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Challenging Anatomy Predicts Mortality and Complications After Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
Erasmus Univ, Dept Vasc Surg, Med Ctr, Rotterdam, Netherlands; Hosp Santa Marta, Dept Angiol & Vasc Surg, Ctr Hosp Lisboa Cent, Lisbon, Portugal.
Erasmus Univ, Dept Vasc Surg, Med Ctr, Rotterdam, Netherlands; Hosp Divino Espirito Santo Ponta Delgada, Dept Angiol & Vasc Surg, Azores, Portugal.
Erasmus Univ, Dept Vasc Surg, Med Ctr, Rotterdam, Netherlands.
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2016 (English)In: Journal of Endovascular Therapy, ISSN 1526-6028, E-ISSN 1545-1550, Vol. 23, no 6, p. 919-927Article in journal (Refereed) Published
Abstract [en]

PURPOSE: To analyze the effects of aortic anatomy and endovascular aneurysm repair (EVAR) inside and outside the instructions for use (IFU) on outcomes in patients treated for ruptured abdominal aortic aneurysms (rAAA).

METHODS: All 112 patients (mean age 73 years; 102 men) treated with standard EVAR for rAAA between 2000 and 2012 in 3 European centers were included in the retrospective analysis. Patients were grouped based on aortic anatomy and whether EVAR was performed inside or outside the IFU. Data on complications, secondary interventions, and mortality were extracted from the patient records. Cox regression analysis was performed to assess predictors of mortality and complications; results are presented as the hazard ratio (HR) with 95% confidence interval (CI). Survival was analyzed using the Kaplan-Meier method.

RESULTS: Of the 112 patients examined, 61 (54%) were treated inside the IFU, 43 (38%) outside the IFU, and 8 patients lacked adequate preoperative computed tomography scans for determination. Median follow-up of those surviving 30 days was 2.5 years. Mortality at 30 days was 15% (95% CI 6% to 24%) inside the IFU vs 30% (95% CI 16% to 45%) outside (p=0.087). Three-year mortality estimates were 33.8% (95% CI 20.0% to 47.5%) inside the IFU vs 56% (95% CI 39.7% to 72.2%) outside (p=0.016). At 5 years, mortality was 48% (95% CI 30% to 66%) inside the IFU vs 74% (95% CI 54% to 93%) outside (p=0.015). Graft-related complications occurred in 6% (95% CI 0% to 13%) inside the IFU and 30% (95% CI 14% to 42%) outside (p=0.015). The rate of graft-related secondary interventions was 14% (95% CI 4% to 22%) inside the IFU vs 35% (95% CI 14% to 42%) outside (p=0.072). In the multivariate analysis, neck length <15 mm (HR 8.1, 95% CI 3.0 to 21.9, p<0.001) and angulation >60° (HR 3.1, 95% CI 1.0 to 9.3, p=0.045) were independent predictors of late graft-related complications. Aneurysm neck diameter >29 mm (HR 2.5, 95% CI 1.1 to 5.9, p=0.035) was an independent predictor of overall mortality.

CONCLUSION: Long-term mortality and complications after rEVAR are associated with aneurysm anatomy. The role of adjunct endovascular techniques and the outcome of open repair in cases with challenging anatomy warrant further study.

Place, publisher, year, edition, pages
2016. Vol. 23, no 6, p. 919-927
Keyword [en]
abdominal aortic aneurysm, complications, endovascular aneurysm repair, instructions for use, mortality, neck angulation, neck diameter, neck length, secondary interventions, stent-graft
National Category
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-308343DOI: 10.1177/1526602816658494ISI: 000387483900012PubMedID: 27385153OAI: oai:DiVA.org:uu-308343DiVA: diva2:1049439
Available from: 2016-11-24 Created: 2016-11-24 Last updated: 2017-12-04Bibliographically approved
In thesis
1. Endovascular aortic aneurysm repair: Aspects of follow-up and complications
Open this publication in new window or tab >>Endovascular aortic aneurysm repair: Aspects of follow-up and complications
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Endovascular aortic aneurysm repair (EVAR) is the procedure of choice in most patients with abdominal aortic aneurysm. The drawbacks of EVAR are a higher rate of complications and frequent need for reinterventions, requiring regular postoperative follow-up. Non-stratified follow-up may have a deleterious effect on patients and the health care system. The aim of this thesis is to develop strategies that can stratify the EVAR follow-up programme according to an individual patient´s risk profile.

Study I, an international multicentre study of all abdominal aortic aneurysm (AAA) patients with EVAR in three centres (2000 to 2011) demonstrated a lower rate of late complications and reinterventions in patients with sac shrinkage during the first postoperative year, compared to the non-shrinkage group.

Study II, an international multicentre study of patients treated for a ruptured aortic aneurysm with EVAR in three centres (2000 to 2012) demonstrated that ruptured EVAR (rEVAR) in patients with hostile anatomy is associated with a high rate of graft-related complications, reinterventions and increased overall mortality.

Study III, a two-centre cohort study of 326 patients with EVAR (2001 to 2012), with first postoperative computerised tomographic angiography (CTA) within one year of the operation. Patients with adequate proximal and distal sealing zones and no endoleak in the first postoperative CTA had significantly lower risk for AAA-related complications and reinterventions up to five years postoperatively.

Study IV, studied all complications and reinterventions in a two-centre cohort study of all EVAR patients (1998 to 2012), One-fourth of the patients in the study developed complications during a mean follow-up of five years. Most complications were asymptomatic imaging-detected. Ultrasound could detect most of the clinically significant complications.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 89
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1402
Keyword
abdominal aortic aneurysm, EVAR, rEVAR surveillance
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-334369 (URN)978-91-513-0167-9 (ISBN)
Public defence
2018-01-19, Gustavianum, Akademigatan 3, 753 10 Uppsala, Sverige, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2017-12-22 Created: 2017-11-23 Last updated: 2017-12-22

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Baderkhan, HassanWanhainen, AndersMani, Kevin

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