Stratification of chronic and complex wounds according to healing characteristics: a retrospective study.

OBJECTIVE: Wound risk-stratified analyses are clinically relevant as they can assist in identifying hard-to-heal wounds. The aim of the study is to develop risk categories for wound healing based on a limited number of reliably recordable clinical data. METHOD: This retrospective study used observational data. The primary outcome measure was wound healing at the end of treatment and the secondary outcome measure was the time to wound healing. A stratification model using regression analyses was developed to assign the patients to risk categories for wound healing and the time-to-heal. RESULTS: The study cohort comprised of 540 patients. The most common wound diagnoses were diabetic ulcers, wounds in irradiated areas and wound dehiscence after surgery. Average wound duration before starting treatment at the wound centre was 11.7 months. Healing was achieved in 382 (71%) wounds, after an average treatment time of 4.4 months. A total of four risk categories for wound healing were developed by combining wound diagnosis (favourable versus unfavourable) and duration (<3 months versus >3 months). These risk categories demonstrated healing percentages ranging from 69-97% (p=0.0004) and mean time-to-healing varying from 2.7-5.9 months (p=0.01). CONCLUSION: Using two clinical wound variables, diagnosis and duration, stratification categories were identified with significant associations with wound healing outcomes. Longer wound duration and unfavourable diagnoses, when combined into unfavourable risk categories, were associated with a lower percentage of wound healing and a longer treatment time until healing.

Use of epidermal skin grafts in chronic wounds: a case series.

In stalled, chronic wounds, more aggressive and proactive wound closure efforts are needed. We describe adjunctive use of epidermal grafting in patients with chronic wounds. Wound bed preparation consisted of surgical necrotectomy or sharp debridement, hyperbaric oxygen therapy, negative pressure wound therapy, compression therapy, platelet-rich plasma therapy and/or heparan sulphate agents. Epidermal grafts were harvested from the patient's thigh and applied to the wound. Wound and donor site healing was monitored. A total of 78 patients (average age = 64·1 ± 15·6 years) were included in the study. Common comorbidities included hypertension (47·4%), venous insufficiency (37·2%) and obesity (28·2%). Average wound duration was 13·2 months (range: 0·3-180 months). The most common wound types were dehiscence (29·5%), radiation ulcer (24·4%) and venous ulcer (17·9%). Total time from epidermal grafting to wound closure was 10·0 ± 7·3 weeks. Of the 78 wounds, 66 (84·6%) reached full wound closure (49 < 3 months, 16 > 3 months, 1 without time data). Of 78 wounds, 10 (12·8%) underwent partial wound healing, while 2 wounds (2/78; 2·6%) remained unhealed. These results suggest that wound surface reduction can be achieved by proactive early application of biological therapies and epidermal skin grafts, which may help decrease time to wound healing.

Sex differences in 30-day and 5-year outcomes after endovascular repair of abdominal aortic aneurysms in the EUROSTAR study.

OBJECTIVE: The purpose of this study was to determine the effect of sex on 30-day and long-term outcomes after elective endovascular aneurysm repair. METHODS: Patients entered into the European collaborators on stent graft techniques for abdominal aortic aneurysm repair (EUROSTAR) study formed the basis of our study. Data were analyzed by means of multivariable logistic regression for 30-day mortality and composite outcome of mortality, systemic complication, or conversion. Kaplan-Meier survival analyses were used to compare long-term survival and long-term event-free survival times between women and men. The log-rank test was used to test for differences. Cox proportional hazards regression was used to analyze survival and event-free survival (with end point mortality or reintervention). Multivariable analyses were adjusted for age, comorbidities, aneurysm characteristics, and treatment characteristics. RESULTS: There were 623 women and 8604 men available for analysis. No difference in 30-day mortality was demonstrated for women compared with men (odds ratio, 0.89; 95% confidence interval [CI], 0.48-1.67), but women did have a significantly higher cumulative incidence of the composite end point (odds ratio, 1.32; 95% CI, 1.05-1.66). The Kaplan-Meier curves demonstrated worse outcomes for both long-term survival (P = .05) and long-term event-free survival (P =.005). Survival analyses adjusting for covariates demonstrated a higher albeit nonsignificant difference in long-term mortality for women compared to men (hazard rate ratio, 1.21; 95% CI, 0.96-1.53) and a significant higher rate of the composite end point mortality or reintervention (hazard rate ratio, 1.28; 95% CI, 1.07-1.54). CONCLUSIONS: Women undergoing endovascular aortic repair have higher complication and reintervention rates compared with men, implying that the role of elective endovascular aneurysm repair in women needs to be examined more closely.

