Defining risk and identifying predictors of mortality for open conversion after endovascular aortic aneurysm repair.

Scali ST ，Beck AW ，Chang CK ，Neal D ，Feezor RJ ，Stone DH ，Berceli SA ，Huber TS ... -  《-》

Outcomes after endovascular aneurysm repair conversion and primary aortic repair for urgent and emergency indications in the Society for Vascular Surgery Vascular Quality Initiative.

Open conversion after endovascular aortic aneurysm repair (EVAR-c) is performed nonelectively in up to 60% of cases. EVAR-c has been reported to have significantly greater risk of postoperative morbidity and mortality than primary aortic repair, but few data exist on outcomes for symptomatic or ruptured presentations. This study determined outcomes and identified predictors of postoperative major adverse cardiac events (MACEs) and mortality for patients undergoing nonelective EVAR-c compared with nonelective primary aortic repair (PAR) in the Vascular Quality Initiative (VQI). All VQI patients undergoing urgent/emergency EVAR-c or urgent/emergency PAR from 2002 to 2014 were reviewed. Urgent presentation was defined by repair ≤24 hours of a nonelective admission, and emergency operations had clinical or radiographic evidence, or both, of rupture. End points included in-hospital MACE (myocardial infarction, dysrhythmia, congestive heart failure) and 30-day mortality. Possible covariates identified on univariate analysis (P < .2) were entered into a multivariable model, and stepwise elimination identified the best subset of predictors. Generalized estimating equations logistic regression analysis was used to determine the relative effect of EVAR-c compared with PAR on outcomes. During the study interval, we identified 277 EVAR-c, and 118 (43%) underwent urgent/emergency repair. nonelective PAR was performed in 1388 of 6152 total (23%). EVAR-c patients were older (75 ± 9 vs 71 ± 10 years; P < .0001), more likely to be male (84% vs 74%; P = .02), and had a higher prevalence of hypertension (88% vs 79%; P = .02) and coronary artery disease (38% vs 27%; P = .01). No differences in MACE (EVAR-c, 31% [n = 34] vs PAR, 30% [n = 398]) or any major postoperative complication (EVAR-c, 57% [n = 63] vs PAR, 55% [n = 740]; P = .8) were found; however, 30-day mortality was significantly greater in EVAR-c (37% [n = 41]) than in (PAR, 24% [n = 291]; P = .003), with an odds ratio (OR) of 2.2 (95% confidence interval [CI], 1.04-4.77; P = .04) for EVAR-c. Predictors of any MACE included age (OR, × 1.03 for each additional year; 95% CI, 1.01-1.03; P = .0002), male gender (OR, 1.3; 95% CI, 1.03-1.67; P = .03), body mass index ≤20 kg/m2 (OR, 1.8; 95% CI, 1.13-2.87; P = .01), chronic obstructive pulmonary disease (OR, 1.2; 95% CI, 0.86-1.80; P = .25), congestive heart failure (OR, 1.5; 95% CI, 0.98-2.34; P = .06), preoperative chronic β-blocker use (OR, 1.3; 95% CI, 0.97-1.63; P = .09), and emergency presentation (OR, 2.3; 95% CI, 1.8-3.01; area under the curve, 0.70; P < .0001). Significant predictors for 30-day mortality were age (OR × 1.07 for each additional year; 95% CI, 1.05-1.09; P < .0001), female gender (OR, 1.6; 95% CI, 1.01-2.46; P = .04), preoperative creatinine >1.8 mg/dL (OR, 1.6; 95% CI, 1.04-2.35; P = .03), an emergency presentation (OR, 4.8; 95% CI, 2.93-7.93; P < .0001), and renal/visceral ischemia (OR, × 1.1 for each unit increase log (time-minutes); 95% CI, 1.02-1.22; area under the curve, 0.84; P = .01). Nonelective EVAR-c patients are older and have higher prevalence of cardiovascular risk factors than PAR patients. Similar rates of postoperative complications occur; however, urgent/emergency EVAR-c has a significantly higher risk of 30-day mortality than nonelective PAR. Several variables are identified that predict outcomes after these repairs and may help risk stratify patients to further inform clinical decision making when patients present nonelectively with EVAR failure.

