George A. Antoniou

Hybrid Treatment of Complex Aortic Arch Disease with Supra-aortic Debranching and Endovascular Stent Graft Repair

BACKGROUND Aortic arch disease has conventionally been the domain of open surgical repair. Hybrid open and endovascular repair has evolved as an alternative, less invasive, treatment option with promising results. A systematic literature review and analysis of the reported outcomes was undertaken. METHODS An Internet-based literature search using MEDLINE was performed to identify all studies reporting on hybrid aortic arch repair with supra-aortic branch revascularisation and subsequent stent graft deployment. Debranching should involve at least one carotid artery, so that patients merely requiring a carotid-subclavian bypass were not included. Only reports of five patients or more were included in the analysis. Outcome measures were technical success, perioperative, 30-day and late morbidity and mortality. RESULTS Eighteen studies fulfilled our search criteria, and data from 195 patients were entered for the analysis. No comparative studies of hybrid aortic arch repair with other conventional or innovative treatment modalities were identified. Complete arch repair was performed in 122 patients (63%). The overall technical success rate was 86% (167/195). The most common reason for technical failure was endoleak (9%, 17/195). Overall perioperative morbidity and mortality rates were 21% (41/195) and 9% (18/195), respectively. The most common perioperative complication was stroke (7%, 14/195). Four aneurysm-related deaths were reported during follow-up (2%). No long-term data on hybrid aortic arch repair were identified. CONCLUSIONS Hybrid repair of complex aortic arch disease is an alternative treatment option with acceptable short-term results. Stroke remains a frequent complication and mortality rates are significant. Further research with large comparative studies and longer follow-up is required.

Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair

BACKGROUND Despite the intuitive advantages of endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (AAAs), uncertainty remains about the optimal management in the absence of convincing high-quality evidence. Our objective was to undertake a comprehensive literature review and perform a meta-analysis of outcome data of treatment modalities for ruptured AAAs. METHODS Systematic searches were conducted of electronic information sources to identify studies comparing perioperative outcomes of EVAR and open repair for AAA rupture. Summary estimates of odds ratios (ORs) or standardized mean difference and 95% confidence intervals (CIs) were obtained with a random-effects model. Meta-regression models were formed to explore potential heterogeneity as a result of changes in practice over time. RESULTS We selected 41 studies for analysis. The entire meta-analysis population comprised 59,941 patients (8201 EVAR patients and 51,740 open repair patients). EVAR was associated with a significantly lower incidence of in-hospital mortality (OR, 0.56; 95% CI, 0.50-0.64; P < .01; meta-analysis of risk-adjusted observational studies and randomized controlled trials: OR, 0.58; 95% CI, 0.46-0.73; P < .01). EVAR patients had a significantly decreased risk of developing respiratory complications (OR, 0.59; 95% CI, 0.49-0.69; P < .01) and acute renal failure (OR, 0.65; 95% CI, 0.55-0.78; P < .01) and a trend toward a reduced incidence of cardiac complications (OR, -0.02; 95% CI, -0.03 to 0.00; P = .05) and mesenteric ischemia (OR, 0.66; 95% CI, 0.44-1.00; P = .05). Patients treated with EVAR had significantly less requirements of intraoperative blood transfusion (standardized mean difference, -0.88; 95% CI, -1.06 to -0.70; P < .01). Random-effects meta-regression revealed no statistical evidence for an association between death and year of publication (P = .19). CONCLUSIONS Our analysis provides evidence to motivate the adoption of an EVAR-first policy in a nonelective setting and the establishment of standardized protocols for the management ruptured AAAs.

A meta-analysis of endovascular versus surgical reconstruction of femoropopliteal arterial disease.