Long-term outcome of open or endovascular repair of abdominal aortic aneurysm.

BACKGROUND: For patients with large abdominal aortic aneurysms, randomized trials have shown an initial overall survival benefit for elective endovascular repair over conventional open repair. This survival difference, however, was no longer significant in the second year after the procedure. Information regarding the comparative outcome more than 2 years after surgery is important for clinical decision making. METHODS: We conducted a long-term, multicenter, randomized, controlled trial comparing open repair with endovascular repair in 351 patients with an abdominal aortic aneurysm of at least 5 cm in diameter who were considered suitable candidates for both techniques. The primary outcomes were rates of death from any cause and reintervention. Survival was calculated with the use of Kaplan-Meier methods on an intention-to-treat basis. RESULTS: We randomly assigned 178 patients to undergo open repair and 173 to undergo endovascular repair. Six years after randomization, the cumulative survival rates were 69.9% for open repair and 68.9% for endovascular repair (difference, 1.0 percentage point; 95% confidence interval [CI], -8.8 to 10.8; P=0.97). The cumulative rates of freedom from secondary interventions were 81.9% for open repair and 70.4% for endovascular repair (difference, 11.5 percentage points; 95% CI, 2.0 to 21.0; P=0.03). CONCLUSIONS: Six years after randomization, endovascular and open repair of abdominal aortic aneurysm resulted in similar rates of survival. The rate of secondary interventions was significantly higher for endovascular repair. (ClinicalTrials.gov number, NCT00421330.)

Infrarenal abdominal aortic aneurysm with concomitant urologic malignancy: treatment results in the era of endovascular aneurysm repair.

During diagnostic workup for urologic malignancies, an abdominal aortic aneurysm (AAA) is identified in a proportion of patients. In the era of open AAA repair, these patients presented a surgical dilemma with regard to the sequence of the operations: cancer treatment first or AAA repair first? Previous assessments have concluded that irrespective of the followed strategy, the early and mediumterm mortality from the two operative procedures in this patient category was significant. With the introduction of endovascular aneurysm repair (EVAR), the mortality and morbidity associated with the treatment of both pathologic conditions may be more favorable than with open aneurysm repair. The objective of this study was to assess, in an institutional series of patients receiving EVAR, the early and long-term survival and complication rates in patients with urologic malignancies. In a series of 385 patients receiving EVAR, 14 had a concomitant urologic malignancy: renal cell carcinoma (5 patients), prostate carcinoma (6 patients), and carcinoma of the bladder (3 patients). The first-month mortality was nil. Long-term survival was 80%, 83%, and 67% for the three tumor types, respectively. EVAR offers improved treatment in patients with concomitant AAA and urologic malignancy and should be considered the first choice for these patients.

The mechanical role of thrombus on the growth rate of an abdominal aortic aneurysm.

OBJECTIVES: In the decision for surgical repair of abdominal aortic aneurysms (AAAs), the maximum diameter is the main factor. Several studies have concluded that the diameter may not be reliable as rupture risk criterion for the individual patient and wall stress was found to have a higher sensitivity and specificity. The AAA wall stress may also be an influential factor in growth of the AAA. This study investigates the effect of intraluminal thrombus on the wall stress and growth rate of aneurysms, using both idealized and patient-specific AAA models in wall stress computations. METHODS: Idealized AAA models were created for wall stress analysis. Thrombus was modeled as an incompressible linear elastic material and was fixed to the wall. The reduction in wall stress for a range of thrombus volumes and shear moduli was computed. For 30 patient-specific AAA models with varying thrombus volumes, the wall stress was computed with and without thrombus. The diameter growth rate was compared for AAAs with a small and large thrombus volume. The results were compared between the idealized and patient-specific models. RESULTS: The thrombus caused a reduction in wall stress, which was stronger for larger thrombi and higher elastic moduli. Any AAAs with a large thrombus were found to have significant stronger growth in diameter than aneurysms with a small thrombus (P < .01). The stress reduction due to the thrombus showed the same trend for the idealized and patient-specific models, although the effect was overestimated by the idealized models and a considerable variation between patients was observed. CONCLUSION: A larger thrombus in AAA was associated with a higher AAA growth rate, but also with a lower wall stress. Therefore, weakening of the AAA wall, under the influence of thrombus, may play a more imminent role in the process of AAA growth than the stress acting on the wall.

