Journal of vascular surgery
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Multicenter Study
Differences in patient selection and outcomes based on abdominal aortic aneurysm diameter thresholds in the Vascular Quality Initiative.
Randomized trials have shown no benefit for repair of small abdominal aortic aneurysms (AAAs), although repair of small AAAs is widely practiced. It has also been suggested that repair of large-diameter AAAs may incur worse outcomes. We sought to examine differences in patient selection, operative outcomes, and survival after elective endovascular aneurysm repair (EVAR) based on AAA diameter thresholds. ⋯ Small AAAs represent >40% of elective EVARs in the Vascular Quality Initiative. Patients with small AAAs selected for repair are younger and have fewer comorbidities. Consequently, EVAR for small AAAs carries lower risk of operative and 5-year mortality. Aneurysm diameter is independently associated with reinterventions and mortality after EVAR, suggesting that AAA diameter may have an important clinical effect on outcomes.
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Comparative Study
Surgically positioned paravertebral catheters and postoperative analgesia after open abdominal aortic aneurysm repair.
To compare postoperative morphine equivalent intake after open abdominal aortic aneurysm (AAA) repair among analgesic modalities: systemic analgesia (SA) only with no regional anesthesia, surgically positioned paravertebral catheter (PVC), and thoracic epidural analgesia (TEA). ⋯ PVC and TEA are associated with decreased MEQ compared with SA. PVC is associated with earlier discharge from intensive care compared with SA and similar rates of opioid-related adverse events compared with TEA. Paravertebral analgesia appears to be a safe and effective analgesic modality in patients undergoing retroperitoneal approach for abdominal aneurysm repair.
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Endovascular aneurysm repair (EVAR) is currently the most common treatment of abdominal aortic aneurysms. Potential predictors of long-term survival after EVAR include physiologic, functional, and cognitive status, but assessments of these conditions have been difficult to standardize. Objective radiographic findings, such as skeletal muscle atrophy, or sarcopenia, may provide an additional means for selection of patients. This study investigates sarcopenia as a method to predict 1-year survival in patients undergoing EVAR. ⋯ Sarcopenia can assist in identifying EVAR candidates who are less likely to benefit from surgery. It can be readily evaluated from preoperative CT scans and may be a useful tool in evaluation of abdominal aortic aneurysm patients with applications in risk evaluation and telemedicine.
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Although the absence of aneurysm-related mortality, postimplantation rupture, and reintervention after endovascular aneurysm repair (EVAR) is desirable, it may not necessarily reflect successful aneurysm sac exclusion. Sac regression may be a more sensitive marker for EVAR success and may be influenced by factors beyond the presence or absence of an endoleak. The objective of this study is to determine the rate of overall long-term sac regression after EVAR and the influence of nonanatomic factors, and endograft devices used at our center. ⋯ This study demonstrated a pattern of sac diameter change after EVAR, with the majority of sac regression occurring within the first 2 years. Variability in sac regression was influenced by nonanatomic variables including age, sex, original AAA diameter, and specific endograft device, even after controlling for the presence or absence of an endoleak. The biophysical relationship between specific endograft design and materials, and sac regression is yet to be determined.
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The Guatemalan Foundation for Children with Kidney Diseases was established in 2003 as the first and only comprehensive pediatric nephrology program and hemodialysis unit in Guatemala. Bridge of Life (BOL) is a not-for-profit charitable organization focused on chronic kidney disease and supplied equipment, training and support during formation of the hemodialysis unit. Pediatric permanent vascular access (VA) expertise had not been established and noncuffed dialysis catheters provided almost all VA, many through subclavian vein access sites. BOL assistance was requested for establishing a VA surgical program, resulting in recurring BOL surgical missions to create arteriovenous fistulas (AVF) in these children. This study analyzes the BOL pediatric VA missions to Guatemala. ⋯ Pediatric VA missions to Guatemala created safe and functional AVFs in concert with local pediatric surgeons and pediatric nephrologists. Three surgical missions included access operations in 54 new patients. Cumulative AVF patency was 85% at 36 months.