Treatment Outcomes of Patients With Ruptured Abdominal Aortic Aneurysms

Background@#Ruptured abdominal aortic aneurysm (rAAA) is a serious complication of abdominal aortic aneurysm associated with high operative mortality and morbidity rates. The present study evaluated the perioperative and long-term outcomes of Korean patients with rAAA based on national health insurance claims data. @*Methods@#The National Health Insurance Service (NHIS) database was searched retrospectively to identify patients with rAAA who underwent endovascular aneurysm repair (EVAR) and open surgical repair (OSR) from 2009 to 2018. Perioperative (≤ 30 days), early postoperative (≤ 3 month), and long-term (> 3 month) survival, reinterventions, and complications were assessed. @*Results@#The search identified 1,034 patients with rAAA, including 594 who underwent EVAR and 440 who underwent OSR. When the study period was divided into two, the total numbers of patients with rAAA, patients who underwent EVAR, and octogenarians were higher during the second half. The perioperative mortality rate was 29.8% in the EVAR and 35.0% in the OSR group (P = 0.028). Hartmann’s procedure for bowel infarction was performed more frequently in the OSR than in the EVAR group (adjusted odds ratio, 6.28; 95% confidence interval [CI], 2.33–21.84; P = 0.001), but other complication rates did not differ significantly. All-cause mortality during the entire observation period did not differ significantly in the EVAR and OSR groups (adjusted hazard ratio, 1.17; 95% CI, 0.98–1.41; P = 0.087). Abdominal aortic aneurysm-related reintervention rate was significantly lower in the OSR group (adjusted hazard ratio, 0.31; 95% CI, 0.14–0.70; P = 0.005). @*Conclusion@#Although EVAR showed somewhat superior perioperative outcomes for rAAA, the long-term outcomes of EVAR after excluding initial 3 months were significantly worse than OSR. When anatomically feasible for both treatments, the perioperative mortality risk and reasonable prospects of long-term survival should be considered in rAAA.

National trend of the treatment for chronic venous diseases in Korea between 2010 and 2020

Purpose@#Limited data are available on the nationwide trend of treatments for chronic venous disease (CVD). The aim of the present study was to identify the nationwide trends of CVD treatments in Korea. @*Methods@#A serial, cross-sectional study was conducted with the use of time trends to analyze patients with CVD between 2010 and 2020. The trends in the number of patients and procedures were analyzed including sclerotherapy, open surgery, and endovenous thermal ablation (ETA). Health Insurance Review and Assessment Service data were used to analyze the trends. For the statistical analysis, MedCalc Statistical software was used. P < 0.05 was considered statistically significant. @*Results@#A total of 1,867,307 patients with CVD were managed in Korea between 2010 and 2020. The annual number of patients with CVD increased from 143,108 in 2010 to 219,319 in 2020 (risk ratio [RR], 1.53; P < 0.001). The percentage of patients with CVD who had venous ulcer gradually decreased from 3.1% in 2010 to 1.7% in 2020 (RR, 0.86; P < 0.001). The number of conventional surgeries including stripping and local resection of varicose veins decreased from 32,384 in 2010 to 21,792 in 2020 (RR, 0.67; P < 0.001). The number of ETAs performed increased, from 290 in 2011 to 12,126 procedures in 2020 (RR, 41.81; P < 0.001). @*Conclusion@#The total number of patients with CVD increased during the last 11 years. The number of conventional open surgery and sclerotherapy procedures decreased. On the contrary, the number of ETAs significantly increased in Korea.

Clinical outcome of graft removal versus preservation in abdominal aortic graft infection: a systematic review and meta-analysis

Purpose@#The purpose of this study was to compare the clinical outcomes of abdominal aortic graft infection (AGI) treated with removal of the graft vs. graft preservation. @*Methods@#The electronic databases PubMed, Embase, and Cochrane Library for studies that reported on AGI were searched. Observational studies and case series of at least 10 cases that reporting on the prevalence, microbiology, and outcomes of AGI were included. @*Results@#Our search identified 23 studies that met our inclusion criteria, reporting on a total of 873 patients who underwent open surgical repair (OSR) or endovascular aneurysm repair (EVAR). Of these patients, 833 received graft removal, and 40 received graft preservation. The prevalence of AGI was reported to be 1.0% (95% confidence interval [CI], 0.5%–1.8%) after OSR and 0.4% (95% CI, 0%–1.1%) after EVAR. The pooled estimates of 1-year, 2-year, and 5-year mortality were 28.7% (95% CI, 19.4%–38.8%), 36.6% (95% CI, 24.6%–49.5%), and 51.8% (95% CI, 38.4%–65.1%) in the graft removal group and 16.1% (95% CI, 4.1%–32.2%), 18.5% (95% CI, 5.7%–35.1%), and 50.0% (95% CI, 31.6%–68.4%) in the graft preservation group.The 30-day mortality rate’s risk ratio (RR) for graft removal vs. preservation was 0.98 (95% CI, 0.40–2.38), while the 1-year mortality rate’s RR was 3.44 (95% CI, 1.60–7.42). @*Conclusion@#The 30-day mortality rate of AGI treatment was found to be high, whether using graft removal or preservation.In selected patients, implementing antibiotics with graft preservation as an initial management may be helpful in reducing the mortality rate.

