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Background: Conflicting evidence exists regarding the comparative effects of endovascular aneurysm repair (EVAR) with and without suprarenal fixation. We compare outcomes in patients treated by EVAR with baseline normal kidney function and moderate and severe chronic kidney disease., Methods: Patients with normal kidney function (glomerular filtration rate [GFR] ≥60 mL/min/1.73 m 2 ) or moderate (GFR = 30-59 mL/min/1.73 m 2 ) or severe (GFR <30 mL/min/1.73 m 2 ) kidney disease who underwent EVAR (N = 5534) were identified from the American College of Surgeons National Surgical Quality Improvement Program targeted database (2011-2015). Groups were determined by the presence (Cook Zenith [Cook Medical, Bloomington, Ind] or Medtronic Endurant [Medtronic, Minneapolis, Minn]) or absence (Gore Excluder [W. L. Gore & Associates, Flagstaff, Ariz]) of a suprarenal fixation system. Postoperative renal complications, defined as rise in creatinine concentration of >2 mg/dL without dialysis or new dialysis requirements, were analyzed within the first 30 days with results stratified by degree of kidney disease., Results: A total of 5534 patients underwent EVAR, with 3225 (58.3%) receiving a device using a suprarenal fixation system. Suprarenal fixation systems were less commonly used for symptomatic patients (11.0% vs 13.7%; P = .002) and patients with ruptured abdominal aortic aneurysm (4.5% vs 6.3%; P = .01). There was no difference in baseline kidney function between groups. EVAR with suprarenal fixation was associated with more renal complications (1.40% vs 0.65%; P = .008). In subgroup analysis, patients with moderate kidney dysfunction (n = 1780) had more renal complications (2.2% vs 0.8%; P = .02) with suprarenal fixation systems. No differences were seen in patients with normal kidney function (0.4% vs 0.2%; P = .32; n = 3597) or severe kidney dysfunction (14.3% vs 10.2%; P = .45; n = 157). This difference was driven mostly by postoperative elevation of creatinine concentration (0.6% vs 0.2%; P = .03) without requirements for new dialysis (0.8% vs 0.4%; P = .08). After adjustments with multivariate logistic regression models, EVAR with suprarenal fixation was associated with more renal complications (odds ratio, 2.65; 95% confidence interval, 1.32-5.34)., Conclusions: In our study, EVAR with suprarenal fixation devices was associated with more perioperative renal complications in patients with moderate kidney dysfunction. Long-term evaluation of these patients undergoing EVAR should be considered., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is being considered for temporizing catastrophic hemorrhage before arriving at a specialty center for definitive surgical management., Case: We describe the clinical case of a 72-year-old male with a ruptured infrarenal aortic abdominal aneurysm initially stabilized with REBOA at an outside facility and transferred to our care. Transport time was >100 minutes. Despite successful surgical repair of the ruptured aneurysm, the patient expired from multiple-organ failure likely related to ischemia-reperfusion injuries from prolonged balloon occlusion of the aorta., Conclusions: Ischemia-mitigating techniques and therapies need to improve drastically before the clinical application of REBOA can be effectively extended to outside the vicinity of specialty centers., (Published by Elsevier Inc.)

Background: Endovascular simulation employing computer, animal, and static models are common and useful adjuncts for teaching endovascular procedures and developing novel, complex endovascular techniques. Unfortunately, these models lack realistic haptic feedback and thus do not faithfully replicate many of the technical challenges associated with clinical endovascular procedures (e.g., arterial calcification, rigidity, and stenosis). We sought to develop a realistic and reproducible perfused cadaver model for endovascular training, device development, and research., Methods: Fresh frozen, elderly (age 50-80 years) male cadavers were thawed and prepared for open dissection. The entire arterial tree (ascending aorta to femoral arteries) was dissected free and major branch vessels exposed. Sheaths were placed to allow outflow from selected vessels. A Dacron conduit was sewn to the ascending aorta to generate arterial inflow, which was provided by a centrifugal pump. Aortic aneurysms were created in the descending thoracic and abdominal aorta. Digital subtraction arteriography and various endovascular interventions were performed, including stent grafts and EndoAnchors deployment., Results: Continuous antegrade flow was achieved in the thoracic, abdominal, iliac, and femoral segments. Open and percutaneous access at the femoral region was obtained with realistic back-bleeding and tactile feedback. Adequate, fluoroscopically documented flow was observed in both cannulated major and noncannulated smaller branches. We performed angiography with standard techniques via a pigtail catheter and contrast injector throughout the arterial system. Abdominal and thoracic endografts were deployed with appropriate angiographic guidance and realistic haptic feedback for both guidewire and stent grafts. Additional applications, including selective cannulation, aorto-iliac occlusive disease interventions, and anchor placement, were also successfully simulated. Finally, the model was used as a platform to test investigational devices., Conclusions: Our pressurized cadaver flow model successfully replicated multiple aspects of advanced endovascular procedures with haptic feedback. This novel human cadaver model allows for training and device development under clinically realistic conditions., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Endovascular aneurysm repair (EVAR) is considered a lower risk option for treating abdominal aortic aneurysms and is of particular utility in patients with poor functional status who may be poor candidates for open repair. However, the specific contribution of preoperative functional status to EVAR outcomes remains poorly defined. We hypothesized that impaired functional status, based simply on