BACKGROUND Controversy exists as to the relative merits of surgical and endovascular treatment of femoropoliteal arterial disease. METHODS A systematic review of the literature was undertaken to identify studies comparing open surgical and percutaneous transluminal methods for the treatment of femoropopliteal arterial disease. Outcome data were pooled and combined overall effect sizes were calculated using fixed or random effects models. RESULTS Four randomized controlled trials and six observational studies reporting on a total of 2817 patients (1387 open, 1430 endovascular) were included. Endovascular treatment was accompanied by lower 30-day morbidity (odds ratio [OR], 2.93; 95% confidence interval [CI], 1.34-6.41) and higher technical failure (OR, 0.10; 95% CI, 0.05-0.22) than bypass surgery, whereas no differences in 30-day mortality between the two groups were identified (OR, 0.92; 95% CI, 0.55-1.51). Higher primary patency in the surgical treatment arm was found at 1 (OR, 2.42; 95% CI, 1.37-4.28), 2 (OR, 2.03; 95% CI, 1.20-3.45), and 3 (OR, 1.48; 95% CI, 1.12-1.97) years of intervention. Progression to amputation was found to occur more commonly in the endovascular group at the end of the second (OR, 0.60; 95% CI, 0.42-0.86) and third (OR, 0.55; 95% CI, 0.39-0.77) year of intervention. Higher amputation-free and overall survival rates were found in the bypass group at 4 years (OR, 1.31; 95% CI, 1.07-1.61 and OR, 1.29; 95% CI, 1.04-1.61, respectively). CONCLUSIONS High-level evidence demonstrating the superiority of one method over the other is lacking. An endovascular-first approach may be advisable in patients with significant comorbidity, whereas for fit patients with a longer-term perspective a bypass procedure may be offered as a first-line interventional treatment.

Early results of the Endurant endograft system in patients with friendly and hostile infrarenal abdominal aortic aneurysm anatomy

OBJECTIVE To evaluate and compare the outcome after endovascular abdominal aortic aneurysm repair (EVAR) with the newly released Endurant endograft system in patients with different aortoiliac anatomic characteristics. METHODS We conducted a prospective observational study assigning patients with infrarenal abdominal aortic aneurysm (AAA) treated with the Endurant endoprosthesis from February 2009 to March 2010. Two groups were studied, according to the presence of a friendly (group I [GI] = 43) or hostile (group II [GII] = 34) infrarenal aortoiliac anatomy. Hostile profile was defined as any (or combination) of the following measurements: 5 mm ≤ proximal neck length (Lpr) ≤ 12 mm, 60° < proximal neck angle (A°pr) ≤ 90° and 60° < any iliac axis angle (A°iliac) ≤ 90°. Primary end points included technical and clinical success, freedom from early or late secondary interventions, any type of endoleak, and aneurysm-related death. All outcome measures were calculated using the Kaplan-Meier method and the log rank test was applied for comparisons between the groups. RESULTS The mean comorbid severity scoring was higher in GII (P = .018). The mean follow-up period in GI and GII was 12.9 ± 3.9 months (± SD, range: 6.4-19.8) and 12.4 ± 4 months (range: 4.2-19.6), respectively. Two unplanned conversions to aortouniiliac configurations were required in GI. The technical success rate in GI and GII was 95.4% and 100%, respectively. The requirement for intentional occlusion of the internal iliac artery, the requirement for cross-limb technique, the necessity of troubleshooting techniques, the procedure and radiation times, the frequency of postimplantation syndrome, and mean hospital stay were significantly higher in GII (P = .028, P = .013, P = .005, P = .037, P < .001, P = .032, P = .021, respectively). Two patients of GI died in the early postoperative period (one aneurysm but not device-related death), whereas no deaths in GII were recorded, yielding an overall 30-day mortality rate of 2.3%. No type I/III endoleaks were recorded up to the end of the study. Freedom from any type of endoleak, early or late secondary interventions, and aneurysm-related death at 12 months were found in 93.2%, 87.1%, and 93.3% of GI patients; respective values for GII were 86% (P = .21), 93.4% (P = .066), and 93.4%. The clinical success rate was 82.1% and 100% at 12 months for GI and GII, respectively. CONCLUSIONS Early (12 months) results suggest similar clinical performance of the Endurant stent graft system in endovascular treatment of AAAs with friendly and hostile anatomies, however, demonstrating more intra- and perioperative adversities for the last group. Larger prospective studies or even randomized trials comparing different new generation graft models are required to evaluate the comparable long-term results and possible expansion of EVAR indications for this specific endograft in adverse anatomies.

Late Rupture of Abdominal Aortic Aneurysm After Previous Endovascular Repair: A Systematic Review and Meta-analysis.

