Aneurysm Morphology Is a More Significant Predictor of Survival than Hardman's Index in Patients with Ruptured or Acutely Symptomatic Abdominal Aortic Aneurysms.

Scoring systems such as Hardman's index are used to predict outcomes and stratify patients with ruptured abdominal aortic aneurysm (RAAA) or acutely symptomatic abdominal aortic aneurysm (SAAA) to active treatment or palliation. Aneurysm morphology is not included in these scoring systems. The aim of this study was to assess whether aneurysm morphology was an independent predictor of survival. Consecutive patients admitted from January 2006 to March 2017 with emergency presentation and primary diagnosis of abdominal aortic aneurysm were identified. Patients were stratified by age, gender, mode of presentation (RAAA versus SAAA), Hardman's Index, aneurysm morphology (suitability for endovascular aneurysm repair [EVAR]), and the procedure performed (endovascular versus open). Multivariable logistic regression analysis was used to determine predictors of survival. A total of 346 patients were included (RAAA: 250, SAAA: 96). Median age of patients was 75 years (range: 44-96); 284 (79%) were men and 75 (21%) were women. Three hundred twenty-five patients underwent preoperative computed tomography (CT) scan of these 156 (48%) fulfilled conservative instructions for use (IFU) for EVAR and another 64 (20%) were within the liberal IFU for EVAR. Median Hardman Index was 1 (range 0-5). Age (odds ratio [OR]: 1.72 [95% confidence interval {CI}: 1.15-2.23] [P < 0.001]), mode of presentation [(OR: 2.05 (95% CI: 1.45-3.31) (P < 0.001)], and aneurysm morphology being within conservative IFU for EVAR [(OR: 1.61 (95% CI: 1.08-2.03) (P = 0.02)], modality of repair (open versus EVAR), (OR: 0.81 [95% CI: 0.67-0.92], [P < 0.001]) were independent predictors of survival. Hardman's index (OR: 0.86 [95% CI: 0.69-1.11], [P = 0.16]) and gender (OR: 1.15 [95% CI: 0.83-1.32], [P = 0.24]) were not. Aneurysm morphology is a significant predictor of survival after RAAA. This information should be included in any scoring system.

The fate of patients with large abdominal aortic aneurysms referred for consideration for elective repair.

BACKGROUND: The premise of the Vascular Services Quality Improvement Programme (VSQIP) in management of patients with asymptomatic large abdominal aortic aneurysms (AAA) is reducing mortality from ruptured AAA in a sustainable way without introducing excessive procedure related mortality. Inevitably a proportion of patients are deemed unfit for elective repair. The aim of this study was to report outcomes of patients who were referred with large asymptomatic AAAs including those turned down for elective repair and identify independent risk factors for being turned down for elective open or endovascular repair of AAA. METHODS: Consecutive patients referred to a regional vascular center with a large AAA (greater than 55 mm) between 1st January 2008 and 31st March 2018 were included. All patients underwent the nationally agreed VSQIP pathway which included preoperative cardio-pulmonary exercise testing and contrast enhanced CT scan of aorta. The decision to repair and the modality of repair were made through a Multi-Disciplinary Team MDT process on each patient. Patients were classified into two groups; those managed non-operatively and those offered elective repair. Survival was assessed using Kaplan-Meier analysis. Factors associated with non-operative management were examined using multivariate analysis. RESULTS: A total of 876 patients of whom 768 were men and 108 were women with a mean age of 74 years (SD: 7.2) and a diagnosis of a large asymptomatic AAA were assessed. One hundred and seventy-four patients (19.9%) were turned down for elective repair and 702 (80.1%) underwent repair [Open: 244(34.8%), EVAR: 458 (65.2%] with perioperative and 30 day mortality of 1.13% (8 patients). Median duration of follow-up was 1530 days (51 months), (inter quartile range: 1714 days). Patients who underwent repair had significantly higher survival rates compared with those who were turned down (P<0.0001). Risk factors for being turned down for elective AAA included anaerobic threshold <8 mL kg-1 min-1 [OR: (95% CI): 2.27 (1.31-3.92)], (P=0.0005), Age>80 yrs. [OR (95% CI): 1.32 (1.012-1.52], (P=0.0203), complex aneurysm morphology [OR (95% CI): 3.70 (2.82-4.87], (P<0.0001), Female gender: [OR: (95% CI): 2.41 (1.32-3.92)], (P<0.0001) and being classed high or very high risk for open AAA repair OR: (95% CI): 6.48 (4.01-10.49)], (P<0.0001). CONCLUSIONS: A significant cohort of patients with large asymptomatic AAA is turned down for elective AAA repair. These patients appear to have significantly lower survival rates than those who are treated. Information on patients turned down for elective AAA repair should be routinely reported.

Is gender still a risk factor for mortality in patients who undergo elective repair of abdominal aortic aneurysms? Experience of a single center.

