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Background: Although obese patients seem to be susceptible to chronic diseases, obesity paradox has been observed in the field of vascular surgery, in which many previous studies have reported that overweight patients have good postoperative outcomes and underweight patients have poor postoperative outcomes. The purpose of our study is to evaluate the impact of body mass index (BMI) and serum albumin levels, which are evaluated as indicators of nutritional status, on outcomes of open abdominal aortic aneurysm (AAA) repair., Methods: We reviewed the vascular surgery database of a single tertiary referral center for all patients who underwent open AAA repair due to degenerative etiology from 1996 to 2021. To analyze the effect of BMI, patients were classified into 4 groups according to the Asian-Pacific classification of BMI: underweight (UW) (<18.5 kg/m 2 ), normal weight (NW) (18.5-22.9 kg/m 2 ), overweight (OW) (23-24.9 kg/m 2 ), and obese (OB) (≥25 kg/m 2 ). The χ 2 , Fisher's exact, and Kruskal-Wallis tests were used to compare demographics, comorbidities, radiologic findings, surgical details, and 1-year mortality rates between the 4 groups. We also compared the preoperative serum albumin levels of each group to assess nutritional status indirectly. Cox's proportional hazards model was performed to determine factors associated with mortality. A Kaplan-Meier survival analysis was performed, and the differences were analyzed by a log-rank test. We did not perform an analysis for 30-day mortality because cases of 30-day mortality in UW patients were rare due to the unbalanced distribution of the number of patients in the 4 groups., Results: Among a total of 678 patients, 22 were classified as UW (3.2%), 200 as NW (29.5%), 183 as OW (27.1%), and 273 as OB (40.1%). The median age was 70 (64-75) years and 577 of 678 (85.1%) patients were male gender. Higher serum albumin level was associated with decreased 1-year mortality (hazard ratio [HR], 0.3; 95% confidence interval [CI], 0.15-0.63; P = 0.001). UW patients had a higher 1-year mortality rate than NW patients (HR, 3.67; 95% CI, 1.02-13.18; P = 0.046). OB patients had a lower overall mortality rate than NW patients (HR, 0.73; 95% CI, 0.53-1; P = 0.05)., Conclusions: Low BMI (<18.5 kg/m 2 ) and low serum albumin level were associated with poor 1-year survival after elective open AAA repair. These patients also need more careful preoperative intervention, like weight gain or nutritional support, for better outcomes. The obesity paradox existed in our study; high BMI (≥25 kg/m 2 ) was associated with better overall survival after elective open AAA repair., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background and Aims: The association between metabolic syndrome (MetS) and abdominal aortic aneurysm (AAA) remains unclear. We investigated the potential association between AAA and MetS and its components in a large population-based cohort., Methods: We used the Korean National Health Insurance Service database including 4,162,640 participants aged ≥50 years who received a routine health examination in 2009. Cox proportional hazards models were used to analyze the association between MetS and its components (elevated waist circumference, blood pressure, glucose, triglycerides, and reduced high-density lipoprotein cholesterol [HDL-C]) with AAA incidence, with adjustment for confounders., Results: During a median 9.4 years of follow-up, 18,160 participants developed incident AAA. MetS was associated with an increased risk of AAA compared to the non-MetS group (adjusted hazard ratio [aHR], 1.38; 95% confidence interval [CI], 1.34-1.43). Among the individual components, elevated waist circumference, blood pressure, triglycerides, and reduced HDL-C were associated with increased AAA risk, while elevated glucose alone was associated with reduced AAA risk (aHR, 0.85; 95% CI, 0.82-0.87). AAA risk also increased linearly with the increasing number of MetS components, with the highest risk found in the presence of all 5 components (aHR, 1.98, 95% CI, 1.83-2.15)., Conclusions: MetS and its individual components, with the exclusion of elevated glucose, were associated with higher risk of AAA. Further studies are warranted to elucidate the association between MetS and AAA., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: To