OBJECTIVE: Analysis of gender-specific differences in short- and long-term outcome after elective open abdominal aortic aneurysm repair (OAR) regarding the distal anastomosis.
METHODS: In this retrospective cohort study, data from 4853 patients of a German health insurance company undergoing OAR for infrarenal abdominal aortic aneurysms (AAAs) between 2010 and 2016 were analysed. The patients were followed through 2018.
RESULTS: A total of 4050 (83.5%) men and 803 (16.6%) women underwent OAR. Women were older than men (72.9 ± 8.7 vs 69.8 ± 8.5 years; P < .001). A tube graft was used in 2644 (54.5%) patients, an aorto-biiliac bifurcated graft in 1657 (34.1%) and an aorto-bifemoral bifurcated graft in 552 (11.4%). Perioperative mortality was not significantly different between men (5.7%) and women (6.5%) in the total patient population (P = .411). This was true for aorto-aortic tube grafting (P = .361), aorto-biiliac reconstructions (P = 1.000) and aorto-bifemoral reconstructions (P = .345). Kaplan-Meier estimated long-term survival of men after 9 years was better than that of women (55.0% vs 43.8%; P = .006). However, separated by the site of the distal anastomosis, this was only true for aorto-aortic reconstructions (survival men vs women 56.0% vs 42.1%; P = .005), not for aorto-biiliac and aorto-bifemoral reconstructions. In the multivariate Cox regression analysis, age over 80 years, heart failure, aorto-bifemoral reconstruction, chronic kidney disease stage 3-5, chronic obstructive pulmonary disease, peripheral artery disease, arterial hypertension, but not gender (P = .531), had a negative impact on long-term survival.
CONCLUSIONS: If possible, an aorto-aortic tube graft should be preferred to aorto-biiliac and aorto-bifemoral reconstructions in OAR. Patients selected for aorto-bifemoral artery reconstruction exhibit higher perioperative morbidity and mortality as well as worse long-term survival compared to patients selected for an intra-abdominal reconstruction. In the multivariate regression analysis, gender was not an independent risk factor for either short- or long-term outcomes.

BACKGROUND: Previous studies report that patients of racial/ethnic minorities more frequently present with ruptured abdominal aortic aneurysms (rAAAs) than their counterparts. The distribution of rAAA treatment modality, whether open aneurysm repair (OAR) or endovascular aneurysm repair (EVAR), by race/ethnicity classification remains uncertain. This study aims to investigate disparities, as represented by race/ethnic classification, median income, and insurance status, in the management of rAAA in a national cohort.
METHODS: We conducted a retrospective analysis of patients admitted with rAAA managed with either OAR or EVAR from 2002 to 2020 using the National Inpatient Sample, comparing repair type by race/ethnicity group. Multilevel mixed effects logistic regression models, adjusted for patient- and system-level factors, were used to calculate difference in use of OAR or EVAR dependent on race/ethnicity classification.
RESULTS: We identified 10,788 admissions for rAAA repairs, of which 9506 (88.1%) were White, 605 (5.6%) were Black, 424 (3.9%) were Hispanic, and 253 (2.4%) were Asian/Native American. Asians/Native Americans underwent the highest frequency of OAR as compared with EVAR (61.7% vs 38.3%). In the adjusted model, there was no statistically significant difference in the use of OAR vs EVAR by race/ethnicity classification. In total, primary payer and median income were also not statistically significant predictors of AAA treatment modality.
CONCLUSIONS: Our study found no statistical evidence of disparities with respect to race, insurance, or median income and use of OAR or EVAR for the management of rAAA.

