Total fluid and specific beverage intake and mortality due to IHD and stroke in the Netherlands Cohort Study.

Chronic mild dehydration has been associated with several diseases, including fatal IHD and stroke. It has been suggested that hydration through total fluid intake (or water) is inversely associated with IHD or stroke mortality. The objective of the present study was to evaluate the relationship between total fluid (and specific beverage) intake and IHD or stroke mortality in the Netherlands Cohort Study (NLCS). In 1986, 120,852 participants aged 55-69 years were enrolled into the NLCS. Mortality data were collected over a 10-year follow-up period. Analysis was done through a case-cohort approach, and it was based on the subjects without a history of heart disease, stroke or diabetes at baseline. A total of 1789 IHD mortality cases and 708 stroke mortality cases occurred during the follow-up. Higher total fluid consumption was not associated with either IHD mortality or stroke mortality in men or women. When analysing specific beverages, a positive association between coffee consumption (increment 270 ml/d) and IHD mortality was observed in men (hazard ratio (HR) 1.09, 95% CI 1.00, 1.18), while an inverse relationship was observed in women (HR: 0.88, 95% CI 0.78, 1.00). For tea consumption (increment of 253 ml/d), an inverse relationship with IHD mortality was observed in men (HR: 0.91, 95% CI 0.83, 1.00). No association with water intake was observed. In the study population, fresh water consumption was very low. In conclusion, total fluid intake was not associated with IHD or stroke mortality in either men or women. Coffee consumption was inversely associated with IHD mortality in women only, while a higher tea intake was associated with lower IHD mortality in men only.

Fluid intake and colorectal cancer risk in the Netherlands Cohort Study.

Total fluid intake, specifically water intake, has been suggested to protect against colorectal cancer. We examined the association of total fluid intake with colorectal cancer endpoints and possible effect modification by fiber intake within the Netherlands Cohort Study (N = 120,852). We also investigated intake of specific beverages. After 13.3 yr, 1,443 male and 1,040 female colorectal cancer cases with complete baseline questionnaires were available for case-cohort analyses. Multivariate analyses showed no dose-response relationship of total fluid intake and intake of specific beverages with the risk of overall colorectal, proximal, and distal colon cancer. For rectal cancer risk in men, there was a nonsignificant positive trend for total fluid intake [> 1,500 vs. 6 vs.

Relationship between tap water hardness, magnesium, and calcium concentration and mortality due to ischemic heart disease or stroke in The Netherlands.

BACKGROUND: Conflicting results on the relationship between the hardness of drinking water and mortality related to ischemic heart disease (IHD) or stroke have been reported. OBJECTIVES: We investigated the possible association between tap water calcium or magnesium concentration and total hardness and IHD mortality or stroke mortality. METHODS: In 1986, a cohort of 120,852 men and women aged 5569 years provided detailed information on dietary and other lifestyle habits. Follow-up for mortality until 1996 was established by linking data from the Central Bureau of Genealogy and Statistics Netherlands. We calculated tap water hardness for each postal code using information obtained from all pumping stations in the Netherlands. Tap water hardness was categorized as soft [< 1.5 mmol/L calcium carbonate (CaCO3)], medium hard (1.62.0 mmol/L CaCO3), and hard (> 2.0 mmol/L CaCO3). The multivariate case-cohort analysis was based on 1,944 IHD mortality and 779 stroke mortality cases and 4,114 subcohort members. RESULTS: For both men and women, we observed no relationship between tap water hardness and IHD mortality [hard vs. soft water: hazard ratio (HR) = 1.03; 95% confidence interval (CI), 0.851.28 for men and HR = 0.93; 95% CI, 0.711.21 for women) and stroke mortality (hard vs. soft water HR = 0.90; 95% CI, 0.661.21 and HR = 0.86; 95% CI, 0.621.20, respectively). For men with the 20% lowest dietary magnesium intake, an inverse association was observed between tap water magnesium intake and stroke mortality (HR per 1 mg/L intake = 0.75; 95% CI, 0.610.91), whereas for women with the 20% lowest dietary magnesium intake, the opposite was observed. CONCLUSIONS: We found no evidence for an overall significant association between tap water hardness, magnesium or calcium concentrations, and IHD mortality or stroke mortality. More research is needed to investigate the effect of tap water magnesium on IHD mortality or stroke mortality in subjects with low dietary magnesium intake.

