Anesthetic Considerations in Combined TAVR and Aortic Endovascular Procedures, a Case Report.

ABSTRACT: We report a case of simultaneous transcatheter aortic valve replacement and endovascular aneurysm repair. Our aim was to advocate the role of local and regional anesthesia as a key contributor in maintaining hemodynamic stability and avoiding abrupt blood pressure change. Endovascular combined procedures are gaining popularity for their numerous advantages. Nevertheless, they carry significant risks for their hemodynamic implications. It is imperative to acknowledge the modifications occurring after each correction and act accordingly. Different anesthesia approaches can dramatically influence hemodynamics; among all, we found local and regional anesthesia would better serve this objective.

Endovascular repair of an abdominal aortic aneurysm with external iliac artery occlusion using VBX as the contralateral leg via axillary delivery: A case report.

RATIONALE: A hostile iliac access route is an important consideration when enforcing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA). Herein, we report a case of AAA with unilateral external iliac artery occlusion, for which bifurcated EVAR was successfully performed using a single femoral and brachial artery access. PATIENT CONCERNS: A 76-year-old man who had undergone surgery for lung cancer 4.5 years prior was diagnosed AAA by computed tomography (CT). DIAGNOSIS: Two and a half years before presentation, CT revealed an infrarenal 48 mm AAA, which had enlarged to 57 mm by 2 months preoperatively. CT identified occlusion from the right external iliac artery to the right common femoral artery, with no observed ischemic symptoms in his right leg. The right external iliac artery, occluded and atrophied, had a 1 to 2 mm diameter. INTERVENTION: Surgery was commenced with the selection of a Zenith endovascular graft (Cook Medical) with an extended body length. Two Gore Viabahn VBX balloon expandable endoprosthesis (VBX; W.L. Gore & Associate) were delivered from the right axilla as the contralateral leg. OUTCOMES: CT scan on the 2nd day after surgery revealed no endoleaks. LESSONS: While the long-term results remain uncertain, this method may serve as an option for EVAR in patients with unilateral external iliac artery occlusion.

Surgeon-modified fenestrated endovascular grafts and thoracoscope-assisted fixation for treatment of thoraco-abdominal aortic aneurysms.

BACKGROUND: Total endovascular technique with fenestrated endovascular graft might be hampered for the late dilatation of proximal landing zone, which may cause endografts migration. We describe a successful urgent hybrid procedure for extent III thoracoabdominal aortic aneurysm with aortic intramural hematoma. CASE PRESENTATION: A 55-year-old female with thoracoabdominal aortic aneurysm was considered at high surgical risk and unfit for open repair due to multiple comorbidities. Therefore, a hybrid procedure of surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted Transaortic epicardial fixation of endograft was finally chosen and performed in the endovascular operating room. A 3-port technique was performed through a left video-assisted thoracoscopic approach. After the first tampering stent-graft was deployed, a double-needle suture was penetrated both the aortic wall and stent-graft to fixate it in the proximal descending aorta. Then the second endograft, which had been fenestrated on table, was introduced and oriented extracorporeally by rotating superior mesenteric artery and left renal artery fenestration radiopaque markers and deployed with perfect apposition between the fenestrations and target visceral artery. Each vessel was sequentially stented using Viabahn self-expandable stent to finish target vessel stenting. An Ankura cuff stent was deployed in the distal abdominal aortic artery. CONCLUSION: Surgeon-modified fenestrated endovascular graft combined with thoracoscope-assisted fixation may be an innovative and viable alternative for selected high-risk patients with extent III thoracoabdominal aortic aneurysm. A longer follow-up is needed to ascertain the success of this approach.

Protocol for an independent patient data meta-analysis of prophylactic mesh placement for incisional hernia prevention after abdominal aortic aneurysm surgery: a collaborative European Hernia Society project (I-PREVENT-AAA).

