Outcomes Following Use of Bovine Pericardium (Xenoprosthetic) Grafts for Reconstruction of Mycotic Aortic Aneurysms and Infected Aortic Grafts: A Systematic Review and Meta-Analysis.

BACKGROUND: Infected aortic grafts and mycotic aneurysms represent one of the most complex challenges faced by vascular surgeons. Treatment has progressed from extra-anatomical bypass to in situ reconstruction. Additionally, bovine pericardium reconstruction (BPR) has increased, due to accessibility and reduced lower limb morbidity. There remains, however, limited evidence for its use. The aim is to pool all known data to understand outcomes following BPR of mycotic aneurysms or infected vascular grafts. METHODS: A systematic review was conducted in November 2021 with subsequent computerized meta-analysis of the pooled results and a final search in March 2022. Three databases, Excerpta Medica dataBASE (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and National Institutes of Health PubMed (PubMed), were searched for the search term "(bovine OR xenoprosthetic) AND (aneurysm)", according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: From 9 studies, there were 133 patients: 67% graft infections and 33% mycotic aneurysms. Fifty-seven percent of reconstructions were in the abdominal aorta and 33% were in the thoracic aorta. One hundred fifty-eight pathogens were identified, including Staphylococcus aureus (23%), Candida albicans (13%), and Escherichia coli (13%). In 12%, no microorganisms were identified. Thirty-day mortality was 19.14% (CI 10.83-28.71), late mortality was 19.08% (confidence interval [CI] 7.76-32.83), and overall mortality was 40.20% (CI 29.82-50.97). One patient died intraoperatively. There were a total of 151 in-hospital complications after 30 days postoperation. Common complications were acute renal failure (17%), pneumonia (14%), delirium (12%), respiratory insufficiency (11%) and renal insufficiency (7%). Lower limb ischemia was low, occurring in 5.66% (CI 0.54-13.82) of patients. Loss of graft patency leading to reintervention occurred in 1.20% (CI 0.00-7.71) of the grafts. Reinfection rate was 0.00% (CI 0.00-1.21). CONCLUSIONS: This meta-analysis highlights low reinfection and high graft patency using BPR with medium-length follow-up; however, there remain limited long-term and comparative data regarding options for aortic reconstruction. As expected in this complex cohort, the complication rate and 30-day mortality remain high.

Factors Related to Limb Occlusion After Endovascular Abdominal Aortic Aneurysm Repair (EVAR).

BACKGROUND: Limb occlusion is a potentially serious consequence of endovascular abdominal aortic aneurysm (EVAR). This case-control study identifies factors that predispose to limb occlusion. METHODS: A consecutive series of patients from 2 centers undergoing EVAR over an 11-year period 2007-2017 were identified retrospectively. Patient records were interrogated allowing collations of demographics, intraoperative and perioperative data and surveillance data. The preoperative computed tomography angiogram was analyzed to determine EVAR relevant anatomical data. The primary outcome was occlusion of the iliac limb of the implanted EVAR. Raw data are presented as percentages, with comparative data analyzed using Mann-Whitney U-test and binomial logistic regression. RESULTS: A total of 787 patients (702 males; median age 78 years, range 53-94 years old) were analyzed. Fifty patients reached the primary outcome, resulting in an overall limb occlusion rate of 6.35%. Factors predictive of limb occlusion were oversizing by >10% native vessel diameter, with oversizing of >20% in 50% of those that occluded. External iliac artery landing zone (12/50 limb occlusions) 24% and postoperative kinking (5/50 limb occlusions) 10% were also more common in those that occluded. Fifty randomly selected controls with similar baseline characteristics were studied. Oversizing of the iliac endograft was found to be significantly greater in the limb occlusion group compared to the controls (P < 0.001) which remained significant on regression analysis. There was no correlation with iliac tortuosity. The Cook stent graft had a 9% limb occlusion rate across sites. Medtronic and Vascutek endografts had 2.4% and 2.5% limb occlusion rates respectively. CONCLUSIONS: Oversizing of iliac limbs by >20% could be a contributing factor to limb occlusion after EVAR and judicious oversizing should be used.