Biomechanical properties of abdominal aortic aneurysms assessed by simultaneously measured pressure and volume changes in humans.

BACKGROUND: Abdominal aortic aneurysms (AAA) are at risk of rupture when the internal load (blood pressure) exceeds the aneurysm wall strength. Generally, the maximal diameter of the aneurysm is used as a predictor of rupture; however, biomechanical properties may be a better predictor than the maximal diameter. Compliance and distensibility are two biomechanical properties that can be determined from the pressure-volume relationship of the aneurysm. This study determined the compliance and distensibility of the AAA by simultaneous instantaneous pressure and volume measurements; as a secondary goal, the influence of direct and indirect pressure measurements was compared. METHODS: Ten men (aged 73.6 +/- 6.4 years) with an infrarenal AAA were studied. Three-dimensional balanced turbo field echo (3D B-TFE) images were acquired with noncontrast-enhanced magnetic resonance imaging (MRI) for the aortic region proximal to the renal arteries until just beyond the bifurcation. Volume changes were extracted from the electrocardiogram-triggered 3D B-TFE MRI images using dedicated prototype software. Pressure was measured simultaneously within the AAA using a fluid-filled pigtail catheter. Noninvasive brachial cuff measurements were also acquired before and after the imaging sequence simultaneously with the invasive pressure measurement to investigate agreement between the techniques. Compliance was calculated as the slope of the best linear fit through the pressure volume data points. Distensibility was calculated by dividing the compliance by the diastolic aneurysmal volume. Young's moduli were estimated from the compliance data. RESULTS: The AAA maximal diameter was 5.8 +/- 0.6 cm. A strong linear relation between the pressure and volume data was found. Distensibility was 1.8 +/- 0.7 x 10(-3) kPa(-1). Average compliance was 0.31 +/- 0.15 mL/kPa with accompanying estimates for Young's moduli of 9.0 +/- 2.5 MPa. Brachial cuff measurements demonstrated an underestimation of 5% for systolic (P < .001) and an overestimation of 12% for diastolic blood pressure (P < .001) compared with the pressure measured within the aneurysm. CONCLUSION: Distensibility and compliance of the wall of the aneurysm were determined in humans by simultaneous intra-aneurysmal pressure and volume measurements. A strong linear relationship existed between the intra-aneurysmal pressure and the volume change of the AAA. Brachial cuff measurements were significantly different compared with invasive intra-aneurysmal measurements. Consequently, no absolute distensibility values can be determined noninvasively. However, because of a constant and predictable difference between directly and indirectly derived blood pressures, MRI-based monitoring of aneurysmal distensibility may serve the online rupture risk during follow-up of aneurysms.

Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms.

Not every patient is fit for open thoracoabdominal aortic aneurysm (TAAA) repair, nor is every TAAA or juxtarenal abdominal aortic aneurysm suitable for branched or fenestrated endovascular exclusion. The hybrid procedure consists of debranching of the renal and visceral arteries followed by endovascular exclusion of the aneurysm and might be an alternative in these patients. Between May 2004 and March 2006, 16 patients were treated with a hybrid procedure. The indications were recurrent suprarenal or thoracoabdominal aneurysms after previous abdominal and/or thoracic aortic surgery (n = 8), type I to III TAAAs (n = 3), proximal type I endoleak after endovascular repair (n = 2), penetrating ulcer of the juxtarenal aorta (n = 1), visceral patch aneurysm after type IV open repair (n = 1), and primary suprarenal aneurysm (n = 1). Eight (50%) of 16 patients were judged to be unfit for open TAAA repair. The hospital mortality rate was 31% (5 of 16). Four of five deceased patients were unfit for thoracophrenic laparotomy. Two patients died from cardiac complications and three from visceral ischemia. No spinal cord ischemia was detected, and temporary renal failure occurred in four patients (25%). The mean follow-up was 13 months (range 6-28 months). During follow-up, no additional grafts occluded and no patients died. Hybrid procedures are technically feasible but have substantial mortality (31%), especially in patients unfit for open repair (80%). They might be indicated when urgent TAAA surgery is required or when vascular anatomy is unfavorable for fenestrated endografts in patients with extensive previous open aortic surgery.

