Identifying patients with AAA with the highest risk following endovascular repair.

INTRODUCTION: It has been demonstrated that endovascular repair of arterial disease results in reduced perioperative morbidity and mortality compared to open surgical repair. The rates of complications and need for reinterventions, however, have been found to be higher than that in open repair. The purpose of this study was to identify the predictors of endograft complications and mortality in patients undergoing endovascular abdominal aortic aneurysm (AAA) repair; specifically, our aim was to identify a subset of patients with AAA whose risk of periprocedure mortality was so high that they should not be offered endovascular repair. METHODS: We undertook a prospective review of patients with AAA receiving endovascular therapy at a single institution. Collected variables included age, gender, date of procedure, indication for procedure, size of aneurysm (where applicable), type of endograft used, presence of rupture, American Society of Anesthesiologists (ASA) class, major medical comorbidities, type of anesthesia (general, epidural, or local), length of intensive care unit (ICU) stay, and length of hospital stay. These factors were correlated with the study outcomes (overall mortality, graft complications, morbidity, and reintervention) using univariate and multivariate logistic regression. RESULTS: A total of 199 patients underwent endovascular AAA repair during the study period. The ICU stay, again, was significantly correlated with the primary outcomes (death and graft complications). In addition, length of hospital stay greater than 3 days, also emerged as a statistically significant predictor of graft complications in this subgroup (P = .024). Survival analysis for patients with AAA revealed that age over 85 years and ICU stay were predictive of decreased survival. Statistical analysis for other subgroups of patients (inflammatory AAA or dissection) was not performed due to the small numbers in these subgroups. CONCLUSIONS: Patients with AAA greater than 85 years of age are at a greater risk of mortality following endovascular repair. In addition, patients who are expected to require postprocedure ICU admission are also at an increased risk of mortality following endovascular repair.

Endovascular repair in traumatic thoracic aortic injuries: comparison with open surgical repair.

PURPOSE: Thoracic endovascular aortic repair (TEVAR) has emerged as an alternative to open surgical repair (OSR) of traumatic thoracic aortic injury (TTAI). Herein immediate and midterm outcomes of TEVAR are compared with those of OSR. MATERIALS AND METHODS: Health records were used to identify patients with TTAI presenting between April 1995 and September 2006. Preoperative patient characteristics, intraoperative variables, procedural costs, and outcomes were recorded. RESULTS: A total of 103 patients were identified. Twenty-two died before treatment, 19 were treated conservatively, 36 received OSR, and 26 received TEVAR. In the OSR group, time from diagnosis to treatment was 8 hours, the 30-day mortality rate was 11.1%, and all deaths occurred intraoperatively. Thoracic nerve injury occurred in four patients (12.5%), pneumonia in 12 (37.5%), temporary renal failure in one (3%), paraparesis in three (9.4%), and paraplegia in five (15.6%). On follow-up (mean, 61 months), postthoracotomy pleural reaction was seen in three cases (9.4%). In the TEVAR group, time to treatment was 38 hours (P < .01) and the 30-day mortality rate was 7.4% with no intraoperative deaths. Pneumonia was seen in two cases (8.3%) and left arm ischemia was seen in two of 17 patients in whom the left subclavian artery was covered. On midterm follow-up (mean, 17 months), there were no graft failures or repeat aortic interventions. Costs of each procedure were initially comparable, but follow-up expenses with TEVAR were $1,284 (Canadian) greater per year. CONCLUSIONS: TEVAR of TTAI is associated with lower perioperative mortality and morbidity rates than OSR, with no significant graft-related complications on midterm follow-up. The study data support the continued use of TEVAR in this context.