A systematic review and meta-analysis of the use of the Omniflow II biosynthetic graft for aortic reconstruction.

OBJECTIVE: Despite the improvements in xenogeneic grafts and surgical techniques, management of aortic graft infection has remained challenging. The optimal graft material has remained controversial, with high rates of reinfection using prosthetic grafts and a limited time for venous harvest in an emergent setting. Recent studies have highlighted an increase in the use of Omniflow II biosynthetic vascular grafts (LeMaitre Vascular, Burlington, MA) for aortic reconstruction. The primary aim of the present study was to review the key outcomes for the Omniflow II graft in terms of reinfection and complications. METHODS: The National Healthcare Service healthcare databases advanced search function was used to search nine databases for the search term "Omniflow." The present study complied with the PRISMA (preferred reporting items for systematic review and meta-analysis) statement. Eligible studies related to aortic graft infection or in situ aortic reconstruction were selected in accordance with prespecified eligibility criteria and included for review. Data on the surgical technique, comorbidities, graft reinfection, mortality, and complications were combined. The data were analyzed using Stata/MP, version 17 (StataCorp, College Station, TX), and the probabilities were pooled using a DerSimonian and Laird random effects model with Freeman-Tukey arcsine transformation. RESULTS: Six studies with 60 patients (44 men; age range, 29-89 years) were included. Of the 60 patients, 25 had undergone surgical reconstruction because of early graft infection (<4 months after the index procedure), 24 for late graft infection, and 3 because of mycotic aneurysms. Eight high-risk patients had undergone surgical reconstruction for prevention of an initial graft infection. Staphylococcus aureus, Escherichia coli, and S. epidermis were the most common organisms. Early mortality was 8.83% (95% confidence interval [CI], 1.12%-20.53%), and late mortality was 18.49% (95% CI, 5.51%-35.34%). Follow-up varied from 9 months to 2 years. No graft rupture or graft degeneration had occurred during follow-up. However, 6.2% (95% CI, 0.39%-15.81%) had experienced early graft occlusion, and 3.83% (95% CI, 0.00%-16.34%) had developed early graft stenosis. Two cases of postoperative reinfection were reported. The freedom from reinfection was 97.71% (95% CI, 87.94%-100.00%). CONCLUSIONS: Use of the Omniflow II graft for aortic reconstruction is a feasible alternative with acceptable mortality and low reinfection rates. However, there is a risk of limb occlusion. Although these studies were of low quality, the Omniflow II graft shows promise in this difficult patient cohort, especially when bifurcated reconstruction is required.

Predicting Features of Visceral Stent Failure in Fenestrated Endovascular Aortic Aneurysm Repair.

PURPOSE: Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure. MATERIALS: A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected. METHODS: Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels. RESULTS: Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure. CONCLUSIONS: The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term. CLINICAL IMPACT: With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper.

Leg ulcer service provision in NHS hospitals.

AIM: To explore the service provision for compression therapy for inpatients with leg ulcers in UK hospitals. METHODS: An online survey was carried out to explore the service provision in hospital settings. It was distributed to Wounds UK National Conference delegates and to wound care specialist groups using social media. RESULTS: The authors received 101 responses from health professionals in the UK. Of these, 67.3% reported there was no dedicated service for inpatients with leg ulceration and only 32% said compression therapy was provided in their hospitals. CONCLUSION: This survey confirmed there is a significant shortfall in care provision for patients with leg ulcers in secondary care and highlighted the wide variations in service delivery in hospitals. Further research is needed to understand the reasons for these variations.

Ligation Alone Versus Immediate Revascularization for Femoral Artery Pseudoaneurysms Secondary to Intravascular Drug Use: A Systematic Review and Meta-Analysis.