Multicenter randomized controlled trial of the costs and effects of noninvasive diagnostic imaging in patients with peripheral arterial disease: the DIPAD trial.

OBJECTIVE: The purpose of our study was to compare the costs and effects of three noninvasive imaging tests as the initial imaging test in the diagnostic workup of patients with peripheral arterial disease. MATERIALS AND METHODS: Of 984 patients assessed for eligibility, 514 patients with peripheral arterial disease were randomized to MR angiography (MRA) or duplex sonography in three hospitals and to MRA or CT angiography (CTA) in one hospital. The outcome measures included the clinical utility, functional patient outcomes, quality of life, and actual diagnostic and therapeutic costs related to the initial imaging test during 6 months of follow-up. RESULTS: With adjustment for potentially predictive baseline variables, the learning curve, and hospital setting, a significantly higher confidence and less additional imaging were found for MRA and CTA compared with duplex sonography. No statistically significant differences were found in improvement in functional patient outcomes and quality of life among the groups. The total costs were significantly higher for MRA and duplex sonography than for CTA. CONCLUSION: The results suggest that both CTA and MRA are clinically more useful than duplex sonography and that CTA leads to cost savings compared with both MRA and duplex sonography in the initial imaging evaluation of peripheral arterial disease.

Outpatient treatment of arterial inflow stenoses of dysfunctional hemodialysis access fistulas by retrograde venous access puncture and catheterization.

OBJECTIVE: To determine the feasibility of endovascular treatment of inflow stenoses in arteriovenous fistulae (AVFs) through retrograde venous access catheterization. METHODS: We included all 22 dysfunctional AVFs with arterial inflow stenoses at access imaging between January 2002 and September 2006. Following retrograde venous access puncture, an interventional radiologist intended to cross the arteriovenous anastomosis and advance a catheter into the aortic arch. After depiction of the complete vascular access tree, angioplasty and/or stent placement was aimed for stenoses with a >50% luminal diameter reduction at digital subtraction angiography (DSA). RESULTS: In one radiocephalic AVF, a catheter could not be positioned into the aortic arch after retrograde venous access puncture. DSA depicted 28 inflow stenoses in the remaining 21 patients (11 radiocephalic AVFs and 10 brachiocephalic AVFs). Clinical improvement was obtained in 18 out of 19 patients with a technically successful intervention (<30% residual stenosis after angioplasty or stent placement). Following endovascular therapy, access flow of 12 patients with a low flow access improved from 431 +/- 150 ml/min to 818 +/- 233 ml/min, and four patients with steal symptoms became symptom free. One nonmaturing fistula could be salvaged by angioplasty, and access cannulation problems were solved in another patient following angioplasty. Brachial artery stent placement did not reduce steal symptoms in one case, whereas two patients, in whom stent placement was not thought desirable, showed a >30% residual arterial stenosis after angioplasty. No complications were observed at DSA and endovascular intervention. CONCLUSION: Retrograde venous access puncture and catheterization, as an alternative to a potentially more hazardous brachial artery or more invasive femoral artery approach, should be considered for the visualization of the arterial inflow and endovascular treatment of inflow stenoses.

Non-linear viscoelastic behavior of abdominal aortic aneurysm thrombus.

The objective of this work was to determine the linear and non-linear viscoelastic behavior of abdominal aortic aneurysm thrombus and to study the changes in mechanical properties throughout the thickness of the thrombus. Samples are gathered from thrombi of seven patients. Linear viscoelastic data from oscillatory shear experiments show that the change of properties throughout the thrombus is different for each thrombus. Furthermore the variations found within one thrombus are of the same order of magnitude as the variation between patients. To study the non-linear regime, stress relaxation experiments are performed. To describe the phenomena observed experimentally, a non-linear multimode model is presented. The parameters for this model are obtained by fitting this model successfully to the experiments. The model cannot only describe the average stress response for all thrombus samples but also the highest and lowest stress responses. To determine the influence on the wall stress of the behavior observed the model proposed needs to implemented in the finite element wall stress analysis.