Treatment of abdominal aortic aneurysms in Korea: a nationwide study

Purpose@#Although endovascular aneurysm repair (EVAR) has been shown to be superior to open surgical repair (OSR) for abdominal aortic aneurysm (AAA) treatment, no large-scale studies in the Korean population have compared outcomes and costs. @*Methods@#The National Health Insurance Service database in Korea was screened to identify AAA patients treated with EVAR or OSR from 2008 to 2019. Perioperative, early postoperative, and long-term survival were compared, as were reinterventions and complications. Patients were followed-up through 2020. @*Results@#Of the 13,631 patients identified, 2,935 underwent OSR and 10,696 underwent EVAR. Perioperative mortality rate was lower in the EVAR group (4.2% vs. 8.0%, P < 0.001) even after excluding patients with ruptured AAA (2.7% vs.3.3%, P = 0.003). However, long-term mortality rate per 100 person-years was significantly higher in the EVAR than in the OSR group (9.0 vs. 6.4, P < 0.001), and all-cause mortality was lower in the OSR group (hazard ratio, 0.9; 95% confidence interval, 0.87–0.97, P = 0.008). EVAR had a higher AAA-related reintervention rate per 100 person-years (1.75 vs. 0.52), and AAA-related reintervention costs were almost 10-fold higher with EVAR (US dollar [USD] 6,153,463) than with OSR (USD 624,216). @*Conclusion@#While EVAR may have short-term advantages, OSR may provide better long-term outcomes and costeffectiveness for AAA treatment in the Korean population, under the medical expense system in Korea.

Ultrasound Elastography to Differentiate the Thrombus and Plaque in Peripheral Arterial Diseases

Purpose@#Arterial stiffness and steno-occlusion of the lower-extremity can result from many vascular lesions, including acute thromboembolisms, soft plaques, calcified plaques, or inflammatory disease. Ultrasound (US) elastography measures the tissue deformation response to compression and displays tissue stiffness. This study aimed to evaluate the characteristics of arterial lesions in the lower extremities using US elastography. @*Materials and Methods@#We retrospectively analyzed the data of 20 patients who visited our institute for arterial disease treatment between May 2016 and November 2017. An US examination with B-mode and strain elastography (SE) was performed of four different lesion types at 45 sites: acute and subacute thromboembolisms, soft plaques, calcified plaques, and thromboangiitis obliterans lesions (TAOs). During SE, stress was externally applied by the operator using the transducer. Strain ratio (SR) was calculated as the fraction of the average strain in the reference area divided by the average strain in the lesion. The SR was compared among different lesion types, with the accompanying vein as the reference region of interest. @*Results@#The strain was highest in the soft plaques (0.63%±0.23%), followed by the TAOs (0.45%±0.11%), calcified plaques (0.44%±0.13%), and acute thromboembolisms (0.34%±0.23%), which were statistically significant (P=0.026). However, the mean SR was highest for the calcified plaques (2.33%±0.80%), followed by the TAOs (1.63%±0.40%), acute thromboembolisms (1.60%±0.48%), and soft plaques (1.51±0.39), and which were statistically significant (P=0.013). @*Conclusion@#Despite several limitations, vascular elastography may be useful for differentiating between lesion types in peripheral arterial disease.

