The fate of patients with large abdominal aortic aneurysms referred for consideration for elective repair.

BACKGROUND: The premise of the Vascular Services Quality Improvement Programme (VSQIP) in management of patients with asymptomatic large abdominal aortic aneurysms (AAA) is reducing mortality from ruptured AAA in a sustainable way without introducing excessive procedure related mortality. Inevitably a proportion of patients are deemed unfit for elective repair. The aim of this study was to report outcomes of patients who were referred with large asymptomatic AAAs including those turned down for elective repair and identify independent risk factors for being turned down for elective open or endovascular repair of AAA. METHODS: Consecutive patients referred to a regional vascular center with a large AAA (greater than 55 mm) between 1st January 2008 and 31st March 2018 were included. All patients underwent the nationally agreed VSQIP pathway which included preoperative cardio-pulmonary exercise testing and contrast enhanced CT scan of aorta. The decision to repair and the modality of repair were made through a Multi-Disciplinary Team MDT process on each patient. Patients were classified into two groups; those managed non-operatively and those offered elective repair. Survival was assessed using Kaplan-Meier analysis. Factors associated with non-operative management were examined using multivariate analysis. RESULTS: A total of 876 patients of whom 768 were men and 108 were women with a mean age of 74 years (SD: 7.2) and a diagnosis of a large asymptomatic AAA were assessed. One hundred and seventy-four patients (19.9%) were turned down for elective repair and 702 (80.1%) underwent repair [Open: 244(34.8%), EVAR: 458 (65.2%] with perioperative and 30 day mortality of 1.13% (8 patients). Median duration of follow-up was 1530 days (51 months), (inter quartile range: 1714 days). Patients who underwent repair had significantly higher survival rates compared with those who were turned down (P<0.0001). Risk factors for being turned down for elective AAA included anaerobic threshold <8 mL kg-1 min-1 [OR: (95% CI): 2.27 (1.31-3.92)], (P=0.0005), Age>80 yrs. [OR (95% CI): 1.32 (1.012-1.52], (P=0.0203), complex aneurysm morphology [OR (95% CI): 3.70 (2.82-4.87], (P<0.0001), Female gender: [OR: (95% CI): 2.41 (1.32-3.92)], (P<0.0001) and being classed high or very high risk for open AAA repair OR: (95% CI): 6.48 (4.01-10.49)], (P<0.0001). CONCLUSIONS: A significant cohort of patients with large asymptomatic AAA is turned down for elective AAA repair. These patients appear to have significantly lower survival rates than those who are treated. Information on patients turned down for elective AAA repair should be routinely reported.

Is gender still a risk factor for mortality in patients who undergo elective repair of abdominal aortic aneurysms? Experience of a single center.

BACKGROUND: Vascular Services Quality Improvement Program (VSQIP) was introduced to reduce mortality from elective repair of AAA in the UK. This study examines the differences in perioperative mortality and postoperative survival between men and women following elective repair of AAAs in the 10 years after implementation of the (VSQIP). METHODS: Consecutive patients who underwent elective repair of AAA between 1st January 2008 and 31st March 2018 were included. All patients were assessed using the nationally agreed VSQIP pathway which involved cardiopulmonary exercise testing as well as contrast enhanced CT scan of aorta and multidisciplinary assessment to plan each treatment. CT scans were examined to assess the morphology of AAA. Patients were stratified by age, gender, AAA morphology and preoperative anaerobic threshold. Postoperative survival was assessed using Kaplan-Meier analysis. Cox regression analysis was used to determine predictors of postoperative mortality. RESULTS: A total of 702 patients underwent elective repair of AAA of whom 632 were men and 70 were women. The mean age of study cohort was 73.5±7.3 years and mean AAA diameter was 62±9.9 mm. Two hundred and forty-four patients underwent open repair, 402 underwent infrarenal endovascular aneurysm repair (EVAR) and 56 underwent complex EVAR with perioperative and 30-day mortality of 1.13%. No significant difference was observed in perioperative/30-day mortality between men and women (χ2=0.06, P=0.81). Anaerobic threshold <8 (HR=0.68 [95% CI: 0.51-0.92]), complex aneurysm morphology (HR=1.7 [95% CI: 1.39-2.19]) risk category (HR=1.89 [95% CI: 1.48-2.42]) and patients age (HR=1.41 [95% CI: 1.13-1.89]) were independent risk factor for mortality following repair of AAA, whilst female gender (HR=0.89 [95% CI: 0.54-1.48]) and AAA size (HR=1.01 [95% CI: 0.84-1.22]) were not. There was no difference in postoperative survival between men and women who underwent elective repair of AAA (Log rank: 1.82, P=0.61). CONCLUSIONS: Following the implementation of VSQIP female gender is no longer a significant risk factor for perioperative mortality or reduced survival following elective repair of large asymptomatic AAA.