INTRODUCTION: Incisional hernia (IH) is a prevalent and potentially dangerous complication of abdominal surgery, especially in high-risk groups. Mesh reinforcement of the abdominal wall has been studied as a potential intervention to prevent IHs. Randomised controlled trials (RCTs) have demonstrated that prophylactic mesh reinforcement after abdominal surgery, in general, is effective and safe. In patients with abdominal aortic aneurysm (AAA), prophylactic mesh reinforcement after open repair has not yet been recommended in official guidelines, because of relatively small sample sizes in individual trials. Furthermore, the identification of subgroups that benefit most from prophylactic mesh placement requires larger patient numbers. Our primary aim is to evaluate the efficacy and effectiveness of the use of a prophylactic mesh after open AAA surgery to prevent IH by performing an individual patient data meta-analysis (IPDMA). Secondary aims include the evaluation of postoperative complications, pain and quality of life, and the identification of potential subgroups that benefit most from prophylactic mesh reinforcement. METHODS AND ANALYSIS: We will conduct a systematic review to identify RCTs that study prophylactic mesh placement after open AAA surgery. Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase, Web of Science Core Collection and Google Scholar will be searched from the date of inception onwards. RCTs must directly compare primary sutured closure with mesh closure in adult patients who undergo open AAA surgery. Lead authors of eligible studies will be asked to share individual participant data (IPD). The risk of bias (ROB) for each included study will be assessed using the Cochrane ROB tool. An IPDMA will be performed to evaluate the efficacy, with the IH rate as the primary outcome. Any signs of heterogeneity will be evaluated by Forest plots. Time-to-event analyses are performed using Cox regression analysis to evaluate risk factors. ETHICS AND DISSEMINATION: No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publications in peer-reviewed journals and summaries posted online. PROSPERO REGISTRATION NUMBER: CRD42022347881.

The ARIA trial protocol: a randomised controlled trial to assess the clinical, technical, and cost-effectiveness of a cloud-based, ARtificially Intelligent image fusion system in comparison to standard treatment to guide endovascular Aortic aneurysm repair.

BACKGROUND: Endovascular repair of aortic aneurysmal disease is established due to perceived advantages in patient survival, reduced postoperative complications, and shorter hospital lengths of stay. High spatial and contrast resolution 3D CT angiography images are used to plan the procedures and inform device selection and manufacture, but in standard care, the surgery is performed using image-guidance from 2D X-ray fluoroscopy with injection of nephrotoxic contrast material to visualise the blood vessels. This study aims to assess the benefit to patients, practitioners, and the health service of a novel image fusion medical device (Cydar EV), which allows this high-resolution 3D information to be available to operators at the time of surgery. METHODS: The trial is a multi-centre, open label, two-armed randomised controlled clinical trial of 340 patient, randomised 1:1 to either standard treatment in endovascular aneurysm repair or treatment using Cydar EV, a CE-marked medical device comprising of cloud computing, augmented intelligence, and computer vision. The primary outcome is procedural time, with secondary outcomes of procedural efficiency, technical effectiveness, patient outcomes, and cost-effectiveness. Patients with a clinical diagnosis of AAA or TAAA suitable for endovascular repair and able to provide written informed consent will be invited to participate. DISCUSSION: This trial is the first randomised controlled trial evaluating advanced image fusion technology in endovascular aortic surgery and is well placed to evaluate the effect of this technology on patient outcomes and cost to the NHS. TRIAL REGISTRATION: ISRCTN13832085. Dec. 3, 2021.

Endovascular Repair of Ruptured Aortic Aneurysm: A Single-Center Experience.