Association between Laterality and Location of Deep Vein Thrombosis of Lower Extremity and Pulmonary Embolism

Purpose@#The aim of this study was to investigate the relationship between the anatomical location of thrombi in the lower extremities and the development of pulmonary embolism (PE). @*Materials and Methods@#We collected and analyzed the data of patients diagnosed with deep vein thrombosis (DVT) of the lower extremities between 2006 and 2015, and included those whose computed tomography (CT) data were available for PE identification. We evaluated the relationship between the laterality and the proximal/distal location of the thrombi in lower extremites and the location of PE. @*Results@#CT images were available for 388/452 patients with DVT. After excluding 32 cases with bilateral involvement, 356 cases were included for analysis in this study. The ratio of DVT in the left:right leg was 232:124. PEs developed in 121 (52.2%) patients with left-sided DVT and in 78 (62.9%) with right-sided DVT (P=0.052). PEs in the main pulmonary arteries developed in 36 (15.5%) patients with left leg DVT and in 30 (24.2%) with right leg DVT (P=0.045). The most frequent site of thrombosis associated with the development of PE was the left iliac vein (59/199, 29.6%). According to the anatomical segment of the leg affected by DVT, patients with DVT in the right femoral vein (50/71, 70.4%; P=0.016) had the highest rate of occurrence of PE. @*Conclusion@#PE develops more frequently in patients with right-sided DVT than in those with left-sided DVT. Therefore, careful observation for the possible development of PE is recommended in cases with right-sided DVT of the lower extremity.

Association between Laterality and Location of Deep Vein Thrombosis of Lower Extremity and Pulmonary Embolism

Purpose@#The aim of this study was to investigate the relationship between the anatomical location of thrombi in the lower extremities and the development of pulmonary embolism (PE). @*Materials and Methods@#We collected and analyzed the data of patients diagnosed with deep vein thrombosis (DVT) of the lower extremities between 2006 and 2015, and included those whose computed tomography (CT) data were available for PE identification. We evaluated the relationship between the laterality and the proximal/distal location of the thrombi in lower extremites and the location of PE. @*Results@#CT images were available for 388/452 patients with DVT. After excluding 32 cases with bilateral involvement, 356 cases were included for analysis in this study. The ratio of DVT in the left:right leg was 232:124. PEs developed in 121 (52.2%) patients with left-sided DVT and in 78 (62.9%) with right-sided DVT (P=0.052). PEs in the main pulmonary arteries developed in 36 (15.5%) patients with left leg DVT and in 30 (24.2%) with right leg DVT (P=0.045). The most frequent site of thrombosis associated with the development of PE was the left iliac vein (59/199, 29.6%). According to the anatomical segment of the leg affected by DVT, patients with DVT in the right femoral vein (50/71, 70.4%; P=0.016) had the highest rate of occurrence of PE. @*Conclusion@#PE develops more frequently in patients with right-sided DVT than in those with left-sided DVT. Therefore, careful observation for the possible development of PE is recommended in cases with right-sided DVT of the lower extremity.

Multifocal Myoclonus as a Manifestation of Acute Cerebral Infarction Recovered by Carotid Arterial Stenting

No abstract available.

Report of a case of ischemic colitis with bilaterally patent internal iliac arteries after endovascular abdominal aneurysm repair / 대한외과학회지

During endovascular aneurysm repair (EVAR), interruption of the internal iliac arteries (IIAs) or the inferior mesenteric artery by stents or embolization is thought to cause colon ischemia. To minimize this risk, attempts have been made to preserve the IIAs using iliac branch devices or IIA revascularization. Here we present our experience of colon ischemia after EVAR in a patient with bilaterally patent IIAs without evidence of embolism. A 70-year-old man had abdominal pain and a ruptured abdominal aortic aneurysm was found. We performed EVAR with custom-made tube grafts preserving the bilateral IIAs. On postoperative day 2, the patient complained of abdominal pain, a sigmoidoscopy was performed revealing colon ischemia. On laparotomy, transmural infarction of the sigmoid colon was found and resected. Because IIA preservation cannot guarantee protection against colon ischemia, surgeons should maintain a high level of suspicion and use surveillance liberally after EVAR for early diagnosis of colon ischemia, even if both IIAs are preserved.

Surgical Treatment of Inferior Vena Cava Tumor Thrombus in Patients with Renal Cell Carcinoma

Radical nephrectomy with inferior vena cava (IVC) thrombectomy remains the most effective therapeutic option in patients with renal cell carcinoma and IVC tumor thrombus. Cephalic extension of the thrombus is closely related to perioperative morbidity. We purposed to design a safe and successful surgical strategy through a review of our surgical experience and treatment results in 35 patients (male:female=28:7, mean age=56 yr [32-77]) who underwent IVC thrombectomy with radical nephrectomy between January 1997 and December 2006. The limit of tumor extension was level I in 10 patients (28.6%), level II in 17 (48.6%), and level III and IV in 4 patients each (11.4%). Liver mobilization with hepatic vascular exclusion was performed in 12 patients and cardiopulmonary bypass in 7. Thirty-two primary closures, 2 patch closures, and 1 graft interposition were performed. One patient underwent simultaneous pulmonary embolectomy because of an operative pulmonary embolism. There was no operative mortality, and the overall survival at 5-yr was 50.8%. Complete thrombus removal without tumor fragmentation under long venotomy on fully exposed involved IVC is recommended for successful result in a bloodless operative field. The applicability of liver mobilization, hepatic vascular exclusion, and cardiopulmonary bypass, can be determined by the level of thrombus.