OBJECTIVE: Observational studies demonstrate reduced mortality after endovascular (EVAR) compared with open aneurysm repair (OAR) for ruptured abdominal aortic aneurysms (rAAAs). We sought to determine national trends in repair type and in-hospital mortality rates for rAAAs.
METHODS: We analyzed patients with rAAAs managed with OAR or EVAR from 2002 to 2020 in the National Inpatient Sample and evaluated annual trends in volume and in-hospital mortality by repair type. Multilevel mixed effects logistic regression model was fit for patient and system-level risk adjustment. We assessed interactions between time, sex, and Elixhauser index with repair type.
RESULTS: We examined 13,376 patients with rAAAs. Of these, 8357 (62.5%) underwent OAR. Patients receiving EVAR were slightly older (73.7 vs 72.5 years; P < .001) with slightly higher mean Elixhauser index (4.0 vs 3.8; P < .001). Unadjusted in-hospital mortality was 37.4% vs 22.4% for OAR and EVAR, respectively. EVAR offered a risk-adjusted survival advantage (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.32-0.46). There was a statistically significant reduction of in-hospital mortality over time in the EVAR group (interaction OR, 0.96; 95% CI, 0.95-0.98). The interaction between Elixhauser index and repair was not statistically significant (interaction OR, 0.95; 95% CI, 0.87-1.05).
CONCLUSIONS: Survival rates for OAR and EVAR improved over time. EVAR persistently provided a substantial survival advantage over OAR in patients with rAAAs over the past 2 decades.

BACKGROUND: Open surgery is still acknowledged as the gold standard for complex abdominal aortic aneurysm (c-AAA). Recently, advanced-endovascular aortic aneurysm repair (EVAR) for c-AAA has been developed, but its effectiveness compared to open surgery is still unclear.
METHODS: A systematic search was performed on the MEDLINE through PubMed and ScienceDirect databases. The search was aimed to investigate outcomes of both fenestrated- and chimney-EVAR (consider as advanced EVAR) compared to open surgery in c-AAA. Outcomes included postoperative complications, 30-day mortality, long-term mortality, and reintervention rate. Data were collected using the Mantel-Haenszel fixed effects model with relative risk (RR) as the effect size with 95% confidence interval (CI).
RESULTS: A total of 25 studies (n = 12,845 patients) were included in our study. The results demonstrated that advanced-EVAR correlated with diminished postoperative complications (RR 0.53; 95% CI 0.49-0.57; p < 0.001) compared to open surgery. Advanced-EVAR was associated with lower 30-day mortality compared to open surgery (RR 0.66; 95% CI 0.53-0.82; p < 0.001). Subgroup analysis revealed that fenestrated-EVAR resulted in superior outcomes (p < 0.001), whereas the chimney-EVAR subgroup did not show significant differences (p = 0.79), compared to open surgery in terms of 30-day mortality. Unfortunately, advanced-EVAR was associated with a higher long-term mortality rate (RR 1.46; 95% CI 1.20-1.78; p < 0.001) and a higher reintervention rate (RR 1.26; 95% CI 1.01-1.59; p = 0.04) compared to open surgery.
CONCLUSIONS: Advanced EVAR, especially fenestrated-EVAR, presented better short-term outcomes compared to open surgery; however, it failed to demonstrate superiority over open surgery in improving long-term outcomes.

UNASSIGNED: Abdominal aortic aneurysm (AAA) is a growing public health problem, and not all patients have access to surgery when needed. This study aimed to analyze spatiotemporal variations in AAA mortality and surgical procedures in Brazilian intermediate geographic regions and explore the impact of different surgical techniques on operative mortality.
UNASSIGNED: A retrospective longitudinal study was conducted to evaluate AAA mortality from 2008 to 2020 using space-time cube (STC) analysis and the emerging hot spot analysis tool through the Getis-Ord Gi* method.
UNASSIGNED: There were 34,255 deaths due to AAA, 13,075 surgeries to repair AAA, and a surgical mortality of 14.92%. STC analysis revealed an increase in AAA mortality rates (trend statistic = +1.7693, p = 0.0769) and a significant reduction in AAA surgery rates (trend statistic = -3.8436, p = 0.0001). Analysis of emerging hotspots revealed high AAA mortality rates in the South, Southeast, and Central-West, with a reduction in procedures in São Paulo and Minas Gerais States (Southeast). In the Northeast, there were extensive areas of increasing mortality rates and decreasing procedure rates (cold spots).
UNASSIGNED: AAA mortality increased in several regions of the country while surgery rates decreased, demonstrating the need for implementing public health policies to increase the availability of surgical procedures, particularly in less developed regions with limited access to services.