BACKGROUND: Femoral artery pseudoaneurysms (FA-PSAs) remain a common vascular aneurysmal pathology associated with intravascular drug use (IVDU). To date no internationally agreed consensus regarding optimal surgical management of FA-PSAs exists. The aim of this systematic review and meta-analysis was to determine the optimal surgical treatment of FA-PSAs associated with IVDU. METHODS: A systematic search was undertaken following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines identifying original studies reporting outcomes of ligation-debridement and/or excision-revascularization of FA-PSAs secondary to IVDU. Outcomes of interest were 30-day mortality, incidence of amputation at 12 months, chronic limb threatening ischemia (CLTI) at any follow-up appointment, reintervention, and bleeding. RESULTS: A total of 39 cohort studies describing 1,217 FA-PSA operative outcomes met inclusion criteria, 993 (81.6%) treated by ligation-debridement and 224 (18.4%) by excision-revascularization. The incidence of 30-day mortality was 0.8% (n = 8) and 1.3% (n = 3) in the ligation-debridement and excision-revascularization groups, respectively, with only one study reporting mortality in both groups. This meta-analysis found no difference in amputation (8.89% vs. 8.03%, odds ratio (OR) 0.74 95% confidence interval (CI) 0.35-1.56, P = 0.42, 11 studies) or CLTI (21.5% vs. 12.4%, OR 1.24 95% CI 0.35-4.38, P = 0.74, 9 studies) after ligation and debridement compared with excision and revascularization. There was a higher incidence of reintervention (24.7% vs. 10.6%, OR 0.31 [95% CI 0.16, 0.62], P = 0.0009, 13 studies) and rebleeding (7.1% vs. 1.6%, OR 0.61 [95% CI 0.16, 2.38], P = 0.48, 5 studies) after excision and revascularization compared with ligation alone. CONCLUSIONS: For treatments of IVDU-related FA-PSAs, this study suggests no significant difference in association of mortality, incidence of amputation, or CLTI with ligation-debridement or excision-revascularization, but a significantly higher reintervention rate and greater rebleeding rate for revascularized patients.

Long-term Outcomes Following Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms.

Purpose: To investigate the long-term outcomes of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) from a single center over an 11-year period. Materials and Methods: A retrospective analysis was conducted of 121 patients (median age 78 years; 100 men) with rAAA who underwent emergency EVAR at a single tertiary vascular center from January 2006 to December 2016. The study included only ruptures confirmed by evidence of hematoma on preoperative computed tomography; both iliac and aortic aneurysm ruptures were eligible. The primary outcome measures included mortality and reintervention rates. Kaplan-Meier estimates of survival and freedom from reintervention are reported with the 95% confidence interval (CI). Results: In-hospital and 30-day mortality rates for emergency EVAR were 16.5%; 90-day mortality was 24.0%. The mortality estimates were 27.3% (95% CI 20% to 36%) at 1 year and 61.7% (95% CI 51% to 72%) at 5 years. In the observation period to 2017, 63 reinterventions were performed on 37 patients (30.6%). Median time to the first reintervention was 3.2 years. Freedom from reintervention in surviving patients at 1 year was 86% (95% CI 72% to 94%) and 51% (95% CI 26% to 71%) at 5 years. Four patients (3.3%) had a secondary sac rupture over the study period. Conclusion: Emergency EVAR for ruptured AAA can be performed with acceptable short-term outcomes; however, long-term surveillance is necessary, and reintervention is common.

A comparison of inpatients with leg ulceration using published randomised controlled trials.

BACKGROUND: Leg ulcers are a significant burden and reduce patients' quality of life. In recent years, a plethora of information has been issued regarding leg ulcer management and 'the demographics of patients affected in the community. However, little is known about the leg ulcer population and how these patients should be managed in acute hospitals. AIM: To compare the demographic data of inpatients with leg ulcers referred to the tissue viability service in a large teaching hospital with data on leg ulcer populations in acute and community settings. METHODS: Inpatient demographic data were retrospectively obtained from electronic patient records. A literature search identified studies regarding leg ulcer populations in acute and community settings. RESULTS: The patient population in acute settings is around 10 years older than that in community settings, with much greater levels of comorbidity and higher mortality rates. CONCLUSION: An improved understanding of inpatients with leg ulcers would allow investigations and interventions to be targeted better, enabling evidence-based, patient-centred referral and care pathways. Further research is required to understand the aetiology and outcomes of leg ulcers for the inpatient population.