Effect of Anastomotic Method on Intimal Hyperplasia in Rabbit Aorta

PURPOSE: The clinical advantages of end-to-end (ETE) anastomosis have not been clear despite its biomechanical advantage over end-to-side (ETS) anastomosis. We compared the histomorphometric features of intimal remodeling after ETE and ETS anastomosis in a rabbit aortic bypass model. METHODS: Thirty-two bypass operations, 16 with ETS and 16 with ETE anastomoses, were performed using aortic allografts of donor rabbits (15 per group) and polytetrafluoroethylene (PTFE) grafts (1 per group). To minimize bias from the immunologic response to aortic allografts or graft size, a long aortic tissue obtained from one donor was divided into 2 pieces and shared between each ETE and ETS bypass. PTFE graft bypasses, which are commonly used in clinical practice, were performed to provide comparison results for an allograft with a different compliance. Vessels were harvested at 1 day (1 per group), 5 days (1 per group), and 4 weeks (14 per group, including the PTFE bypass group) after surgery. Intimal thickening was evaluated with hematoxylin-eosin, van Gieson, immunohistochemical staining and Western blot analysis of TNF-alpha and proliferative cell nuclear antigen (PCNA) expression. RESULTS: Mean intimal thickness and volume (0.721+/-0.047 mm, 5.734+/-0.387 mm3 vs. 0.883+/-0.048 mm, 9.068+/-0.462 mm3) and intima/media volume ratio (0.70+/-0.05 vs 1.08+/-0.06) were significantly smaller in ETE (P<0.05). Western blotting showed a marked increase in TNF-alpha (203.15+/-5.29 vs. 494.49+/-6.11) and PCNA concentrations (152.66+/-7.37 vs. 175.53+/-4.36) in the ETS group. CONCLUSION: ETE anastomosis results showed significantly decreased inflammatory reaction and volume of intimal hyperplasia, and therefore seemed to be associated with better long-term graft patency.

A Right Gastroepiploic Artery Aneurysm Treated by Surgical Excision

A 65-year-old male patient was referred to our hospital for postprandial abdominal pain. Computed tomography and angiography revealed 2 aneurysms of the right gastroepiploic artery, which were measured 0.8x1.3 cm and 1.9x3.4 cm. Excision of 2 saccular and fusiform aneurysms by laparotomy was performed. His hospital course was uneventful and symptoms disappeared after surgery. A gastroepiploic artery aneurysm can cause recurrent abdominal pain and surgical resection is warranted in symptomatic aneurysms.

The Relation between Distal Runoff and Clinical Outcome after Aorto-iliac Reconstruction Surgery

PURPOSE: We sought to evaluate the relationship between distal runoff and long-term graft patency in aorto-iliac occlusive disease. METHOD: A retrospective review was performed on 192 patients with aorto-iliac occlusive disease who underwent surgery between September 1995 and November 2005. Patients who underwent percutaneous angioplasty or stent placement were excluded. Preoperative angiograms were scored according to the SVS/ISVS Ad Hoc Committee guidelines. RESULT: The mean duration of follow-up was 50 months. Procedure indications consisted of claudication in 68 patients and critical limb ischemia in 124 patients. Procedures included 176 bypasses (50 aorto-iliac/aorto-femoral, 32 ilio-femoral, 46 axillo-femoral, and 48 femoro-femoral) and 16 endarterectomies with patch angioplasty. Overall 5-year patency rate was 84.1%. Higher primary patency was observed when the occlusion score of the superficial femoral artery (SFA) or deep femoral artery (DFA) was lower than 2 (P<0.05). Cox proportional hazard model showed run-off resistance values to be significant determinants of graft patency (p=0.000, Exp(B)=1.236). The group that underwent profundoplasty had significantly better long-term patency (P=0.009). CONCLUSION: Poor distal runoff score was related to lower primary patency. In patients with aorto-iliac occlusive disease and poor distal outflow, profundoplasty can improve primary patency.