The Impact of Intra-Operative Heparin on Thromboembolism and Death in a Matched Cohort of Patients with a Ruptured Abdominal Aortic Aneurysm.

Objective: Portuguese nationwide estimates indicate that 20% of abdominal aortic aneurysms (AAAs) are treated when ruptured. In these cases, intra-operative unfractionated heparin (UFH) usage rates vary widely. Evidence on this topic is scarce and focused on patients treated by open repair (OSR). The aim was to determine the influence of UFH on peri-operative thromboembolic events (TEs) and death in a cohort of ruptured AAA (rAAA). Methods: Retrospective, single-centre, comparative study. From 2011 to April 2023, all consecutive rAAAs (endovascular repair [EVAR] and OSR) were considered. Primary outcomes were 30-day TE free survival and TE rates. The secondary outcome was 30-day death. Safety endpoints were procedural blood loss, blood product requirements, and secondary interventions due to haemorrhage. Using propensity score matching (PSM) each UFH patient was matched with one no UFH patient in a 1:1 ratio. Results: The study included 250 patients. After PSM, 190 patients were analysed (EVAR: 60.0% no-UFH vs. 64.4% UFH). TE free survival estimates favoured the UFH group (67.3% vs. 47.2%, p = .009; UFH adjusted odds ratio [aOR] 2.01, 95% confidence interval [CI] 1.04-4.17). TEs were more frequent in the no UFH group (20.0% vs. 44.2% patients, p < .001; UFH aOR 0.31, 95% CI 0.15-0.65 for any TE), driven by an increase in bowel ischaemia (17.9% no UFH vs. 3.2% UFH, p = .001). Most events occurred in the first 72 hours. EVAR was associated with reduced TE and improved TE free survival (aOR 0.20, 95% CI 0.09-0.45 and aOR 5.54, 95% CI 2.34-13.08, respectively). No significant differences in 30-day survival were noted (75% no-UFH vs. 83% UFH, p = .26; aOR 1.08, 95% CI 0.48-2.43) nor in blood loss, peri-operative red blood cell and fresh frozen plasma requirements, or secondary interventions due to haemorrhage (p = .10; p = .11; p = .13 and p = .18 respectively). Conclusion: In this cohort, intra-operative UFH was safe and associated with improved TE free survival, driven by a reduction in bowel ischaemia. Conversely, mortality remained unaffected. Randomised controlled trials are required to confirm these findings.

Emergency endovascular repair of aortoiliac aneurysms in COVID-19 times.

In this paper, we describe a case series of four patients who were admitted with emergencies related to aortic aneurysms over a 3-day period and were treated with endovascular repair. The first patient was an 81-year-old female with a history of abdominal pain and a ruptured aortic aneurysm diagnosed by AngioCT-scan. The second patient was a 63-year-old male with a history of oral digestive bleeding and an AngioCT-scan showing an aortoenteric fistula. The third patient was a 77-year-old female with sudden-onset abdominal pain and ruptured right common iliac aneurysm. The fourth patient presented with abdominal pain and an AngioCT-scan showed aortic rupture. All four patients were discharged with no major complications or surgical mortality. These case series show that despite the Covid-19 pandemic situation, since elective surgeries decreased, vascular emergencies have increased.

Relatamos uma série de casos de quatro pacientes consecutivos, admitidos com emergências relacionadas a aneurismas aortoilíacos em um período de 3 dias e submetidos a tratamento endovascular. A primeira paciente, do sexo feminino, com 81 anos e com histórico de aneurisma da aorta, apresentou dor abdominal iniciada nos últimos 12 dias. O segundo paciente era do sexo masculino, com 63 anos e foi admitido com hematêmese 3 dias antes da admissão, com angiotomografia demonstrando fistula aortoentérica. A terceira paciente, do sexo feminino e com 77 anos, foi admitida com quadro de ruptura de aneurisma da artéria ilíaca comum direita. O quarto paciente consecutivo apresentou dor abdominal iniciada 2 semanas antes da internação e aneurisma roto da aorta. Todos os quatro pacientes apresentaram emergências aortoilíacas e receberam alta sem complicações maiores ou mortalidade cirúrgica. O relato desta série de casos demonstra que, apesar da situação pandêmica da COVID-19, uma vez que as cirurgias eletivas diminuíram, as urgências vasculares aumentaram.