the ability of patients to perform activities of daily living, is associated with worse outcomes after EVAR., Methods: Patients undergoing nonemergent EVAR for abdominal aortic aneurysm between 2010 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. The primary outcomes were 30-day mortality and major operative and systemic complications. Secondary outcomes were inpatient length of stay, need for reoperation, and discharge disposition. Using the NSQIP-defined preoperative functional status, patients were stratified as independent or dependent (either partial or totally dependent) and compared by univariate and multivariable analyses., Results: Of 13,432 patients undergoing EVAR between 2010 and 2014, 13,043 were independent (97%) and 389 were dependent (3%) before surgery. Dependent patients were older and more frequently minorities; had higher rates of chronic pulmonary, heart, and kidney disease; and were more likely to have an American Society of Anesthesiologists score of 4 or 5. On multivariable analysis, preoperative dependent status was an independent risk factor for operative complications (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.5-3.9), systemic complications (OR, 2.8; 95% CI, 2.0-3.9), and 30-day mortality (OR, 3.4; 95% CI, 2.1-5.6). Secondary outcomes were worse among dependent patients., Conclusions: Although EVAR is a minimally invasive procedure with substantially less physiologic stress than in open aortic repair, preoperative functional status is a critical determinant of adverse outcomes after EVAR in spite of the minimally invasive nature of the procedure. Functional status, as measured by performance of activities of daily living, can be used as a valuable marker of increased perioperative risk and may identify patients who may benefit from preoperative conditioning and specialized perioperative care., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Cardiac arrest in patients with ruptured abdominal aortic aneurysm (rAAA) is not uncommon and associated with significantly increased mortality. Although it has been suggested as a contraindication to aortic repair, the prognostic implications of preoperative cardiac arrest in the face of rAAA are controversial. The purpose of this structured review is to analyze the reported outcomes of patients with rAAA and preoperative cardiac arrest., Methods: English language single- and multi-institutional series reporting outcomes of patients with rAAA and cardiac arrest were identified by systematic literature search and review. An aggregate analysis and structured review of outcomes after subsequent aortic repair was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The primary outcome was short-term overall mortality., Results: Sixteen studies involving 2669 patients with rAAA were analyzed, including 334 (13%) with preoperative cardiac arrest. Cardiac arrest was associated with significantly increased mortality compared with patients with rAAA without arrest (86% vs 44%; P < .0001), although cardiac arrest in isolation was poorly predictive of mortality. Four patients were treated by endovascular aortic repair, and all survived. Shorter resuscitation times and return of signs of life prior to aortic repair are associated with improved survival, and long-term functional outcomes among survivors have been reported., Conclusions: Mortality among patients with rAAA and preoperative cardiac arrest is high but not prohibitive. Aortic repair should not be withheld from such patients who are otherwise reasonable candidates for intervention, provided resources for emergent aortic repair are available., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Previous reports have documented perioperative outcomes and major complications (renal failure, spinal cord ischemia, death) after repair of aneurysms of the thoracoabdominal aorta (TAA). This study documented long-term functional outcomes after open TAA repair., Methods: The Medical Outcomes Study Short-Form 36-Item Survey (SF-36) was administered to 134 survivors (83 men, 51 women; mean age, 69.5 years) of TAA repair at a mean follow-up from surgery of 60 +/- 38.7 months. Raw scores were compared against cohorts adjusted for age and comorbidity (cardiovascular disease). Assessed was the influence of preoperative and intraoperative factors, as well as postoperative complications on long-term quality of life (QOL)., Results: Raw scores for the eight SF-36 domains and the composite physical and mental component scores were lower (P < .01) in the TAA cohort compared with an age-adjusted reference population. Female gender and age >75 years decreased the physical functioning (P = .02) and role physical (P = .04) domains compared with male gender and patients <65 years old. Previously recognized systemic vascular disease lowered QOL in three SF-36 domains: general health (P = .013), social functioning (P = .003), and role emotional (P = .003); systemic vascular disease also showed a strong trend toward reduction in physical functioning (P = .09) compared with patients without systemic vascular disease. Neither TAA extent (I to IV) nor elective vs urgent/emergency operation influenced long-term QOL in our cohort. Patients with postoperative paraplegia, cerebrovascular accident/cardiac event, and those requiring reoperation showed lower scores in the physical functioning (P = .036), general health (P = .02), and Mental Health (P = .04) domains. Increased length of stay negatively impacted long-term QOL. The TAA cohort and the cardiovascular disease cohort had similar SF-36 scores for four domains (general health, bodily pain, vitality, and social functioning) and physical component scores. The cardiovascular disease group had higher scores in the physical functioning, role physical, role emotional, and mental health domains, and in mental component scores (P < .01)., Conclusion: Permanent loss of functional capacity, measured at a mean of 5 years postoperatively, occurs rarely in survivors of TAA repair. Further studies are needed to define the role of hybrid or endovascular strategies, including their impact on long-term functional outcome compared with open TAA repair.

