Kevin Mani

Endovascular repair of mycotic aortic aneurysms

PURPOSE We report our single-center experience of early and midterm outcome after endovascular repair of mycotic aortic aneurysms (MAA). METHODS Case records were retrospectively reviewed of 11 patients who underwent endovascular repair of 13 MAAs between 2000 and 2007. The aneurysms were localized in the aortic arch in 1 patient, descending thoracic aorta in 4, suprarenal abdominal aorta in 3, and infrarenal abdominal aorta in 5. RESULTS Mean follow-up was 27 months. A bleeding aortoesophageal fistula resulted in one in-hospital death <or=30 days. Three patients died later: one each of sepsis, stent migration that caused intestinal ischemia, and an unknown cause. Two patients had recurrent sepsis postoperatively but no vascular complications, two had elevated inflammatory markers during follow-up but were asymptomatic, and three patients had an uneventful follow-up. CONCLUSIONS Endovascular treatment for MAA was feasible, with acceptable perioperative mortality and midterm outcome in this single-center case series. Recurrent sepsis and late relapse with a second MAA occurred, indicating the need of long-term antibiotic therapy and follow-up, as well as the possible need for secondary open repair in selected cases. Further research is warranted to evaluate long-term outcome.

Early and late outcomes of percutaneous treatment of TransAtlantic Inter-Society Consensus class C and D aorto-iliac lesions

OBJECTIVES The aim of this study was to analyze the technical success and long-term patency of the endovascular treatment of TransAtlantic Inter-Society Consensus (TASC) C and D aorto-iliac arterial lesions. METHODS All studies reporting original series of patients published in English between 2000 and 2010 were enrolled into meta-analysis. Separate meta-analyses were performed for groups with immediate technical success, 12-month patency, and long-term outcomes. Subgroup analyses were performed to determine if there were differences in outcomes between patients with varying types of lesions (TASC C or D lesions) or between different stenting strategies, including primary or selective stenting. RESULTS Sixteen articles consisting of 958 patients were enrolled in this meta-analysis. The pooled estimate for technical success was 92.8% (95% confidence interval [CI], 89.8%-95.0%, 749 cases). Primary patency at 12 months was 88.7% (95% CI, 85.9%-91.0%, 787 cases). Subgroup analyses demonstrated a technical success rate of 93.7% (95% CI, 88.9%-96.5%) and a 12-month primary patency rate of 89.6% (95% CI, 84.8%-93.0%) for TASC C lesions. For TASC D lesions, these rates were 90.1% (95% CI, 76.6%-96.2%) and 87.3% (95% CI, 82.5%-90.9%), respectively. The technical success and 12-month primary patency rates for primary stenting were 94.2% (95% CI, 91.8%-95.9%) and 92.1% (95% CI, 89.0%-94.3%), respectively; for selective stenting, these rates were 88.0% (95% CI, 67.9%-96.2%) and 82.9% (95% CI, 72.2%-90.0%), respectively. The long-term, primary patency rates for patients receiving primary stenting were significantly better than those receiving selective stenting. Publication bias was not significant for these analyses. CONCLUSIONS This study demonstrates that early and midterm outcomes of endovascular treatment for TASC C and D aorto-iliac lesions were acceptable, with a better patency for primary stenting than selective stenting.

