity. This retrospective analysis aimed to study the impact of sac dynamics on survival within the Endurant Stent Graft Global Registry (ENGAGE) with five year follow up. METHODS: A total of 1 263 subjects were enrolled in the ENGAGE Registry between March 2009 and April 2011. One year aneurysm sac changes were calculated between the one month post-operative imaging scans and the scan closest to the time of one year follow up. Sac regression was defined as a sac decrease of ≥ 5 mm and sac expansion as aneurysm sac growth ≥ 5 mm. The primary outcome was the five year all cause mortality rate. Kaplan-Meier estimates for freedom from all cause death were calculated. Multivariable Cox regression was used to determine the association between sac dynamics and all cause death. RESULTS: At one year, 441 of the 949 study participants with appropriate imaging (46%) had abdominal aortic aneurysm sac regression, 462 (49%) remained stable, and 46 (4.8%) had sac expansion. For patients with sac regression, the five year all cause mortality rate was 20%, compared with 28% for stable sac (p = .007) and 37% for the sac expansion (p = .010) cohorts. After adjustment, the sac expansion and stable sac cohorts were associated with a greater all cause mortality rate (expansion: hazard ratio [HR] 1.8; 95% CI 1.1 - 3.2; p = .032; stable: HR 1.4; 95% CI 1.1 - 1.9; p = .019). CONCLUSION: In the ENGAGE Global Registry, the one year rate of sac regression was 46%, and one year sac regression was observed to be associated with greater five year survival, corroborating prior findings using data from vascular registries. Sac regression could become the new standard for success after EVAR.