OBJECTIVE: Aortic rupture is a rare and catastrophic emergency. Prompt diagnosis and treatment are the primary determinants of mortality. During follow-up, the majority of patients who have been effectively treated die from hypovolemic shock and multiorgan failure. This article describes the clinical and procedural details of sixteen patients with ruptured aortic aneurysms treated endovascularly. In addition, it discusses the main factors contributing to the mortality of these patients. METHOD: Patients who underwent endovascular treatment for acute aortic rupture at our center from October 2016 to March 2023 were included in this retrospective study. RESULTS: A total of 16 patients underwent endovascular aneurysm repair (EVAR) or thoracic endovascular aneurysm repair (TEVAR) for acute aortic rupture. The patients' mean age was 73.06 years (range: 52-92), and 15 of them were male. The ruptures occurred in the abdominal aortic aneurysm in ten patients, in thoracic aortic aneurysm in three patients, in the isolated iliac artery aneurysm in two patients, and there was one case of non-aneurysmal aortic rupture. In our series, patients who presented with an impending, self-limited rupture and stable hemodynamic status had good prognostic outcomes. However, eight patients died due to multiorgan failure, hemorrhagic shock, disseminated intravascular coagulopathy, renal failure, or abdominal compartment syndrome. These patients generally had poor admission vital signs and low hemoglobin values. The most critical determinants for the success of the procedure are promptly stopping the bleeding, avoiding general anesthesia, and opting for blood product replacement instead of fluid replacement. CONCLUSION: Each patient with ruptured aortic aneurysm should be managed according to the patient's hemodynamics at presentation, the size of the aneurysm, the suitability for percutaneous procedure, logistical factors, and the operator-center's experience.

Calprotectin as a new inflammatory marker of abdominal aortic aneurysm: A pilot study.

INTRODUCTION: Abdominal aortic aneurysm (AAA) is a relevant clinical problem due to the risk of rupture of progressively dilated infrarenal aorta. It is characterized by degradation of elastic fibers, extracellular matrix, and inflammation of the arterial wall. Though neutrophil infiltration is a known feature of AAA, markers of neutrophil activation are scarcely analyzed; hence, the main objective of this study. METHODS: Plasma levels of main neutrophil activation markers were quantified in patients with AAA and a double control group (CTL) formed by healthy volunteers (HV) and patients with severe atherosclerosis submitted for carotid endarterectomy (CE). Calprotectin, a cytoplasmic neutrophil protein, was quantified, by Western blot, in arterial tissue samples from patients with AAA and organ donors. Colocalization of calprotectin and neutrophil elastase was assessed by immunofluorescence. RESULTS: Plasma calprotectin and IL-6 were both elevated in patients with AAA compared with CTL (p ⩽ 0.0001) and a strong correlation was found between both molecules (p < 0.001). This difference was maintained when comparing with HV and CE for calprotectin but only with HV for IL-6. Calprotectin was also elevated in arterial tissue samples from patients with AAA compared with organ donors (p < 0.0001), and colocalized with neutrophils in the arterial wall. CONCLUSIONS: Circulating calprotectin could be a specific AAA marker and a potential therapeutical target. Calprotectin is related to inflammation and neutrophil activation in arterial wall and independent of other atherosclerotic events.

Trends in AAA Repair in Australia Over Twenty Years.

Background: The advent of endovascular techniques has revolutionised the treatment of abdominal aortic aneurysms (AAA). Many countries have seen a transition from open AAA repair (OAR) to endovascular AAA repair (EVAR) over the past 25 years. The only study done in Australia that describes this change was done in the private sector. Majority of healthcare in Australia is delivered through the public, universal healthcare system. The aim of this study was to evaluate the trends in AAA repair in the Australian public sector over the past two decades. Methods: The Australian Institute of Health and Welfare (AIHW) Procedures Data Cubes from the National Hospitals Data Collection was used to extract data pertaining to AAA repairs from 2000 to 2021. Population data from the Australian Bureau of Statistics was used to calculate incidence of each type of repair per 100,000 population. Results: There were 65,529 AAA repairs performed in the Australian public sector from 2000 to 2021. EVARs accounted for 64.4% (42,205) and OARs accounted for 35.6% (23, 324) of them. EVAR surpassed OAR as the preferred method of AAA repair in 2006. This trend was observed in both males and females and across all age groups. Conclusion: There was a consistent and steady transition from OAR to EVAR over the 21 year period with EVAR surpassing OAR as the preferred method of AAA repair relatively early in Australia compared to other countries. Further research that investigates medium- and long-term outcomes of newer stent grafts is needed to further ascertain the continued viability and effectiveness of this trend in AAA treatment.

Early and midterm outcomes of fenestrated and branched endovascular aortic repair in thoracoabdominal aneurysms types I through III.

