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Budtz-Lilly, Jacob
Publications (8 of 8) Show all publications
Budtz-Lilly, J., Liungman, K., Wanhainen, A. & Mani, K. (2019). Correlations Between Branch Vessel Catheterization and Procedural Complexity in Fenestrated and Branched Endovascular Aneurysm Repair. Vascular and Endovascular Surgery, 53(4), 277-283
Open this publication in new window or tab >>Correlations Between Branch Vessel Catheterization and Procedural Complexity in Fenestrated and Branched Endovascular Aneurysm Repair
2019 (English)In: Vascular and Endovascular Surgery, ISSN 1538-5744, E-ISSN 1938-9116, Vol. 53, no 4, p. 277-283Article in journal (Refereed) Published
Abstract [en]

Introduction: The use of fenestrated and branched endovascular technologies in complex aortic aneurysm repair (F/BEVAR) is increasing, with a trend toward using longer sealing zones and incorporating more target vessels. Successful aneurysm exclusion and prevention of long-term treatment failure need to be balanced against the increased complexity of more extensive procedures. The aim of this study was to analyze relationships between the number of catheterized vessels and multiple operative variables as a means for evaluating procedural complexity.

Methods: Operative data from consecutive F/BEVAR procedures performed at a single center from 2012 to 2015 were analyzed. An equal number of EVAR procedures, randomly selected, from this period were also analyzed. Only intact aneurysms were included. Complex aneurysms were grouped based on the required number of target vessel catheterization. Ten procedural variables, categorized as perioperative, postoperative, and radiologic-related, were compared. Pearson correlation analysis and regression analysis were performed. The correlation coefficients, r, were classified using Cohen boundaries, r >= 0.5 indicating a strong relationship.

Results: There were 63 EVAR, 40 FEVAR, and 22 BEVAR procedures. There was no significant difference in patient comorbidities between conventional EVAR and complex procedure groups. The complex procedures included 23 two-vessel, 20 three-vessel, and 19 four-vessel catheterizations. Strong linear relationships between the number of branch vessel catheterizations and the following variables were identified: accumulated skin dose (r = .504), contrast volume (r = .652), fluoroscopy duration (r = .598), number of angiography series (r = .650), anesthesiology duration (r = .742), procedure duration (r = .554), and total length of stay (r = .533).

Conclusion: The complexity of FEVAR and BEVAR procedures reveals strong correlations between multiple peri- and postoperative variables. These exposures and risks should be borne in mind when considering treatment of complex abdominal aortic aneurysms as well as long-term clinical outcomes.

Place, publisher, year, edition, pages
SAGE PUBLICATIONS INC, 2019
Keywords
endovascular aneurysm repair, FEVAR, BEVAR, catheterization, radiation exposure, abdominal aortic aneurysm
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-382819 (URN)10.1177/1538574418823594 (DOI)000464423700001 ()30614400 (PubMedID)
Available from: 2019-05-06 Created: 2019-05-06 Last updated: 2019-10-28Bibliographically approved
Budtz-Lilly, J. (2019). On Surgical Treatment of Aortic Pathology. (Doctoral dissertation). Uppsala: Acta Universitatis Upsaliensis
Open this publication in new window or tab >>On Surgical Treatment of Aortic Pathology
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The use of endovascular aneurysm repair (EVAR) in the treatment of abdominal aortic aneurysms has advanced from a premature characterization as a “failed experiment” in early 2000 to the predominant modern method of treatment. Technology has accommodated initial shortcomings, but it has also led to expansions in the treatment of ruptured aneurysms and complex aortic pathologies. The overall aim of this thesis is to characterize the contemporary utilization of endovascular repair in the international setting and to evaluate its expanding use in complex aortic disease treatment.

Paper I is an analysis of outcomes after intact aneurysm treatment from registries of 12 countries. From 2005 to 2013, and with 83,253 patients included, it was shown that the use of EVAR has increased while, the perioperative mortality has decreased. This was counterbalanced by a worsening mortality for those patients treated with open aortic repair.

Paper II is an analysis of ruptured aneurysms from the above-mentioned international registries. EVAR is also increasing for these patients, although open repair is still the predominant treatment strategy in most centres. Perioperative mortality was superior for EVAR patients, despite increased age and comorbidities. An association between patient-volume and perioperative mortality could be shown for open repair, but the same could not be demonstrated for EVAR.

