Editor's Choice - International Variations and Sex Disparities in the Treatment of Peripheral Arterial Occlusive Disease: A Report from VASCUNET and the International Consortium of Vascular Registries.

OBJECTIVE: The aim of this study was to determine sex specific differences in the invasive treatment of symptomatic peripheral arterial occlusive disease (PAOD) between member states participating in the VASCUNET and International Consortium of Vascular Registries. METHODS: Data on open surgical revascularisation and peripheral vascular intervention (PVI) of symptomatic PAOD from 2010 to 2017 were collected from population based administrative and registry data from 11 countries. Differences in age, sex, indication, and invasive treatment modality were analysed. RESULTS: Data from 11 countries covering 671 million inhabitants and 1 164 497 hospitalisations (40% women, mean age 72 years, 49% with intermittent claudication, 54% treated with PVI) in Europe (including Russia), North America, Australia, and New Zealand were included. Patient selection and treatment modality varied widely for the proportion of female patients (23% in Portugal and 46% in Sweden), the proportion of patients with claudication (6% in Italy and 69% in Russia), patients' mean age (70 years in the USA and 76 years in Italy), the proportion of octogenarians (8% in Russia and 33% in Sweden), and the proportion of PVI (24% in Russia and 88% in Italy). Numerous differences between females and males were observed in regard to patient age (72 vs. 70 years), the proportion of octogenarians (28% vs. 15%), proportion of patients with claudication (45% vs. 51%), proportion of PVI (57% vs. 51%), and length of hospital stay (7 days vs. 6 days). CONCLUSION: Remarkable differences regarding the proportion of peripheral vascular interventions, patients with claudication, and octogenarians were seen across countries and sexes. Future studies should address the underlying reasons for this, including the impact of national societal guidelines, reimbursement, and differences in health maintenance.

Editor's Choice - Assessment of Correlation Between Mean Size of Infrarenal Abdominal Aortic Aneurysm at Time of Intact Repair Against Repair and Rupture Rate in Nine Countries.

OBJECTIVE: This study aimed to analyse the mean abdominal aortic aneurysm (AAA) diameter for repair in nine countries, and to determine variation in mean AAA diameter for elective AAA repair and its relationship to rupture AAA repair rates and aneurysm related mortality in corresponding populations. METHODS: Data on intact (iAAA) and ruptured infrarenal AAA (rAAA) repair for the years 2010-2012 were collected from Denmark, England, Finland, Germany, Hungary, New Zealand, Norway, Sweden, and the USA. The rate of iAAA repair and rAAA per 100 000 inhabitants above 59 years old, mean AAA diameter for iAAA repair and rAAA repair, and the national rates of rAAA were assessed. National cause of death statistics were used to estimate aneurysm related mortality. Direct standardisation methods were applied to the national mortality data. Logistic regression and analysis of variance model adjustments were made for age groups, sex, and year. RESULTS: There was a variation in the mean diameter of iAAA repair (n = 34 566; range Germany = 57 mm, Denmark = 68 mm). The standardised iAAA repair rate per 100000 inhabitants varied from 10.4 (Hungary) to 66.5 (Norway), p<.01, and the standardised rAAA repair rate per 100 000 from 5.8 (USA) to 16.9 (England), p<.01. Overall, there was no significant correlation between mean diameter of iAAA repair and standardised iAAA rate (r2 = 0.04, p = .3). There was no significant correlation between rAAA repair rate (n = 12 628) with mean diameter of iAAA repair (r2 = 0.2, p = .1). CONCLUSION: Despite recommendations from learned society guidelines, data indicate variations in mean diameter for AAA repair. There was no significant correlation between mean diameter of AAA repair and rates of iAAA repair and rAAA repair. These analyses are subject to differences in disease prevalence, uncertainties in rupture rates, validations of vascular registries, causes of death and registrations.

Recommendations for management of infected aortic pathology based on current evidence.

The management of infection involving the abdominal aorta requires clinical decisions based on patient factors and the nature of the infectious process. Any infection occurring after endovascular aortic aneurysm repair or open aortic replacement grafting should be treated promptly with appropriate systemic antibiotic therapy. Once a vascular prosthesis becomes infected, surgical treatment is necessary. There should be a low threshold for graft excision and extra-anatomic bypass in the presence of fistula or abscess cavity, when feasible entire graft should be excised. In selected patients, graft excision with in situ aorta reconstruction is an appropriate option using an autogenous femoral vein, cryopreserved allograft, or a prosthetic graft impregnated with antibiotic. The replaced in situ aortic graft should be covered with an omental pedicle. For primary aortic graft infections, endovascular treatment may act as a bridge to more definitive treatment; or, in the absence of gross retroperitoneal infections, endovascular grafting alone with prolonged systemic antibiotic therapy is a viable option, particularly in patients not fit for open surgical procedures.

Multicentre Post-EVAR Surveillance Evaluation Study (EVAR-SCREEN).

OBJECTIVE: Surveillance imaging is considered mandatory after endovascular aneurysm repair (EVAR), but many patients are lost to follow up and the impact of this is poorly understood. This study aimed to examine compliance with post-operative surveillance in the UK and the impact of mal-/non-compliance on endograft re-interventions and survival. METHODS: EVAR-SCREEN centres reported EVAR for intact infrarenal abdominal aortic aneurysms (AAA) from 1 January 2007 to 31 December 2010, with follow up included up to 31 July 2014. Non-compliance was defined by the presence of a single 18 month period in which no surveillance imaging was performed. The outcomes were reported in compliant and non-compliant groups with survival analysis. RESULTS: EVAR was performed in 1414 patients in 10 UK centres. At the end of the study period there were 378 patients with five years of follow up available for analysis. Compliance with surveillance was 66% (61-68%). Compliance varied widely, from 9% to 88% between centres. Age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.01-1.05; p = .02) and distance from hospital (HR 1.01, 95% CI 1.00-1.01; p < .001) were independent predictors of non-compliance. Non-compliant patients had lower all cause mortality in the first three years after EVAR, whereas compliant patients had lower all cause mortality 4-5 years after EVAR (p < .001). No significant difference in re-intervention rates was found between compliant and non-compliant patients. CONCLUSION: A substantial proportion of patients were non-compliant with surveillance after EVAR in the UK with considerable variation between centres. The survival benefit for EVAR after three years appeared to be related to compliance with surveillance which has implications for the future delivery of EVAR.

