Preoperative assessment and optimisation prior to planned aortic aneurysm repair: a UK survey examining current practice and attitudes of vascular surgeons and vascular anaesthetists.

BACKGROUND: The majority of those diagnosed with aortic aneurysm in the UK are older, multi-morbid patients. Decision-making as to who may benefit from intervention (open or endovascular aneurysm repair) is highly variable across the NHS (as is the mode of intervention), in part because there are no detailed guidelines or consensus on preoperative assessment. Thus, there is likely to be significant variation in the pre-operative assessment and optimisation of these patients. METHODS: A survey was designed to understand current practice and attitudes of vascular surgeons and vascular anaesthetists in the UK regarding preoperative assessment and optimisation of patients undergoing elective aortic aneurysm repair. The survey was reviewed and validated by an expert panel, then distributed electronically to all vascular surgical and vascular anaesthetic leads in the UK. RESULTS: Overall, the response rate was 68%. The responses were varied between surgeons and anaesthetists, with differences reported in the preoperative assessment and optimisation of patients, the approach to shared decision-making, and the perioperative pathway. CONCLUSIONS: Despite initiatives such as Getting It Right First Time (GIRFT) and National Institute for Health and Care Excellence (NICE) guidelines, variation still exists between centres with some differences in opinion observed between surgeons and anaesthetists. These differences may be leading to duplication of work in the perioperative pathway, inconsistencies in how risk is assessed and communicated with consequent variation in patient care. Addressing these issues requires awareness and implementation of existing guidelines, transdisciplinary working, efficient data-driven pathways, and structured aortic aneurysm multi-disciplinary team to promote meaningful shared decision-making.

Perioperative care in open aortic vascular surgery: A consensus statement by the Enhanced Recovery After Surgery (ERAS) Society and Society for Vascular Surgery.

The Society for Vascular Surgery and the Enhanced Recovery After Surgery Society formally collaborated and elected an international, multidisciplinary panel of experts to review the literature and provide evidence-based recommendations related to all the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites) for aortic aneurysm and aortoiliac occlusive disease. Structured around the Enhanced Recovery After Surgery core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

The chimney technique in endovascular aortic aneurysm repair: late ruptures after successful single renal chimney stent grafts.

BACKGROUND: The chimney graft technique has been proposed as an alternative endovascular treatment of juxtarenal aortic aneurysms, extending the landing zone and enabling successful exclusion of the aneurysm with standard endograft devices. METHODS: A prospective observational study assigning patients with juxtarenal aortic aneurysm treated with single renal chimney grafts in a tertiary vascular center in the United Kingdom was conducted. Primary outcome endpoints were defined as technical success, perioperative morbidity and mortality, and freedom from any type of endoleak, reintervention, and aneurysm-related death. RESULTS: Nine patients were enrolled. Successful aortic and chimney graft implantation was achieved in all patients. A proximal type I endoleak noticed on completion angiogram was treated with an aortic extension cuff. None of the patients died within 30 days of treatment. Two patients developed a type IA endoleak during follow-up, resulting in aneurysm rupture and death. Both patients had had uneventful chimney procedures, and no endoleak was evident on previous surveillance computed tomographic scans. All chimney grafts remained patent, and none of the patients developed renal impairment during the follow-up period. CONCLUSIONS: Proximal type I endoleak constitutes a weak point of chimney graft interventions. Increased vigilance in surveillance of such patients to prevent late aneurysm-related complications is required. Additional research to identify potential poor prognostic morphologic indicators is expected.

A ruptured thoracoabdominal aortic aneurysm managed endovascularly using the telescoping chimney technique.

Extending the proximal landing zone to facilitate endovascular repair of aortic aneurysms with short proximal necks using the chimney, top-fenestration, or snorkel technique has been previously reported. In addition, extending the distal landing zone using the periscope technique has also been recently described. In this study, we used an extended chimney technique, the "telescoping technique," to successfully treat a ruptured Crawford type III thoracoabdominal aortic aneurysm in a patient with pre-existing renal failure and an occluded superior mesenteric artery.