A systematic review and meta-analysis of remote ischemic preconditioning for vascular surgery.

BACKGROUND: Remote ischemic preconditioning (RIPC) is a method of preparing the body for a later prolonged ischemic episode to protect against subsequent detrimental effects. This study aimed to identify the effects of RIPC in vascular surgery. METHODS: A standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was conducted of randomized controlled trials of RIPC in patients undergoing open or endovascular aneurysm repair, carotid endarterectomy, or lower limb bypass reporting on mortality and renal or cardiac outcomes. Random-effects meta-analysis was performed using Review Manager 5.3 (The Nordic Cochrane Center, Copenhagen, Denmark). RESULTS: A total of 13 randomized controlled trials in the meta-analysis included 548 patients in the RIPC cohort and 549 controls. There was no significant difference in mortality, renal dysfunction, myocardial infarction, myocardial injury, or length of stay between the groups, with subgroup and sensitivity analysis showing no significant difference. CONCLUSIONS: Current evidence demonstrates no benefit of RIPC in vascular surgery. Further large multicenter trials of RIPC in major vascular surgery should be considered.

Outcomes of Sub-threshold Abdominal Aortic Aneurysms Undergoing Surveillance in Patients Aged 85 Years or Over.

OBJECTIVE: Despite an increasing elderly population there is limited evidence regarding the surveillance and management of small abdominal aortic aneurysms (AAAs) in octogenarians. This study investigated outcomes of patients aged ≥85 years undergoing AAA surveillance to identify whether discontinuation of surveillance might be safe. METHODS: This was a retrospective cohort study of all patients aged 85 years undergoing surveillance with a small (30-54 mm) AAA between January 2007 and November 2017. Patients were stratified depending on aneurysm diameter at index (<40 mm, 40-50 mm, > 50 mm). A threshold of 55 mm was used to decide intervention in all patients. Subsequent management of threshold aneurysms, aneurysm related and all cause mortality were also collected. RESULTS: One hundred and one patients were included (88 male, mean diameter at index 45 mm, median follow up 56.0 months). The majority of patients (72.3%) undergoing surveillance had not reached threshold at the end of follow up. Only one patient in the <40 mm group developed a threshold aneurysm, compared with five (11.6%) and 22 (75.9%) in the 40-50 mm and >50 mm groups, respectively (p < .0001). Of the 28 patients reaching threshold, eight (28.6%) underwent surgical repair (5 standard endovascular, one complex endovascular, and two open). Twenty-six (25.7%) patients died during follow up, with cardiorespiratory pathologies being the leading cause of death. Only three aneurysm related deaths were observed, including two fatal ruptures and one death following repair from an infected stent graft (all in the >50 mm index group). CONCLUSION: The present data suggests that discontinuation of aneurysm surveillance in patients aged 85 years with aneurysms < 40 mm might be safe. In patients with a larger aneurysm or those approaching threshold, early assessment of fitness for surgery may prevent unnecessary surveillance. The decision to treat aneurysms reaching threshold is complex but is appropriate in selected patients.

The Impact of Operating Surgeon Experience, Supervised Trainee vs. Trained Surgeon, in Vascular Surgery Procedures: A Systematic Review and Meta-Analysis.

