Journal of vascular surgery
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Practice Guideline
The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.
Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related death or morbidity. ⋯ Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices.
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Patients undergoing endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms can exhibit variations in sac behavior ranging from complete regression to expansion. We evaluated the impact of sac behavior at 1-year follow-up on late survival. ⋯ These data suggest that an abdominal aortic aneurysm sac diameter increase of at least 5 mm at 1 year, although infrequent, is independently associated with late mortality regardless of the presence or absence of endoleak and warrants close observation and perhaps early intervention.
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The benefit of prophylactic repair of abdominal aortic aneurysms (AAAs) is based on the risk of rupture exceeding the risk of death from other comorbidities. The purpose of this study was to validate a 5-year survival prediction model for patients undergoing elective repair of asymptomatic AAA <6.5 cm to assist in optimal selection of patients. ⋯ Across different populations of patients, assessment of age and level of cardiac, pulmonary, and renal disease can accurately predict 5-year survival in patients with AAA <6.5 cm undergoing repair. This risk prediction model is a valid method to assess mortality risk in determining potential overall survival benefit from elective AAA repair.
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Patients with medically managed type B aortic dissection (TBAD) have a high incidence of aorta-related complications over time. Whereas early thoracic endovascular aortic repair (TEVAR) to seal the entry tear can promote aortic remodeling and prevent late aneurysm formation, there are sparse data as to which patients will benefit from such therapy. The goal of this study was to identify clinical and anatomic factors that are associated with the need for subsequent aortic intervention in patients who present with uncomplicated TBAD. These factors could guide the selection of patients who will benefit from TEVAR in the subacute phase. ⋯ Nearly 40% of patients who present with an uncomplicated TBAD will ultimately require an aortic intervention. All of the late interventions were performed for aneurysmal degeneration. A variety of readily available anatomic features can predict the need for eventual operative intervention in TBAD; accordingly, these parameters can guide the desirability of early TEVAR.
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Multicenter Study Comparative Study
Carotid artery revascularization in patients with contralateral carotid artery occlusion: Stent or endarterectomy?
The Centers for Medicare and Medicaid Services (CMS) considers that contralateral carotid artery occlusion puts the patients at high risk for carotid endarterectomy (CEA) and agrees to reimburse for carotid artery stenting (CAS) in these patients. However, there is a paucity of evidence that support the superiority of CAS compared with CEA in patients with contralateral carotid occlusion. ⋯ In this exclusive large cohort of patients with contralateral carotid artery occlusion, CAS did not perform better compared with CEA in asymptomatic patients and had significantly worse outcomes in symptomatic patients in the perioperative period. The 2-year stroke rate was similar between the two procedures, but the risk of stroke or death was consistently higher for CAS patients. CAS is not safer than CEA in patients with contralateral carotid artery occlusion, and refinement of current guidelines is warranted to provide appropriate surgical care specifically tailored for the patient's presentation.