Ron Balm

Long-term outcome of open or endovascular repair of abdominal aortic aneurysm.

BACKGROUND For patients with large abdominal aortic aneurysms, randomized trials have shown an initial overall survival benefit for elective endovascular repair over conventional open repair. This survival difference, however, was no longer significant in the second year after the procedure. Information regarding the comparative outcome more than 2 years after surgery is important for clinical decision making. METHODS We conducted a long-term, multicenter, randomized, controlled trial comparing open repair with endovascular repair in 351 patients with an abdominal aortic aneurysm of at least 5 cm in diameter who were considered suitable candidates for both techniques. The primary outcomes were rates of death from any cause and reintervention. Survival was calculated with the use of Kaplan-Meier methods on an intention-to-treat basis. RESULTS We randomly assigned 178 patients to undergo open repair and 173 to undergo endovascular repair. Six years after randomization, the cumulative survival rates were 69.9% for open repair and 68.9% for endovascular repair (difference, 1.0 percentage point; 95% confidence interval [CI], -8.8 to 10.8; P=0.97). The cumulative rates of freedom from secondary interventions were 81.9% for open repair and 70.4% for endovascular repair (difference, 11.5 percentage points; 95% CI, 2.0 to 21.0; P=0.03). CONCLUSIONS Six years after randomization, endovascular and open repair of abdominal aortic aneurysm resulted in similar rates of survival. The rate of secondary interventions was significantly higher for endovascular repair. (ClinicalTrials.gov number, NCT00421330.)

Endovascular repair versus open repair of ruptured abdominal aortic aneurysms: a multicenter randomized controlled trial.

Objective: Randomized comparison of endovascular repair (EVAR) with open repair (OR) in patients with a ruptured abdominal aortic aneurysm (RAAA). Background: Despite advances in operative technique and perioperative management RAAA remains fraught with a high rate of death and complications. Outcome may improve with a minimally invasive surgical technique: EVAR. Methods: All patients with a RAAA in the larger Amsterdam area were identified. Logistics for RAAA patients was changed with centralization of care in 3 trial centers. Patients both fit for EVAR and for OR were randomized to either of the treatments. Nonrandomized patients were followed in a prospective cohort. Primary endpoint of the study was the composite of death and severe complications at 30 days. Results: Between April 2004 and February 2011, we identified 520 patients with a RAAA of which 116 could be randomized. The primary endpoint rate for EVAR was 42% and for OR was 47% [absolute risk reduction (ARR) = 5.4%; 95% confidence interval (CI): −13% to +23%]. The 30-day mortality was 21% in patients assigned to EVAR compared with 25% for OR (ARR = 4.4% 95% CI: −11% to +20%). The mortality of all surgically treated patients in the nonrandomized cohort was 30% (95% CI: 26%–35%) and 26% (95% CI: 20% to 32%) in patients with unfavorable anatomy for EVAR, treated by OR at trial centers. Conclusions: This trial did not show a significant difference in combined death and severe complications between EVAR and OR. Mortality for OR both in randomized patients and in cohort patients was lower than anticipated, which may be explained by optimization of logistics, preoperative CT imaging, and centralization of care in centers of expertise.

Meta Analysis on Mortality of Ruptured Abdominal Aortic Aneurysms

OBJECTIVES To assess the mortality of patients with ruptured abdominal aortic aneurysms undergoing open surgery and examine changes in mortality over time. METHODS Literature databases were searched for relevant articles published between 1991 and 2006. Two reviewers independently performed study inclusion and data extraction. Primary outcome measure was 30 day or in-hospital mortality. Subgroup analyses were performed examining the effect of population- and hospital-based studies, hospital volume and type of surgeon. RESULTS From a total of 1419 identified studies, 145 observational studies met the inclusion criteria of which 116 were included in the systematic review comprising 60,822 patients. Overall mortality was 48.5% (95% CI: 48.1-48.9%) and did not change significantly over the years. Age increased over the years. For overall mortality a trend was seen in favour of high-volume hospitals. CONCLUSIONS This meta-analysis suggests that mortality of patients with RAAA treated by open surgery has not changed over the past 15 years. This could be explained by increased age of patients undergoing RAAA repair.