Objective: In multiple comparisons of open vs endovascular (EVAR) repair of abdominal aortic aneurysms, the prior assumption that open repair produced superior durability has been challenged by advocates of EVAR. Although focus on EVAR reintervention has been intense, few contemporary studies document late outcomes after open repair; this was the goal of this study., Methods: From January 1994 to December 1998 (chosen to ensure a minimum 5-year follow-up), 540 patients underwent elective open repair. Surveillance imaging (computed tomographic and magnetic resonance imaging scans) was obtained for 152 (57%) of the 269 patients who remained alive at a mean follow-up of 87 months. Study end points included freedom from graft-related interventions and aneurysm-related and overall survival (Kaplan-Meier test); factors predictive of these end points were determined by multivariate analysis., Results: The mean age at operation was 73 years. A total of 76% of patients were male; 11% had renal insufficiency (creatinine > or =1.5 mg/dL), and 13% had chronic obstructive pulmonary disease. The aortic cross-clamp position was suprarenal in 135 (25%) patients, and 284 (53%) of patients had bifurcated grafts placed. Operative mortality (30 days) was 3%, and the median length of hospital stay was 7 days. Postoperative complications occurred in 68 (13%) patients. Predictors of postoperative complications included a history of myocardial infarction (hazard ratio [HR], 2.0; P = .01) and renal insufficiency (HR, 2.5; P = .02). The mean follow-up for all patients was 87 months. Actuarial survival was 70.7% +/- 2% and 44.3% +/- 2.4% at 5 and 10 years, respectively. Negative predictors of long-term survival included advanced age (HR, 1.1; P < .001), history of myocardial infarction (HR, 1.37; P = .02), and renal insufficiency (HR, 1.5; P = .04). Freedom from graft-related reintervention was 98.2% +/- 0.8% and 94.3% +/- 3.4% at 5 and 10 years, respectively. There were 13 late graft-related complications in 11 (2%) patients (mean follow-up, 7.2 years). Findings included seven anastomotic pseudoaneurysms (five were repaired), four graft limb occlusions, and two graft infections. Aneurysms were identified in noncontiguous arterial segments in 68 (45%) of 152 patients, most of which involved the iliac arteries and required no treatment because of small size. Late aortic aneurysms proximal to the repair were identified in 24% of patients, and 29 (19%) patients had multiple late synchronous aneurysms., Conclusions: Open repair remains a safe and durable option for the management of abdominal aortic aneurysms, with an excellent associated 10-year survival in patients who undergo operation at 75 years of age or younger. In addition, the freedom from graft-related reintervention is superior to that of EVAR. Finally, continued surveillance after open repair is appropriate and should be directed toward the detection of other aneurysms.

Background: A variety of operative approaches and protective adjuncts have been used to minimize organ dysfunction and, in particular, spinal cord injury (SCI) after thoracoabdominal aneurysm (TAA) repair. There is no consensus with respect to the optimal approach., Methods: Reviewed were 445 consecutive TAA repairs done between January 1987 and December 2005. Clinical features included urgent operation in 103 patients (22.6%), of which 52 (11.4%) were ruptures. Operative management consisted of a clamp-and-sew technique with adjuncts in 417 patients (92%). Epidural cooling to prevent SCI was used in 240 (68%) extent I to III repairs. Predictors of mortality and SCI were assessed with multivariate analysis, and long-term survival was determined with Kaplan-Meier life-table analysis., Results: Operative mortality was 8.2% and was associated with preoperative serum creatinine level of 1.8 mg/dL or more (p = 0.005), intraoperative hypotension (p = 0.01), intraoperative transfusion requirement (p = 0.0008), postoperative SCI (p = 0.02), and postoperative renal failure (p < 0.0001). SCI of any severity occurred in 60 patients (13.2%), and 43 (9.5% of the total cohort) sustained major paraplegia. Epidural cooling significantly reduced the risk of SCI in patients with types I to III TAA (13.7% versus 29%, p = 0.01). Independent predictors of SCI included extent I/II aneurysms (p = 0.02), epidural cooling (p = 0.02), urgent/emergent operation (p = 0.02), intraoperative hypotension (p = 0.005), total aortic cross-clamp time (p = 0.01), and postoperative pulmonary complications (p = 0.003). Late survival rates were at 54.4% at 5 years, 28.7% at 10 years, and 20.5% at 15 years., Conclusions: Despite the favorable impact of operative adjuncts on perioperative mortality and SCI, major morbidity after TAA remains a challenge; the implications to further develop stent graft strategies are clear.