Anaerobic threshold as an independent predictor of mid-term survival following elective endovascular repair of abdominal aortic aneurysm.

BACKGROUND: The aim of this study was to examine the value preoperative AT as predictor of postoperative survival in patients who underwent elective EVAR for repair of asymptomatic AAA. METHODS: Consecutive patients who underwent elective EVAR between 2008 and 2018 were analyzed. Cardiopulmonary exercise testing was performed. Perioperative 30-day mortality was compared between patients who had AT ≥8 mL/kg/min and those with AT<8 mL/kg/min. Risk factors for postoperative survival following EVAR were examined using Cox's regression analysis. RESULTS: Between 1st January 2008 and 31st December 2017, 430 patients underwent elective EVAR (standard device: N.=374, fenestrated/branched: N.=56); their median age was 76 years (range: 53-91 years), median AT was 9.3 (range: 5.4-16.1), and 30-day mortality was 0.9%. These patients were followed up for a median of 1630 days. There was no significant difference in perioperative 30-day mortality between patients who had AT≥8 and those who had AT<8 (χ2=1.56, P=0.22). Age (HR=1.51 [CI: 1.07-1.99], P<0.05) and AT (HR=0.59 [CI: 0.45-0.76], P=0.0003) were predictors of reduced postoperative survival following elective EVAR whereas gender (HR=0.75 [CI: 0.4-1.4], P=0.37), AAA diameter (HR=0.95 [CI: 0.77-1.16], P=0.6), and AAA morphology (HR=1.23 [CI: 0.68-1.76], P=0.95) were not. CONCLUSIONS: Anaerobic threshold is an independent predictor of prolonged survival following elective EVAR and can be used to identify patients who receive most benefit from elective EVAR.

Identification of the medial femoral safe zone for drilling during dynamic hip screw side plate fixation: A CT angiogram tracing of the profunda femoris artery.

OBJECTIVES: Iatrogenic injury of the Profunda Femoris Artery (PFA) at time of hip fixation surgery can increase morbidity and mortality and prolong the hospital stay. This is an injury that tends to pass unnoticed as a cause of postoperative deterioration despite being frequently reported in the literature. Our study aims to describe the anatomy of the PFA in relation to the medial femoral cortex with specific emphasis on its orientation relative to the position of a sliding hip screw side plate construct. By doing so we are able to present clear guidance to orthopaedic surgeons on how to avoid iatrogenic PFA injury at the time of hip fracture fixation. METHODS: Using Computed Tomography Angiographic (CTA) studies, the course of the PFA in relation to the medial femoral cortex was traced in 44 patients (28 males and 16 females) with mean age of 65.6 years. Coronal and axial CT sections were cross-linked to specify the position of the PFA at 1 cm intervals. RESULTS: The course of the artery could be divided into three parts relative to a fixed reference point. Proximal and distal parts of the artery were in a safer position in comparison to the middle part of the artery that was found very close to the femoral cortex and along the coronal axis of the femur (mean angle 2.9° from the femoral coronal axis and 13.8 mm from the medial femoral cortex). Using the commercially available side plate constructs, this part of the artery corresponded to the distal part of the plate (third and fourth holes). CONCLUSION: Special attention needs to be practiced by the operating surgeon while drilling into the third and fourth holes of the side plate.

Aneurysm Morphology Is a More Significant Predictor of Survival than Hardman's Index in Patients with Ruptured or Acutely Symptomatic Abdominal Aortic Aneurysms.