Endovascular Treatment of Mycotic Aortic Aneurysms A European Multicenter Study

Background— Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection–related complications and long-term survival. Methods and Results— All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39–86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella–positive culture as predictors for late infection–related death. Conclusions— Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonella–positive blood cultures were more likely to die from late infection. # CLINICAL PERSPECTIVE {#article-title-32}Background— Mycotic aortic aneurysm (MAA) is a rare and life-threatening disease. The aim of this European multicenter collaboration was to study the durability of endovascular aortic repair (EVAR) of MAA, by assessing late infection–related complications and long-term survival. Methods and Results— All EVAR treated MAAs, between 1999 and 2013 at 16 European centers, were retrospectively reviewed. One hundred twenty-three patients with 130 MAAs were identified. Mean age was 69 years (range 39–86), 87 (71%) were men, 58 (47%) had immunodeficiency, and 47 (38%) presented with rupture. Anatomic locations were ascending/arch (n=4), descending (n=34), paravisceral (n=15), infrarenal aorta (n=63), and multiple (n=7). Treatments were thoracic EVAR (n=43), fenestrated/branched EVAR (n=9), and infrarenal EVAR (n=71). Antibiotic was administered for mean 30 weeks. Mean follow-up was 35 months (range 1 week to 149 months). Six patients (5%) were converted to open repair during follow-up. Survival was 91% (95% confidence interval, 86% to 96%), 75% (67% to 83%), 55% (44% to 66%), and 41% (28% to 54%) after 1, 12, 60, and 120 months, respectively. Infection-related death occurred in 23 patients (19%), 9 after discontinuation of antibiotic treatment. A Cox regression analysis demonstrated non-Salmonella–positive culture as predictors for late infection–related death. Conclusions— Endovascular treatment of MAA is feasible and for most patients a durable treatment option. Late infections do occur, are often lethal, and warrant long-term antibiotic treatment and follow-up. Patients with non-Salmonella–positive blood cultures were more likely to die from late infection.

Changes in the management of infrarenal abdominal aortic aneurysm disease in Sweden

Treatment of abdominal aortic aneurysm (AAA) has changed over time, with endovascular repair (EVAR) being the main technical revolution. This study assessed the effect of this change on outcome on a national basis over a 17‐year interval.

Screening for Abdominal Aortic Aneurysm in 65-Year-old Men Remains Cost-effective with Contemporary Epidemiology and Management

OBJECTIVES The epidemiology and management of abdominal aortic aneurysms (AAA) has changed significantly, with lower prevalence, increased longevity of patients, increased use of endovascular aneurysm repair (EVAR), and improved outcome. The clinical and health economic effectiveness of one-time screening of 65-year-old men was assessed within this context. METHODS One-time ultrasound screening of 65-year-old men (invited) versus no screening (control) was analysed in a Markov model. Data on the natural course of AAA (risk of repair and rupture) was based on randomised controlled trials. Screening detected AAA prevalence (1.7%), surgical management (50% EVAR), repair outcome, costs, and long-term survival were based on contemporary population-based data. Incremental cost-efficiency ratios (ICER), absolute and relative risk reduction for death from AAA (ARR, RRR), numbers needed to screen (NNS), and life-years gained were calculated. Annual discounting was 3.5%. RESULTS In base case at 13-years follow-up the ICER was €14,706 per incremental quality-adjusted life-year (QALY); ARR was 15.1 per 10,000 invited, NNS was 530, and QALYs gained were 56.5 per 10,000 invited. RRR was 42% (from 0.36% in control to 0.21% in invited). In a lifetime analysis the ICER of screening decreased to €7,570/QALY. The parameters with highest impact on the cost-efficiency of screening in the sensitivity analysis were the prevalence of AAA (threshold value <0.5%) and degree of incidental detection in the control cohort. CONCLUSIONS In the face of recent changes in the management and epidemiology of AAA, screening men for AAA remains cost-effective and delivers significant clinical impact.