BACKGROUND: Fenestrated and branched endovascular aortic repair (F/BEVAR) of thoracoabdominal aortic aneurysms (TAAAs) has shown high technical success and low early mortality rates. Aneurysm extent has been reported as a factor affecting outcomes. This study aimed to assess the early and midterm follow-up outcomes of patients managed by F/BEVAR for types I through III TAAAs. METHODS: A single-center retrospective analysis was conducted, including data from consecutive, elective and urgent (symptomatic and ruptured cases), patients treated for types I through III TAAAs, between October 1, 2011, and October 1, 2022, using F/BEVAR. Degenerative and postdissection TAAAs were included. Patients received prophylactic cerebrospinal fluid drainage (CSFD), except those under therapeutic anticoagulation, those who were hemodynamically unstable, or those with failed CSFD application. When an initial thoracic endovascular aortic repair was performed, as part of a staged procedure, no CSFD was used. Later stages and nonstaged procedures were performed under CSFD. Thirty-day mortality and major adverse events (MAEs) were analyzed. Kaplan-Meier estimates were used for follow-up outcomes. RESULTS: F/BEVAR for types I through III TAAAs was performed in 209 patients (56.9% males; mean age, 69.6 ± 3.2 years; mean aneurysm diameter, 65.2 ± 6.2 mm); 29.2% type I, 57.9% type II, and 12.9% type III. Urgent repair was performed in 26.7% of patients (56 cases; 23 ruptured and 33 symptomatic cases) and 153 were treated electively. Thirty-two patients (15.3%) were classified as American Society of Anesthesiologists (ASA) class IV. CSFD was used in 91% and staged thoracic endovascular aortic repair was performed in 51.2% of patients. Technical success was 93.8% (96.7% in elective vs 94.6% in urgent cases; P = .92). Thirty-day mortality was 11.0% (4.6% in elective vs 28.5% in urgent cases; P < .001) and MAEs were recorded in 17.2% of cases (7.8% in elective vs 42.8% in urgent cases; P < .001). Spinal cord ischemia rate was 20.5% (17.6% in elective vs 28.7% in urgent cases; P = .08), whereas 2.9% of patients presented paraplegia (1.3% in elective and 7.1% in urgent cases; P = .03). The mean follow-up was 16 ± 5 months. Survival was 75.0% (standard error, 4.0%) and freedom from reintervention was 73.3% (standard error, 4.4%) at 36 months. ASA IV and urgent repair were detected as independent factors related to early mortality and MAE, whereas ruptured aneurysm status was related to spinal cord ischemia evolution. CONCLUSIONS: Endovascular repair for types I through III TAAAs provides encouraging early outcomes in terms of mortality, MAE, and paraplegia, especially in an elective setting. Setting of repair and baseline ASA score should be taken into consideration during decision-making.

Health Insurance Status and Unplanned Surgery for Access-Sensitive Surgical Conditions.