Procedure-related mortality of endovascular abdominal aortic aneurysm repair using revised reporting standards.

OBJECTIVE: The aim of this study was to evaluate the definition of Procedure-related mortality after endovascular aneurysm repair (EVAR) as defined by the Committee for Standardized Reporting Practices in Vascular Surgery. METHODS: Data on patients with an AAA were taken from the EUROSTAR database. The patients underwent EVAR between June 1996 and February 2004 and were analyzed retrospectively. Explicit probability of cause of death was recorded. The time interval from operation, hospital discharge or second interventions till death was recorded. RESULTS: A total of 589 out of 5612 patients (10.5%) died after EVAR in total follow up and all causes of death were included. 141 (2.5%) patients died due to aneurysms reported after the EVAR procedure of which 28 (4.8%) were ruptures, 25 (4.2%) graft-infections and 88 (14.9%) patients who died within 30 days after the initial procedure (present definition, also known as short term clinical outcome). In addition 25 patients died after 30 days, but were then (at moment of death) still in the hospital, or were transferred to a nursing home for further re-evaluation, or needed second interventions. Taking into account the duration of hospitalization and mortality immediately after procedure-related second interventions, 49 delayed deaths might also be regarded as being EVAR procedure-related. CONCLUSION: Delayed deaths are a considerable proportion of procedure-related deaths after EVAR within the revised time frame.

Tube stent-grafts for infrarenal aortic aneurysm: a matched-paired analysis based on EUROSTAR data.

OBJECTIVE: Tube stent-grafts for treatment of infrarenal aortic aneurysms (AAAs) are a nearly forgotten concept. For focal aortic pathologies tube stent-grafts may be a treatment option. We have performed a retrospective matched-paired analysis of the EUROSTAR registry regarding the outcome of tube vs. bifurcated stent-grafts for AAA. Tapered aortomonoiliac stent-grafts were not the objective of this study. MATERIALS AND METHODS: From July 1997 to June 2006, 7581 patients who underwent an endovascular AAA repair were entered in the EUROSTAR registry by 164 centers. One hundred fifty-three patients were treated with tube stent-grafts. For each of these 153 patients we selected one patient from a bifurcated stent-graft group (BGG-original, 7428 patients) matched according to gender, ASA, age, AAA diameter, and type of anesthesia. Differences in preoperative details between the two study groups were analyzed using chi-square test for discrete variables and Wilcoxon rank-sum test for continuous variables. Multivariate logistic regression analysis was performed on early complications. Midterm outcomes (>30 days) were analyzed by Kaplan-Meier and multivariate Cox proportional hazard model. RESULTS: The duration of the procedure was shorter in the tube stent-graft group (TGG; 102.3 +/- 52.2) than in BGG (128.3 +/- 55.0; p = 0.0002). Type II endoleak was less frequent in TGG (4.0%; mean follow-up, 23.12 +/- 23.9 months) than in BGG (14.3%; mean follow-up, 20.77 +/- 20.0 months; p = 0.0394). Type I endoleaks and migration were distributed equally, without significant differences between the groups. Combined 30-day and late mortality was higher for TGG (p = 0.0346) and was obviously not aneurysm related. CONCLUSIONS: We conclude that after selection of patients, tube stent-grafts for infrarenal aortic repair can be performed with great safety regarding endoleaks and migration. The combined higher 30-day mortality and non-aneurysm-related mortality during follow-up were mainly caused by cardiac failures in our sample.

Secondary interventions after elective endovascular repair of degenerative thoracic aortic aneurysms: results of the European collaborators registry (EUROSTAR).