BACKGROUND: Current guidelines for AAA management are based on landmark trials comparing EVAR and open aneurysm repair (OAR) conducted more than 20 years ago. Important advancements have been made in peri-operative care but the impact of EVAR and OAR on long-term patient survival has not been well reported using contemporary data. The objective of this study was to compare the short and long-term outcomes of OAR and EVAR in the recent era.
METHODS: This retrospective observational study included all patients undergoing intact AAA repair in NZ from 1st of January 2011 until 31st of December 2019. Data was collected from national administrative and clinical vascular databases and matched using unique identifiers. Time-to-event survival analyses was conducted using cox proportional hazard models to adjust for confounders and propensity score matching were used.
RESULTS: Two thousand two hundred and ninety-seven patients had an intact AAA repair with a median (IQR) age of 75 (69-80) years; 494 (21.2%) patients were females and 1206 (53%) underwent EVAR. The 30-day mortality for OAR and EVAR was 4.8% and 1.2%. The median (IQR) follow up was 5.2 (2.3-9.2) years. After propensity matching for co-variates, the study cohort consisted of 835 patients in each matched group. Patients undergoing EVAR had a higher overall mortality (HR 1.48 (95% CI: 1.26-1.74) after adjusting for confounders compared to OAR.
CONCLUSIONS: Analysis of survival following EVAR and OAR in the current era demonstrates that patients that underwent EVAR had a lower 30-day mortality. However, in the long-term after adjusting for confounders OAR had a better overall survival.

Preoperative anemia has been consistently shown to be a risk factor for acute kidney injury (AKI) after cardiac surgery. However, this association has not been examined in the open abdominal aortic aneurysm repair (OAR) population and is the subject of this analysis.
Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried for patients undergoing OAR from 2013 to 2019. Anemia was defined according to World Health Organization Guidelines: Hematocrit<36% for women or <39% for men. Primary endpoint was 30-day AKI. Anemia\'s effect on AKI was determined using inverse probability weighted logistic regression.
There were 2275 OAR; mean age was 70.9 ± 8.2 y; 24.0% were women. Anemia was present in 498 (26.3%) patients; 165 (7.6%) had a hematocrit<33% and 8 (0.35%) had a hematocrit<24%. Differences in patient factor were nonsignificant after weighting. Any degree of postoperative AKI was more common in the anemia group (11.2% vs 5.1%; unweighted P < 0.001), as was AKI requiring hemodialysis (7.7% vs 3.2%; unweighted P < 0.001). In the weighted multivariable analysis, anemia was independently associated with postoperative AKI (odds ratio 1.51; 95% confidence interval: 1.01-2.26; P = 0.042) while controlling for age and operative factors. Patients with postoperative AKI were significantly more likely to die postoperatively than those without (26.1% vs 1.9%; <0.001).
Preoperative anemia was independently associated with post-OAR AKI after propensity weighting and controlling for operative factors. AKI is a major source of morbidity and mortality in these patients, and, if time permits, preoperative correction of anemia or its underlying cause should be considered in high-risk patients.