evaluate early outcomes of aortoiliac or isolated iliac artery aneurysm repair using the Zenith® Bifurcated Iliac Side (ZBIS) stent graft combined with the LifeStream™ Balloon Expandable Vascular Covered Stent as a bridging stentgraft., Methods: Between August 2018 and February 2020, 38 patients (37 male, mean age 72.7 years) received 46 LifeStream stents in conjunction with 38 ZBIS stent grafts to bridge hypogastric arteries for aneurysm repair in six university hospitals in Korea. The primary outcomes were technical success rate and procedure-related complications. Secondary outcomes were bridging stent graft patency and re-intervention., Results: All procedures were performed as elective standard endovascular aortic aneurysm repair (EVAR) and unilateral iliac branch device (IBD). Mean follow-up was 13.1 months, and patient overall survival rate was 96.7%. Technical success rate was 76.3% (n = 29). Causes of failure included seven total endoleaks; six type Ic and one type IIIc from the IBD junction, one unintentional IIA coverage, and one failure to deploy the IIA stent graft. Procedure-related complications occurred in two patients: one LifeStream migration and one ZBIS stent graft migration. Overall patency rates for the LifeStream and ZBIS stents were 97.4% and 97.2%, respectively., Conclusion: This multicenter preliminary experience with the LifeStream™ Balloon Expandable Vascular Covered Stent in IBD demonstrated good patency; however, an unexpectedly high rate of type Ic endoleaks was observed. Combined use of the LifeStream stent with the ZBIS stent graft is safe and feasible to preserve pelvic circulation with good patency and a low rate of device-related reintervention., Competing Interests: Declaration of competing interest There are no conflicts of interest to declare., (Copyright © 2022 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Background: Although the first choice of treatment for abdominal aortic aneurysm (AAA) is endovascular aneurysm repair, especially in elderly patients, some patients require open surgical repair. The purpose of this study was to compare the mortality outcomes of open AAA repair between octogenarians and younger counterparts and to identify the risk factors associated with mortality., Methods: All consecutive patients who underwent elective open AAA repair due to degenerative etiology at a single tertiary medical center between 1996 and June 2020 were included in this retrospective review. Medical records and imaging studies were reviewed to collect the following information: demographics, comorbid medical conditions, clinical presentations, radiologic findings, surgical details, and morbidity and mortality rates. For analysis, patients were divided into two groups: older and younger than 80 years of age. Multivariate analysis was performed to identify factors associated with mortality after elective open AAA repair., Results: Among a total of 650 patients who underwent elective open AAA repair due to degenerative AAA during the study period, 58 (8.9%) were octogenarians and 595 (91.1%) were non-octogenarians. Patients in the octogenarian group were predominantly female and more likely to have lower body weight and body mass index (BMI), hypertension, chronic kidney disease, and lower preoperative serum hemoglobin and albumin compared with patients in the non-octogenarian group. Maximal aneurysm diameter was larger in octogenarians. During the median follow-up duration of 34.4 months for 650 patients, the median length of total hospital and intensive care unit stay was longer in octogenarians. The 30-day (1.7% vs. 0.7%, P = 0.374) and 1-year (6.9% vs. 2.9%, P = 0.108) mortality rates were not statistically significantly different between the two groups. Multivariate analysis showed that low BMI was associated with increased 30-day (odds ratio [OR], 16.339; 95% confidence interval [CI], 1.192-224.052; P = 0.037) and 1-year (OR, 8.236; CI, 2.301-29.477; P = 0.001) mortality in all patients., Conclusion: Because the mortality rate of octogenarians after elective open AAA repair was not significantly different compared with their younger counterparts, being elderly is not a contraindication for open AAA repair. Low BMI might be associated with increased postoperative mortality., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2021 The Korean Academy of Medical Sciences.)