PURPOSE: The need for secondary interventions is an important indicator of intermediate and long-term success of endovascular repair of degenerative thoracic aortic aneurysm. The purpose of this study was to analyze the occurrence and consequences of secondary procedures. MATERIALS AND METHODS: Data from 213 patients electively subject to operation for degenerative thoracic aortic aneurysm and achieving primary success and who were enrolled in the EUROSTAR registry were analyzed. Secondary procedures were categorized as follows: transfemoral endovascular reintervention, extraanatomic secondary procedures, and transthoracic surgery. RESULTS: Overall, 25 (12%) of the patients with an elective treatment for a degenerative thoracic aneurysm had secondary intervention, occurring at a mean of 8 months after the initial procedure. Seventeen (68%) of the secondary interventions were via a transfemoral approach, six (24%) involved a transthoracic procedure, and two (8%) involved extraanatomic bypass. The cumulative percentage of freedom from intervention at 1 and 2 years was 86% and 83%, respectively. Endoleak (relative risk, 5.21) was the most frequent cause for secondary transfemoral intervention. For the other secondary interventions, no principal indication for reintervention could be identified. Patients who needed secondary interventions more frequently suffered from preoperative back pain (20% vs 44%, P = .008), and their thoracic aneurysms had a longer length (mean, 95.6 mm vs 133.2 mm, P = .006). The 2-year cumulative survival rate of patients without secondary intervention was 85% compared with 58% in the patients who received secondary intervention (P = .0001). CONCLUSIONS: Regular surveillance after endovascular degenerative thoracic aneurysm repair is needed as secondary interventions were required throughout the follow-up period.

Mortalidade relacionada ao tratamento endovascular do aneurisma da aorta abdominal com o uso dos modelos revisados / Procedure-related mortality of endovascular abdominal aortic aneurysm repair using revised reporting standards

OBJETIVO: O objetivo do estudo foi avaliar a definição da mortalidade relacionada ao procedimento após tratamento endovascular do aneurisma de aorta abdominal (EVAR) como definido pelo Committee for Standardized Reporting Practices in Vascular Surgery. MÉTODO: Dados de pacientes com aneurisma de aorta abdominal foram analisados do banco de dados EUROSTAR. Os pacientes foram submetidos ao EVAR entre junho de 1996 a fevereiro de 2004 e foram estudados retrospectivamente. A probabilidade explicita da causa de morte foi registrada. O intervalo entre a operação, alta hospitalar ou intervenção secundária até a morte foi registrado. RESULTADOS: De um total de 5612 pacientes, 589 (10,5 por cento) faleceram após o EVAR em acompanhamento total e qualquer causa de morte foi inclusa. Cento e quarenta e um pacientes (12,5 por cento) morreram devido a causa relacionada ao aneurisma, sendo que 28 (4,8 por cento) foram rupturas, 25 (4,2 por cento) infecções do implante e 88 (14,9 por cento) foram pacientes que morreram num prazo de 30 dias após o procedimento inicial (definição atualmente utilizada, também conhecido como resultado clínico a curto prazo). Além disso, 25 pacientes faleceram após 30 dias, mas continuavam ainda hospitalizados (ou transferidos a home-care para reavaliação posterior, ou necessitaram intervenção secundária). Levando em conta a duração da admissão ao hospital e a mortalidade imediata após o procedimento relacionada a intervenções secundárias, 49 mortes tardias também podem ser relacionadas ao EVAR. CONCLUSÃO: Morte tardia compõe uma proporção considerável da mortalidade relacionada ao EVAR dentro do tempo de análise revisado.

OBJECTIVE: The aim of this study was to evaluate the definition of Procedure-related mortality after endovascular aneurysm repair (EVAR) as defined by the Committee for Standardized Reporting Practices in Vascular Surgery. METHODS: Data on patients with an AAA were taken from the EUROSTAR database. The patients underwent EVAR between June 1996 and February 2004 and were analyzed retrospectively. Explicit probability of cause of death was recorded. The time interval from operation, hospital discharge or second interventions till death was recorded. RESULTS: A total of 589 out of 5612 patients (10.5 percent) died after EVAR in total follow up and all causes of death were included. 141 (2.5 percent) patients died due to aneurysms reported after the EVAR procedure of which 28 (4.8 percent) were ruptures, 25 (4.2 percent) graft-infections and 88 (14.9 percent) patients who died within 30 days after the initial procedure (present definition, also known as short term clinical outcome). In addition 25 patients died after 30 days, but were then (at moment of death) still in the hospital, or were transferred to a nursing home for further re-evaluation, or needed second interventions. Taking into account the duration of hospitalization and mortality immediately after procedure-related second interventions, 49 delayed deaths might also be regarded as being EVAR procedure-related. CONCLUSION: Delayed deaths are a considerable proportion of procedure-related deaths after EVAR within the revised time frame.