Although the Society for Vascular Surgery recommends repair of abdominal aortic aneurysms (AAA) at 5.5 cm or greater in men and 5.0 cm or greater in women, AAA repair below these thresholds has been well-documented. There are clear indications for repair other than these strict size criteria, but the expected proportion of such repairs in one\'s practice has not been studied. We sought to characterize the indications for repairs of aneurysms below diameter recommendations at a single academic center. Using the assumption that this real-world experience would approximate that of other practices, we then used national data to extrapolate these findings.
A single-center retrospective review was conducted of all elective open AAA (oAAA) and endovascular aneurysm repair (EVAR) from 2010 to 2020 to assess the incidence of and indications for repair of aneurysms below diameter recommendations (defined as <5.5 cm in men and <5.0 cm in women). Reasons for these repairs were defined as (1) iliac aneurysm, (2) saccular morphology, (3) rapid expansion, (4) patient anxiety, (5) distal embolization, (6) other, and (7) no documented reason. The Vascular Quality Initiative (VQI) was queried for all asymptomatic oAAA and EVAR (2010-2020) and repairs below diameter recommendations were identified. Findings from the single-center analysis were applied to the VQI cohort to extrapolate estimates of reasons for repairs done nationally. In-hospital mortality and major adverse cardiac events (MACE) were compared between those below size recommendations and those meeting size recommendations.
Of 456 elective AAA repairs at our center, 147 (32%) were below size recommendations. This finding was more common for EVAR (35% vs 28%). Reasons were: not documented (41%), iliac aneurysm (23%), saccular (10%), rapid expansion (10%), patient anxiety (7%), other (6%), and distal embolism (3%). Of 44,820 elective AAA repairs in the VQI, 17,057 (38%) were below size recommendations (40% EVAR, 26% oAAA). Patients who were repaired below size recommendations had lower in-hospital death (oAAA, 2.4% vs 4.6% [P < .0001]; EVAR, 0.3% vs 0.8% [P < .0001]). When single-center findings were applied to the VQI dataset, an estimated 10,064 repairs were performed nationally for acceptable indications other than size criteria. Conversely, there may have been 6993 repairs (with an associated 35 deaths) performed without documented indication.
Repairs for AAA below the recommended diameter guidelines account for approximately one-third of all elective AAA procedures in both the VQI and our single-center experience. Assuming our practice is typical, nearly 60% of repairs below size recommendations meet the criteria for other clear reasons. The remaining 40% lack a documented reason, meaning that 13% of all elective AAA repairs were done for aneurysms below size recommendations without an acceptable indication. As awareness of overuse and underuse is heightened, these data help to estimate the expected proportion of repairs for less common pathologies. They also provide a potential baseline data point for efforts at decreasing overuse.

OBJECTIVE: Primary infected aortic aneurysms are life-threatening if not treated promptly, but still possess a high mortality rate following open repair. The goal of treatment is to prevent rupture and clear infection. An endovascular approach is accepted as a bridge to definitive open repair. Our study compares the outcomes of endovascular versus conventional open repair of infected aortic aneurysms.
METHODS: A single-center retrospective review was conducted of data from January 2012 to December 2021. Patients were categorized into three cohorts according to aortic involvement: thoracic aortic aneurysm (TAA), thoracoabdominal aortic aneurysm (TAAA), and abdominal aortic aneurysm (AAA). The primary endpoint was survival rate and the assessment of any associated factors.
RESULTS: Ninety-nine patients presented with infected aortic aneurysms. Of the 56 patients who presented with infected TAA, 38 patients underwent thoracic endovascular aortic repair and 18 patients underwent open TAA repair. Forty patients presented with infected AAA, of which 21 patients underwent endovascular aortic repair and 19 patients underwent open repair. Three patients presented with infected TAAA and all underwent open repair. The mean age was 67 years (range 33-88); 74 patients (74.8%) were men and 71 patients (71.7%) had immune dysfunction. Mean follow-up time was 24 months in the endovascular repair group and 38 months in the open repair group. The probability survival rate in the endovascular repair group was 86%, 86%, 77% and 51% at 1 year, 2 years, 5 years and 10 years, respectively, and in the open repair group this was 81%, 81%, 76%, and 64% at 1 year, 2 years, 5 years and 10 years, respectively.
CONCLUSIONS: Endovascular repair for primary infected aortic aneurysms plays an important role in current practice as an alternate to open surgery or used as bridging to definitive open surgical repair. No significant difference was observed in either short- or long-term survival in patients with infected aortic aneurysm undergoing open or endovascular repairs.

Minimizing ischemic injury during surgical repair of thoracoabdominal aortic aneurysms (TAAAs) is vital for preventing complications such as paraplegia and acute renal failure. In this report, we describe a new technique for TAAA open repair that aims to minimize visceral organ ischemia times. Unlike typical Crawford extent II TAAA open repair, which begins with aortic clamping and proceeds from the proximal to the distal anastomoses, our method reverses the anastomosis order and minimizes aortic clamping. Between January 2016 and December 2020, we used this approach in 29 patients undergoing TAAA repair. We present one of these cases, a 29-year-old patient with progressive aneurysmal dilatation of a DeBakey type III chronic aortic dissection that extended beyond the aortic bifurcation. Our technique reduced aortic cross-clamping, left heart bypass, and internal organ and spinal cord ischemia times and appears to be safe and effective.