Paper III is an evaluation of the adaptation of a total endovascular approach for the treatment of complex abdominal aortic aneurysms from a single centre. The technical success and midterm mortality, as well as post-operative complications, including spinal ischemia, were similar to those reported from large and multi-centre analyses. Previous studies reveal disparate results for centres performing open complex aortic repair. The results here suggest that a total endovascular approach is feasible for dedicated centres contemplating this strategy.  

Paper IV is an analysis of multiple pre-, peri-, and post-operative variables documented from complex aneurysm procedures. A relationship between increased complexity and variables such as anaesthesia duration, bleeding, hospital stay, and radiation exposure was found. As patients and their comorbidities increase, a decision to embark on a complex procedure should be made with due diligence to these relationships.

Paper V is a technical analysis of patients following acute treatment for Type A aortic dissections. Many patients are unfit for open aortic arch repair. Based on current availability of endovascular aortic stentgrafts, it was shown that the majority of patients can be treated endovascularly, while anticipated device improvements should further increase the proportion of eligibility. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. p. 61
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1613
Keywords
Abdominal aortic aneurysm, EVAR, F/BEVAR, aorta dissection.
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-395964 (URN)978-91-513-0806-7 (ISBN)
Public defence
2019-12-18, Rosénsalen, entrance 95/96, NBV, Akademiska sjukhuset, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2019-11-26 Created: 2019-10-28 Last updated: 2020-01-13
Sörelius, K., Budtz-Lilly, J., Mani, K. & Wanhainen, A. (2019). Systematic Review of the Management of Mycotic Aortic Aneurysms. European Journal of Vascular and Endovascular Surgery, 58(3), 426-435
Open this publication in new window or tab >>Systematic Review of the Management of Mycotic Aortic Aneurysms
2019 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 58, no 3, p. 426-435Article, review/survey (Refereed) Published
Abstract [en]

Objectives: The aim of this systematic literature review was to compile an updated overview of mycotic aortic aneurysm (MAA) treatment and outcomes.

Methods: A systematic literature review was performed using the search terms mycotic and infected aortic aneurysms in the MEDLINE and ScienceDirect databases, published between January 2000 and September 2018. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, articles were scrutinised regarding surgical technique, aortic segment involved, pre- and post-operative antibiotic regimens, survival and infection related complications (IRCs), and factors associated with adverse or favourable outcomes.

Results: Twenty-eight studies, with a total of 963 patients, were included. All publications were observational, retrospective studies. Patient and study heterogeneity, along with missing data, precluded meta-analyses. Overall treatment consisted of open surgical repair (OSR; n = 556 [58%]), endovascular aortic repair (EVAR; n = 373 [39%]), and medical treatment alone (n = 34 [3%]). OSR was the dominant surgical technique prior to 2010, shifting to EVAR thereafter. For MAAs located in the abdominal aorta, EVAR was associated with better short term survival than OSR. Antibiotic treatment for more than six months post-operatively was associated with better survival, but there was no consensus on the length of treatment. MAAs were complicated by IRCs in 21%, irrespective of surgical technique, of which 46%-70% were fatal. The most consistently reported factors associated with adverse outcomes were increasing age, rupture, suprarenal abdominal aneurysm location, and non-Salmonella positive culture.

Conclusions: With few exceptions, the literature mainly consists of small, retrospective single centre studies. Standardised reporting is needed to increase comparability of studies. EVAR appears to be associated with superior short term survival without late disadvantages, compared with OSR. This suggests that EVAR can be an acceptable alternative to OSR. However, MAA treatment should always be tailor made and planned individually, and general recommendations are in vain. IRCs pose a significant threat to patients after MAA repair and require further investigation.

Place, publisher, year, edition, pages
W B SAUNDERS CO LTD, 2019
Keywords
Aneurysm, EVAR, Infected, Aorta, Mycotic, Review, Surgery, Treatment
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-394719 (URN)10.1016/j.ejvs.2019.05.004 (DOI)000484010400026 ()31320247 (PubMedID)
Available from: 2019-10-11 Created: 2019-10-11 Last updated: 2019-10-11Bibliographically approved
Budtz-Lilly, J., Vikholm, P., Wanhainen, A., Astudillo, R., Thelin, S. & Mani, K. (2019). Technical eligibility for endovascular treatment of the aortic arch after open type A aortic dissection repair. Journal of Thoracic and Cardiovascular Surgery
Open this publication in new window or tab >>Technical eligibility for endovascular treatment of the aortic arch after open type A aortic dissection repair
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2019 (English)In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685XArticle in journal (Refereed) Submitted
Abstract [en]

Objective: To report on the technical eligibility of patients previously treated for Stanford type A aorta dissection (AAD) for endovascular aortic arch repair based on contemporary anatomical criteria for an arch inner-branched stentgraft (AIBS). 