Scoring systems such as Hardman's index are used to predict outcomes and stratify patients with ruptured abdominal aortic aneurysm (RAAA) or acutely symptomatic abdominal aortic aneurysm (SAAA) to active treatment or palliation. Aneurysm morphology is not included in these scoring systems. The aim of this study was to assess whether aneurysm morphology was an independent predictor of survival. Consecutive patients admitted from January 2006 to March 2017 with emergency presentation and primary diagnosis of abdominal aortic aneurysm were identified. Patients were stratified by age, gender, mode of presentation (RAAA versus SAAA), Hardman's Index, aneurysm morphology (suitability for endovascular aneurysm repair [EVAR]), and the procedure performed (endovascular versus open). Multivariable logistic regression analysis was used to determine predictors of survival. A total of 346 patients were included (RAAA: 250, SAAA: 96). Median age of patients was 75 years (range: 44-96); 284 (79%) were men and 75 (21%) were women. Three hundred twenty-five patients underwent preoperative computed tomography (CT) scan of these 156 (48%) fulfilled conservative instructions for use (IFU) for EVAR and another 64 (20%) were within the liberal IFU for EVAR. Median Hardman Index was 1 (range 0-5). Age (odds ratio [OR]: 1.72 [95% confidence interval {CI}: 1.15-2.23] [P < 0.001]), mode of presentation [(OR: 2.05 (95% CI: 1.45-3.31) (P < 0.001)], and aneurysm morphology being within conservative IFU for EVAR [(OR: 1.61 (95% CI: 1.08-2.03) (P = 0.02)], modality of repair (open versus EVAR), (OR: 0.81 [95% CI: 0.67-0.92], [P < 0.001]) were independent predictors of survival. Hardman's index (OR: 0.86 [95% CI: 0.69-1.11], [P = 0.16]) and gender (OR: 1.15 [95% CI: 0.83-1.32], [P = 0.24]) were not. Aneurysm morphology is a significant predictor of survival after RAAA. This information should be included in any scoring system.

Validation of a Decision Tree to Streamline Infrainguinal Vein Graft Surveillance.

BACKGROUND: Duplex ultrasound (DU)-based graft surveillance remains controversial. The aim of this study was to assess the ability of a recently proposed decision tree in identifying high-risk grafts which would benefit from DU-based surveillance. MATERIALS AND METHODS: Consecutive patients undergoing infrainguinal vein graft bypass from January 2008 to December 2015 were identified from the National Vascular registry and enrolled in a duplex surveillance program. An early postoperative DU was performed at a median of 6 weeks (range: 4-9 weeks). Grafts were classified into high risk or low risk based on the findings of the earliest postoperative scan and 4 established risk factors for graft failure (diabetes, smoking, infragenicular distal anastomosis, and revision bypass surgery) using a classification and regression tree (CRT). The accuracy of the CRT model was evaluated using area under receiver operator characteristic (AROC) curve. RESULTS: About 278 vein graft bypasses were performed; 29 grafts had occluded by the first surveillance visit; 249 vein grafts were entered into surveillance. Sixty-four (23%) developed critical stenosis. Overall 30-month primary patency, primary-assisted patency, and secondary patency rates were 71.2%, 77.2%, and 80.1%, respectively. AROC for prediction of graft stenosis or occlusion was 83% (95% confidence interval [CI]: 78-87%). The sensitivity and specificity of the CRT model for prediction of graft stenosis or occlusion were 95% (95% CI: 88-98%) and 52.2% (95% CI: 45-60%). CONCLUSIONS: A prediction model based on commonly recorded clinical variables and early postoperative DU scan is accurate at identifying grafts which are at high risk of failure. These high-risk grafts may benefit from DU-based surveillance.

British Society of Interventional Radiology Iliac Artery Angioplasty-Stent Registry III.

The objective of this study was to audit current practice in iliac artery intervention in the United Kingdom. In 2001 the British Society of Interventional Radiology Iliac Artery Angioplasty-Stent (BIAS) III registry provided the first national database for iliac intervention. It recommended that data collection needed to continue in order to facilitate the dissemination of comparative data to individual units. BIAS III was designed to continue this work and has a simplified data set with an online submission form. Interventionalists were invited to complete a 3-page tick sheet for all iliac angioplasties and stents. Questions covered risk factors, procedural data, and outcome. Data for 2233 patients were submitted from 37 institutions over a 43-month period. Consultants performed 80% of the procedures, 62% of which were for claudication. Fifty-four percent of lesions were treated with stents and 25% of patients underwent bilateral intervention, resulting in a residual stenosis of <50% in 98%. Ninety-seven percent of procedures had no limb complication and there was a 98% inpatient survival rate. In conclusion, these figures provide an essential benchmark for both audit and patient information. National databases need to be expanded across the range of interventional procedures, and their collection made simple and, preferably, online.