Fluoroquinolones as a trigger for rupture of abdominal aortic aneurysm: A case-crossover analysis.

Fluoroquinolones (FQ) are associated with an increased risk of tendinopathy, including rupture. Our study aimed to investigate whether FQ use triggered the rupture of aortic aneurysms using a self-controlled design. We hypothesised that the use of FQ was associated with aortic rupture shortly after redeemed FQ prescriptions. Using nationwide data sources, we performed a case-crossover study of cases with ruptured aortic aneurysms. From 1996 to 2016, 58 persons presented with rupture of an aortic aneurysm and a redeemed prescription for any FQ within 28 days. 67% were men, and the median age was 77 years. Some 82.9% presented with a ruptured abdominal aneurysm. In our conditional regression, the crude OR for having rupture with a recent FQ redemption was 1.36 (CI 1.00-1.86). After adjusting for potential confounders, the OR was 1.35 (CI 0.98-1.85). Changing the hazard period to FQ redemption within 60 and 90 days, the OR was 2.16 (CI 1.70-2.76) and 2.21 (CI 1.78-2.75), respectively. In conclusion, we demonstrated an association between FQ use within 60 and 90 days and a diagnosis of ruptured aortic aneurysm.

Emergency endovascular repair of aortoiliac aneurysms in COVID-19 times / Tratamento endovascular das emergências dos aneurismas aortoilíacos em tempos de COVID-19

Abstract In this paper, we describe a case series of four patients who were admitted with emergencies related to aortic aneurysms over a 3-day period and were treated with endovascular repair. The first patient was an 81-year-old female with a history of abdominal pain and a ruptured aortic aneurysm diagnosed by AngioCT-scan. The second patient was a 63-year-old male with a history of oral digestive bleeding and an AngioCT-scan showing an aortoenteric fistula. The third patient was a 77-year-old female with sudden-onset abdominal pain and ruptured right common iliac aneurysm. The fourth patient presented with abdominal pain and an AngioCT-scan showed aortic rupture. All four patients were discharged with no major complications or surgical mortality. These case series show that despite the Covid-19 pandemic situation, since elective surgeries decreased, vascular emergencies have increased.

Resumo Relatamos uma série de casos de quatro pacientes consecutivos, admitidos com emergências relacionadas a aneurismas aortoilíacos em um período de 3 dias e submetidos a tratamento endovascular. A primeira paciente, do sexo feminino, com 81 anos e com histórico de aneurisma da aorta, apresentou dor abdominal iniciada nos últimos 12 dias. O segundo paciente era do sexo masculino, com 63 anos e foi admitido com hematêmese 3 dias antes da admissão, com angiotomografia demonstrando fistula aortoentérica. A terceira paciente, do sexo feminino e com 77 anos, foi admitida com quadro de ruptura de aneurisma da artéria ilíaca comum direita. O quarto paciente consecutivo apresentou dor abdominal iniciada 2 semanas antes da internação e aneurisma roto da aorta. Todos os quatro pacientes apresentaram emergências aortoilíacas e receberam alta sem complicações maiores ou mortalidade cirúrgica. O relato desta série de casos demonstra que, apesar da situação pandêmica da COVID-19, uma vez que as cirurgias eletivas diminuíram, as urgências vasculares aumentaram.

Sex differences in Japanese patients with ruptured aortic aneurysms.