Endovascular Versus Open Repair for Chronic Type B Dissection Treatment: A Meta-Analysis.

BACKGROUND: The respective place of endovascular repair (ER) versus open surgery (OS) in thoracic dissecting aneurysm treatment remains debatable. This comprehensive review seeks to compare the outcomes of ER versus OS in chronic type B aortic dissection treatment. METHODS: Embase and Medline searches (2000 to 2017) were performed following PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) guidelines. Outcomes data extracted comprised (1) early mortality and major complications: stroke, spinal cord ischemia (SCI), dialysis, and respiratory complications; and (2) late survival and reinterventions. Reintervention causes were divided into proximal, adjacent, and distal. Comparative studies allowed comparative meta-analysis. Noncomparative studies were analyzed in pooled proportion meta-analyses for each group. RESULTS: A total of 39 studies were identified after exclusions, of which 4 were comparative. Comparative meta-analysis demonstrated lower early mortality for ER (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.10 to 15.4), stroke (OR, 4.33; 95% CI, 1.02 to 18.35), SCI (OR, 3.3; 95% CI, 0.97 to 11.25), and respiratory complications (OR, 6.88; 95% CI,1.52 to 31.02), but higher reintervention rate (OR, 0.34; 95% CI, 0.16 to 0.69). Midterm survival was similar (OR, 1.19; 95% CI, 0.42 to 3.32). Noncomparative studies demonstrated that most reinterventions were related to the aortic segment distal to primary intervention in both groups (OS 73%, ER 59%). Reintervention procedures were mainly surgical for OS (85%), mainly endovascular for ER (75%). Rupture rates were 1.2% (OS) and 3% (ER). CONCLUSIONS: Endovascular repair is associated with significant early benefits, but this is not sustained at midterm. Reintervention is more frequent, but the OS is not exempt from reintervention or late rupture. Both techniques have their place, but patient selection is key.

An arterioarterial prosthetic graft as an alternative option for haemodialysis access: a systematic review.

INTRODUCTION: All arteriovenous fistula/grafts options should be exhausted before haemodialysis is carried out via central venous catheters (CVC). CVCs carry high morbidity and mortality risks and in some patients, the central veins could be exhausted. In these patients, an arterioarterial prosthetic loop (AAPL) or straight graft can be the only option for haemodialysis. A systematic review was thus carried out to look at the use of arterioarterial graft for haemodialysis, with regards to dialysis adequacy, complications, and patency rates. METHODS: An electronic search was performed using the EMBASE and MEDLINE databases from inception until June 2017. Study retrieval was conducted according to PRISMA guidelines. RESULTS: A total of eight studies published between 1976 and 2017 were identified for pooled analysis. The studies were retrospective cohort in design and reported data on 151 patients. Primary patency rate ranged from 67%-94.5% at six months to 54%-61% at 36 months, with secondary patency rates from 83%-93% at six months to 72%-87% at 36 months. All studies documented satisfactory haemodialysis. Although limited by the size of the cohort of patients studied, patients with end-to-side grafts did not suffer from distal ischaemia when the graft occluded unlike patients who had their graft sutured as end-to-end. CONCLUSIONS: This review highlights the potential benefit of arterioarterial grafts for dialysis as an alternative vascular access option. As a result, this review calls for registry-based multicentre study to evaluate this treatment arm as an alternative option when all AVF/AVG options are exhausted.

A Systematic Review of Predictors of Reintervention After EVAR: Guidance for Risk-Stratified Surveillance.

BACKGROUND: Current surveillance protocols after endovascular aneurysm repair (EVAR) are ineffective and costly. Stratifying surveillance by individual risk of reintervention requires an understanding of the factors involved in developing post-EVAR complications. This systematic review assessed risk factors for reintervention after EVAR and proposals for stratified surveillance. METHODS: A systematic search according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed using EMBASE and MEDLINE databases to identify studies reporting on risk factors predicting reintervention after EVAR and proposals for stratified surveillance. RESULTS: Twenty-nine studies reporting on 39 898 patients met the primary inclusion criteria for reporting predictors of reintervention or aortic complications with or without suggestions for stratified surveillance. Five secondary studies described external validation of risk scores for reintervention or aortic complications. There was great heterogeneity in reporting risk factors identified at the pre-EVAR, intraoperative, and post-EVAR stages of treatment, although large preoperative abdominal aortic aneurysm diameter was the most commonly observed risk factor for reintervention after EVAR. CONCLUSION: Existing data on predictors of post-EVAR complications are generally of poor quality and largely derived from retrospective studies. Few studies describing suggestions for stratified surveillance have been subjected to external validation. There is a need to refine risk prediction for EVAR failure and to conduct prospective comparative studies of personalized surveillance with standard practice.

Type II endoleaks: when and how.

Although most type II endoleaks are self-limiting, the most common indication for secondary intervention after endovascular aneurysm repair (EVAR) is type II endoleak. However, it is still debatable when to treat them. Furthermore, different intervention techniques are available to treat type II endoleaks. The aim of this review is to look at current evidence and updates on type II endoleaks after EVAR for abdominal aortic aneurysm and their management.