Purpose: To report a systematic literature review of late rupture of abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) and the results of a pooled analysis of causes, treatment, and outcomes. Methods: Electronic information sources and bibliographic reference lists were interrogated using a combination of free text and controlled vocabulary searches; 11 articles were ultimately identified that fulfilled the inclusion criteria. The articles reported a total of 190 patients who were included in the qualitative and quantitative synthesis. Mortality within 30 days or during the admission with aneurysm rupture was a primary endpoint; major perioperative morbidity was a secondary endpoint. A meta-analysis was performed for 30-day/in-hospital mortality using the random effects model. Results: A total of 152 ruptures occurred after 16,974 EVAR procedures reported by 8 of the case series, giving an incidence of 0.9% [95% confidence interval (CI) 0.77 to 1.05]. The mean time to rupture was 37 months. Twenty-nine percent (95% CI 20 to 39) of the patients had at least one previous secondary endovascular intervention following the initial EVAR, and 37% (95% CI 30 to 45) were not compliant with surveillance. Type I and III endoleaks were the predominant causes of rupture. Open surgical treatment was undertaken in 61% (95% CI 53 to 68) of the patients who underwent treatment. The pooled estimate for perioperative mortality was 32% (95% CI 24 to 41). A significantly lower mortality was found with endovascular treatment than open surgical management (p=0.027). Conclusion: Graft-related endoleaks appear to be the predominant causes of late aneurysm rupture. Quality of and compliance with post-EVAR surveillance are important factors in late rupture; a large proportion of late ruptures are amenable to endovascular treatment.

Lower recurrence rates after mesh-reinforced versus simple hiatal hernia repair: a meta-analysis of randomized trials.

Mesh hiatoplasty has been postulated to reduce recurrence rates, it is however prone to esophageal stricture, and early-term and mid-term dysphagia. The present meta-analysis was designed to compare the outcome between mesh-reinforced and primary hiatal hernia repair. The databases of Medline, EMBASE, and the Cochrane Library were searched; only randomized controlled trials entered the meta-analytical model. Anatomic recurrence documented by barium oesophagography was defined as the primary outcome endpoint. Three randomized controlled trials reporting the outcomes of 267 patients were identified. The follow-up period ranged between 6 and 12 months. The weighted mean recurrence rates after primary and mesh-reinforced hiatoplasty were 24.3% and 5.8%, respectively. Pooled analysis demonstrated increased risk of recurrence in primary hiatal closure (odds ratio, 4.2; 95% confidence interval, 1.8-9.5; P=0.001). Mesh-reinforced hiatal hernia repair is associated with an approximately 4-fold decreased risk of recurrence in comparison with simple repair. The long-term results of mesh-augmented hiatal closure remain to be investigated.

Meta-analysis of randomized trials on single-incision laparoscopic versus conventional laparoscopic appendectomy

BACKGROUND Single-incision laparoscopic appendectomy has emerged as a less invasive alternative to conventional laparoscopic surgery. High-quality relevant evidence is limited. METHODS A systematic review of electronic information sources was undertaken, with the objective of identifying randomized trials that compared single-incision with conventional laparoscopic appendectomy. Outcome measures included 30-day morbidity, abdominal abscess, wound infection, open conversion, reoperation, operative time, length of hospital stay, and postoperative pain. Fixed-effects and random-effects models were used to calculate combined overall effect sizes of pooled data. Data are presented as odds ratios or weighted mean differences with 95% confidence intervals (CIs). RESULTS Five randomized trials were identified, with a total of 746 patients. Thirty-day morbidity (9.6% vs 8.6%; odds ratio, 1.14; 95% CI, .69 to 1.89) and wound infection rates were similar between single-incision and conventional laparoscopy (4.0% vs 4.8%; odds ratio, .83; 95% CI, .41 to 1.68), whereas the duration of surgery was longer in the single-incision group (46.3 vs 40.7 minutes; weighted mean difference, 6.01; 95% CI, 2.26 to 9.76). Available data were not adequately robust to reach conclusions regarding the remaining outcome measures. CONCLUSIONS Similar postoperative morbidity and wound infection rates for single-incision and conventional laparoscopic appendectomy are supported by the current literature, but single-incision surgery requires longer operative time.

Meta-analysis of the effects of statins on perioperative outcomes in vascular and endovascular surgery.

BACKGROUND Compelling evidence from large randomized trials demonstrates the salutary effects of statins on primary and secondary protection from adverse cardiovascular events in high-risk populations. Our objective was to investigate the role of perioperative statin therapy in noncardiac vascular and endovascular surgery. METHODS Electronic information sources were systematically searched to identify studies comparing outcomes after noncardiac surgical or endovascular arterial reconstruction in patients who were and were not taking statin in the perioperative or peri-interventional period. The Cochrane Collaborations tool and the Newcastle-Ottawa scale were used to assess the methodologic quality and risk of bias of the selected studies. Random-effects models were applied to calculate pooled outcome data. RESULTS Four randomized controlled trials and 20 observational cohort or case-control studies were selected for analysis. The randomized studies enrolled 675 patients, and the observational studies enrolled 22,861 patients. Statin therapy was associated with a significantly lower risk of all-cause mortality (odds ratio [OR], 0.54; 95% CI, [CI], 0.38-0.78), myocardial infarction (OR, 0.62; 95% CI, 0.45-0.87), stroke (OR, 0.51; 95% CI, 0.39-0.67), and the composite of myocardial infarction, stroke, and death (OR, 0.45; 95% CI, 0.29-0.70). No significant differences in cardiovascular mortality (OR, 0.82; 95% CI, 0.41-1.63) and the incidence of kidney injury (OR, 0.90; 95% CI, 0.58-1.39) between the groups were identified. CONCLUSIONS Our analysis demonstrated that statin therapy is beneficial in improving operative and interventional outcomes and should be considered as part of the optimization strategy for prevention of adverse cardiovascular and cerebrovascular events and death.