Influence of pulmonary status and diabetes mellitus on aortic neck dilatation following endovascular repair of abdominal aortic aneurysms: a EUROSTAR report.

PURPOSE: To elucidate the association of impaired pulmonary status (IPS) and diabetes mellitus (DM) with clinical outcome and the incidences of aortic neck dilatation and type I endoleak after elective endovascular infrarenal aortic aneurysm repair (EVAR). METHODS: In 164 European institutions participating in the EUROSTAR registry, 6383 patients (5985 men; mean age 72.4+/-7.6 years) underwent EVAR. Patients were divided into patients without versus with IPS or with/without DM. Clinical assessment and contrast-enhanced computed tomography (CT) were performed at 1, 3, 6, 12, 18, and 24 months and annually thereafter. Cumulative endpoint analysis comprised death, aortic rupture, type I endoleak, endovascular reintervention, and surgical conversion. RESULTS: Prevalence of IPS was 2733/6383 (43%) and prevalence of DM was 810/6383 (13%). Mean follow-up was 21.1+/-18.4 months. Thirty-day mortality, AAA rupture, and conversion rates did not differ between patients with versus without IPS and between patients with versus without DM. All-cause and AAA-related mortality, respectively, were significantly higher in patients with IPS compared to patients with normal pulmonary status (31.0% versus 19.0%, p<0.0001 and 6.8% versus 3.3%, p = 0.0057) throughout follow-up. In multivariate analysis adjusted for smoking, age, gender, comorbidities, fitness for open repair, co-existing common iliac aneurysm, neck and aneurysm size, arterial angulations, aneurysm classification, endograft oversizing >or=15%, and type of stent-graft, the presence of IPS was not associated with significantly higher rates of aortic neck dilatation (30.6% versus 38.0%, p>0.05) and did not influence cumulative rates of type I endoleak, endovascular reintervention, or conversion to open surgery (p>0.05). Similarly, the presence of DM did not influence the above-mentioned study endpoints. CONCLUSION: In contrast to observations regarding the natural course of AAAs, impaired pulmonary status does not negatively influence aortic neck dilatation, while the presence of diabetes does not protect from these dismal events after EVAR.

Determination of linear viscoelastic behavior of abdominal aortic aneurysm thrombus.

The objective of this study is to determine whether the linear viscoelastic properties of an abdominal aortic aneurysm thrombus can be determined by rheometry. Although large strains occur in the in vivo situation, in this work only linear behavior is studied to show the applicability of the described methods. A thrombus exists of several layers that vary in composition, structure and mechanical properties. Two types of thrombus are described. In discrete transition thrombi the layers are not or at most weakly attached to each other and the structure of each layer is different. Continuous transition thrombi consist of strongly attached layers whose structure changes gradually throughout the thickness of the thrombus. Shear experiments are performed on samples from both types of thrombus on a rotational rheometer using a parallel plate geometry. In the discrete type the storage modulus G' cannot be assumed equal for the different layers. In the continuous thrombus, G', changes gradually throughout the layered structure. In both types the loss modulus, G'', does not vary throughout the thrombus. Furthermore, it was found that Time-Temperature Superposition is applicable to thrombus tissue. Since results were reproducible it can be concluded that the method we used to determine the viscoelastic properties is applicable to thrombus tissue.

Statin use is associated with reduced all-cause mortality after endovascular abdominal aortic aneurysm repair.

It has been shown that preoperative statin therapy reduces all-cause and cardiovascular mortality in patients undergoing major noncardiac vascular surgery. In this report, we investigated the influence of statin use on early and late outcome following endovascular abdominal aortic aneurysm repair (EVAR). The study population, consisting of patients collated in the EUROSTAR registry, was stratified in two groups according to statin use. Baseline characteristics between the two groups were compared by chi-square and Wilcoxon rank sum tests for discrete and continuous variables. The effects of statin use on outcomes after EVAR were analyzed by multivariate regression models. Of the 5,892 patients enrolled in the EUROSTAR registry, 731 (12.4%) patients used statins for hyperlipidemia. Statin users were younger, were more obese, and had a higher prevalence of diabetes, cardiovascular disease, and hypertension. After 5 years of follow-up, the cumulative survival rate was 77% for nonusers of statin versus 81% for statin users (p = .005). After adjustment for age and other risk factors, statin use was still an independent predictor of improved survival (p = .03). Our results revealed that statin prescription was more frequent in younger patients. However, when adjusted for age and medical risk factors, the use of statin in patients who underwent EVAR was still independently associated with reduced overall mortality.

