Era of endovascular aortic aneurysm repair is linked to preoperative anatomic severity and perioperative patient outcomes.

OBJECTIVE: Varying opinions on optimal elective and emergent surgical management of infrarenal abdominal aortic aneurysms are expressed by the most recent Society for Vascular Surgery (SVS), European Society for Vascular Surgery, vs UK National Institutes for Health and Care Excellence guidelines. The UK National Institutes for Health and Care Excellence guidelines propose that open surgical repair serve as the default treatment for infrarenal abdominal aortic aneurysm. The rationale for this approach relied on data from the early era of endovascular aneurysm repair (EVAR) and are in contrast to the more balanced approaches of the SVS and European Society for Vascular Surgery. We hypothesize that significant differences in patient selection, management, and postoperative outcome are related to the era in which treatment was undertaken, contextualizing the outcomes reported in early-era EVAR randomized controlled trials. METHODS: Retrospectively, two cohorts representing all EVAR patients from "early" (n = 167; 2008-2010) and "late" (n = 129; 2015-2017) periods at a single treating institution were assembled. Primary outcomes of era-related changes in preoperative demographics, anatomy, and intraoperative events were assessed; anatomy was compared using the SVS anatomic severity grading system. These era-related differences were then placed in the context of early perioperative outcomes and at follow-up to 1 year. RESULTS: Choice of surgical strategy differed by era, despite the same patient preoperative comorbidities between EVAR groups. Preoperative anatomic severity was significantly worse in the early cohort (P < .001), with adverse proximal and distal seal zone features (P < .001). Technical success was 16.2% higher in the late cohort, with significantly fewer type 1A/B endoleaks perioperatively (P < .001). In-hospital complications, driven by higher acute kidney injury and surgical site complications in the early cohort, resulted in a 16.5% difference between cohorts (P < .05). At 1 year of follow-up, outcome differences persisted; late-era patients had fewer 1A endoleaks, fewer graft complications, and better reintervention-free survival. CONCLUSIONS: From a granular dataset of EVAR patients, we found an impact of EVAR repair era on early clinical outcomes; late cohort infrarenal EVAR patients had less severe preoperative anatomy and improved perioperative and follow-up outcomes to 1 year, suggesting that the results of early EVAR randomized controlled trials may no longer be generalizable to modern practice.

Survival and durability after endovascular aneurysm repair reflect era-related surgical judgement.

OBJECTIVE: Abdominal aortic aneurysm management guidelines from the National Institute for Clinical Excellence in 2020, based heavily on randomized controlled trials in an early era of infrarenal endovascular aneurysm repair (EVAR), suggested that the long-term outcomes after EVAR jeopardize its use in elective abdominal aortic aneurysm repair. We hypothesized that, in a rapidly evolving surgical field, the era of aneurysm repair may have a significant influence on long-term patient outcomes. METHODS: Using a single-center retrospective cohort design, we identified two EVAR cohorts, the early cohort (n = 166) who underwent EVAR from 2008 to 2010, and a contemporary late cohort (n = 129) from 2015 to 2017. We assessed patient preoperative demographics and era of repair against the primary outcomes of reinterventions, reintervention-free survival, and mortality, addressing their relationships to anatomic selection criteria, graft durability, endoleak, and aneurysm diameter to 5 years after the procedure. RESULTS: Early cohort patients had decreased reintervention-free survival (early 80.1% vs late 93.3%) and decreased overall survival (early 71.3% vs late 81%) at 3 years and throughout follow-up. The preoperative anatomy judged suitable for EVAR in early cohort patients was more variable than for late cohort patients, including 104% larger proximal and 106% larger distal landing zone diameters, with a mean 11.6-mm shorter length infrarenal aortic and 13.3-mm shorter length iliac sealing zones in the early group. Early cohort patients had more complications during follow-up, including graft kinking and endoleaks, and 24.4% of early vs 8.5% of late patients underwent one or more reinterventions. CONCLUSIONS: Although technical skill in EVAR implantation may not evolve significantly after a threshold of cases, surgical judgement, relating to anatomic selection and device sizing, requires feedback from long-term sequalae and significantly impacted EVAR outcomes by era. EVAR patients from an early repair era had significantly worse outcomes, with more complications, reinterventions, and a decrease in survival.