Importance: Access-sensitive surgical conditions, such as abdominal aortic aneurysm, ventral hernia, and colon cancer, are ideally treated with elective surgery, but when left untreated have a natural history requiring an unplanned operation. Patients' health insurance status may be a barrier to receiving timely elective care, which may be associated with higher rates of unplanned surgery and worse outcomes. Objective: To evaluate the association between patients' insurance status and rates of unplanned surgery for these 3 access-sensitive surgical conditions and postoperative outcomes. Design, Setting, and Participants: This cross-sectional cohort study examined a geographically broad patient sample from the Healthcare Cost and Utilization Project State Inpatient Databases, including data from 8 states (Arizona, Colorado, Florida, Kentucky, Maryland, North Carolina, Washington, and Wisconsin). Participants were younger than 65 years who underwent abdominal aortic aneurysm repair, ventral hernia repair, or colectomy for colon cancer between 2016 and 2020. Patients were stratified into groups by insurance status. Data were analyzed from June 1 to July 1, 2023. Exposure: Health insurance status (private insurance, Medicaid, or no insurance). Main Outcomes and Measures: The primary outcome was the rate of unplanned surgery for these 3 access-sensitive conditions. Secondary outcomes were rates of postoperative outcomes including inpatient mortality, any hospital complications, serious complications (a complication with a hospital length of stay longer than the 75th percentile for that procedure), and hospital length of stay. Results: The study included 146 609 patients (mean [SD] age, 50.9 [10.3] years; 73 871 females [50.4%]). A total of 89 018 patients (60.7%) underwent elective surgery while 57 591 (39.3%) underwent unplanned surgery. Unplanned surgery rates varied significantly across insurance types (33.14% for patients with private insurance, 51.46% for those with Medicaid, and 72.60% for those without insurance; P < .001). Compared with patients with private insurance, patients without insurance had higher rates of inpatient mortality (1.29% [95% CI, 1.04%-1.54%] vs 0.61% [0.57%-0.66%]; P < .001), higher rates of any complications (19.19% [95% CI, 18.33%-20.05%] vs 12.27% [95% CI, 12.07%-12.47%]; P < .001), and longer hospital stays (7.27 [95% CI, 7.09-7.44] days vs 5.56 [95% CI, 5.53-5.60] days, P < .001). Conclusions and Relevance: Findings of this cohort study suggest that uninsured patients more often undergo unplanned surgery for conditions that can be treated electively, with worse outcomes and longer hospital stays compared with their counterparts with private health insurance. As efforts are made to improve insurance coverage, tracking elective vs unplanned surgery rates for access-sensitive surgical conditions may be a useful measure to assess progress.

Prehospital point-of-care ultrasound in ruptured abdominal aortic aneurysms-a retrospective cohort study.

BACKGROUND: Patients with ruptured abdominal aortic aneurysm (rAAA) require immediate vascular treatment to survive. The use of prehospital point-of-care ultrasound (POCUS) may support clinical assessment, correct diagnosis, appropriate triage and reduce system delay. The aim was to study the process of care and outcome in patients receiving prehospital POCUS versus patients not receiving prehospital POCUS in patients with rAAA, ruptured iliac aneurysm or impending aortic rupture. METHODS: We performed a retrospective cohort study in patients diagnosed with rAAA in the Central Denmark Region treated by a prehospital critical care physician from 1 January 2017 to 31 December 2021. Performance of prehospital POCUS was extracted from the prehospital electronic health records. System delay was defined as the time from the emergency phone call to the emergency medical service dispatch centre until the start of surgery. Data on patients primary hospital admission to a centre with/without vascular treatment expertise, treatments and complications including death were extracted from electronic health records. RESULTS: We included 169 patients; prehospital POCUS was performed in 124 patients (73%). Emergency surgical treatment was performed in 71 patients. The overall survival in the POCUS group was 39% versus 16% in the NO POCUS group (hazard ratio (HR) (95% 0.60, 95% CI: 0.41-0.89, p = .011). In the POCUS group 99/124 (80%) were directly admitted to a vascular surgical centre versus 25/45 (56%) in the NO POCUS, RD 24% (95% CI: 8-40)), (p = .002). In the POCUS group, system delay was a median of 142 minutes (interquartile range (IQR) 121-189) and a median of 232 minutes (IQR 166-305) in the NO POCUS group (p = .006). In a multivariable analysis incorporating age, sex, previously known rAAA, and typical clinical symptoms of rAAA, the HR for death was 0.57, 95% CI 0.38-0.86 (p = .008) favouring prehospital POCUS. CONCLUSIONS: Prehospital POCUS was associated with reduced time to treatment, higher chance of operability and significantly higher 30-day survival in patients with rAAA, ruptured iliac aneurysm or impending rupture of an AAA in this retrospective study. Residual confounding cannot be excluded. This study supports the clinical relevance of prehospital POCUS of the abdominal aorta.

Contrast-Enhanced Ultrasound after Endovascular Aortic Repair: Supplement and Potential Substitute for CT in Early- and Long-Term Follow-Up.