OBJECTIVE: This study aimed to assess the sex differences in clinical presentation and outcomes of Japanese patients with ruptured aortic aneurysm (rAA) using a large nationwide claims-based database in Japan. METHODS: We identified patients hospitalized in certified teaching hospitals in Japan with rAA between April 1, 2012, and March 31, 2015. Patients' characteristics and in-hospital outcomes were compared between men and women. The Barthel index was used for evaluating functional status at discharge by examining the ability to perform basic daily activities. RESULTS: Of 7086 eligible patients, 32.3% (2291/7086) were women. Women were older than men (81.9 years vs 76.1 years; P < .001), had higher prevalence of coma at admission (33.2% vs 25.2%; P < .001), and were less likely to undergo emergency operation including endovascular aneurysm repair (35.7% vs 51.1%; P < .001). The unadjusted mortality rate (62.5% vs 52.0%; P < .001) and Barthel index at discharge (78.7 vs 86.1; P < .001) were significantly worse in women than in men. However, multilevel mixed-effect logistic regression analyses showed that female sex itself was not an independent predictor for in-hospital death (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.78-1.04; P = .17). Older age, coma at admission, and vasopressor use were detected as independent predictors for in-hospital death. The same results were confirmed for each rupture site. Stratified analyses showed that older women (threshold, 80 years; OR, 0.81; 95% CI, 0.66-0.98; P = .028) and those who underwent emergency operation (OR, 0.75; 95% CI, 0.61-0.93; P = .009) showed significantly better outcomes than men. CONCLUSIONS: In a univariate analysis, female patients with rAA showed worse mortality than men because of their older age, more severe clinical presentation, and low emergency operation rate. However, after adjustment for covariates, female sex itself was not associated with increased mortality.

The impact of institutional case volume on the prognosis of ruptured aortic aneurysms: a Japanese nationwide study.

OBJECTIVES: To improve outcome for ruptured aortic aneurysms (rAAs), centralization of treatment is potentially effective. However, there is no nationwide survey for the current managements and outcomes of rAA in Japan. The aim of this study was to assess the volume-outcome relationship for rAA treatment using the nationwide claim-based database. METHODS: Using the Japanese Registry of All cardiac and vascular Diseases-Diagnostic Procedure Combination database, we identified patients admitted to 564 certified teaching hospitals with rAA between 1 April 2012 and 31 March 2015. Institutional case volume (cardiovascular surgeries per year) was categorized into quartiles (lowest, low, high and highest), and the odds ratios (ORs) for in-hospital mortality and neurological status at discharge were analysed for each quartile. RESULTS: Of 7086 eligible patients, 3925 (55.4%) died in hospital. Mortality rates decreased from 69.4% in the lowest volume to 43.8% in the highest volume category (P < 0.001). The favourable impact of institutional case volume was sustained even after adjustment for covariates [low volume: OR 0.83, 95% confidence interval (CI) 0.65-1.07; P = 0.147; high volume: OR 0.69, 95% CI 0.54-0.89; P = 0.005; and highest volume: OR 0.55, 95% CI 0.42-0.72; P < 0.001 vs lowest volume]. Additionally, other 3 institutional parameters (increased aortic surgery volume, cardiovascular surgeons' volume and certified cardiologists' volume) were consistently associated with reduced in-hospital mortality. The rate of coma at discharge was the lowest in the highest volume group (P < 0.001). Increased institutional volume was associated with lower in-hospital mortality. CONCLUSION: Establishing regionally tailored systems to transfer patients to high-volume centres is needed to improve outcomes.

Epidemiology of fatal ruptured aortic aneurysms in the United States (1999-2016).