Endograft treatment of ruptured abdominal aortic aneurysms using the Talent aortouniiliac system: an international multicenter study.

OBJECTIVE: To understand the potential of endovascular aneurysm repair (EVAR) in patients presenting with a ruptured abdominal aortic aneurysm (rAAA), the proportion in whom this procedure was applicable was assessed. Mortality and morbidity was also determined in patients treated with emergency EVAR (eEVAR) when anatomic and hemodynamic conditions allowed (ie, in the entire cohort with patients receiving endovascular and open repair combined). In addition, a comparison was made between the treatment group with eEVAR and open repair. METHODS: Between February 2003 and September 2004, 10 participating institutions enrolled a representative sample of 100 consecutive patients in whom eEVAR was considered. Patients in the New Endograft treatment in Ruptured abdominal aortic Aneurysm (ERA) trial were offered eEVAR or open repair in accordance with their clinical condition or anatomic configuration. Written informed consent was obtained from all patients or their legal representatives. The study included patients who were treated by stent-graft technique or by open surgery in the case of adverse anatomy for endoluminal stent-grafting or severe hemodynamic instability, or both. Data were collated in a centralized database for analysis. The study was sponsored and supported by Medtronic, and eEVAR was uniquely performed with a Talent aortouniiliac (AUI) system in all patients. Crude and adjusted 30-day or in-hospital and 3-month mortality rates were assessed for the entire group as a whole and the EVAR and open repair category separately. Complication rates were also assessed. RESULTS: Stent-graft repair was performed in 49 patients and open surgery in 51. No significant differences were observed between these treatment groups with regard to comorbidity at presentation, hemodynamic instability, and the proportion of patients who could be assessed by preoperative computed tomography scanning. Patients with eEVAR more frequently demonstrated a suitable infrarenal neck for endovascular repair, a longer infrarenal neck, and suitable iliac arteries for access than patients with open repair. The primary reason to perform open aneurysm repair was an unfavorable configuration of the neck in 80% of the patients. In patients undergoing eEVAR, operative blood loss was less, intensive care admission time was shorter, and the duration of mechanical ventilation was shorter (P < or = .02, all comparisons). The 30-day or in-hospital mortality was 35% in the eEVAR category, 39% in patients with open repair, and 37% overall. There was no statistically significant difference between the treatment groups with regard to crude mortality rates or rates adjusted for age, gender, hemodynamic shock, and pre-existent pulmonary disease. The cumulative 3-month all-cause mortality was 40% in the eEVAR group and 42% in the open repair group (no significant differences at crude and adjusted comparisons). The 3-month primary complication rate in the two treatment groups was similar at 59%. CONCLUSIONS: In approximately half the rAAA patients, eEVAR appeared viable. An unsuitable infrarenal neck was the most frequent cause to select open repair. In dedicated centers using a Talent AUI system, eEVAR appeared to be a feasible method for treatment of a rAAA. The overall first-month mortality did not differ across treatment groups (patients with endovascular and open repair combined), yet was somewhat lower than observed in a recent meta-analysis reporting on open repair.

Dutch iliac stent trial: long-term results in patients randomized for primary or selective stent placement.