Influence of severe infrarenal aortic neck angulation on complications at the proximal neck following endovascular AAA repair: a EUROSTAR study.

PURPOSE: To examine the influence of severe infrarenal neck angulation (SNA) on complications after endovascular repair of abdominal aortic aneurysm (AAA). METHODS: From October 1996 to January 2006, 5183 patients who underwent endovascular aneurysm repair using a Talent, Zenith, or Excluder stent-graft were enrolled into the EUROSTAR registry. Incidence of proximal type I endoleak, stent-graft migration, proximal neck dilatation, aneurysm rupture, secondary interventions, and all-cause and aneurysm-related mortality were compared between patients with and without severe infrarenal neck angulation (>60 degrees angle between the infrarenal aortic neck and the longitudinal axis of the aneurysm). RESULTS: In the short term (before discharge), proximal type I endoleak (OR 2.32, 95% CI 1.60 to 3.37, p<0.0001) and stent-graft migration (OR 2.17, 95% CI 1.20 to 3.91, p=0.0105) were observed more frequently in patients with SNA. Over the long term, higher incidences of proximal neck dilatation > or =4 mm (HR 1.26, 95% CI 1.11 to 1.43, p=0.0004), proximal type I endoleak (HR 1.80, 95% CI 1.25 to 2.58, p=0.0016), and need for secondary interventions (HR 1.29, 95% CI 1.00 to 1.67, p=0.0488) were seen in patients with SNA. All-cause mortality, aneurysm-related mortality, and rupture of the aneurysm were similar in patients with and without severe neck angulation. In the subgroup of patients with an Excluder endograft, proximal endoleak at the completion angiogram (OR 4.49, 95% CI 1.31 to 15.32, p=0.0166) and long-term proximal neck dilatation (HR 1.67, 95% CI 1.20 to 2.33, p=0.0026) were more frequently observed in patients with SNA. In the Zenith subgroup, proximal endoleak at the completion angiogram (OR 2.62, 95% CI 1.49 to 4.63, p=0.0009) and proximal stent-graft migration before discharge (OR 2.34, 95% CI 1.06 to 5.19, p=0.0353) were more common in patients with SNA. In the Talent subgroup, long-term proximal endoleak (HR 2.09, 95% CI 1.27 to 3.44, p=0.0036), proximal neck dilatation (HR 1.29, 95% CI 1.05 to 1.60, p=0.0168), and secondary interventions (HR 1.54, 95% CI 1.05 to 2.24, p=0.0259) were more frequently observed in patients with SNA. CONCLUSION: Severe infrarenal aortic neck angulation was clearly associated with proximal type I endoleak, while the relationship with stent-graft migration was not clear. Excluder, Zenith, and Talent stent-grafts perform well in patients with severe neck angulation, with only a few differences among devices.

Risk-adapted outcome after endovascular aortic aneurysm repair: analysis of anesthesia types based on EUROSTAR data.

