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1.
Eur J Vasc Endovasc Surg ; 62(4): 532-539, 2021 10.
Artículo en Inglés | MEDLINE | ID: mdl-34266764

RESUMEN

OBJECTIVE: Limb graft occlusion (LGO) is a serious complication after endovascular aneurysm repair (EVAR) and while device development enables treatment of increasingly complex aortic anatomy, little is known about how endograft type affects the risk of occlusion. This observational study aimed to explore the incidence of LGO after EVAR for three major endograft systems. METHODS: All patients with standard EVAR as the primary intervention for infrarenal abdominal aortic aneurysm (AAA), between January 2012 and December 2018, at five Swedish vascular surgery centres, were included in this multicentre retrospective cohort study. LGO was defined as a total limb occlusion regardless of symptoms, or a treated significant stenosis. A nested case control (NCC) design with incidence density sampling of 1:3 was used for analysis of potential per-operative and morphological risk factors. Conditional logistic regression was used to estimate multivariable odds ratios (OR) with 95% confidence intervals (CI) RESULTS: A total of 924 patients were included. The majority were male (84%), the mean age was 76 years (± 7.5 SD), and median AAA diameter was 59 mm (IQR 55, 67). Patients were treated with Zenith Alpha (n = 315, ZISL limbs), Excluder (n = 152, PLC/PXC limbs), and Endurant (n = 457, ETLW/ ETEW limbs). During median follow up of 37 months (IQR 21, 62), 55 occlusions occurred (5.9%); 39 with Zenith Alpha (12.4%), one with Excluder (0.7%), and 15 with Endurant (3.3%). In the NCC analysis, the Zenith Alpha device (OR 5.31, 95% CI 1.97 - 14.3), external iliac artery (EIA) landing (OR 5.91, 95% CI 1.30 - 26.7), and EIA diameter < 10 mm (OR 4.99, 95% CI 1.46 - 16.9) were associated with an increased risk of LGO. CONCLUSION: Endograft device type is an independent risk factor for LGO after EVAR. Specifically, the Zenith Alpha demonstrated an increased risk of LGO compared with the Endurant and Excluder devices. In addition, a narrow EIA and landing zone in EIA are also risk factors for LGO.


Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Oclusión de Injerto Vascular/epidemiología , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/fisiopatología , Femenino , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/fisiopatología , Humanos , Incidencia , Masculino , Diseño de Prótesis , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Suecia/epidemiología , Factores de Tiempo , Resultado del Tratamiento
2.
Eur J Vasc Endovasc Surg ; 62(3): 400-407, 2021 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-34244093

RESUMEN

OBJECTIVE: Ruptured abdominal aortic aneurysms (rAAA) are treated by endovascular aneurysm repair (rEVAR) increasingly often. Despite rEVAR being a minimally invasive method, abdominal compartment syndrome (ACS) remains a significant post-operative threat. The aim of this study was to investigate risk factors for ACS after rEVAR, including aortic morphological features. METHODS: The Swedish vascular registry (Swedvasc) was assessed for ACS after rEVAR in the period 2008 - 2015. All patients identified were compared with controls (i.e., patients who did not develop ACS after rEVAR), matched by centre and repair date. Case records were reviewed, and radiology images analysed in a core laboratory. Comparisons were performed with respect to physiological and radiological risk factors. RESULTS: The study population consisted of 40 patients with ACS and 68 controls. Pre-operatively, patients with ACS had a lower blood pressure (BP) than controls (median 70 mmHg vs. 97 mmHg; p < .001). Intra-operatively, they had aortic balloon occlusion more often (55.0% vs. 10.3%; p < .001) and received more transfusions than controls (median nine units of packed red blood cells [pRBC] vs. two units; p < .001). Ninety-seven per cent of those who developed ACS had a pre-operative BP < 70 mmHg, aortic balloon occlusion, or received more than five pRBC unit transfusions. Treatment outside the instructions for use did not differ between patients and controls (57.5% vs. 54.4%; p = .84), and neither did the pre-operative patency of the inferior mesenteric artery (57.1% vs. 63.9%; p = .52) nor the number of visible lumbar arteries on pre-operative imaging (2 vs. 4; p = .014). In multivariable logistic regression, the number of intra-operative transfusions were predictive of ACS (p < .001), while pre-operative hypotension (p = .32) and aortic balloon occlusion (p = .018) were not. CONCLUSION: ACS after rEVAR is mainly associated with physiological factors and is unlikely to develop without the presence of a pre-operative BP < 70 mmHg, the need for an aortic occlusion balloon, or more than five intra-operative pRBC unit transfusions. Treatment outside the IFU or any other morphological factor were not associated with a risk of ACS.


Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares , Hipertensión Intraabdominal/etiología , Complicaciones Posoperatorias/etiología , Adulto , Anciano , Anciano de 80 o más Años , Oclusión con Balón , Estudios de Casos y Controles , Femenino , Humanos , Hipertensión Intraabdominal/diagnóstico , Hipertensión Intraabdominal/epidemiología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento
3.
J Vasc Surg ; 74(1): 97-104, 2021 07.
Artículo en Inglés | MEDLINE | ID: mdl-33307162

RESUMEN

OBJECTIVE: Colonic ischemia (CI) is a life-threatening complication after aortic surgery. Postoperative surveillance of colonic perfusion might be warranted. The aim of the present study was to evaluate the safety and feasibility of postoperative extraluminal pH measurement (pHe) using colonic tonometry after open abdominal aortic aneurysm (AAA) repair. METHODS: Before closing the abdomen after open AAA repair, a tonometric catheter was placed transabdominally in contact with the sigmoid colon serosa, similar to a drainage catheter. Extraluminal partial pressure of carbon dioxide was measured postoperatively and combined with arterial blood gas analysis to calculate the pHe. The measurements were repeated every 4 hours with simultaneous intra-abdominal pressure measurements. The threshold for colonic malperfusion was set at pHe <7.2. RESULTS: A total of 27 patients were monitored, 12 had undergone surgery for ruptured AAAs and 15 for intact AAAs. Of the 27 patients, 4 developed clinically significant CI requiring surgery. All four cases were preceded by a prolonged (>5 hours) pHe <7.2 indicating malperfusion. A fifth patient, who, during monitoring, had had the lowest pHe of 7.21, developed mild CI with the onset after completion of monitoring, which was successfully managed conservatively. Seven patients who had had brief durations (<5 hours) of pHe <7.2 did not develop clinical signs of CI or any related adverse events. CONCLUSIONS: Measurements of pHe using colonic tonometry indicated malperfusion in all four patients who had developed clinically significant CI. A shorter duration of low pHe was well tolerated without any signs of CI. Measurement of pHe was safe and reliable for the surveillance of colonic perfusion after open aortic surgery, indicating a promising technique. However, larger studies are needed.


Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Catéteres de Permanencia , Colon/irrigación sanguínea , Isquemia/diagnóstico , Monitoreo Fisiológico/instrumentación , Procedimientos Quirúrgicos Vasculares/efectos adversos , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Rotura de la Aorta/diagnóstico por imagen , Análisis de los Gases de la Sangre , Dióxido de Carbono/sangre , Estudios de Factibilidad , Femenino , Humanos , Concentración de Iones de Hidrógeno , Isquemia/sangre , Isquemia/etiología , Masculino , Manometría/instrumentación , Presión Parcial , Proyectos Piloto , Valor Predictivo de las Pruebas , Estudios Prospectivos , Circulación Esplácnica , Factores de Tiempo , Resultado del Tratamiento
4.
Eur J Vasc Endovasc Surg ; 58(5): 671-679, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31405726

RESUMEN

OBJECTIVES: Abdominal compartment syndrome (ACS) is a serious complication after abdominal aortic aneurysm (AAA) repair. The aim was to investigate outcome among subgroups and factors associated with outcome, with emphasis on the duration of intra-abdominal hypertension before treatment. METHODS: Since 2008, ACS and decompressive laparotomy (DL) after AAA repair are registered prospectively in the Swedish vascular registry (Swedvasc). Registry data and case records were reviewed. Subgroups were defined by main pathophysiological finding at DL, timing of DL after AAA repair, and treatment modality. RESULTS: During 2008-2015, 120 of 8765 patients undergoing surgery for infrarenal AAA developed post-operative ACS (1.4%). Eighty-three followed ruptured AAA (rAAA); 45 open surgical repairs (OSR) and 38 endovascular (EVAR), and thirty-seven after intact AAA (iAAA); 30 OSR and seven EVAR. The main pathophysiological findings at DL were bowel ischaemia in 27 (23.3%), post-operative bleeding in 34 (29.3%), and general oedema in 55 (47.4%). DL was performed <24 hours after AAA repair in 56 (48.7%), 24-48 hours in 30 (26.1%), and >48 hours in 29 patients (25.2%). The overall 90 day mortality was 50.0%, neither different depending on main pathophysiological finding, nor on the timing of DL. In multivariable regression analysis, age was a predictor of mortality (p = .017), while duration of intra-abdominal hypertension (IAH) prior to DL predicted the need for renal replacement therapy (RRT) (p = .033). DL was performed earlier after EVAR compared with OSR in rAAA (p < .001). CONCLUSIONS: Mortality in ACS was high, irrespective of the main pathophysiological finding and timing of DL. The duration of IAH prior to DL predicted the need for RRT. DL was performed earlier after EVAR than after OSR for rAAA, underlining the importance of monitoring IAP after EVAR for rAAA.


Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Descompresión Quirúrgica , Procedimientos Endovasculares , Hipertensión Intraabdominal , Complicaciones Posoperatorias , Anciano , Aneurisma de la Aorta Abdominal/complicaciones , Rotura de la Aorta/etiología , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Descompresión Quirúrgica/métodos , Descompresión Quirúrgica/estadística & datos numéricos , Diagnóstico Precoz , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/métodos , Femenino , Humanos , Hipertensión Intraabdominal/etiología , Hipertensión Intraabdominal/mortalidad , Hipertensión Intraabdominal/fisiopatología , Hipertensión Intraabdominal/cirugía , Laparotomía/métodos , Laparotomía/estadística & datos numéricos , Masculino , Evaluación de Procesos y Resultados en Atención de Salud , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/cirugía , Terapia de Reemplazo Renal/estadística & datos numéricos , Reoperación/métodos , Reoperación/estadística & datos numéricos , Medición de Riesgo , Suecia
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