BACKGROUND: Endoleaks are the most common complication after endovascular aneurysm repair (EVAR). Computed tomography angiography (CTA) is presently the golden standard for lifelong surveillance after EVAR. Several studies and meta-analyses have shown contrast-enhanced ultrasound (CEUS) to be a good alternative. The main goal of our study was to further validate the inclusion of CEUS in follow-up examination protocols for the systematic surveillance after EVAR. METHODS: A retrospective analysis of patients who had received CEUS as part of their routine surveillance after EVAR at our center was conducted. Detection rate and classification of endoleak types were compared between available postinterventional CTA/magnetic resonance angiography and follow-up CEUS examinations. Last preinterventional CTAs before EVAR served as baselines with focus on potential cofactors such as age, body mass index, maximum aortic aneurysm diameters, endoleak orientation, and distance-to-surface influencing detection rates and classification. RESULTS: In total, 101 patients were included in the analysis. Forty-four endoleaks (43.5% of cases) were detected by either initial CEUS or CTA, mostly type II (37.6% of the included patients). Initial CEUS showed an endoleak sensitivity of 91.2%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 84.6%. No covariate with an influence on the correct classification could be identified either for CEUS or CT. CONCLUSIONS: CEUS should be considered a valid complementary method to CTA in the lifelong surveillance after EVAR. As type II endoleaks seem to be a common early-term, sometimes spontaneously resolving complication that can potentially be missed by CTA, we suggest combined follow-up protocols including CEUS in the early on postinterventional assessment.

Local Anesthesia for Endovascular Repair of Abdominal Aortic Aneurysm Allows for Accurate Graft Deployment with Durable Results.

BACKGROUND: Local anesthesia (LA) is sparsely used in endovascular aneurysm repair (EVAR) despite short-term benefit, likely secondary to concerns over patient movement preventing accurate endograft deployment. The objective of this study is to examine the association between anesthesia type and endoleak, sac regression, reintervention, and mortality. METHODS: The Vascular Quality Initiative database was queried for all EVAR cases from 2014 to 2022. Patients were included if they underwent percutaneous elective EVAR with anatomical criteria within instructions for use of commercially approved endografts. Multivariable logistic regression with propensity score weighting was used to determine the association between anesthesia type on the risk of any endoleak noted by intraoperative completion angiogram and sac regression. Multivariable survival analysis with propensity score weighting was used to determine the association between anesthesia type and endoleak at 1 year, long-term reintervention, and mortality. RESULTS: Thirteen thousand nine hundred thirty two EVARs met inclusion criteria: 1,075 (8%) LA and 12,857 (92%) general anesthesia (GA). On completion angiogram, LA was associated with fewer rates of any endoleaks overall (16% vs. 24%, P < 0.001). On multivariable analysis with propensity score weighting, LA was associated with similar adjusted odds of any endoleak on intraoperative completion angiogram (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.47-0.68) as well as combined type 1a and type 1b endoleaks (OR 0.72, 95% CI 0.47-1.09). Follow-up computed tomography imaging at 1 year was available for 4,892 patients, 377 (8%) LA and 4,515 (92%) GA. At 1 year, LA was associated with similar rate of freedom from any endoleaks compared to GA (0.66 [95% CI 0.63-0.69] vs. 0.71 [95% CI 0.70-0.72], P = 0.663) and increased rates of sac regression (50% vs. 45%, P = 0.040). On multivariable analysis with propensity score weighting, LA and GA were associated with similar adjusted odds of sac regression (OR 1.22, 95% CI 0.97-1.55). LA and GA had similar rates of endoleak at 1 year (hazard ratio [HR] 0.14, 95% CI 0.63-1.07); however, LA was associated with decreased hazards of combined type 1a and 1b endoleaks at 1 year (HR 0.87, 95% CI 0.80-0.96). LA and GA had similar adjusted long-term reintervention rate (HR 0.77, 95% CI 0.44-1.38) and long-term mortality (HR 1.100, 95% CI 079-1.25). CONCLUSIONS: LA is not associated with increased adjusted rates of any endoleak on completion angiogram or at 1-year follow-up compared to GA. LA is associated with decreased adjusted rates of type 1a and type 1b endoleak at 1 year, but similar rates of sac regression, long-term reintervention, and mortality. Concerns for accurate graft deployment should not preclude use of LA and LA should be increasingly considered when deciding on anesthetic type for standard elective EVAR.