Scali ST ，Runge SJ ，Feezor RJ ，Giles KA ，Fatima J ，Berceli SA ，Huber TS ，Beck AW ... -  《-》

Conversion from endovascular to open abdominal aortic aneurysm repair.

Previous studies have found conflicting results regarding the operative risks associated with conversion to open abdominal aortic aneurysm (AAA) repair after failed endovascular treatment (endovascular aneurysm repair [EVAR]). The purpose of this study was to assess the outcome of patients undergoing a conversion, and compare outcomes with standard open AAA repair and EVAR. In addition, we sought out to identify factors associated with conversion. All patients undergoing a conversion to open repair, and those undergoing standard EVAR and open repair between 2005 and 2013 were included from the National Surgical Quality Improvement Program. Multivariable logistic regression analysis was used to identify factors associated with conversion, and to assess independent perioperative risks associated with conversion compared with standard AAA repair. Subanalysis for factors associated with conversion was performed among patients additionally included in the more detailed targeted vascular module of the National Surgical Quality Improvement Program. A total of 32,164 patients were included, with 300 conversions, 7188 standard open repairs, and 24,676 EVARs. Conversion to open repair was associated with a significantly higher 30-day mortality than standard open repair (10.0% vs 4.2%; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6; P < .001), and EVAR (10.0% vs 1.7%; OR, 7.2; 95% CI, 4.8-10.9; P < .001). Conversion surgery was additionally followed by an increased occurrence of any complication (OR, 1.5; 95% CI, 1.2-1.9 [open]; OR, 7.8; 95% CI, 6.1-9.9 [EVAR]). Factors associated with conversion were young age (OR, 1.2 per 10 years decrease; 95% CI, 1.1-1.4), female gender (OR, 1.5; 95% CI, 1.2-2.0), and nonwhite race (OR, 1.8; 95% CI, 1.3-2.6). Conversely, body mass index >30 was negatively associated with (OR, 0.7; 95% CI, 0.5-0.9). Among anatomic characteristics captured in the targeted vascular data set (n = 4555), large aneurysm diameter demonstrated to be strongly associated with conversion (OR, 1.1 per 1 cm increase; 95% CI, 1.03-1.1). Conversion to open repair after failed EVAR is associated with substantially increased perioperative morbidity and mortality compared with standard AAA repair. Factors associated with conversion are large diameter of the aneurysm, young age, female gender, and nonwhite race, whereas obesity is inversely related to conversion surgery.

Ultee KH ，Soden PA ，Zettervall SL ，Darling J ，Verhagen HJ ，Schermerhorn ML ... -  《-》

Fenestrated endovascular repair of abdominal aortic aneurysms is associated with increased morbidity but comparable mortality with infrarenal endovascular aneurysm repair.

A recent prospective study found that fenestrated endovascular abdominal aortic aneurysm (AAA) repair (FEVAR) was safe and effective in appropriately selected patients at experienced centers. As this new technology is disseminated to the community, it will be important to understand how this technology compares with standard endovascular AAA repair (EVAR). The goal of this study was to compare the outcomes of FEVAR vs EVAR of AAAs. The American College of Surgeons-National Surgical Quality Improvement Program database from 2005 to 2012 was queried for AAAs (International Classification of Diseases, Ninth Revision code 441.4). Patients were stratified according to procedure (FEVAR vs EVAR). A bivariate analysis was done to assess preoperative and intraoperative risk factors for postoperative outcomes. Thirty-day postoperative mortality and complication rates were described for each procedure type. Multivariable logistic regression was performed to assess the association between the type of procedure and the risk of postoperative complications. A total of 458 patients underwent FEVAR and 19,060 patients underwent EVAR for AAA. Patients undergoing FEVAR were older (P = .02) and less likely to have a bleeding disorder (P = .046). Otherwise, the incidence of comorbidities in both groups was similar. FEVAR was associated with increased median operative time (156 vs 137 minutes; P < .001), and average postoperative length of stay (3.3 vs 2.8 days; P = .03). There was a statistically significant increase in overall complications (23.6% vs 14.3%; P < .001) and postoperative transfusions (15.3% vs 6.1%, P < .001) and trends toward increased cardiac complications (2.2% vs 1.3%; P = .09) and the need for dialysis (1.5% vs 0.8%; P = .08) in the FEVAR group. Mortality (2.4% vs 1.5%; P = .12) was not statistically different. On multivariable analysis, FEVAR remained independently associated with the need for postoperative transfusions when operative time was <75th percentile (adjusted odds ratio, 1.72; 95% confidence interval, 1.09-2.72; P = .02) as well as when operative time was >75th percentile for respective procedures (adjusted odds ratio, 5.33; 95% confidence interval, 3.55-8.00; P < .001). Patients undergoing FEVAR are more likely than patients undergoing EVAR to receive blood transfusions postoperatively and are more likely to sustain postoperative complications. Although mortality was similar, trends toward increased cardiac and renal complications may suggest the need for judicious dissemination of this new technology. Future research with larger number of FEVAR cases will be necessary to determine if these associations remain.