OBJECTIVE: The operative caseload of a surgeon has a positive influence on post-operative outcomes. For surgical trainees to progress effectively, maximising operating room exposure is essential, vascular surgery being no exception. Our aim was to ascertain the impact of supervised trainee led vs. expert surgeon led procedures on post-operative outcomes, across three commonly performed vascular operations. METHODS: A literature search was undertaken using the MEDLINE, Web of Science, and Cochrane databases up to 1 January 2018. Studies reporting outcomes following major lower limb amputation, fistula formation, or carotid endarterectomy (CEA) that involved a direct comparison between supervised trainee and experts were included, with odds ratios (ORs) calculated. Primary outcomes varied depending on the specific procedure: amputations-rate of amputation revision within 30 days; fistula formation-primary patency; CEA-stroke rate at 30 days. Meta-analysis with the Mantel-Haenszel method was performed for each outcome. RESULTS: Sixteen studies were included in the final review. Overall, trainees accounted for a third of all procedures analysed (n = 2 421/7 017; 34.5%). Only one study was identified that described rates of amputation revision, precluding any further analysis. Four studies on fistula formation were included, showing no significant difference in outcomes between trainees and experts in primary patency (OR 1.68, 95% confidence interval [CI] 0.42-6.75). Nine studies were identified reporting post-CEA stroke rates, also demonstrating no difference between trainees and experts (OR 0.89, 95% CI 0.59-1.32). CONCLUSION: In select cases, with appropriate training and suitable experience, supervised trainees can perform surgical procedures without any detriment to patient care. To ensure high standards for patients of the future, supported training programmes are essential for today's surgical trainees.

Review of adjustable velcro wrap devices for venous ulceration.

Compression therapy is the mainstay of treatment for patients with venous leg ulcers. Current gold standard is 4 layer bandaging, which has a significant impact on patients comfort, ability to wear their own shoes, and quality of life, as well as taking significant time to apply, and losing compression over time. This systematic review aims to evaluate the use of Velcro wrap devices for the treatment of venous ulceration. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to identify articles reporting the use of Velcro wrap devices in patients with venous ulceration. Sixteen articles were identified (14 case series, 1 randomised trial, and 1 audit) reporting on 192 patients. There were reports of improved time to healing, reduced cost by >50%, reduced number and duration of nursing appointments, and improved quality of life in patients in Velcro wrap devices. Although the evidence remains poor, Velcro devices have potential to improve outcomes for patients with venous ulceration and further good quality studies should be undertaken to evaluate these further.

Meta-analysis of Renal Function Following Infrarenal EVAR using Suprarenal or Infrarenal Fixation Devices.

OBJECTIVE/BACKGROUND: The effect of suprarenal (SR) as opposed to infrarenal (IR) fixation on renal outcomes post-endovascular aneurysm repair (EVAR) remains controversial. This meta-analysis aims to update current understanding of this issue. METHODS: A prior meta-analysis was updated through a Preferred Reporting Items for Systematic reviews and Meta-Analyses search for additional studies published in the last 3 years reporting on renal dysfunction or related outcomes post-EVAR. Random effects meta-analysis was undertaken using SPSS. RESULTS: A total of 25 non-randomised studies comparing SR with IR fixation were included, totalling 54,832 patients. In total, 16,634 underwent SR and 38,198 IR. Baseline characteristics, including age, baseline estimated glomerular filtration rate, diabetes, cardiac disease, and smoking, were similar between the groups. There was a small but significant difference in outcomes for renal dysfunction at the study end point (SR 5.98% vs. IR 4.83%; odds ratio [OR] 1.29, 95% confidence interval [CI] 1.18-1.40 [p < .001]); however, at 30 days and 12 months there was no significant difference, and this did not hold up to sensitivity analysis. Incidence of renal infarcts (SR 6.6% vs. IR 2.3%; OR 2.78, 95% CI 1.46-5.29 [p = .002]), renal stenosis (SR 2.4% vs. IR 0.8%; OR 2.89, 95% CI 1.00-8.38 [p = .05]), and renal artery occlusion (SR 2.4% vs. IR 1.2%; OR 2.21, 95% CI 1.15-4.25 [p = 0.02]) favoured IR fixation; however, there was no difference in haemodialysis rates. CONCLUSION: This meta-analysis has identified small but significantly worse renal outcomes in patients having SR fixation devices compared with IR; however, there was no difference in dialysis rates and a small effect on renal dysfunction, which did not stand up to rigorous sensitivity analysis. This should be taken into consideration during graft selection, and further studies must assess renal outcomes in the longer term, and in those with pre-existing renal dysfunction.