Variations in Abdominal Aortic Aneurysm Care: A Report from the International Consortium of Vascular Registries

Background: This project by the ICVR (International Consortium of Vascular Registries), a collaboration of 11 vascular surgical quality registries, was designed to evaluate international variation in the contemporary management of abdominal aortic aneurysm (AAA) with relation to recommended treatment guidelines from the Society for Vascular Surgery and the European Society for Vascular Surgery. Methods: Registry data for open and endovascular AAA repair (EVAR) during 2010 to 2013 were collected from 11 countries. Variations in patient selection and treatment were compared across countries and across centers within countries. Results: Among 51 153 patients, 86% were treated for intact AAA (iAAA) and 14% for ruptured AAA. Women constituted 18% of the entire cohort (range, 12% in Switzerland–21% in the United States; P<0.01). Intact AAAs were repaired at diameters smaller than recommended by guidelines in 31% of men (<5.5 cm; range, 6% in Iceland–41% in Germany; P<0.01) and 12% of women with iAAA (<5 cm; range, 0% in Iceland–16% in the United States; P<0.01). Overall, use of EVAR for iAAA varied from 28% in Hungary to 79% in the United States (P<0.01) and for ruptured AAA from 5% in Denmark to 52% in the United States (P<0.01). In addition to the between-country variations, significant variations were present between centers in each country in terms of EVAR use and rate of small AAA repair. Countries that more frequently treated small AAAs tended to use EVAR more frequently (trend: correlation coefficient, 0.51; P=0.14). Octogenarians made up 23% of all patients, ranging from 12% in Hungary to 29% in Australia (P<0.01). In countries with a fee-for-service reimbursement system (Australia, Germany, Switzerland, and the United States), the proportions of small AAA (33%) and octogenarians undergoing iAAA repair (25%) were higher compared with countries with a population-based reimbursement model (small AAA repair, 16%; octogenarians, 18%; P<0.01). In general, center-level variation within countries in the management of AAA was as important as variation between countries. Conclusions: Despite homogeneous guidelines from professional societies, significant variation exists in the management of AAA, most notably for iAAA diameter at repair, use of EVAR, and the treatment of elderly patients. ICVR provides an opportunity to study treatment variation across countries and to encourage optimal practice by sharing these results.

Similar Cost for Elective Open and Endovascular AAA Repair in a Population-Based Setting

Purpose: To compare cost differences between elective open repair (OR) and endovascular repair (EVAR) of abdominal aortic aneurysm in a population-based setting. Methods: Clinical data and hospital-related costs (pre-, peri-, and postoperative) were analyzed for 109 consecutive AAA procedures (98 men; mean age 73 years, range 48–95; mean aneurysm diameter 61 mm, range 42–120) performed from 2001 to 2005 (58 OR, 51 EVAR) in our primary catchment area. Data were obtained through case records and hospital accounting systems. Nonparametric bootstrap was used for cost comparison. Results: EVAR patients were older (76 versus 70 years, p<0.001) and had more comorbidities (ASA class 2.6 versus 2.3, p=0.025). OR patients more often had anatomically complex aneurysms (52% versus 14%, p<0.001). Comparison of data with diagnosis-based reimbursement levels nationally and internationally indicated adequate cost level in the study. No difference was observed in total cost between OR and EVAR (€29,786 versus €26,382; p=0.336). Preoperative cost was lower for OR compared to EVAR (€661 versus €1494, p=0.002). OR patients had higher cost of intensive care [36% (€8921) of perioperative cost versus 7% (€1460), p=0.001], while EVAR had higher implant cost [36% (€7468) versus 2% (€448), p<0.001]. Mean follow-up was 2.5 years (range 0.5–5.4). Mean postoperative cost was similar (OR €4613 versus EVAR €4403, p=0.209; 16% and 17% of total cost, respectively). Postoperative cost after OR was high early on, with lower cost thereafter. Postoperative cost after EVAR was more homogenously distributed, leveling off at €500 to €1000 annually over 5 years. Conclusion: In a population-based setting, total cost was similar for OR and EVAR. There were, however, important differences in patient characteristics and cost structure.

Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair

Aneurysm shrinkage has been proposed as a marker of successful endovascular aneurysm repair (EVAR). Patients with early postoperative shrinkage may experience fewer subsequent complications, and consequently require less intensive surveillance.

Selective screening for abdominal aortic aneurysm among patients referred to the vascular laboratory.