PURPOSE: To compare anesthesia techniques in high-risk versus low-risk patients treated with endovascular aortic aneurysm repair (EVAR) with respect to outcomes. METHODS: From July 1997 to August 2004, 5557 patients were enrolled in the EUROSTAR registry by 164 centers. Low-risk and high-risk patients were each divided into 3 groups according to anesthesia used during operation [general (GA), regional (RA), and local (LA)], resulting in 6 groups. Differences in preoperative and operative details among the 3 types of anesthesia were analyzed using a chi-square test for discrete variables and the Kruskal-Wallis test for continuous variables for each risk profile. Multivariate logistic regression analysis was performed on early complications. RESULTS: Intensive care unit (ICU) admission was less frequent for high-LA (1.2% of patients) than high-RA (7.8%, p=0.0071) and high-GA (16.2%, p<0.0001), but high-RA still had a distinct advantage (p<0.0001) over high-GA. Systemic complications were lower both for high-LA (9.0%, p=0.0128) and for high-RA (10.7%, p<0.0001) than for high-GA (18.3%). Early death (< or =30 days) was reduced in high-RA (3.0%) versus high-GA (4.3%, p=0.0286). CONCLUSION: On the basis of the EUROSTAR data, high-risk patients in particular attain important advantages from minimally invasive anesthetic techniques. Mortality, morbidity, hospital stay, and ICU admission are significantly lower for locoregional versus general anesthesia in the EUROSTAR registry. These results should encourage greater use of regional anesthesia in high-risk patients. Local anesthesia seems to be of similar benefit for EVAR in high-risk patients.

Long-term results of endovascular abdominal aortic aneurysm treatment with the first generation of commercially available stent grafts.

HYPOTHESIS: Little information about the long-term results of endovascular abdominal aortic aneurysm repair is available. This study was performed to evaluate the long-term data of patients treated with the first generation of commercially available stent grafts. DESIGN: Multicenter registry. SETTING: Sixty-two European centers that participated in the EUROSTAR (EUROpean collaborators on Stent-graft Techniques for abdominal aortic Aneurysm Repair) registry. PATIENTS: A total of 1190 patients with a follow-up of up to 8 years, who underwent endovascular abdominal aortic aneurysm repair with a stent graft (Stentor or Vanguard). INTERVENTION: Elective endovascular abdominal aortic aneurysm repair. MAIN OUTCOME MEASURES: The morbidity and mortality data of patients treated with the first-generation stent graft who enrolled in the EUROSTAR registry were analyzed. Incidence rates of complications were calculated to quantify annual risks. Life-table analyses and multivariate Cox proportional hazards models were used for the survival analysis. RESULTS: Conversion to open repair, aneurysm rupture, all-cause death, and aneurysm-related death occurred in 7.1%, 2.4%, 19.9%, and 3.0% of the patients, respectively. The cumulative percentage of the combined outcome event, conversion-free and rupture-free survival, after 8 years was 48.0%. Procedure-related complications that frequently occurred were endoleak (13.0 cases per 100 patient-years), stenosis/thrombosis (4.6 cases per 100 patient-years), and stent migration (4.3 cases per 100 patient-years). CONCLUSIONS: Patients treated with the first generation of stent grafts will need lifelong surveillance because of a considerable risk of late complications. How these findings translate to the outcome of newer-generation stent grafts is unknown. For this reason, vigilant surveillance remains indicated in all patients who undergo endovascular abdominal aortic aneurysm repair.

Influence of infrarenal neck length on outcome of endovascular abdominal aortic aneurysm repair.

PURPOSE: To evaluate the influence of the infrarenal neck length on clinical outcome after endovascular abdominal aortic aneurysm repair (EVAR). METHODS: Data were analyzed from 3499 patients enrolled in the EUROSTAR registry between January 1999 and April 2005 who underwent EVAR with a Talent or Zenith endograft and had detailed morphological data recorded. The study cohort was divided into 3 groups according to infrarenal neck length: >15 mm (reference group A, n=2822), 11 to 15 mm (group B, n=485), and < or =10 mm (group C, n=192). Uni- and multivariate analyses were performed to evaluate differences in clinical outcomes among the study groups. RESULTS: After correction for confounders, proximal type I endoleak within 30 days occurred in 10.9% of group C compared to 2.6% of group A (OR 4.46, 95% CI 2.61 to 7.61). Within 48 months of follow-up (median 12 months), the incidence of proximal endoleaks was higher in groups B (9.6%; HR 1.98, 95% CI 1.16 to 3.38) and C (11.3%; HR 2.132, 95% CI 1.17 to 4.60) compared to group A (3.4%). CONCLUSION: Our study indicates that endovascular treatment of abdominal aortic aneurysms with infrarenal neck length <15 mm is associated with significantly increased risk of short- and midterm proximal endoleaks after EVAR. The greater risk of proximal endoleaks should be weighed against the risks of alternative treatment modalities.