Neoaortic Xenoprosthetic Grafts for Treatment of Mycotic Aneurysms and Infected Aortic Grafts.

BACKGROUND: There is no international consensus regarding the optimum management of infected aortae (mycotic aneurysms, infected aortic grafts). Neoaortoiliac reconstruction has advantages over extra-anatomical bypass grafting; however, the use of autologous vein is associated with venous hypertension and compartment syndrome, alternatively cadaveric homografts are associated with high rates of perianastomotic hemorrhage, limb occlusion, and pseudoaneurysm. Arterial repair using xenoprosthetic patches is associated with lower infection rates compared to the use of prosthetic material. The aim of this case series and literature review is to report the use of xenoprosthetic bovine biomaterial for neoaortic repair of mycotic aneurysmal disease and infected aortic grafts. METHODS: Patients with evidence of infected aortic grafts or mycotic aneurysms who were suitable for open aortic surgery were included. Following removal of the graft/excision of the aneurysmal sac, a 10 × 16 cm XenoSure Biologic Surgical Patch (LeMaitre, Germany) was rolled into a tube, or bifurcated tube graft, and secured with prolene sutures. Proximal and distal anastomoses were conducted as per standard aortic anastomoses. Patients were continued on long-term antibiotics and surveyed with computerized tomography at 1, 3, 6, and 12 months. RESULTS: Six patients underwent bovine aortic repair between 2013 and 2015: an infected Dacron aortobi-iliac graft causing iliac pseudoaneurysm, an infected Dacron aortic graft from open repair later relined with endovascular stent graft, a mycotic iliac aneurysm, and 3 mycotic aortic aneurysms. All were treated with bovine reconstructed aortic grafts or patches. Patients had a median age of 69.5 years (range 67-75), with perioperative and 30-day mortality of 0%. Median follow-up was 13 months (range 2-23). Postoperative contrast-enhanced computed tomography revealed no evidence of infection at the operative site in all patients. Freedom from reinfection and reintervention was 100%. CONCLUSIONS: Xenoprosthetic (bovine) neoaortic grafts are an alternative method to treat infected aortae with excellent short-term freedom from infection and reintervention. Optimum duration of postoperative antibiotic therapy remains undetermined. Further cases and longer follow-up are required to determine the true efficacy of this technique.

Endovascular abdominal aortic aneurysm sealing: A systematic review of early outcomes.

Objectives There has been a clear move towards endovascular repair of abdominal aortic aneurysms owing to better peri-operative outcomes compared with open surgical repair. However, follow-up has continued to reveal relatively high rates of endoleaks and re-interventions. Improvements in endovascular stent-grafts aim to decrease these complications. This systematic review aims to determine the early outcomes of abdominal aortic aneurysm sealing. Methods Standard PRISMA guidelines were followed. A literature search was performed with the aim to extract any publication related to the endovascular aneurysm sealing device. Results The total number of patients in this systematic review of 11 studies is 684, with a mean age of 73.2 years, and 587 (88.0%) males. The majority were undergoing elective procedures ( n = 606, 91.0%), the remainder as emergencies ( n = 30, 4.5% as ruptures, n = 30, 4.5% as symptomatic). Technical success rate including emergency cases was 99.1%. Thirty-day mortality rate was 2.6% ( n = 17) including all cases, and 1.0% ( n = 6) including elective cases only. Thirty -day endoleak detection rate was 4.7% ( n = 31) including all cases, and 4.8% ( n = 29) including elective cases only. Thirty-day aneurysm-related re-intervention rate was 5.7% ( n = 38) including all cases, and 4.6% ( n = 28) including elective cases only. There was no conversion to open surgery within 30 days post-op in the elective cases. There were three delayed conversions to open surgery within 30 days and one report of stent migration causing rupture in the emergency setting. Conclusions This novel endovascular aneurysm-sealing device for abdominal aortic aneurysm repair has shown respectable early outcomes. Good technical success rates, in both elective and emergency settings, low rates of all-type endoleaks and low re-intervention rates have all been demonstrated. It is proving to be a safe alternative to open and endovascular aneurysm repair; however, longer term follow-up results are needed to assess the safety and effectiveness of the device in the long term.

