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Background: Elective endovascular aneurysm repair (EVAR) can be performed via local anesthetics and/or regional (epidural or spinal) anesthesia (locoregional [LR]), versus general anesthesia (GA), conferring reduced intensive care unit (ICU) and hospital stays. Current analyses fail to account for temporal changes in vascular practice. Therefore, this study aimed to confirm reductions in ICU and hospital stays among LR patients while accounting for changes in practice patterns., Materials and Methods: Using the Society for Vascular Surgery's Vascular Quality Initiative, elective EVARs from August 2003 to June 2021 were grouped into LR or GA. Outcomes included ICU admission and prolonged hospital stay (>2 d). Procedures were stratified into groups of 2 y periods, and outcomes were analyzed within each time period. Univariable and multivariate analyses were used to assess outcomes., Results: LR was associated with reduced ICU admissions (22.3% versus 32.1%, P < 0.001) and prolonged hospital stays (14.3% versus 7.9%, P < 0.001) overall. When stratified by year, LR maintained its association with reduced ICU admissions in 2014-2015 (21.8% versus 34.0%, P < 0.001), 2016-2017 (23.6% versus 31.6%, P < 0.001), 2018-2019 (18.5% versus 30.2%, P < 0.001), and 2020-2021 (15.8% versus 28.8%, P < 0.001), although this was highly facility dependent. LR was associated with fewer prolonged hospital stays in 2014-2015 (15.6% versus 20.4%, P = 0.001) and 2016-2017 (13.3% versus 16.6%, P = 0.006) but not after 2017., Conclusions: GA and LR have similar rates of prolonged hospital stays after 2017, while LR anesthesia was associated with reduced rates of ICU admissions, although this is facility-dependent, providing a potential avenue for resource preservation in patients suitable for LR., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Based on data supporting a volume-outcome relationship in elective aortic aneurysm repair, the Society of Vascular Surgery (SVS) guidelines recommend that endovascular aortic repair (EVAR) be localized to centers that perform ≥10 operations annually and have a perioperative mortality and conversion-to-open rate of ≤2% and that open aortic repair (OAR) be localized to centers that perform ≥10 open aortic operations annually and have a perioperative mortality ≤5%. However, the number and distribution of centers meeting the SVS criteria remains unclear. This study aimed to estimate the temporal trends and geographic distribution of Centers Meeting the SVS Aortic Guidelines (CMAG) in the United States., Methods: The SVS Vascular Quality Initiative was queried for all OAR, aortic bypasses, and EVAR from 2011 to 2019. Annual OAR and EVAR volume, 30-day elective operative mortality for OAR or EVAR, and EVAR conversion-to-open rate for all centers were calculated. The SVS guidelines for OAR and EVAR, individually and combined, were applied to each institution leading to a CMAG designation. The proportion of CMAGs by region (West, Midwest, South, and Northeast) were compared by year using a χ 2 test. Temporal trends were estimated using a multivariable logistic regression for CMAG, adjusting by region., Results: Overall, 67,865 patients (49,264 EVAR; 11,010 OAR; 7591 aortic bypasses) at 336 institutions were examined. The proportion of EVAR CMAGs increased nationally by 1.7% annually from 51.6% (n = 33/64) in 2011 to 67.1% (n = 190/283) in 2019 (β = .05; 95% confidence interval [CI], 0.01-0.09; P = .02). The proportion of EVAR CMAGs across regions ranged from 27.3% to 66.7% in 2011 to 63.9% to 72.9% in 2019. In contrast, the proportion of OAR CMAGs has decreased nationally by 1.8% annually from 32.8% (n = 21/64) in 2011 to 16.3% (n = 46/283) in 2019 (β = -.14; 95% CI, -0.19 to -0.10; P < .01). Combined EVAR and OAR CMAGs were even less frequent and decreased by 1.5% annually from 26.6% (n = 17/64) in 2011 to 13.1% (n = 37/283) in 2019 (β = -.12; 95% CI, -0.17 to -0.07; P < .01). In 2019, there was no significant difference in regional variation of the proportion of combined EVAR and OAR CMAGs (P = .82)., Conclusions: Although an increasing proportion of institutions nationally meet the SVS guidelines for EVAR, a smaller proportion meet them for OAR, with a concerning downward trend. These data question whether we can safely offer OAR at most institutions, have important implications about sufficient OAR exposure for trainees, and support regionalization of OAR., Competing Interests: Disclosures None., (Copyright © 2023. Published by Elsevier Inc.)