 

Methods: All patients treated for AAD from 2004-2015 at a single aortic centre were identified. Extent of repair and use of circulatory arrest were reported. Survival and reoperation were assessed using Kaplan Meier and competing risk models. Anatomic assessment was performed using 3-dimensional CT-imaging software. Primary outcome was survival ≥ 1 year and fulfilment of the AIBS anatomical criteria. 

 

Results: A total of 198 patients were included (158 Debakey I, 32 Debakey II, and 8 Intramural hematoma). Mortality was 30-days: 16.2%, 1-year: 19.2%, 10-years: 45.0%. There were 129 patients with imaging beyond 1 year (mean, 47.8 months), while 89 (69.0%) were AIBS eligible. During follow-up, 19 (14.7%) patients met the threshold criteria for aortic arch treatment, of which 14 (73.7%) would be considered eligible for AIBS. Patients who underwent AAD repair with circulatory arrest and no distal clamp were more often eligible for endovascular repair (88.8%) than those operated with a distal clamp (72.5%), p=0.021. Among patients who did not meet the AIBS anatomical criteria, the primary reasons were mechanical valve (40%) and insufficient proximal seal (30%). 

 

Conclusion: More than two thirds of post AAD patients repair are technically eligible for endovascular AIBS repair. Development of devices that can accommodate a mechanical aortic valve and a greater awareness of sufficient graft length would significantly increase availability.

National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-393182 (URN)
Available from: 2019-09-17 Created: 2019-09-17 Last updated: 2019-10-28Bibliographically approved
Budtz-Lilly, J., Björck, M., Venermo, M., Debus, S., Behrendt, C.-A., Altreuther, M., . . . Mani, K. (2018). Editor's Choice - The Impact of Centralisation and Endovascular Aneurysm Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries. European Journal of Vascular and Endovascular Surgery, 56(2), 181-188
Open this publication in new window or tab >>Editor's Choice - The Impact of Centralisation and Endovascular Aneurysm Repair on Treatment of Ruptured Abdominal Aortic Aneurysms Based on International Registries
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2018 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 56, no 2, p. 181-188Article in journal (Refereed) Published
Abstract [en]

Objectives: Current management of ruptured abdominal aortic aneurysms (RAAA) varies among centres and countries, particularly in the degree of implementation of endovascular aneurysm repair (EVAR) and levels of vascular surgery centralisation. This study assesses these variations and the impact they have on outcomes.

Materials and methods: RAAA repairs from vascular surgical registries in 11 countries, 2010-2013, were investigated. Data were analysed overall, per country, per treatment modality (EVAR or open aortic repair [OAR]), centre volume (quintiles IV), and whether centres were predominantly EVAR (>= 50% of RAAA performed with EVAR [EVAR(p)]) or predominantly OAR [OAR(p)]. Primary outcome was peri-operative mortality. Data are presented as either mean values or percentages with 95% CI within parentheses, and compared with chi-square tests, as well as with adjusted OR.

Results: There were 9273 patients included. Mean age was 74.7 (74.5-74.9) years, and 82.7% of patients were men (81.9-83.6). Mean AAA diameter at rupture was 7.6 cm (7.5-7.6). Of these aneurysms, 10.7% (10.0-11.4) were less than 5.5 cm. EVAR was performed in 23.1% (22.3-24.0). There were 6817 procedures performed in OAR(p) centres and 1217 performed in EVAR(p) centres. Overall peri-operative mortality was 28.8% (27.9-29.8). Peri-operative mortality for OAR was 32.1% (31.0-33.2) and for EVAR 17.9% (16.3-19.6), p < .001, and the adjusted OR was 0.38 (0.31-0.47), p < .001. The peri-operative mortality was 23.0% in EVAR(p) centres (20.6-25.4), 29.7% in OAR(p) centres (28.6-30.8), p < .001; adjusted OR = 0.60 (0.46-0.78), p < .001. Perioperative mortality was lower in the highest volume centres (QI > 22 repairs per year), 23.3% (21.2-25.4) than in QII-V, 30.0% (28.9-31.1), p < .001. Peri-operative mortality after OAR was lower in high volume centres compared with the other centres, 25.3% (23.0-27.6) and 34.0% (32.7-35.4), respectively, p < .001. There was no significant difference in peri-operative mortality after EVAR between centres based on volume.