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.

Influence of anesthesia type on outcome after endovascular aortic aneurysm repair: an analysis based on EUROSTAR data.

BACKGROUND: Local and regional anesthesia was used in endovascular aortic aneurysm repair (EVAR) shortly after its introduction, and the feasibility has been documented several times. Nevertheless, locoregional anesthesia has not become accepted on a large scale, probably owing to a traditional surgical attitude preferring general anesthesia. This study compared various anesthesia techniques in patients treated with EVAR for infrarenal aortic aneurysms. METHODS: From July 1997 to August 2004, 5557 patients who underwent EVAR repair in 164 centers were enrolled in the EUROSTAR registry. Data were compared among three groups: a general anesthesia group (GA-G) of 3848 patients (69%), a regional anesthesia group (RA-G) of 1399 patients (25%), and the local anesthesia group (LA-G) of 310 patients (6%). Differences in preoperative and operative details among the three study groups were analyzed using the chi(2) test for discrete variables and the Kruskal-Wallis test for continuous variables. Multivariate logistic regression analysis was performed on early complications. RESULTS: The duration of the operation was reduced in the LA-G (115.7 +/- 42.2 minutes) compared with the RA-G (127.6 +/- 52.8 min, P < .0009) and GA-G (133.3 +/- 59.1 minutes, P < .0001). Admission to the intensive care unit was significantly less for LA-G patients (2%) than RA-G (8.3%, P = .0004) and GA-G (16.2%, P < .0001), but RA-G still had a distinct advantage (P < .0001) over GA-G. Hospital stay was significantly shorter in LA-G (3.7 +/- 3.1 days [P < .0001] vs GA-G [P = .007] vs RA-G), but RA-G (5.1 +/- 7.5 days) still had an advantage (P < .0001) vs GA-G (6.2 +/- 8.5 days). In EUROSTAR, systemic complications were significantly lower both for LA-G (6.6%, P = .0015) and RA-G (9.5%, P = .0007) than for GA-G (13.0%). CONCLUSION: The EUROSTAR data indicate that patients appeared to benefit when a locoregional anesthetic technique was used for EVAR. Locoregional techniques should be used more often to enhance the perioperative advantage of EVAR in treating infrarenal aneurysms of the abdominal aorta.

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.

Endovascular repair of abdominal aortic aneurysm in octogenarians: an analysis based on EUROSTAR data.

PURPOSE: To investigate the early and late outcome after endovascular treatment of abdominal aortic aneurysm (EVAR) in octogenarians compared with patients aged < 80 years. METHODS: Patients treated for abdominal aortic aneurysm (AAA) with endovascular repair during the period 1996 to 2004 were collated in the EUROSTAR registry. This study group consisted of 697 patients aged > or = 80 years. Comparison was made with 4198 patients aged < 80 years with regard to the incidence of preoperative characteristics and outcomes of the procedure. RESULTS: The proportion of octogenarians treated by EVAR increased during the study period, from 11% in the first year to 18% in the last year. Octogenarians more frequently had cardiac disease, impaired renal function, and pulmonary disease (P = .03, P < .0001 and P = .0001). Thirty-two percent of the octogenarians were recorded unfit for open surgery as opposed to 22% in younger patients (P < .0001); they also had a larger aneurysm diameter (62 vs 58 mm, respectively; P < .0001). The 30-day and in-hospital mortality in octogenarians was 5% vs 2% in the younger group (P < .0001). More device-related complications and systemic complications, including cardiac disease, were noted in octogenarians (7% vs 5% and 19% vs 11%, P = .03 and P < .0001, respectively). This group of patients also had a higher incidence of postoperative hemorrhagic complications, including hematoma (7% vs 3%, P < .0001, respectively). No differences in conversion to open repair and post-EVAR rupture rate were observed. Aneurysm-related mortality and late all-cause mortality was 7% vs 3% and 10% vs 7%, both P < .0001. CONCLUSION: Our study supports that EVAR might be considered when treating elderly patients, provided their aneurysms are anatomically suited for the endovascular technique. The risk for late complications compared with open repair may be outweighed by a lower early mortality as well as a shorter time for physical recovery.