Objective: It has been shown local or regional anesthetic techniques are a feasible alternative to general anesthesia for endovascular aortic aneurysm repair (EVAR). However, studies to date have shown controversial findings with respect to the benefit of locoregional anesthesia (LR) in the elective setting. The objective of this study is to compare postoperative outcomes between LR and general anesthesia (GA) in the setting of elective EVAR, using a large, multicenter database., Methods: Using the Society for Vascular Surgery Vascular Quality Initiative database, we retrospectively analyzed all patients who underwent elective EVAR from August 2003 to June 2021. Patients were grouped by anesthetic type based on the level of consciousness afforded by the anesthetic: local or regional anesthesia (LR) vs GA. Primary outcomes were total postoperative hospital length-of-stay (LOS) and intensive care unit (ICU) LOS. Propensity score matching was used for risk adjustment and to analyze the primary outcomes with confirmatory analysis using logistic or linear regression, as appropriate, in single and multilevel models. Secondary outcomes were 30-day mortality, 1-year mortality, postoperative outcomes, operative time, fluoroscopy time, and reoperation rate. These were analyzed following propensity score matching as well as using logistic regression and Cox proportional hazard regression in single and multilevel models, as appropriate., Results: A total of 50,809 patients underwent elective EVAR from 2003 to 2021. Of these, 4302 repairs used LR (8.5%) and 46,507 (91.5%) were performed under GA. After employing propensity score matching, two groups of 3027 patients were produced. These showed no significant difference in 30-day mortality (odds ratio, 1.22; P = .53), 1-year mortality (hazard ratio, 1.06; P = .62), or any postoperative outcomes. LR was found to be significantly associated with shorter hospital stays (≤2 days) (12.5% vs 14.8%; P = .01), decreased ICU utilization (19.3% vs 30.6%; P < .001), decreased operative time (110.8 vs 117.3 minutes; P < .001), decreased fluoroscopy time (21.0 vs 22.7 minutes; P < .001), and a slight reduction in reoperation rate (1.2% vs 1.9%; P = .02), which all remained significant following single-level and multilevel multivariate analyses accounting for hospital and physician random effects., Conclusions: These data suggest that LR anesthesia is safe and may offer advantages in reducing resource utilization for patients undergoing elective EVAR, primarily based on associations with reduced ICU care and reduced hospital stay. Given these findings, LR may prove an advantageous technique in appropriately selected patient populations., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Within the context of endovascular aneurysm repair (EVAR), the role of anticoagulation therapy on endoleak development and subsequent reintervention is unclear with conflicting data in the literature. The hypothesis of this study is that long-term anticoagulation is associated with persistent type II endoleaks and failure of sac regression in patients undergoing endoluminal repair of intact infrarenal aortic aneurysm., Methods: Retrospective cohort abstracted from the Vascular Quality Initiative index hospitalization and long-term follow-up datasets for EVAR (2003-2017) were included in the analysis. Patients not taking aspirin preoperatively and postoperatively were excluded. Patients taking anticoagulation and aspirin concomitantly (treatment) after the index procedure were compared against patients taking aspirin alone (control). Anticoagulation included warfarin and novel oral anticoagulants, including factor Xa inhibitors and direct thrombin inhibitors. One-to-one greedy matching using propensity scores was implemented to match patients. The primary end points were failure of aneurysm sac regression, sac expansion, risk of endoleak, and reintervention rate for endoleak at follow-up. Sac regression was defined as a decrease of at least 5 mm and sac expansion was defined as an increase of at least 5 mm., Results: There were 9004 patients who received ASA alone and 332 patients who received ASA and anticoagulation. Propensity scores were used to create 301 matching pairs to account for differences in baseline characteristics and comorbidities, including but not limited to age, sex, smoking, coronary artery disease, heart failure, and chronic kidney disease between the treatment and control groups. After adjusting for covariables anticoagulation use was independently associated with a significantly decreased abdominal aortic aneurysm sac regression (41.59% vs 58.41%; P = .001), but no statistically significant difference in sac expansion with long-term anticoagulation use (9.7% vs 4.9%; P = .056). There was increased risk of type II endoleaks (11.96% vs 6.31%; P = .023; relative risk, 1.89; 95% confidence interval, 1.11-3.23; P = .016), but no significant differences in type I, III, or indeterminate endoleaks. There was no statistical difference in 2-year reintervention rates (4.32% vs 2.66%; hazard ratio, 1.43; 95% confidence interval, 0.55-3.77; P = .461). There were no differences in any primary outcome between warfarin and novel oral