BACKGROUND: Vascular Services Quality Improvement Program (VSQIP) was introduced to reduce mortality from elective repair of AAA in the UK. This study examines the differences in perioperative mortality and postoperative survival between men and women following elective repair of AAAs in the 10 years after implementation of the (VSQIP). METHODS: Consecutive patients who underwent elective repair of AAA between 1st January 2008 and 31st March 2018 were included. All patients were assessed using the nationally agreed VSQIP pathway which involved cardiopulmonary exercise testing as well as contrast enhanced CT scan of aorta and multidisciplinary assessment to plan each treatment. CT scans were examined to assess the morphology of AAA. Patients were stratified by age, gender, AAA morphology and preoperative anaerobic threshold. Postoperative survival was assessed using Kaplan-Meier analysis. Cox regression analysis was used to determine predictors of postoperative mortality. RESULTS: A total of 702 patients underwent elective repair of AAA of whom 632 were men and 70 were women. The mean age of study cohort was 73.5±7.3 years and mean AAA diameter was 62±9.9 mm. Two hundred and forty-four patients underwent open repair, 402 underwent infrarenal endovascular aneurysm repair (EVAR) and 56 underwent complex EVAR with perioperative and 30-day mortality of 1.13%. No significant difference was observed in perioperative/30-day mortality between men and women (χ2=0.06, P=0.81). Anaerobic threshold <8 (HR=0.68 [95% CI: 0.51-0.92]), complex aneurysm morphology (HR=1.7 [95% CI: 1.39-2.19]) risk category (HR=1.89 [95% CI: 1.48-2.42]) and patients age (HR=1.41 [95% CI: 1.13-1.89]) were independent risk factor for mortality following repair of AAA, whilst female gender (HR=0.89 [95% CI: 0.54-1.48]) and AAA size (HR=1.01 [95% CI: 0.84-1.22]) were not. There was no difference in postoperative survival between men and women who underwent elective repair of AAA (Log rank: 1.82, P=0.61). CONCLUSIONS: Following the implementation of VSQIP female gender is no longer a significant risk factor for perioperative mortality or reduced survival following elective repair of large asymptomatic AAA.

Anaerobic threshold as an independent predictor of mid-term survival following elective endovascular repair of abdominal aortic aneurysm.

BACKGROUND: The aim of this study was to examine the value preoperative AT as predictor of postoperative survival in patients who underwent elective EVAR for repair of asymptomatic AAA. METHODS: Consecutive patients who underwent elective EVAR between 2008 and 2018 were analyzed. Cardiopulmonary exercise testing was performed. Perioperative 30-day mortality was compared between patients who had AT ≥8 mL/kg/min and those with AT<8 mL/kg/min. Risk factors for postoperative survival following EVAR were examined using Cox's regression analysis. RESULTS: Between 1st January 2008 and 31st December 2017, 430 patients underwent elective EVAR (standard device: N.=374, fenestrated/branched: N.=56); their median age was 76 years (range: 53-91 years), median AT was 9.3 (range: 5.4-16.1), and 30-day mortality was 0.9%. These patients were followed up for a median of 1630 days. There was no significant difference in perioperative 30-day mortality between patients who had AT≥8 and those who had AT<8 (χ2=1.56, P=0.22). Age (HR=1.51 [CI: 1.07-1.99], P<0.05) and AT (HR=0.59 [CI: 0.45-0.76], P=0.0003) were predictors of reduced postoperative survival following elective EVAR whereas gender (HR=0.75 [CI: 0.4-1.4], P=0.37), AAA diameter (HR=0.95 [CI: 0.77-1.16], P=0.6), and AAA morphology (HR=1.23 [CI: 0.68-1.76], P=0.95) were not. CONCLUSIONS: Anaerobic threshold is an independent predictor of prolonged survival following elective EVAR and can be used to identify patients who receive most benefit from elective EVAR.

Reducing the risk of venous thromboembolism following superficial endovenous treatment: A UK and Republic of Ireland consensus study.

OBJECTIVES: Venous thromboembolism is a potentially fatal complication of superficial endovenous treatment. Proper risk assessment and thromboprophylaxis could mitigate this hazard; however, there are currently no evidence-based or consensus guidelines. This study surveyed UK and Republic of Ireland vascular consultants to determine areas of consensus. METHODS: A 32-item survey was sent to vascular consultants via the Vascular and Endovascular Research Network (phase 1). These results generated 10 consensus statements which were redistributed (phase 2). 'Good' and 'very good' consensus were defined as endorsement/rejection of statements by >67% and >85% of respondents, respectively. RESULTS: Forty-two consultants completed phase 1. This generated seven statements regarding risk factors mandating peri-procedural pharmacoprophylaxis and three statements regarding specific pharmacoprophylaxis regimes. Forty-seven consultants completed phase 2. Regarding venous thromboembolism risk factors mandating pharmacoprophylaxis, 'good' and 'very good' consensus was achieved for 5/7 and 2/7 statements, respectively. Regarding specific regimens, 'very good' consensus was achieved for 3/3 statements. CONCLUSIONS: The main findings from this study were that there was 'good' or 'very good' consensus that patients with any of the seven surveyed risk factors should be given pharmacoprophylaxis with low-molecular-weight heparin. High-risk patients should receive one to two weeks of pharmacoprophylaxis rather than a single dose.

A Stab in the Dark? Point-of-Care Testing in the Population With Hip Fracture.

Hip fracture incidence rises globally in an aging population who live in an era of financial austerity. Health service providers are under pressure both to optimize care and to increase efficiencies in the management of this vulnerable patient group. One area of inefficiency in perioperative processes is the assessment of deranged clotting profiles secondary to warfarinization and in the monitoring of hemoglobin. Delays are inherent in these processes, threatening patient care and impacting on financial incentivisation of performance. Point-of-care testing, while widespread in other areas of health care, is underutilized in hip fracture management. This work explores the application to hip fracture care of this technology and suggests future direction to investigate its potential benefits.