Mortality from thoracic aortic diseases and associations with cardiovascular risk factors.

BACKGROUND: Temporal trends in mortality from thoracic aortic disease are unclear. This study examined trends in mortality from thoracic aortic aneurysm (TAA) and aortic dissection (AD) with the aim of identifying associations with trends in established cardiovascular risk factors. METHODS AND RESULTS: TAA and AD mortality (1994-2010) using International Classification of Diseases codes was extracted from the World Health Organization mortality database and age standardized. World Health Organization InfoBase and International Mortality and Smoking Statistics provided risk factor data. Eighteen World Health Organization member states were included (Europe=13, Australasia=2, North America=2, Asia=1). Ecological regression was performed of temporal trends in cardiovascular risk factors (1946-2010) and independent correlations to mortality trends. TAA and AD mortality trends show substantial heterogeneity but are generally declining. TAA mortality has increased in Hungary, Romania, Japan, and Denmark, and AD mortality has increased in Romania and Japan; therefore, the mortality decline is not universal. A linear relationship exists between trends in systolic blood pressure, cholesterol, and body mass index and mortality from TAA. Body mass index demonstrated a negative linear association with female AD mortality, whereas trends in systolic blood pressure demonstrated a positive linear relationship with male AD mortality. Trends in smoking prevalence were not associated with TAA or AD mortality trends. CONCLUSIONS: This population-level ecological regression provides evidence that mortality secondary to TAA and mortality secondary to AD are both in decline. Differences between countries could be explained by population-level changes in common cardiovascular risk factors. Public health measures could further reduce mortality from TAA and AD.

Aneurysm global epidemiology study: public health measures can further reduce abdominal aortic aneurysm mortality.

BACKGROUND: Contemporary data from Western populations suggest steep declines in abdominal aortic aneurysm (AAA) mortality; however, international trends are unclear. This study aimed to investigate global AAA mortality trends and to analyze any association with common cardiovascular risk factors. METHODS AND RESULTS: AAA mortality (1994-2010) using International Classification of Diseases codes were extracted from the World Health Organization mortality database and age standardized. The World Health Organization InfoBase and International Mortality and Smoking Statistics provided risk factor data. Nineteen World Health Organization member states were included (Europe, 14; Australasia, 2; North America, 2; Asia, 1). Regression analysis of temporal trends in cardiovascular risk factors (1946-2010) was done independently for correlations to AAA mortality trends. Global AAA mortality trends show substantial heterogeneity, with the United States and United Kingdom recording the greatest national decline, whereas internationally, male individuals and those <75 years of age demonstrated the greatest reductions. AAA mortality has increased in Hungary, Romania, Austria, and Denmark; therefore, the mortality decline is not universal. A positive linear relationship exists between global trends in systolic blood pressure (P≤0.03), cholesterol (P≤0.03), and smoking prevalence (P≤0.02) in males and females. Body mass index demonstrated a negative linear association with AAA mortality (P≤0.007), whereas fasting blood glucose showed no association. CONCLUSIONS: AAA mortality has not declined globally, and this study reveals that differences between nations can be explained by variations in traditional cardiovascular risk factors. Declines in smoking prevalence correlate most closely with declines in AAA mortality, and a novel obesity paradox has been identified that requires further investigation. Public health measures could therefore further reduce global AAA mortality, with greatest benefits in the younger age group.