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Ruptured abdominal aortic aneurysms (rAAAs) are life-threatening and require emergent surgical therapy. Endovascular aortic repair for rupture (rEVAR) has become the leading strategy due to its minimal invasive approach with expected lower morbidity and mortality, especially in patients presenting with hemodynamic instability and relevant comorbidities. Following rEVAR, intraoperative angiography or early postinterventional computed tomography angiography have to exclude early type 1 or 3 endoleaks requiring immediate reintervention. Persistent type 2 endoleaks (T2ELs) after rEVAR, in contrast to elective cases, can cause possibly lethal situations due to continuing extravascular blood loss through the remaining aortic aneurysm rupture site. Therefore, early identification of relevant persistent T2ELs associated with continuous bleeding and hemodynamic instability and immediate management is mandatory in the acute postoperative setting following rEVAR. Different techniques and concepts for the occlusion of T2ELs after rEVAR are available, and most of them are also used for relevant T2ELs after elective EVAR. In addition to various interventional embolization procedures for persistent T2ELs, some patients require open surgical occlusion of T2EL-feeding arteries, abdominal compartment decompression or direct surgical patch occlusion of the aneurysm rupture site after rEVAR. So far, in the acute situation of rAAAs, indications for preemptive or intraoperative T2EL embolization during rEVAR have not been established. In the long term, persistent T2ELs after rEVAR can lead to continuous aneurysm expansion with the possible development of secondary proximal type I endoleaks and an increased risk of re-rupture requiring regular follow-up and early consideration for reintervention. To date, only very few studies have investigated T2ELs after rEVAR or compared outcomes with those from elective EVAR regarding the special aspects of persisting T2ELs. This narrative review is intended to present the current knowledge on the incidence, natural history, relevance and strategies for T2EL management after rEVAR. [ABSTRACT FROM AUTHOR]

Purpose. The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA). Materials and Methods. A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)? Results. The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies. Conclusions. The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events. [ABSTRACT FROM AUTHOR]

Background: To define proximal neck dilation (PND) after standard endovascular aneurysm repair (EVAR) and fenestrated EVAR (FEVAR), determining: incidence and risk factors; evidence base that links PND to outcomes of patients; recurring themes or gaps in the literature. Methods: We performed a scoping review and included only full-text English articles with follow-up focusing on PND in patients undergoing EVAR or FEVAR, published between 2000 and 2022. The following PICO question was used to build the search equation: in patients with abdominal-aortic-aneurysm (AAA) (Population) undergoing endovascular repair (Intervention), what are the incidence, risk factors and prognosis of radiologically defined PND (Comparison) on short-term and long-term outcomes (Outcomes)? Results: 15 articles were included after review. Measurement protocols for proximal aortic neck (PAN) varied among individual studies and the definition of PND resulted as heterogeneous. Rate of patients with a PND ranged between 0% and 41%. Large proximal neck (>28 mm) and excessive graft sizing (30%) were predictors for PND. New endografts with low outward radial forces and FEVAR seemed to be protective. Surgical conversion was the definitive option in the case of patients unfit for other endovascular treatments. Conclusions: PND is a frequent finding after EVAR and FEVAR. Excessive graft oversizing and large baseline PAN were predictors of neck enlargement, independently by the type of standard endograft used. FEVAR may be considered protective against complications, together with endografts using low outward radial forces. Lifelong radiological follow-up is mandatory. [ABSTRACT FROM AUTHOR]