anticoagulants., Conclusions: These data demonstrate that long-term aspirin plus anticoagulation use is associated with a lack of aortic sac reduction and persistent type II endoleak, but not an increased risk for subsequent reintervention. Because prior studies have demonstrated that sac regression is a correlate of survival, these findings associating regression failure suggest a potential therapeutic failure for patients undergoing EVAR who also require long-term anticoagulation therapy. Although not a contraindication, long-term anticoagulation should be considered when counseling patients with a surgical indication aortic aneurysm., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Anatomic severity grade (ASG) can be used to assess abdominal aortic aneurysm (AAA) anatomic complexity. High ASG is associated with complications following endovascular repair of AAAs and we have demonstrated that ASG correlates with resource utilization. The hypothesis of this study is that ASG is directly related to midterm mortality in patients undergoing AAA repair., Methods: Patients who underwent infrarenal AAA repairs between July 2007 and August 2014 were retrospectively reviewed and ASG scores were calculated using 3-dimensional computed tomography reconstructions. Perioperative mortalities (≤30 days) were excluded. The ASG value of 15 was chosen based on previous receiver-operator curve analysis, which showed that an ASG of 15 was predictive of postoperative complications and resource utilization. The 5-year survivors and mortalities were compared utilizing comorbidities, pharmacologic variables, and anatomic variables at or above the defined threshold., Results: A total of 402 patients (80% male and 96% Caucasian) with complete anatomic and survival data were included in the analysis. Mean ASG and age at the time of repair were 16 ± 0.15 and 73 ± 0.43 years old, respectively. The 5-year mortality was significantly associated with ASG >15 (hazard ratio [HR]: 1.504, confidence interval [CI]: 1.077-2.100, P < .017), hyperlipidemia (HR: 1.987, CI: 1.341-2.946, P < .001), coronary artery disease (HR: 1.432, CI: 1.037-1.978, P < .029), and chronic obstructive pulmonary disease (HR: 1.412, CI: 1.027-1.943, P < .034). Kaplan-Meier analysis demonstrated improved survival in the low score ASG ≤15 group at 1, 3, and 5 years (96% vs 93%, 81% vs 69%, and 53% vs 41%; P = .0182; Figure 1)., Conclusions: Increasing aortic anatomic complexity as characterized by ASG >15 is an independent predictor of midterm mortality following elective infrarenal AAA repair. Therefore, it may be a useful tool for appropriate patient selection and risk stratification prior to elective infrarenal AAA repair.

Background: An anatomic severity grade (ASG) score to categorize and to define anatomic factors for abdominal aortic aneurysm (AAA) repair was proposed. Other studies have previously reported that aortic anatomic complexity is a marker of survival and resource utilization after repair, although it remains unclear whether individual components of the ASG score independently contribute to survival. This study analyzed and validated an aortic and iliac artery calcium scoring system that can potentially predict survival after AAA repair., Methods: Patients who underwent infrarenal AAA repairs from July 2007 to May 2012 were analyzed using complete 5-year records. Those who died ≤30 days of surgery were excluded. Calcium score (CS) was defined using the ASG scoring system for its basis by preoperative imaging <6 months before surgery. A CS for any patient was 0 to 5 points, the sum of the points assigned to aortic neck (2 points total) and iliac artery (3 points total) calcification. A receiver operating characteristic curve was used to determine a CS threshold for mortality. The 5-year survivors and deaths were compared in regard to comorbidities, pharmacology, and CS at or above the defined threshold. Each variable with a P value <.1 between the groups was then placed into a Cox proportional hazards model, with statistical significance of P < .05., Results: There were 356 patients who underwent AAA repair with complete 5-year follow-up data; 26% died within 5 years of surgery. Of these, 13% had CS of 0 with 15% mortality, 28% had CS of 1 with 21% mortality, 24% had CS of 2 with 24% mortality, 23% had CS of 3 with 35% mortality, 10% had CS of 4 with 40% mortality, and 2% had CS of 5 with 17% mortality. The receiver operating characteristic curve demonstrated an appropriate threshold of CS 3. Of these patients, 65% had a CS <3, whereas 35% had a CS ≥3. Patients with a CS ≥3 had a lower 5-year survival probability (P = .003). Comparing 5-year survivors and deaths in a Cox proportional hazards analysis, CS ≥3 was associated with a hazard ratio of 1.579 (95% confidence interval, 1.038-2.402; P = .0328)., Conclusions: A CS ≥3 is linked to a lower 5-year survival after AAA repair in our population. This system potentially can be another measure for risk stratification and serve as a means to predict midterm mortality in AAA repairs. Future study will be needed for further validation to predict midterm mortality and to better guide surgical decision-making., (Published by Elsevier Inc.)