Risk Factors for Delirium after Vascular Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Vascular surgery is considered a risk factor for the development of postoperative delirium (POD). In this systematic review we provide a report on the incidence and risk-factors of POD after vascular surgery. METHODS: A systematic literature search was conducted using Pubmed with the MeSH terms and key words "delirium" or "confusion", "vascular surgery procedures" and "risk factors or "risk assessment". Studies were selected for review after meeting the following inclusion criteria: vascular surgery, POD diagnosed using validated screening tools, and DSM-derived criteria to assess delirium. A meta-analysis was performed for each endpoint if at least two studies could be combined. RESULTS: Sixteen articles met the abovementioned criteria. The incidence of delirium ranged from 5% to 39%. Various preoperative risk factors were identified that is, age (Random MD 3.96, CI 2.57-5.35), hypertension (Fixed OR 1.30, CI 1.05-1.59), diabetes mellitus (Random OR 2.15, CI 1.30-3.56), hearing impairment (Fixed OR 1.89, CI 1.28-2.81), history of cerebrovascular incident or transient ischemic attack (Fixed OR 2.20, CI 1.68-2.88), renal failure (Fixed OR 1.61, CI 1.19-2.17), and pre-operative low haemoglobin level (fixed MD -0.76, CI -1.04 to -0.47). Intra-operative risk factors were duration of surgery (Random MD 15.68; CI 2.79-28.57), open aneurysm repair (Fixed OR 4.99, CI 3.10-8.03), aortic cross clamping time (fixed MD 7.99, CI 2.56-13.42), amputation surgery (random OR 3.77, CI 2.13-6.67), emergency surgery (Fixed OR 4.84, CI 2.81-8.32) and total blood loss (Random MD 496.5, CI 84.51-908.44) and need for blood transfusion (Random OR 3.72, CI 1.57-8.80). Regional anesthesia on the other hand, had a protective effect. Delirium was associated with longer ICU and hospital length of stay, and more frequent discharge to a care facility. CONCLUSIONS: POD after vascular surgery is a frequent complication and effect-size pooling supports the concept that delirium is a heterogeneous disorder. The risk factors identified can be used to either design a validated risk factor model or individual preventive strategies for high-risk patients.

Open, percutaneous, and hybrid deep venous arterialization technique for no-option foot salvage.

OBJECTIVE: Deep venous arterialization (DVA) is a technique aimed at providing an option for chronic limb-threatening ischemia patients with no options except amputation. In patients with no outflow distal targets permitting bypass, DVA involves creating a connection between a proximal arterial inflow and a distal venous outflow in conjunction with disruption of the vein valves in the foot. This permits blood flow to reach the foot and potentially to resolve rest pain or to assist in healing of a chronic wound. We aimed to provide an up-to-date review of DVA indications; to describe the open, percutaneous, and hybrid technique; to detail outcomes of each of the available techniques; and to relay the postoperative considerations for the DVA approach. METHODS: A literature review of relevant articles containing all permutations of the terms "deep venous arterialization" and "distal venous arterialization" was undertaken with the MEDLINE, Cochrane, and PubMed databases to find cases of open, percutaneous, and hybrid DVA in the peer-reviewed literature. The free text and Medical Subject Headings search terms included were "ischemia," "lower extremity," "venous arterialization," "arteriovenous reversal," and "lower limb salvage." Studies were primarily retrospective case series but did include two studies with matched controls. Recorded primary outcomes were patency, limb salvage, wound healing, amputation, and resolution of rest pain, with secondary outcomes of complication and overall mortality. Studies were excluded if there was insufficient discussion of technical details (graft type, target vein) or lack of reported outcome measure. RESULTS: Studies that met inclusion criteria (12 open, 3 percutaneous, 2 hybrid) were identified, reviewed, and summarized to compare technique, patient selection, and outcomes between open, percutaneous, and hybrid DVA. For open procedures, 1-year primary patency ranged from 44.4% to 87.5%; secondary patency was less reported but ranged from 55.6% at 1 year to 72% at 25-month follow-up. Limb salvage rates ranged from 25% to 100%, wound healing occurred in 28.6% to 100% of cases, and rest pain resolved in 11.9% to 100% across cohorts. For the endovascular approach, primary patency ranged from 28.6% to 40% at 6-month and 10-month follow-up. Limb salvage rates ranged from 60% to 71%, with rates of major amputation ranging from 20% to 28.5%. CONCLUSIONS: This review provides an up-to-date review of DVA indications, description of various DVA techniques, patient selection associated with each approach, and outcomes for each technique.

Women undergoing endovascular thoracoabdominal aortic aneurysm repair differ significantly from their male counterparts preoperatively and postoperatively.