Collapse of a stent-graft following treatment of a traumatic thoracic aortic rupture.

Purpose: To report a collapsed stent-graft used to treat a traumatic aortic rupture. Case Report: A Gore TAG stent-graft was placed in a 20-year-old man with multiple injuries. Postimplantation computed tomographic angiography (CTA) demonstrated no contrast extravasation and total exclusion of the traumatic rupture. Routine CTA 3 months after implantation revealed a collapsed stent-graft located in the outer curve of the distal aortic arch. A Talent stent-graft was placed successfully within the collapsed prosthesis. Postimplantation CTA demonstrated no contrast extravasation and good apposition of the endograft to the aortic wall. At 6 months, the repair remains secure; there is no sign of graft collapse or endoleak. Conclusions: Collapse of stent-grafts can occur after treatment for traumatic aortic ruptures; endovascular methods can be used to restore a satisfactory luminal contour.

Systematic review and meta‐analysis of population‐based mortality from ruptured abdominal aortic aneurysm

A substantial proportion of patients with a ruptured abdominal aortic aneurysm (rAAA) die outside hospital. The objective of this study was to estimate the total mortality, including prehospital deaths, of patients with rAAA.

CT-angiography of abdominal aortic aneurysms after transfemoral endovascular aneurysm management

OBJECTIVE To evaluate short-term effect of Transfemoral Endovascular Aneurysm Management (TEAM) on aortic diameters and volumes after aneurysm exclusion, using CT-angiography. DESIGN Analysis of preoperative, 1 week postoperative and 6 months postoperative CT measurements. SETTING University Hospital. MATERIALS Nine patients treated with an endovascular tube prosthesis. CHIEF OUTCOME MEASURES True cross-sectional diameters of the aorta and the aneurysm, volume of the infrarenal aortic lumen, of the thrombus and of the iliac arteries and length of the aorta and of the endovascular prosthesis. MAIN RESULTS CT-angiography detected shrinkage of the aneurysm in seven patients. Aneurysm growth was observed in one patient with persistent flow outside the graft and in one patient with fully thrombosed aneurysm sac. In the two patients with increasing thrombus volume, the volume of the aortic lumen decreased. CONCLUSIONS Although successful aneurysm exclusion can be confirmed by maximum aneurysm diameter measurement, changes in aortic lumen volume and thrombus volume may be more appropriate to discriminate successful from failed exclusion.

Editor's Choice – Endovascular Aneurysm Repair Versus Open Repair for Patients with a Ruptured Abdominal Aortic Aneurysm: A Systematic Review and Meta-analysis of Short-term Survival

BACKGROUND There is clinical equipoise between open (OR) and endovascular aneurysm repair (EVAR) for the best treatment of ruptured abdominal aortic aneurysm (RAAA). OBJECTIVE The aim of the study was to perform a systematic review and meta-analysis to estimate the short-term (combined 30-day or in-hospital) survival after EVAR and OR for patients with RAAA. Data sources included Medline, Embase, and the World Health Organization International Clinical Trials Registry until 13 January 2014. All randomised controlled trials (RCTs), observational cohort studies, and administrative registries comparing OR and EVAR of at least 50 patients were included. Articles were full-length and in English. METHODS Standard PRISMA guidelines were followed. The methodological quality of RCTs was assessed with the Cochrane Collaborations tool for assessing risk of bias. The quality of observational studies was assessed with a modified Cochrane Collaborations tool for assessing risk of bias, the Newcastle-Ottawa Scale, and the Methodological Index for Non-Randomized Studies. The results of the RCTs, of the obersvational studies, and of the administrative registries were pooled separately and analysed with the use of a random effects model. RESULTS From a total of 3,769 articles, three RCTs, 21 observational studies, and eight administrative registries met the inclusion criteria. In the RCTs, the risk of bias was lowest and the pooled odds ratio for death after EVAR versus OR was 0.90 (95% CI 0.65-1.24). The majority of the observational studies had a high risk of bias and the pooled odds ratio for death was 0.44 (95% CI 0.37-0.53). The majority of the administrative registries had a high risk of bias and the pooled odds ratio for death was 0.54 (95% CI 0.47-0.62). CONCLUSION Endovascular aneurysm repair is not inferior to open repair in patients with a ruptured abdominal aortic aneurysm. This supports the use of EVAR in suitable patients and OR as a reasonable alternative.