Glebova NO ，Selvarajah S ，Orion KC ，Black JH 3rd ，Malas MB ，Perler BA ，Abularrage CJ ... -  《-》

Contemporary outcomes of open complex abdominal aortic aneurysm repair.

The recent commercial availability of fenestrated stent grafts is likely to result in increasing endovascular repair of complex (juxtarenal and suprarenal) abdominal aortic aneurysms (cAAAs). Whereas most studies providing benchmarking for outcomes after open repair have been from high-volume centers, we sought to evaluate outcomes after elective open cAAA repair vs infrarenal AAA repair at a regional level. We used the Vascular Study Group of New England registry, which recorded 1875 open AAA repairs in New England from 2003 to 2011. Data from 14 hospitals performing both AAA and cAAA repair were used to assess the impact of clinical and technical factors on outcomes of cAAA repair. There were 443 patients who had elective cAAA repair as defined by use of a suprarenal (n = 340; 77%) or supraceliac (n = 103; 23%) clamp, with median survival follow-up of 35 months (interquartile range, 47 months). Compared with AAA repair, patients undergoing cAAA repair were more likely to be female; to have hypertension, congestive heart failure, or chronic obstructive pulmonary disease; and to have a higher baseline creatinine concentration. cAAA cases were repaired through a retroperitoneal incision in 40% of cases, with hypothermic renal perfusion use in 15%, mannitol in 73%, and renal bypass in 13%, with wide variability in the application of these adjuncts. Complex aneurysm repair vs routine AAA repair was associated with a higher independent risk of 30-day mortality (3.6% vs 1.2%; P = .002), respiratory complications (19% vs 10%; P < .001), and renal complications (21% vs 8.7%; P < .001). Among all patients, the only independent clinical or technical predictors of 30-day mortality were preoperative coronary artery disease (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.1-5.4; P = .02) and amount of intraoperative blood transfusion (OR, 2.8; 95% CI, 1.3-6.2; P = .01). In the subgroup undergoing cAAA repair, there were no predictors of operative mortality. Renal or visceral ischemia time was the only technical factor during cAAA repair that independently predicted cardiac (OR, 1.01; 95% CI, 1.00-1.03; P = .04), respiratory (OR, 1.03; 95% CI, 1.01-1.04; P < .001), and renal (OR, 1.03; 95% CI, 1.02-1.05; P < .001) complications. Long-term survival for cAAA patients was 91% ± 1% at 1 year and 71% ± 3% at 5 years and not different from that of patients undergoing infrarenal AAA repair. Risk-adjusted predictors of late mortality after cAAA repair included age (hazard ratio [HR], 1.08; 95% CI, 1.04-1.11; P < .001), chronic obstructive pulmonary disease (HR, 1.9; 95% CI, 1.2-3.0; P = .008), and preoperative creatinine concentration (per mg/dL; HR, 1.8; 95% CI, 1.05-2.9; P = .03). These data highlight excellent operative outcomes for open cAAA repair across the New England region despite significant variation in operative conduct across hospitals. Patients tolerating cAAA repair have durable long-term survival.

Deery SE ，Lancaster RT ，Baril DT ，Indes JE ，Bertges DJ ，Conrad MF ，Cambria RP ，Patel VI ... -  《-》