Objective: Marfan syndrome (MFS) affects the cardiovascular system. Aortic root aneurysm is a pathognomonic feature of MFS; however, the abdominal aorta is rarely affected. A consensus on surveillance for the abdominal aorta in patients with MFS has not been established. In the present study, we compared the outcomes after open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) in patients with and without MFS., Methods: We conducted a retrospective, single-center cohort study from 2003 to 2020. We reviewed and compared 28 patients with MFS and 426 patients without MFS who had undergone OSR for AAAs. The baseline characteristics, medical comorbidities, previous cardiovascular surgery, anatomic features of the AAAs, and surgical treatment outcomes were compared between the two groups., Results: The patients with MFS were younger than those without MFS at the AAA diagnosis (47.2 ± 12.3 vs 70.6 ± 7.9 years; P < .001). The proportion of women was also greater for those with MFS (46.4% vs 15.7%; P < .001). The AAAs were most often located at the infrarenal aorta in both groups. However, thoracoabdominal AAAs were more often found among patients with MFS (10.7% vs 0.9%; P < .012). The proportion of symptomatic patients was lower in the MFS group (3.6% vs 21.6%; P = .022). The maximum median diameter of the AAA at surgery was smaller in the patients with MFS (52 mm vs 58 mm; P = .001). However, concomitant aortic dissection (32.1% vs 3.3%; P < .001) was more prevalent among the patients with MFS. Consequent aneurysmal changes in the iliac artery after AAA repair were more frequent in the patients with MFS (7.1% vs 0%; P = .004). No significant differences were found in 30-day or overall mortality between the patients with and without MFS during a median follow-up period of 71 months (interquartile range, 24.7-121.1 months) and 26.7 months (interquartile range, 7.4-69.5 months), respectively., Conclusions: The surgical outcomes of OSR for AAAs for patients with MFS were not significantly different from those for patients without MFS in a well-established surveillance program of MFS., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Aortic anatomy is important in determining the success or failure of endovascular aortic aneurysm repair (EVAR). Endoleak is another issue which should be addressed for a long-term durability of the procedure. Internal iliac artery (IIA) embolization is required to prevent type II endoleak when the iliac landing zone is not sufficient such that the iliac limb should be extended down to the external iliac artery (EIA). Pelvic ischemia is an important complication of IIA embolization, but its incidence and severity is not exactly known. Our experience suggests this to be common but not severe. In this study we reviewed the clinical outcomes of patients who underwent IIA embolization to facilitate EVAR at one of the major tertiary medical centers in South Korea., Methods: We performed a retrospective review of the patients who underwent IIA embolization prior to EVAR between November 2005 and June 2018 at a single tertiary medical center in South Korea. Patients were interviewed via telephone to determine the severity of buttock claudication according to a previously defined pain scale., Results: The majority of 139 patients in both the unilateral and bilateral IIA embolization groups experienced no (N.=83, 60.0%) or mild (N.=51, 36.7%) buttock claudication. Only three patients in the unilateral IIA embolization group reported that their symptoms affected daily life, but without need for any measures for pain relief. Symptom duration was longer in the bilateral embolization group (12.6 months) compared to the unilateral group (6.6 months) without statistical significance (P=0.559). There were no critical complications such as buttock necrosis, spinal cord ischemia, or ischemic colitis., Conclusions: Based on our experience, IIA embolization does cause buttock claudication of a certain degree. However, the most of them experienced mild discomfort rather than such symptoms severely affect their quality of life. Considering the risks of general anesthesia and complications of surgical procedures, IIA reconstruction along with EVAR may not be necessary.