What determines and are the consequences of surveillance intensity after endovascular abdominal aortic aneurysm repair?

Follow-up examinations are advised 1, 3, 6, 12, 18, and 24 months and yearly thereafter by the European Collaborating Group on Stent-Graft Techniques for Abdominal Aortic Aneurysm Repair (EUROSTAR). The aim of this study was to evaluate the determinants and consequences of surveillance completeness. Patients who underwent endovascular abdominal aortic aneurysm repair between October 1996 and August 2004 and enrolled in the EUROSTAR registry were analyzed. Two groups were compared: patients who attended all scheduled visits (group A) and those who came infrequently (group B). Odds ratios and hazard rates (HRs) with 95% confidence intervals (CIs) were determined to detect which patient characteristics and complications were associated with follow-up intensity. Of the 4,433 patients, 1,538 (35%) attended all scheduled visits until the end of follow-up (group A). Analysis of patient characteristics demonstrated that intensive visitors were more often smokers, hyperlipemic, and considered unfit for open surgery or general anesthesia. Complications during follow-up, including endoleaks (24% vs. 20%), kinking (3.5% vs. 2.5%), and migration (4.9% vs. 3.5%), appeared significantly more frequently in group A. Despite intensive follow-up of this category, still a greater proportion died (12% vs. 9%, adjusted HR = 1.5, 95% CI 1.2-1.8). After 84 months of follow-up, the cumulative survival rates in groups A and B were 71% and 74%, respectively (p < 0.0001). It seems that follow-up intensity was based on baseline patient characteristics. High-risk patients had, despite more intensive surveillance, still more complications after adjustment for patient, morphological, and center-specific characteristics. Further assessment is indicated to evaluate the effectiveness of different frequencies of surveillance visits.

Risk-adjusted outcome analysis of endovascular abdominal aortic aneurysm repair in a large population: how do stent-grafts compare?

PURPOSE: To compare differences in the applicability and incidence of postoperative adverse events among stent-grafts used for repair of infrarenal aortic aneurysms. METHODS: An analysis of 6787 patients from the EUROSTAR Registry database was conducted to compare aneurysm morphological features, patient characteristics, and postoperative events for the AneuRx, EVT/Ancure, Excluder, Stentor, Talent, and Zenith devices versus the Vanguard device (control) and each other. Annual incidence rates of complications were determined, and risks were compared using the Cox proportional hazards analysis. RESULTS: The annual incidence rates were: device-related endoleak (types I and III) 6% (range 4%-10%), type II endoleak 5% (range 0.3%-11%), migration 3% (range 0.5%-5%), kinking 2% (range 1%-5%), occlusion 3% (range 1%-5%), rupture 0.5% (range 0%-1%), and all-cause mortality 7% (range 5%-8%). After adjustment for factors influencing outcome, AneuRx, Excluder, Talent, and Zenith devices were associated with a lower risk of migration, kinking, occlusion, and secondary intervention compared to the Vanguard device. Significant increased risk for conversion (EVT/Ancure) and reduced risk of aneurysm rupture (AneuRx and Zenith) and all-cause mortality (Excluder) were found compared to the Vanguard device. CONCLUSIONS: Significant differences exist between stent-grafts of different labels in terms of applicability and complications during intermediate to long-term follow-up. Since each stent-graft has its drawbacks, no single label can be identified as the best. It is reassuring that developments in stent-grafts indeed result in better performance than the early stent-grafts. However, a single device incorporating all the perceived improvements should still be pursued.

Influence of diabetes mellitus on the endovascular treatment of abdominal aortic aneurysms.