PURPOSE: To determine long-term results of the prospective Dutch Iliac Stent Trial. MATERIALS AND METHODS: The study protocol was approved by local institutional review boards. All patients gave written informed consent. Two hundred seventy-nine patients (201 men, 78 women; mean age, 58 years) with iliac artery disease were randomly assigned to undergo primary stent placement (143 patients) or percutaneous transluminal angioplasty (PTA) with selective stent placement in cases in which the residual mean pressure gradient was greater than 10 mm Hg across the treated site (136 patients). Before and at 3, 12, and 24 months and 5-8 years after treatment, all patients underwent assessment, which included duplex ultrasonography (US), ankle-brachial index (ABI) measurement, Fontaine classification of symptoms, and completion of the Rand 36-Item Health survey for quality-of-life assessment. Treatment was considered successful for symptoms if symptoms increased at least one Fontaine grade, for ABI if ABI increased more than 0.10, for patency if peak systolic velocity ratio at duplex US was less than 2.5, and for quality of life if the RAND 36-Item Health Survey score increased more than 15 points. Effects of both treatments on symptoms, quality of life, patency, and ABI were compared by using survival analyses. RESULTS: Patients who underwent PTA and selective stent placement had better improvement of symptoms (hazard ratio [HR], 0.8; 95% confidence limits [CLs]: 0.6, 1.0) than did patients treated with primary stent placement, whereas ABI (HR, 0.9; 95% CLs: 0.7, 1.3), iliac patency (HR, 1.3; 95% CLs: 0.8, 2.1), and score for quality of life for nine survey dimensions did not support a difference between treatment groups. CONCLUSION: Patients treated with PTA and selective stent placement in the iliac artery had a better outcome for symptomatic success compared with patients treated with primary stent placement, whereas data about iliac patency, ABI, and quality of life did not support a difference between groups.

Adverse events at the aneurysmal neck identified at follow-up after endovascular abdominal aortic aneursym repair: how do they correlate?

The objective of this study was to assess the prevalence of and the correlation between dilatation of the infrarenal neck and proximal device migration after endovascular abdominal aortic aneurysm repair (EVAR). The analysis made use of the EUROSTAR registry. Between 1994 and 2004, 4,233 patients with an abdominal aortic aneurysm larger than 4 cm underwent EVAR. Only patients with available follow-up data regarding neck size and device position were included in this assessment. Chi-square and t-tests or Wilcoxon rank sum tests were used for comparison of discrete and continuous variables, respectively. Time-dependent variables were evaluated by log-rank tests. In addition, multivariate analysis was performed to determine anatomic and operative variables with an independent correlation with neck growth and device migration, respectively. In addition, the association with proximal endoleak was assessed. Neck dilatation and proximal migration were found in 1,342 (32%) and 192 (4.5%) of the 4,233 patients, respectively. One hundred twelve patients (2.5%) had neck dilatation and migration of the proximal device extremity. The correlation between proximal migration and neck dilatation was statistically significant (p < .0001). Other independent variables for migration were a wider neck and aneurysmal diameter, shorter necks, proximal endoleak, and absence of suprarenal fixation. Neck dilatation was predicted by narrow necks, use of devices with suprarenal fixation, and larger device diameters. Proximal endoleak occurred in 136 (3.2%) patients and was significantly associated with shorter, angulated necks and proximal migration. The present study documented that migration may be caused by neck dilatation. However, neck dilatation was not significantly promoted by proximal migration. Other factors, such as dimensions of the neck, the device fixation system, and perhaps progressive wall degeneration, are also likely to play a role in the pathogenesis of neck dilatation. To obtain good results from EVAR, accepted criteria of neck dimensions should be adhered to.

Aneurysm diameter and proximal aortic neck diameter influence clinical outcome of endovascular abdominal aortic repair: a 4-year EUROSTAR experience.

Our objective was to evaluate the effect of preoperative aneurysm and aortic neck diameter on clinical outcome after infrarenal abdominal endovascular aneurysm repair (EVAR). Data of patients in the European Collaborators Registry on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR) registry base who underwent EVAR with Talent stent grafts were analyzed. Patient characteristics and clinical outcomes were compared among four groups defined by preoperative abdominal aortic aneurysm (AAA) and proximal aortic neck diameter: A, AAA < or =60 mm and neck < or =26 mm; B, AAA >60 mm and neck < or =26 mm; C, AAA < or =60 mm and neck >26 mm; and D, AAA >60 mm and neck >26 mm. Over a 7-year period, 1,317 patients underwent EVAR. Patients in groups B and D were significantly older and had a higher American Society of Anesthesiologists score compared with groups A and C (p=0.002 and 0.003, respectively). Mortality rate was highest in group D (p=0.002), as were rupture and conversion rates (p=0.015 and 0.037, respectively). This study demonstrates that patients with an AAA >60 mm and a proximal aortic neck >26 mm have worse clinical outcome after EVAR.