Background: Open surgery of abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD) sometimes requires left renal vein division (LRVD) to gain adequate exposure of the abdominal aorta. The aim of this study is to evaluate the effect of LRVD on the postoperative renal function using propensity score matching (PSM)., Methods: From July 1996 to January 2018, we retrospectively reviewed 698 patients who underwent open aortic surgery, including 543 AAAs and 155 AIODs, at a single institution. 66 patients (9.6%, 47 AAAs, 19 AIODs) needed LRVD during the operation. A 1:3 ratio PSM was used to control the selective bias between the LRVD and non-LRVD groups. We investigated preoperative and postoperative renal function including serum creatinine (sCr) level and estimated glomerular filtration rate (eGFR, mL/min/1.73 m 2 ). Major complications, long-term renal function, and 30-day mortality were also compared., Results: The LRVD group had a significantly higher rate of renal artery reconstruction (15.2% vs. 3.3%, P < 0.001) and suprarenal clamping (54.6% vs. 9.5%, P < 0.001) and higher incidence of juxtarenal AIOD (24.2% vs. 5.4%, P < 0.001). With PSM, 63 patients in the LRVD group and 144 patients in the non-LRVD group were enrolled in this study. The baseline characteristics were well balanced in the groups after PSM. There were no significant differences in preoperative eGFR (72.4 ± 21.3 vs. 76.1 ± 25.0, P = 0.306) and postoperative eGFR on day 3 (69.5 ± 26.6 vs. 77.5 ± 28.5, P = 0.065), day 7 (73.3 ± 24.8 vs. 78.5 ± 27.4, P = 0.264), and in the long-term follow-up period (69.0 ± 22.2 vs. 68.9 ± 27.1, P = 0.986, 50.2 month ± 45.50) in the 2 groups. Only the sCr level (1.40 ± 0.59 vs. 1.21 ± 0.62, P = 0.045) and eGFR (59.5 ± 23.9 vs. 71.4 ± 26.0, P = 0.002) were significantly worse on postoperative day 1 in the LRVD than in the non-LRVD group. There were no significant differences in 30-day mortality (1.6% vs. 1.6%, P = 1.00)., Conclusions: The patients in the LVRD group underwent initial drop in renal function; however, eGFR improved during the follow-up period. There was no difference in renal function and postoperative mortality between LRVD and non-LRVD groups. Therefore, LRVD is a safe and durable procedure during complex abdominal aortic surgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: This study aimed to determine the natural history of spontaneous isolated abdominal aortic dissection (SIAAD) and to establish an optimal management strategy for patients with SIAAD., Methods: We searched the database of thoracoabdominal computed tomography (CT) performed at a single institution from January 2003 to July 2016 using the keywords "aortic dissection" and "dissection AND aorta." Once a diagnosis of SIAAD was made, we investigated the initial clinical and morphologic features and aorta-related events for all patients and morphologic changes of the aortic dissection (AD) during the follow-up period for the patients who underwent follow-up CT scans. We compared characteristics of the patients, frequencies of clinical events (aortic rupture, intervention, death), and morphologic changes (false lumen enlargement, progression of AD, remodeling of AD, and involvement of iliac or visceral artery) during the follow-up period according to the location of AD (infrarenal vs suprarenal), symptom status (symptomatic vs asymptomatic), and gender., Results: There were 210 (10.7%) patients (median age, 69.4 years [interquartile range, 61.3-74.7]; male, 73.3%) who were diagnosed with SIAAD among 1958 patients with AD. SIAAD was most frequently located at the infrarenal aorta (86.2%), extended to the iliac (12.4%) or visceral artery (2.9%), and was symptomatic in 13.3% of patients. During the study period, aortic rupture developed in two patients (0.9%), aortic intervention was required in five (2.4%), and aorta-related deaths were identified in three (1.4%). Among 138 (65.7%) patients who underwent follow-up CT scans, 81.9% showed no morphologic change or remodeling during the follow-up period (median, 25 months; range, 1-158 months; interquartile range, 12.3-49.1 months). In the meantime, false lumen enlargement and longitudinal progression of AD developed in 8.7% and 6.5% of patients, respectively. However, newly developed visceral artery extension was not found in any of the patents. When characteristics of the patients and frequencies of clinical events or late morphologic changes of AD were compared on the basis of the location of AD, symptom status, and gender, female gender, presence of symptoms, and suprarenal SIAAD were more frequently associated with aorta-related mortality. False lumen enlargement was more frequent in the suprarenal AD group than in the infrarenal AD group., Conclusions: Based on our observation, the majority of symptomatic and asymptomatic SIAAD patients can be managed conservatively unless they present with aortic rupture, concomitant large aortic aneurysm, or underlying connective tissue disease. However, a more proactive management strategy may be required for female, symptomatic patients or those with suprarenal SIAAD., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)