A meta-analysis of outcome after percutaneous endovascular aortic aneurysm repair using different size sheaths or endograft delivery systems

Purpose To determine via a meta-analysis if the success rates for percutaneous EVAR using the “preclose” technique with suture-mediated vascular closure devices (SMCDs) are higher for smaller sheaths [≤18-F outer diameter (OD)] than for larger sheaths (≥20-F). Methods All English-language studies on percutaneous EVAR outcomes related to sheath sizes published between 1999 and August 30, 2010, were searched using MEDLINE and SCOPUS. Randomized trials, retrospective or prospective observational studies, and original articles (including a review) were included. The search identified 32 relevant full-text studies; data on percutaneous EVAR outcomes per sheath size category (≤18-F and ≥20-F OD) were included in the final meta-analysis of data from 17 studies (1 randomized controlled trial and 8 retrospective and 8 prospective cohort observational studies). The final analysis included 1440 patients and 2447 femoral access sites. Primary success was defined as closure of a common femoral artery arteriotomy without the need for any adjunctive surgical or endovascular procedure. Results Pooled data revealed that success rates were significantly better when percutaneous EVAR was performed with ≤18-F sheaths than with ≥20-F sheaths (odds ratio 1.78, 95% confidence interval 1.24 to 2.54, p=0.002). This benefit, although not significant, was more pronounced when multiple rather than single pre-applied SMCDs were deployed (odds ratio 2.16 vs. 1.64, respectively; p=0.353). Conclusion When considering primary success, it appears that larger-bore femoral access sheaths (≥20-F) introduced for percutaneous EVAR after pre-application of SMCDs are predictors of primary failure and the need for conversion to a femoral cutdown. More advanced large-bore SMCDs are required to further reduce the necessity for conversion. Planned use of multiple SMCDs might be more beneficial when ≤18-F sheaths are required.

Meta-analysis and Meta-Regression Analysis of Outcomes of Carotid Endarterectomy and Stenting in the Elderly

IMPORTANCE Uncertainty exists about the influence of advanced age on the outcomes of carotid revascularization. OBJECTIVE To undertake a comprehensive review of the literature and conduct an analysis of the outcomes of carotid interventions in the elderly. DESIGN AND SETTING A systematic literature review was conducted to identify articles comparing early outcomes of carotid endarterectomy (CEA) or carotid stenting (CAS) in elderly and young patients. MAIN OUTCOMES AND MEASURES Combined overall effect sizes were calculated using fixed or random effects models. Meta-regression models were formed to explore potential heterogeneity as a result of changes in practice over time. RESULTS Our analysis comprised 44 studies reporting data on 512,685 CEA and 75,201 CAS procedures. Carotid stenting was associated with increased incidence of stroke in elderly patients compared with their young counterparts (odds ratio [OR], 1.56; 95% CI, 1.40-1.75), whereas CEA had equivalent cerebrovascular outcomes in old and young age groups (OR, 0.94; 95% CI, 0.88-0.99). Carotid stenting had similar peri-interventional mortality risks in old and young patients (OR, 0.86; 95% CI, 0.72-1.03), whereas CEA was associated with heightened mortality in elderly patients (OR, 1.62; 95% CI, 1.47-1.77). The incidence of myocardial infarction was increased in patients of advanced age in both CEA and CAS (OR, 1.64; 95% CI, 1.57-1.72 and OR, 1.30; 95% CI, 1.16-1.45, respectively). Meta-regression analyses revealed a significant effect of publication date on peri-interventional stroke (P = .003) and mortality (P < .001) in CAS. CONCLUSIONS AND RELEVANCE Age should be considered when planning a carotid intervention. Carotid stenting has an increased risk of adverse cerebrovascular events in elderly patients but mortality equivalent to younger patients. Carotid endarterectomy is associated with similar neurologic outcomes in elderly and young patients, at the expense of increased mortality.