Conclusions: Peri-operative mortality is lower in centres with a primary EVAR approach or with high case volume. Most repairs, however, are still performed in low volume centres and in centres with a primary OAR strategy. Reorganisation of acute vascular surgical services may improve outcomes of RAAA repair.

Place, publisher, year, edition, pages
W B SAUNDERS CO LTD, 2018
Keywords
Aortic aneurysm, Abdominal, Aortic rupture, Stent grafts, Quality and outcomes
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-365834 (URN)10.1016/j.ejvs.2018.01.014 (DOI)000444272200008 ()29482972 (PubMedID)
Available from: 2018-11-26 Created: 2018-11-26 Last updated: 2020-02-18Bibliographically approved
Budtz-Lilly, J., Wanhainen, A. & Mani, K. (2018). Outcomes of endovascular aortic repair in the modern era.. Journal of Cardiovascular Surgery, 59(2), 180-189
Open this publication in new window or tab >>Outcomes of endovascular aortic repair in the modern era.
2018 (English)In: Journal of Cardiovascular Surgery, ISSN 0021-9509, E-ISSN 1827-191X, Vol. 59, no 2, p. 180-189Article, review/survey (Refereed) Published
Abstract [en]

Monitoring outcomes following endovascular aortic repair (EVAR) is critical. Although evidence from randomized controlled trials has solidified the role of EVAR, the analysis of outcomes and "real-world" data has uncovered limitations, improved the selection of appropriate patients, and underscored the importance of instructions for use. Subsequent studies demonstrated the learning curve of EVAR and gradual improvement of outcomes over time. Outcomes analyses will continue to play an important role, particularly as technological growth of endovascular therapy has enabled treatment of more complex aneurysm pathologies and patients. The important analyses are herein reviewed, following the development of EVAR in the treatment of intact abdominal aortic aneurysms (AAA) to ruptured AAAs, and finally to complex aneurysms, including thoracoabdominal aortic aneurysms and mycotic aneurysms. This includes an overview of the more recent results from analyses of branched and fenestrated EVAR, as well as the use of chimney grafts. It is emphasized that the success of endovascular repair has paradoxically been hampered by its rapid growth and early achievements. Even the most advanced engineering developments cannot overcome the long-term effects of the progression of aortic disease. The long-term benefits thus require careful planning and considerations of the natural history of aneurysms and the life expectancy of the patient. Large and international data registry collaborations should continue to play a role in providing outcomes analyses to guide future improvements.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-336059 (URN)10.23736/S0021-9509.17.10332-0 (DOI)000432308200007 ()29206004 (PubMedID)
Available from: 2017-12-12 Created: 2017-12-12 Last updated: 2018-08-31Bibliographically approved
Budtz-Lilly, J., Wanhainen, A., Eriksson, J. & Mani, K. (2017). Adapting to a total endovascular approach for complex aortic aneurysm repair: Outcomes after fenestrated and branched endovascular aortic repair. Journal of Vascular Surgery, 66(5), 1349-1356, Article ID S0741-5214(17)31065-0.
Open this publication in new window or tab >>Adapting to a total endovascular approach for complex aortic aneurysm repair: Outcomes after fenestrated and branched endovascular aortic repair
2017 (English)In: Journal of Vascular Surgery, ISSN 0741-5214, E-ISSN 1097-6809, Vol. 66, no 5, p. 1349-1356, article id S0741-5214(17)31065-0Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: This study reports the feasibility of adopting a total endovascular approach for the treatment of complex abdominal aortic aneurysms (AAAs) at a European aortic center and compares the short- and midterm results against those from large and multicenter studies.

METHODS: All patients treated endovascular aortic repair (EVAR) for juxta/pararenal AAAs or thoracoabdominal aortic aneurysms (TAAAs), both elective and acute, as well as reoperations, from 2010 to 2015 were included. Treatment was fenestrated (FEVAR) or branched (BEVAR), and outcomes were analyzed for technical success and mortality at 30 and 90 days and by Kaplan-Meier curve estimates at 3 years. Outcomes on target vessels were reported as freedom from branch instability in the follow-up period. Reinterventions, endoleaks and perioperative and postoperative morbidities were analyzed.