Computed tomographic angiographic imaging of abdominal aortic aneurysms: implications for transfemoral endovascular aneurysm management

PURPOSE To describe anatomic features pertinent to patient selection and graft design for transfemoral endovascular aneurysm management (TEAM) of the infrarenal aorta using computed tomographic (CT) angiography. METHODS A prospective noncomparative analysis of 102 spiral CT scans of the abdominal aorta of patients with abdominal aortic aneurysms was performed. From the original CT data set, slices were reconstructed perpendicular to the vessel axis (central lumen line) at a 10 mm interval. In these reconstructed slices, diameter measurements were performed. Vessel length was measured along the central lumen line. In each patient possibilities for TEAM were analyzed. RESULTS Because of technical reasons, 36 scans were excluded from the analysis. Of the remaining 66 patients, 18 could potentially be treated with a bifurcated endovascular device. The infrarenal aortic diameter-to-iliac artery diameter ratio was less than 2 in most patients. The vessel segments judged to be adequate for endovascular graft anchoring had a noncylindrical shape in the majority of cases. CONCLUSION Only a minority of patients with abdominal aortic aneurysms can at this stage be treated with an endovascular graft. The ideal endovascular graft should be a combination of rigid and flexible components. The proximal and distal attachment systems should have some flexibility with an intrinsic maximum diameter while the midsection of the graft can be relatively rigid.

Spiral CT-angiography of the aorta*

AIMS To determine whether the new technique of CT-angiography was accurate in displaying the complex anatomy of the aorta and its major branches. METHODS Seventeen patients with a variety of aortic pathology were examined. Using a spiral CT-scanner a volumetric scan was made during injection of 150 cc of i.v. contrast. Depending on the chosen CT technique, a body volume with a length ranging between 25-100 cm could be examined in one 50 second spiral scan. On the resulting transverse slices vascular lumina and extent of thrombus were studied. Subsequently, the transverse slices were reconstructed in the coronal or sagittal plane in order to appreciate the craniocaudal relations of the vascular anatomy. Finally, three-dimensional reconstructions were made of vascular lumina and thrombus. RESULTS In aortic aneurysms the extent of the aneurysmal dilatation and of the adherent thrombus could be accurately located relative to the origins of renal and visceral branches proximally, and iliac bifurcation distally. In cases of severe elongation, dissection or complex anatomy, a detailed preoperative insight into the individual anatomy could be obtained. The two-dimensional axial and multiplanar reconstructions offered excellent anatomic detail. The three-dimensional reconstructions, being based on a considerable data reduction, offered an efficient means of providing an overall view of complex anatomic relations. CONCLUSION The advantage of CT-angiography is that, based on a single spiral scan, the vascular structures in the examined body volume can be displayed in any desired plane using multiplanar reconstructions. Alternatively, three-dimensional renderings can be created. The combination of multiplanar reconstructions and three-dimensional reconstructions makes CT-angiography an accurate technique for displaying even the most complex aortic anatomy.

Hand-assisted laparoscopic live donor nephrectomy

Hand‐assisted laparoscopic donor nephrectomy (HLDN) may have advantages over laparoscopic donor nephrectomy, such as shorter learning curve, operation and warm ischaemia times. The aim of this study was to evaluate the feasibility and safety of HLDN.