Race-Based Variation in the Utilization of Epidural Analgesia in Addition to General Anesthesia for Open Abdominal Aortic Aneurysm Repair in the United States.

BACKGROUND: Epidural analgesia (EA) is recommended along with general anesthesia (GA) for patients undergoing open abdominal aortic aneurysm repair (AAA) and is known to be associated with improved postoperative outcomes. This study evaluates inequities in using this superior analgesic approach and further assesses the disparities at patient and hospital levels. METHODS: A retrospective analysis was performed using the Vascular Quality Initiative database of adult patients undergoing elective open AAA repair between 2003 and 2022. Patients were grouped and analyzed based on anesthesia utilization, that is, EA + GA (Group I) and GA only (Group II). Study groups were further stratified by race, and outcomes were studied. Univariate and multivariate analyses were performed to study the impact of race on the utilization of EA with GA. A subgroup analysis was also carried out to learn the EA analgesia utilization in hospitals performing open AAA with the least to most non-White patients. RESULTS: A total of 8,940 patients were included in the study, of which EA + GA (Group I) comprised n = 4,247 (47.5%) patients, and GA (Group II) had n = 4,693 (52.5%) patients. Based on multivariate regression analysis, the odds ratio of non-White patients receiving both EA and GA for open AAA repair compared to White patients was 0.76 (95% confidence interval: 0.53-0.72, P < 0.001). Of the patients who received both EA + GA, non-White race was associated with increased length of intensive care unit stay and a longer total length of hospital stay compared to White patients. Hospitals with the lowest quintile of minorities had the highest utilization of EA + GA for all patients compared to the highest quintile. CONCLUSIONS: Non-White patients are less likely to receive the EA + GA than White patients while undergoing elective open AAA repair, demonstrating a potential disparity. Also, this disparity persists at the hospital level, with hospitals with most non-White patients having the least EA utilization, pointing toward system-wide disparities.

A 20-Year Analysis of Ruptured Abdominal Aortic Aneurysm Outcomes and Associated Factors in Korea.

BACKGROUND: Unlike western countries, which have reported distinct decreases in incidence of ruptured abdominal aortic aneurysm (rAAA) over the last few decades, epidemiologic studies in Korea have not shown significant changes in incidence or mortality of rAAA. The purpose of this study was to analyze the changes in rAAA treatment outcomes and various associated risk factors over the past 2 decades. METHODS: A 20-year retrospective multicenter review for rAAA cases from the period of January 2000 to December 2020 was undertaken. Preoperative, intraoperative and postoperative clinical data were extracted for patients diagnosed with rAAA. For analysis, outcomes from the early era, defined as patients treated between January 1, 2000, and December 31, 2010, were compared with outcomes from the late era, defined as patients treated between January 1, 2011, and December 31, 2020. RESULTS: The total in-hospital mortality was 34.1% in the early era compared to 44.8% in the late era. Patients in the late era were older than those in the early era (75.2 ± 10.3 years vs. 70.3 ± 8.9 years; P = 0.009). Treatment with rAAA endovascular aneurysm repair increased from 2.3% in early to 13.8% in late era (P = 0.031). In the early era, more patients were operated by experienced surgeons than the late era (78.1% vs. 45.9%; P = 0.002). The emergency room to operating room time did not show improvement over the 20 years. CONCLUSIONS: The results indicate that mortality rate of rAAA in Korea has not changed over the last 2 decades. The study suggests the need for national preventive strategies, improved systemic coordination, and potential centralization of vascular services to enhance survival rates for rAAA.

Survival, Short And Long-Term Outcomes Of Open And Endovascular Surgical Repair Of Unruptured Infrarenal Abdominal Aortic Aneurysms.