RESULTS: A total of 71 patients were treated for juxta/pararenal AAA (n = 40) or TAAA (n = 31): 14 type II, 4 type III, and 13 type IV. There were 47 FEVAR (including 2 physician-modified fenestrated grafts) and 24 BEVAR procedures performed. Four TAAAs were ruptured. No open repairs were performed for these pathologies in this period. Mortality was 2.8% (n = 2) at 30 days and 9.9% at 90 days (n = 7). One late rupture occurred in a patient whose treatment was a technical failure. Survival at 3 years was 77.9% ± 5.6% overall, 90.9% ± 5.2% for juxta/pararenal AAAs, and 60.7% ± 10.3% for TAAAs. Graft deployment was successful in 69 of 71 patients. Revascularization was successful in 205 of 208 target vessels (98.6%): 51 of 51 superior mesenteric arteries, 27 of 27 celiac arteries, and 127 of 130 renal arteries. There were 131 fenestrated bridging stent grafts and 74 branched bridging stent grafts. Technical success was 68 of 71 (95.7%). There were nine cases of branch instability (5 BEVARs, 4 FEVARs) in five patients (7.0%). Seven vessels (5 renal arteries and 2 superior mesenteric arteries) underwent reintervention: 5 for stenoses, 1 for occlusion, and 1 for stent migration. Freedom from branch instability at 3 years was 92.7% ± 2.5% overall, 88.6% ± 6.4% for BEVAR, and 94.6% for FEVAR.

CONCLUSIONS: The short- and midterm results obtained here indicate that the benefits of a total endovascular treatment for complex aortic aneurysms, as demonstrated by large and multicenter studies, can be adapted and replicated at other centers with a dedicated aortic service. This may help guide future considerations of how to refer or treat this complex patient group.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-336068 (URN)10.1016/j.jvs.2017.03.422 (DOI)000415129100006 ()28647195 (PubMedID)
Available from: 2017-12-12 Created: 2017-12-12 Last updated: 2019-10-28Bibliographically approved
Budtz-Lilly, J., Venermo, M., Debus, S., Behrendt, C.-A. -., Altreuther, M., Belles, B., . . . Mani, K. (2017). Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years. European Journal of Vascular and Endovascular Surgery, 54(1), 13-20
Open this publication in new window or tab >>Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years
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2017 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 54, no 1, p. 13-20Article in journal (Refereed) Published
Abstract [en]

Background: Case mix and outcomes of complex surgical procedures vary over time and between regions. This study analyses peri-operative mortality after intact abdominal aortic aneurysm (AAA) repair in 11 countries over 9 years. Methods: Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analysed. Multivariate adjusted logistic regression analyses were carried out to adjust for variations in case mix. Results: A total of 83,253 patients were included. Over the two periods, the proportion of patients >= 80 years old increased (18.5% vs. 23.1%; p < .0001) as did the proportion of endovascular repair (EVAR) (44.3% vs. 60.6; p < .0001). In the latter period, 25.8% of AAAs were less than 5.5 cm. The mean annual volume of open repairs per centre decreased from 12.9 to 10.6 between the two periods (p < .0001), and it increased for EVAR from 10.0 to 17.1 (p < .0001). Overall, peri-operative mortality fell from 3.0% to 2.4% (p < .0001). Mortality for EVAR decreased from 1.5% to 1.1% (p < .0001), but the outcome worsened for open repair from 3.9% to 4.4% (p = .008). The peri-operative risk was greater for octogenarians (overall, 3.6% vs. 2.1%, p < .0001; open, 9.5% vs. 3.6%, p < .0001; EVAR, 1.8% vs. 0.7%, p < .0001), and women (overall, 3.8% vs. 2.2%, p < .0001; open, 6.0% vs. 4.0%, p < .0001; EVAR, 1.9% vs. 0.9%, p < .0001). Peri-operative mortality after repair of AAAs <5.5 cm was 4.4% with open repair and 1.0% with EVAR, p < .0001. Conclusions: In this large international cohort, total peri-operative mortality continues to fall for the treatment of intact AAAs. The number of EVAR procedures now exceeds open procedures. Mortality after EVAR has decreased, but mortality for open operations has increased. The peri-operative mortality for small AM treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture.

Keywords
Abdominal aortic aneurysm, Outcomes, Clinical practice, Vascular registries
National Category
Cardiac and Cardiovascular Systems Surgery
Identifiers
urn:nbn:se:uu:diva-330016 (URN)10.1016/j.ejvs.2017.03.003 (DOI)000405051200006 ()28416191 (PubMedID)
Available from: 2017-10-11 Created: 2017-10-11 Last updated: 2019-10-28Bibliographically approved
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