OBJECTIVE: A rational approach to the management of aortic aneurysm disease relies on weighing the risk of aneurysm rupture against the complications and durability of operative repair. In men, seminal studies of infrarenal aortic aneurysm disease and its endovascular management can provide a reasoned argument for the timing and modality of surgery, which is then extrapolated to the management of thoracoabdominal aortic aneurysms (TAAAs). In contrast, there is less appreciation for the natural history of TAAA disease in women and its response to therapy. METHODS: We used a retrospective cohort design of women, all men, and matched men, fit for complex endovascular thoracoabdominal aneurysm repair at two large aortic centers. We controlled for preoperative anatomic and comorbidity differences, and assessed technical success, postoperative renal dysfunction, spinal ischemia, and early mortality. Women and matched men were reassessed at follow-up for long-term durability and survival. RESULTS: Assessing women and all men undergoing complex endovascular aortic reconstruction, we demonstrate that these groups are dissimilar before the intervention with respect to comorbidities, aneurysm extent, and aneurysm size; women have a higher proportion of proximal Crawford extent 1, 2, and 3 aneurysms. Matching men and women for demographic and anatomic differences, we find persistent elevated perioperative mortality in women (16%) undergoing endovascular thoracoabdominal aneurysm repair compared with matched men (6%); however, at the 3-year follow-up, both groups have the same survival. Furthermore, women demonstrate more favorable anatomic responses to aneurysm exclusion, with good durability and greater aneurysm sac regression at follow-up, compared with matched men. CONCLUSIONS: Women and unmatched men with TAAA disease differ preoperatively with respect to aneurysm extent and comorbidities. Controlling for these differences, after complex endovascular aneurysm repair, there is increased early mortality in women compared with matched men. These observations argue for a careful risk stratification of women undergoing endovascular thoracoabdominal aneurysm treatment, balanced with women's good long-term survival and durability of endovascular aneurysm repair.

Predicting postoperative delirium after vascular surgical procedures.

OBJECTIVE: The objective of this study was to determine the incidence of and specific preoperative and intraoperative risk factors for postoperative delirium (POD) in electively treated vascular surgery patients. METHODS: Between March 2010 and November 2013, all vascular surgery patients were included in a prospective database. Various preoperative, intraoperative, and postoperative risk factors were collected during hospitalization. The primary outcome variable was the incidence of POD. Secondary outcome variables were any surgical complication, hospital length of stay, and mortality. RESULTS: In total, 566 patients were prospectively evaluated; 463 patients were 60 years or older at the time of surgery and formed our study cohort. The median age was 72 years (interquartile range, 66-77), and 76.9% were male. Twenty-two patients (4.8%) developed POD. Factors that differed significantly by univariate analysis included current smoking (P = .001), increased comorbidity (P = .001), hypertension (P = .003), diabetes mellitus (P = .001), cognitive impairment (P < .001), open aortic surgery or amputation surgery (P < .001), elevated C-reactive protein level (P < .001), and blood loss (P < .001). Multivariate logistic regression analysis revealed preoperative cognitive impairment (odds ratio [OR], 16.4; 95% confidence interval [CI], 4.7-57.0), open aortic surgery or amputation surgery (OR, 14.0; 95% CI, 3.9-49.8), current smoking (OR, 10.5; 95% CI, 2.8-40.2), hypertension (OR, 7.6; 95% CI, 1.9-30.5) and age ≥80 years (OR, 7.3; 95% CI, 1.8-30.1) to be independent predictors of the occurrence of POD. The combination of these parameters allows us to predict delirium with a sensitivity of 86% and a specificity of 92%. The area under the curve of the corresponding receiver operating characteristics was 0.93. Delirium was associated with longer hospital length of stay (P < .001), more frequent and increased intensive care unit stays (P = .008 and P = .003, respectively), more surgical complications (P < .001), more postdischarge institutionalization (P < .001), and higher 1-year mortality rates (P = .0026). CONCLUSIONS: In vascular surgery patients, preoperative cognitive impairment and open aortic or amputation surgery were highly significant risk factors for the occurrence of POD. In addition, POD was significantly associated with a higher mortality and more institutionalization. Patients with these risk factors should be considered for high-standard delirium care to improve these outcomes.

Feasibility study of computed tomography colonography using limited bowel preparation at normal and low-dose levels study.

The purpose was to evaluate low-dose CT colonography without cathartic cleansing in terms of image quality, polyp visualization and patient acceptance. Sixty-one patients scheduled for colonoscopy started a low-fiber diet, lactulose and amidotrizoic-acid for fecal tagging 2 days prior to the CT scan (standard dose, 5.8-8.2 mSv). The original raw data of 51 patients were modified and reconstructed at simulated 2.3 and 0.7 mSv levels. Two observers evaluated the standard dose scan regarding image quality and polyps. A third evaluated the presence of polyps at all three mSv levels in a blinded prospective way. All observers were blinded to the reference standard: colonoscopy. At three times patients were given questionnaires relating to their experiences and preference. Image quality was sufficient in all patients, but significantly lower in the cecum, sigmoid and rectum. The two observers correctly identified respectively 10/15 (67%) and 9/15 (60%) polyps > or =10 mm, with 5 and 8 false-positive lesions (standard dose scan). Dose reduction down to 0.7 mSv was not associated with significant changes in diagnostic value (polyps > or =10 mm). Eighty percent of patients preferred CT colonography and 13% preferred colonoscopy (P<0.001). CT colonography without cleansing is preferred to colonoscopy and shows sufficient image quality and moderate sensitivity, without impaired diagnostic value at dose-levels as low as 0.7 mSv.