Background: Potential cost effectiveness of endovascular aneurysm repair (EVAR) compared with open aortic repair (OAR) is offset by the use of intraoperative adjuncts (components) or late reinterventions. Anatomic severity grade (ASG) can be used preoperatively to assess abdominal aortic aneurysms, and provide a quantitative measure of anatomic complexity. The hypothesis of this study is that ASG is directly related to the use of intraoperative adjuncts and cost of aortic repair., Methods: Patients who undergo elective OAR and EVAR for abdominal aortic aneurysms were identified over a consecutive 3-year period. ASG scores were calculated manually using three-dimensional reconstruction software by two blinded reviewers. Statistical analysis of cost data was performed using a log transformation. Regression analyses, with a continuous or dichotomous outcome, used a generalized estimating equations approach with the sandwich estimator, being robust with respect to deviations from model assumptions., Results: One hundred forty patients were identified for analysis, n = 33 OAR and n = 107 EVAR. The mean total cost (± standard deviation) for OAR was per thousand (k) $38.3 ± 49.3, length of stay (LOS) 13.5 ± 14.2 days, ASG score 18.13 ± 3.78; for EVAR, mean total cost was k $24.7 ± 13.0 (P = .016), LOS 3.0 ± 4.4 days (P = .012), ASG score 15.9 ± 4.13 (P = .010). In patients who underwent EVAR, 25.2% required intraoperative adjuncts, and analysis of this group revealed a mean total cost of k $31.5 ± 15.9, ASG score 18.48 ± 3.72, and LOS 3.9 ± 4.5, which were significantly greater compared with cases without adjunctive procedures. An ASG score of ≥15 correlated with an increased propensity for requirement of intraoperative adjuncts; odds ratio, 5.75 (95% confidence interval, 1.82-18.19). ASG >15 was also associated with chronic kidney disease, end stage renal disease, hypertension, female sex, increased cost, and use of adjunctive procedures., Conclusions: Complex aneurysm anatomy correlates with increased total cost and need for adjunctive procedures during EVAR. Preoperative assessment with ASG scores can delineate patients at greater risk for increased resource use. Patient comorbid factors are associated with anatomic complexity defined according to ASG. A critical examination of the relationship between anatomic complexity and finances is required within the context of aggressive endovascular treatment strategies and shifts toward value-based reimbursement., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The molecular mechanisms leading to the development of abdominal aortic aneurysms (AAAs) remain poorly understood. The aim of this study was to determine the expression of Sonic Hedgehog (SHh), transforming growth factor β (TGF-β), and Notch signaling components in human aneurysmal and nonaneurysmal aorta in vivo., Methods: Paired tissue samples were obtained from aneurysmal and nonaneurysmal (control) segments of the aortic wall of eight patients with suitable anatomy undergoing open repair of infrarenal AAAs. Protein and messenger RNA (mRNA) expression levels were determined by Western blot and quantitative real-time polymerase chain reaction analysis., Results: Aneurysm development resulted in a significant reduction in vascular smooth muscle (vSMC) differentiation genes α-actin and SMC22α at both mRNA and protein levels. In parallel experiments, an 80.0% ± 15% reduction in SHh protein expression was observed in aneurysmal tissue compared with control. SHh and Ptc-1 mRNA levels were also significantly decreased, by 82.0% ± 10% and 75.0% ± 5%, respectively, in aneurysmal tissue compared with nonaneurysmal control tissue. Similarly, there was a 50.0% ± 9% and 60.0% ± 4% reduction in Notch receptor 1 intracellular domain and Hrt-2 protein expression, respectively, in addition to significant reductions in Notch 1, Notch ligand Delta like 4, and Hrt-2 mRNA expression in aneurysmal tissue compared with nonaneurysmal tissue. There was no change in Hrt-1 expression observed in aneurysmal tissue compared with control. In parallel experiments, we found a 2.2 ± 0.2-fold and a 5.6 ± 2.2-fold increase in TGF-β mRNA and protein expression, respectively, in aneurysmal tissue compared with nonaneurysmal tissue. In vitro, Hedgehog signaling inhibition with cyclopamine in human aortic SMCs resulted in decreased Hedgehog/Notch signaling component and vSMC differentiation gene expression. Moreover, cyclopamine significantly increased TGF-β1 mRNA expression by 2.6 ± 0.9-fold., Conclusions: These results suggest that SHh/Notch and TGF-β signaling are differentially regulated in aneurysmal tissue compared with nonaneurysmal tissue. Changes in these signaling pathways and the resulting changes in vSMC content may play a causative role in the development of AAAs., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)