INTRODUCTION: Endovascular Aortic Repair (EVAR) has become the standard management of Unruptured Infrarenal Abdominal Aortic Aneurysm (UIAAA); however, current evidence is limited and uncertain in our environment compared to Open repair. Our study aimed to determine the survival, short and long-term outcomes of EVAR vs. Open in a Peruvian cohort of UIAAA. METHODS: A single-center observational, analytical, longitudinal study using a retrospective registry of 251 patients treated (EVAR=205 vs Open=46) for UIAAA from 2000 to 2017. Variables considered were baseline, comorbidities, type of treatment, short-term (<30 days) and long-term (<5 years) outcomes, postoperative mortality according to the Vascular Quality Initiative (VQI) Risk Score, survival curves including reoperation-free rate and according to size (<65 mm vs. >65 mm) of long-term UIAAA. All variables were grouped according to the treatment performed (EVAR vs. Open) and we used the descriptive, multivariate, Cox regression, and Kaplan-Meier survival statistical analyses. RESULTS: 251 UIAAA were evaluated and the mean age was 74.5 years [±13.32], smoking, family members with UIAAA, and previous abdominal surgery were the main antecedents. Diabetes mellitus 2 was the main comorbidity; more than 50% of patients with UIAAA had diameters greater than 65 mm (p=0.021). The calculated mortality (VQI) was Open=2.21% vs. EVAR=1.65%. The outcomes in short-term were mortality (Open=2.92% vs. EVAR=0%; p=0.039), blood transfusion >4 Units (Open=72.68% vs. EVAR=17.39%; p=0.021) and overall hospital stay (Open=14 vs. EVAR=5 days; p=0.049. A reduction in mortality (HR 0.76, 95% CI, 0.62-0.96, p=0.045) and readmission for aneurysmal rupture was identified for EVAR (HR 0.81, 95% CI, 0.79-0.85, p=0.031). In long-term outcomes, mortality (Open=3.41% vs. EVAR=19.56%; p=0.047), aneurysmal rupture (Open=0% vs. EVAR 13.04%; p=0.032) and reinterventions (Open=2.43% vs. EVAR=10.86%; p=0.002). An 86% risk of mortality (HR 1.86, 95% CI, 1.32-2.38, p=0.039) and elevated risk of readmission for aneurysmal rupture was identified for EVAR (HR 2.21, 95% CI, 1.98-2.45, p=0.028). At 5 years, survival for Open=93.67% vs. EVAR=80.44% (p=0.043), reintervention-free survival for Open=89.26% vs. EVAR=47.82% (p=0.021), survival for treated IUAAA <65 mm for Open=95.77% vs. EVAR=63.63% (p=0.019) and >65 mm for Open=92.53% vs. EVAR=85.71% (p=0.059). CONCLUSION: EVAR has shown better short-term benefits and survival than Open management; however, the latter still prevails in the long term in our Peruvian UIAAA cohort. Further follow-up studies are required to demonstrate the long-term benefit of EVAR in our population.

Endovascular repair with a physician-modified fenestrated endograft to treat abdominal aortic pseudoaneurysm with Behcet's disease: a case report.

BACKGROUND: Aortic involvement in patients with Behcet's disease (BD) is rare, but it is one of the most severe manifestations. Open surgical repair of aortic aneurysm is challenging considering the high risk of postoperative recurrent anastomotic pseudoaneurysms and is associated with a much higher mortality rate. Recently, endovascular treatment has proven to be a feasible, less invasive alternative to surgery for these patients. CASE PRESENTATION: We report a total endovascular repair of a paravisceral abdominal aortic pseudoaneurysm in a 25-year-old male patient with BD. The pseudoaneurysm was successfully excluded, and the blood supply of visceral arteries was preserved with a physician-modified three-fenestration endograft under 3D image fusion guidance. Immunosuppressive therapy was continued for 1 year postoperatively. At 18 months, the patient was asymptomatic without abdominal pain. Computed tomography angiography demonstrated the absence of pseudoaneurysm recurrence, good patency of visceral vessels. DISCUSSION AND CONCLUSIONS: Endovascular repair using physician-modified fenestrated endografts is a relatively safe and effective approach for treating paravisceral aortic pseudoaneurysm in BD patients. This technique enables the preservation of the visceral arteries and prevents aneurysm recurrence at the proximal and distal landing zones, which are common complications of open surgical repair in these patients. Furthermore, we emphasize the importance of adequate immunosuppressive therapy before and after surgical repair in BD patients, which is a major risk factor for recurrence and poor prognosis.