OBJECTIVE: Ruptured aortic aneurysms (rAAs) are associated with high mortality. The purpose of this study was to describe the trends of deaths due to rAA in the United States. METHODS: A retrospective review of the national death certificate data from the U.S. National Vital Statistics System was done to identify deaths due to rAAs in the United States between 1999 and 2016. Patients aged 15 years or older with rAA as the underlying cause of death as defined by International Classification of Diseases, Tenth Revision codes I71.1 (ruptured thoracic aortic aneurysm [rTAA]), I71.3 (ruptured abdominal aortic aneurysm [rAAA]), I71.5 (ruptured thoracoabdominal aortic aneurysm), and I71.8 (rAA of unspecified site) were included and standardized to U.S. Census data. RESULTS: A total of 104,458 deaths due to rAAs occurred during the study period. The overall age-adjusted incidence of fatal rAA was 23.3 per 1 million (rAAA, 15.1; rTAA, 3.1; thoracoabdominal, 0.4; and unspecified site, 4.8). The annual incidence of rAA decreased by 68% from 40.0 (1999) to 12.8 (2016) per 1 million (rTAA by -67% from 5.5 to 1.8 and rAAA by -70% from 26.3 to 7.89 per 1 million; P < .001 for all comparisons). These trends were consistent across age groups, sexes, and races. There was a significant seasonal variation in rAA mortality, with higher deaths in winter months compared with summer months. The incidence of rAA is highest in Midwest states (27.1 per 1 million), followed by Northeast (23.8 per 1 million) and West (14 per 1 million) states, and lowest in Southern states (13.6 per 1 million). Only 57% of rAAA deaths occurred in men ≥65 years. CONCLUSIONS: The incidence of fatal rAA, rTAA, and rAAA drastically decreased in the United States between 1999 and 2016, a trend that was consistent across age groups, sexes, and races. A significant percentage of fatal rAAAs occurred in patients who are not eligible for the current screening program.

Arbitrary Palliation of Ruptured Abdominal Aortic Aneurysms in the Elderly is no Longer Warranted.

OBJECTIVE/BACKGROUND: A consistent number of elderly patients with ruptured abdominal aortic aneurysms (rAAAs) are deemed unfit for repair and excluded from any treatment. The objective of this study was to examine the impact on survival of endovascular repair and open surgery with restricted turndown in acute AAA repair. METHODS: A prospective database for patients treated for rAAA was established. None of the patients admitted alive with rAAA were denied treatment. Multivariate regression models, the predictive risk assessment Glasgow Aneurysm Score (GAS), and subgroup analyses in older patients were applied to identify indicators of excessive 30 day mortality risk that could affect the decision for turndown. RESULTS: From 2006 to 2015, 113 consecutive patients (93 males; mean age 77.2 years) with rAAAs were treated (69 open surgery; 44 EVAR). Overall peri-operative (30 day) mortality was 38.9% (44/113): 40.6% (28/69), and 36.4% (16/44) after open surgery and EVAR, respectively (p = .70). Multivariate logistic regression identified old age as an indicator of increased peri-operative mortality (odd ratio [OR] 1.2, 95% confidence interval [CI] 1.1-1.3; p = .001), as well as free aneurysm rupture (OR 5.0, 95% CI 1.3-19.9; p = .02). GAS was higher in patients who died (97.75 vs. 86.62), but the score failed to identify increased peri-operative mortality risk in adjusted analyses (OR 1.0; p = .06). Almost two thirds of the patients (n = 71) were older than 75 at the time of aneurysm rupture (48.6% octogenarians) and EVAR was more commonly applied than open surgery (86.4% vs. 47.8%; p < .0001). Peri-operative mortality in > 75 year old patients was 46.5% compared with 26.2% in younger patients (p = .05), with rates increased after open surgery (54.5% vs. 27.8%, p = .03) but not after EVAR (39.5% vs. 16.7%; p = .39). According to Kaplan-Meier estimates, mean survival was 39.7 ± 4.8 months. Patients older than 75 years of age survived for a mean of 23.0 ± 4.47 months after rupture. CONCLUSION: In this study aggressive treatment with a very restricted or no turndown strategy for any rAAA, also applied to older patients, allowed for an additional mean 40 months of survival after aneurysm rupture. In the contemporary endovascular era the decision to deny repair arbitrarily to older patients with rAAAs must be revisited.