BACKGROUND Patients examined for peripheral arterial disease at the vascular laboratory, Uppsala University Hospital, are since 1993 screened for abdominal aortic aneurysm (AAA). The objective of this study was to study the prevalence of AAA found at this selective high-risk screening. METHODS All files in the vascular laboratory were retrospectively reviewed. Of 9296 persons examined with arterial duplex between 1993 and October 2005, 5924 were screened for AAA. The primary target vessel was the carotid arteries in 3772 subjects, the renal arteries in 1529 subjects and the lower extremity arteries in 1457 subjects. An AAA was defined as an infrarenal aortic diameter >/=30mm. RESULTS 179 subjects were found to have an AAA. In a logistic regression model male gender, age and duplex-verified arterial stenosis were independently associated with AAA (odds ratio 3.2, 2.0/20 years and 2.0, respectively, p<0.001). In men <60 years the AAA prevalence was 0.9% (95% confidence interval 0.2-1.6%) when arterial stenosis was absent and 1.5% (0.0-3.2%) when present. In men >/=60 years the AAA prevalence was 4.0% (3.0-5.1%) when no arterial stenosis was found and 7.3% (5.7-8.9%) when found. The corresponding prevalences in women were 0%, 0%, 1.2% (0.5-1.8%), and 3.1% (1.9-4.3%), respectively. CONCLUSIONS Men >/=60 years referred for arterial examination have a significant risk of having an AAA while only women >/=65 years with a duplex verified arterial stenosis have a sufficient risk of having an AAA. Studies to evaluate the benefit of selective high-risk screening are warranted.

Endovascular Versus Open Repair as Primary Strategy for Ruptured Abdominal Aortic Aneurysm: A National Population-based Study

OBJECTIVE/BACKGROUND In randomized trials, no peri-operative survival benefit has been shown for endovascular (EVAR) repair of ruptured abdominal aortic aneurysm (rAAA) when compared with open repair. The aim of this study was to investigate the effect of primary repair strategy on early and midterm survival in a non-selected population based study. METHODS The Swedish Vascular Registry was consulted to identify all rAAA repairs performed in Sweden in the period 2008-12. Centers with a primary EVAR strategy (treating > 50% of rAAA with EVAR) were compared with centers with a primary open repair strategy. Peri-operative outcome, midterm survival, and incidence of rAAA repair/100,000 inhabitants aged > 50 years were assessed. RESULTS In total, 1,304 patients were identified. Three primary EVAR centers (pEVARc) operated on 236 patients (74.6% EVAR). Twenty-six primary open repair centers (pORc) operated 1,068 patients (15.6% EVAR). Patients treated at pEVARc were more often referrals (28.0% vs. 5.3%; p < .01), had a higher rate of respiratory comorbidity (36.5% vs. 21.9%; p < .01), and higher pre-operative systolic blood pressure (84.3 vs. 72.3 mmHg; p < .01). There was no difference in mortality based on primary treatment strategy at 30 days (pEVARc 28.0%, n = 66; pORc 27.4%, n = 296 [p = .87]), 1 year (pEVARc 39.9%, n = 93; pORc 34.7%, n = 366 [p = .19]), or 2 years (42.1%, n = 94; 38.3%, n = 394 [p = .28]), either overall or in subgroups based on age or referral status. Overall, patients treated with EVAR were older (mean age 76.4 vs. 74.0 years; p < .01), and had a lower 30 day mortality (EVAR 21.6%, n = 74; odds ratio 29.6%, n = 288 [p = < .01]). Incidence of rAAA repair was lower in pEVARc regions (6.07, 95% confidence interval [CI] 5.01-7.13) when compared with pORc regions (8.15, 95% CI 7.64-8.66). CONCLUSION There was no difference in mortality after rAAA repair among centers with a primary EVAR approach when compared with a primary open repair strategy, either peri-operatively or in the midterm. The study supports the early findings of the randomized controlled trials in a national population based setting.