PURPOSE: To investigate the influence of diabetes mellitus on outcome after endovascular abdominal aortic aneurysm (AAA) repair. METHODS: Of 6017 patients enrolled in the EUROSTAR registry after undergoing endovascular AAA repair between May 1994 and December 2003, 731 (12%) had diabetes mellitus (690 men; mean age 72 years, range 37-100). Patient demographics, risk factors, aneurysm morphology, operative and procedural details, complications, major events, and regular follow-up information were compared. The relationships of complications and events to diabetes mellitus, which were tested with multivariate logistic regression analysis and Cox proportional hazards modeling, are expressed as odds ratios (OR) and hazard rates (HR) with 95% confidence intervals (CI). Survival was compared with life-table analysis. RESULTS: A significantly higher risk of device-related complications was observed in diabetic patients (8% versus 6%, p < 0.049; OR 1.35, 95% CI 1.00 to 1.82). The greatest difference in the groups was in mortality, which was significantly higher in the diabetic population (13%) compared to the nondiabetic patients (10%, p < 0.039; OR 1.27, 95% CI 1.01 to 1.59). Deaths, which occurred at a higher frequency within the 30-day perioperative period in diabetic patients, were primary due to cardiac complications. Insulin-controlled type 2 diabetic patients had significantly lower rates of early and late endoleaks and secondary interventions than diet-controlled type 2 diabetics (p = 0.002, p = 0.0001, and p = 0.0008, respectively) and nondiabetic patients (p = 0.002, p = 0.0005, and p = 0.0025, respectively). The cumulative survival after 48 months did not differ significantly: 74% in diabetics and 79% in the population without diabetes. CONCLUSIONS: Patients with diabetes mellitus had a significantly higher early mortality rate after EVAR, but their long-term survival was similar to nondiabetic patients.

Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries.

PURPOSE: The objective of this study was to assess the initial and 1-year outcome of endovascular treatment of thoracic aortic aneurysms and dissections collated in the European Collaborators on Stent Graft Techniques for Thoracic Aortic Aneurysm and Dissection Repair (EUROSTAR) and the United Kingdom Thoracic Endograft registries. METHODS: Four hundred forty-three patients underwent endovascular repair of thoracic aortic disease between September 1997 and August 2003 (EUROSTAR, 340 patients; UK, 103 patients). Patients represented 4 major disease groups: degenerative aneurysm (n = 249), aortic dissection (n = 131), false anastomotic aneurysm (n = 13), and traumatic aortic injury (n = 50). RESULTS: Mean age in the entire study group was 63 years. Fifty-two percent of patients were deemed at high risk for open surgery because of major comorbidity. Sixty percent of patients underwent an elective procedure, and 35% required emergency treatment. Conventional indications for treatment of aortic dissection, including aortic expansion, continuous pain, rupture, or symptoms of branch occlusion constituted the basis for endograft placement in 57% of patients, whereas in 43% of patients aortic dissections were asymptomatic. Primary technical success was obtained in 87% of patients with degenerative aneurysm and in 89% with aortic dissection. Paraplegia was a postoperative complication in 4.0% of patients with degenerative aneurysm and 0.8% of patients with aortic dissection (not significant). Thirty-day mortality in the entire study group was 9.3%, with mortality rates after elective procedures of 5.3% for degenerative aneurysms and 6.5% for aortic dissection. Mortality for degenerative aneurysm after emergency repair was higher (28%; P <.0001) then after elective procedures. For aortic dissection the emergency repair rate was 12% (not significant compared with elective repair of aortic dissection, and P = .025 compared with emergency repair of degenerative aneurysm). One-year follow-up was complete in 195 patients. The outcome at 1 year was more favorable for aortic dissection than for degenerative aneurysm with regard to aortic expansion (0% vs 15%; P = .001) and late survival (90% vs 80%; P = .048). In the groups with false anastomotic aneurysm and traumatic aortic injury, 30-day mortality rates were 8% and 6%, respectively. CONCLUSION: This multicenter experience demonstrates acceptable rates for operative mortality and paraplegia after endovascular repair of thoracic aortic disease. Outcome after 30 days and 1 year was more favorable for aortic dissection than for degenerative aneurysm. However, the durability of this technique is currently unknown, and continued use of registries should provide data from long-term follow-up.